front 1 An ambulatory client calls the clinic to report edema around both ankles and feet during the day that disappears while sleeping at night. Which is an appropriate follow-up question for the nurse to ask? "Have you been using more pillows to sleep comfortably?" "Do you smoke or use other tobacco products?" "Have you had a recent heart
attack?" | back 1 "Do you become short of breath during your normal daily
activities?" |
front 2 The licensed practical nurse (LPN) is assigned to a client who is receiving intravenous potassium replacement. Which finding indicates that the LPN needs to advise the registered nurse (RN) to evaluate the client’s potassium replacement? Pain radiating down the outer part of the client's arm Reports of abdominal pain and cramping Repeated arrhythmia alarms on the monitor Fast and bounding pulse | back 2 Repeated arrhythmia alarms on the monitor Hyperkalemia may result in cardiac rhythm abnormalities. Moderate hyperkalemia can result in changes to the ECG monitor and set off the alarm. Pain down the outer arm is less likely cardiac in origin; cardiac pain is typically down the inside of the arm. Abdominal cramps or pain is more characteristic of low serum potassium levels. Bradycardia and a weak pulse are serious symptoms of hyperkalemia. |
front 3 The nurse is collecting data on a client with portal hypertension. Which finding should the nurse expect? Obesity Blurred vision Ascites Expiratory wheezes | back 3 Ascites Portal hypertension can occur in a client with right-sided heart failure or cirrhosis of the liver. Portal hypertension can lead to the accumulation of fluid in the peritoneal cavity (ascites) due to the increased portal pressure as well as a lowered osmotic pressure. Ascites can lead to shortness of breath, not expiratory wheezing. |
front 4 A client is admitted in respiratory alkalosis after ingesting excessive amounts of aspirin. The nurse should recognize that respiratory alkalosis was most likely caused by which of the following findings? Minimal use of accessory muscles Diminished respiratory effort Temperature of 96.8 F (36 C) Respiratory rate of 34 | back 4 Respiratory rate of 34 |
front 5 The nurse detects blood-tinged fluid leaking from the nose and ears of a client diagnosed with head trauma. What is the appropriate nursing action? Pack the nose and ears with sterile gauze Position an ice pack at the back of the neck Put manual pressure on the sites that are draining Apply bulky, loose sterile dressings to the nose and ears | back 5 Apply bulky, loose sterile dressings to the nose and ears |
front 6 A neonate born 12 hours ago to a methadone-maintained woman is exhibiting a hyperactive Moro reflex and slight tremors. The newborn passed one loose, watery stool. Which action is a nursing priority? Administer the ordered PRN paregoric to stop the diarrhea Observe for neonatal abstinence syndrome Offer fluids to prevent dehydration Hold the infant at frequent intervals | back 6 Observe for neonatal abstinence syndrome Neonatal abstinence syndrome (NAS) is a cluster of findings that signal the withdrawal of the infant from the opiates. The findings seen in methadone withdrawal are often more severe than for other substances. Initial findings are central nervous system hyperirritability and gastrointestinal findings. If withdrawal signs are severe, mortality risk is increased. Close monitoring of the infant ensures proper treatment during the period of withdrawal |
front 7 A 72-year old client reports having discomfort immediately after a below-the-knee amputation. Which initial action by the nurse is most appropriate? Wrap the stump snugly in an elastic bandage Ensure that the stump is elevated Administer opioid narcotics as ordered Conduct guided imagery or distraction | back 7 Ensure that the stump is elevated Elevating the stump is the priority intervention for the first 24 hours after surgery. This will help prevent pressure due to postoperative swelling, which will minimize pain or discomfort. Without this action, a firm elastic bandage, opioid narcotics, or guided imagery will have little effect. Analgesics appropriate to the level of pain should be administered as needed in the postoperative period to promote client comfort. After the first day, the residual limb should be flat on the bed. |
front 8 The nurse is making rounds at the beginning of the shift and asks how each client is feeling. Which statement made by a client would require immediate action by the nurse? "I feel pressure in the middle of my chest like an elephant is sitting on my chest." "When I take in a deep breath, it stabs like a knife." "When I turn in bed to reach the remote for the TV, my chest hurts." "The pain came on after dinner. That soup seemed very spicy." | back 8 "I feel pressure in the middle of my chest like an elephant is sitting on my chest." This is a classic description of chest pain in men caused by myocardial ischemia, requiring immediate assessment and intervention to prevent possible damage to the heart muscle. Pain after spicy food is often the result of irritation and gastric indigestion. The pain with a deep breath is typically from an inflammation of the pleural covering of the lung, called pleurisy. Pain with movement of the chest, such as turning in bed, is typically caused by costochondritis, which is inflammation of the cartilage between the ribs and the sternum, and can be reproduced by palpation of the the painful area. |
front 9 The practical nurse (PN) is collecting data on a 1 month-old infant in the emergency department. Which finding should the nurse report to the registered nurse (RN) immediately? Inspiratory grunting Abdominal respirations Increased heart rate with crying Irregular breathing rate | back 9 Inspiratory grunting Inspiratory grunting is abnormal and may be a sign of respiratory distress in this infant. The other options are expected findings in newborns. |
front 10 The client is diagnosed with infective endocarditis (IE) and has been receiving antibiotic therapy for four days. Which finding suggests that the antibiotic therapy has not been effective and must be reported to the health care provider (HCP) immediately? Temperature of 103 F (39.5 C) Muscle tenderness Streaks of red under the nails Nausea with vomiting | back 10 Temperature of 103 F (39.5 C) Findings of IE include skin rash (petechiae) and small areas of bleeding (splinter hemorrhages) under the fingernails. Muscle or joint pain or weakness are also common symptoms of IE. Nausea and vomiting may be side effects of the treatment; these findings probably would have appeared shortly after beginning treatment. Prolonged fever after 72 hours of antibiotic therapy indicates the antibiotic regime is not effective against the strain of microorganism - the nurse must call the HCP about this finding. Surgical intervention may be indicated for persistent sepsis after 72 hours of appropriate antibiotic treatment. |
front 11 A client completes a fecal occult blood screening and the results
come back positive. Which factor could have influenced this outcome?
(Select all that apply.) Eating green, leafy vegetables Recent use of corticosteroids Eating a steak dinner Drinking fruit juices that contain vitamin C | back 11 Teeth cleaning during regular dental visit Aspirin (ASA) therapy Recent use of corticosteroids Eating a steak dinner Eating red meat, NSAIDs and steroid use can cause a false positive result; even bleeding gums can cause a false positive result. Using vitamin C supplements and fruit juices can cause a false negative result (because it interferes with the chemical reaction that indicates blood is present.) The test should be repeated and the client should be given specific instructions about special dental, dietary and drug restrictions. |
front 12 The nurse is preparing a client scheduled for an intravenous pyelogram (IVP). What is the most important factor to be obtained by the nurse prior to the procedure? Allergy history Measurement of urine output Time of the last meal Comparison of the radial pulses | back 12 Allergy history The nurse should review any allergies with the client, especially a reaction to previous tests using contrast media. The elderly and those with diabetes and/or heart disease are at greater risk of developing kidney failure following administration of the dye. To avoid this complication, kidney function should be tested (creatinine). The client may be instructed to use a laxative or enema prior to the test and to be NPO for 8-12 hours before the test is done. The client should void prior to the procedure. |
front 13 A nurse is caring for a client who was recently admitted following an episode of status epilepticus. Which of the following data is most important to collect? Level of consciousness (LOC) Injuries to the extremities Amount of intravenous fluid infused Pulse and respiration | back 13 Level of consciousness (LOC) Cerebral blood flow undergoes a significant increase during seizure activity with a depletion of oxygen at the neuronal level. Cerebral anoxia may result in progressive brain tissue injury and destruction. The nurse should continuously monitor the client’s LOC. Even when seizures are controlled, the client may be unconscious for a period of time. Note that this is a neurological question and requires a neurological answer and monitoring LOC is the only neurological response. |
front 14 An x-ray initially confirms the placement of a nasogastric (NG) feeding tube in the stomach. The nurse is now preparing to administer a medication through the tube. What action will the nurse take to verify tube placement? Place the end of the tube in water and observe for bubbling Auscultate for the sound of air produced by forcing air through the NG tube Measure the pH of aspirated gastric contents Assess for client coughing during administration of the medication | back 14 Measure the pH of aspirated gastric contents Bubbling or coughing would indicate the possibility of the tube being in the airway, but neither are used to determine placement in the stomach. Forcing air through the NG tube and auscultating the abdomen for the sound of the air is an unreliable method to determine tube placement. Measuring the pH of aspirated stomach contents confirms gastric placement. |
front 15 A respiratory therapist (RT) is collecting an arterial blood gas (ABG) sample. The RT must respond to an emergency and asks the nurse to manage the puncture site. Which actions should be completed? (Select all that apply.) Apply snug gauze and secure with tape Check for distal capillary refill Thoroughly wash the site with saline, then apply an antibacterial solution Apply pressure for 5 to 10 minutes Remove dressing in one hour | back 15 Apply snug gauze and secure with tape Five to 10 minutes of pressure ensures adequate coagulation at the site. Checking capillary refill indicates if there are any changes to blood flow to the hand. The dressing can be removed prior to the next stick or within 24 hours. |
front 16 A nurse notes that a 2 year-old child recovering from a tonsillectomy has a temperature of 98.2 F (36.7 C) at 11:00 am. At 1:00 pm the child's parent reports that the child "feels very warm" to touch. What should the nurse do first? Reassess the child's temperature Reassure the parent that this is normal Offer the child cold oral fluids Administer the prescribed acetaminophen | back 16 Reassess the child's temperature The nurse should listen to and show respect for what the parent is saying, because the parent is more sensitive to the variations in the child's condition. However, the nurse knows that a low-grade fever (99-101 F or 37.2-38.3 C) is common after surgery, which is why the nurse should first reassess the temperature before implementing any intervention. Usually the surgeon is contacted if the temperature is higher than 101.5 F (38.6 C). |
front 17 The 55 year-old female is scheduled for abdominal surgery. Which factor in the client’s history indicates that the client is at risk for thrombus formation in the postoperative period? Estrogen replacement therapy for the past three years History of acute hepatitis A Hypersensitivity to heparin 20 years ago 10 percent less than ideal body weight for past year | back 17 Estrogen replacement therapy for the past three years Post-menopausal women using hormone replacement therapy have a higher risk of deep vein thrombosis and pulmonary embolism. The estrogen in hormone replacement therapy (and in birth control pills) can increase clotting factors in the blood, especially if the woman is a smoker and/or overweight. The other information in the client's history is unremarkable for postoperative complications. |
front 18 The nurse is assisting with the admission of a toddler who had a seizure at home. Which statement by the child's parent would be important in determining the etiology of the seizure? "My child was diagnosed with an ear infection two days ago." "My child has been drinking more liquids than usual." "My child has been eating more red meat lately." "My child has been taking long naps for a week." | back 18 "My child was diagnosed with an ear infection two days ago." Contributing factors of seizures in children include age (more common in the first two years of life), infections (late infancy and early childhood), fatigue, not eating properly and excessive fluid intake or fluid retention. Although drinking more fluids may be an indication of infection, the statement that the child has an active infection is the best response. |
front 19 An older adult client diagnosed with active tuberculosis has difficulty in appropriately coughing up secretions for a sputum specimen. Which nursing intervention might be the most helpful at this time? Force fluids for the next eight hours Spray the oropharynx with saline Ask the client to drink a warm liquid Have the client sit up on the side of the bed | back 19 Have the client sit up on the side of the bed Correct!Placing the client in sitting position will promote lung expansion and effective coughing, facilitating the sputum specimen collection. While drinking liquids helps to loosen secretions over time, they should not be given when collecting a specimen. Spraying the throat with saline may cause irritation, coughing, and reduce oxygenation. The specimen needs to come from deep in the lungs, not the nose or mouth. |
front 20 A client is receiving heparin and warfarin (Coumadin) after a total hip replacement. Lab results show an international normalized ratio (INR) of 5.5. Which action should the nurse consider as a priority? Check the prior INR reports Stop the warfarin Notify the health care provider (HCP) Check for bruising or bleeding | back 20 Notify the health care provider (HCP) INR is used to evaluate the therapeutic effectiveness of warfarin. The therapeutic range for INR is 2 to 3; a client with a 5.5 INR is at risk for bleeding (and the nurse will probably find bleeding with an INR at this level). The warfarin should be held until the nurse has communicated with the HCP. Because the half-life of warfarin is about 40 hours, there is no need to stop it prior to notifying the provider. Heparin has no influence on an INR. |
front 21 The client is admitted with a diagnosis of ulcerative colitis. Which
laboratory values should the nurse be sure to check? (Select all that
apply.) Albumin T3 and T4 count White blood cell count (WBC) Blood urea nitrogen (BUN) Erythrocyte sedimentation rate (ESR) | back 21 White blood cell count (WBC) Hematocrit and hemoglobin Albumin Erythrocyte sedimentation rate (ESR) |
front 22 A client is scheduled for a CT scan with contrast. What interventions
should be taken by the nurse prior to sending the client to the
imaging department? (Select all that apply.) Ensure the client is well-hydrated Ask the client to remove all metal jewelry Confirm that a signed consent is in the chart Administer prescribed medication to sedate the client | back 22 Reassess the client's allergies Ask the client to remove all metal jewelry Confirm that a signed consent is in the chart Usually the client is NPO prior to a CT scan, particularly when contrast material is being used. Allergies and past reactions to contrast media should be reviewed with the client. Any metal, including body piercings, jewelry, hearing aids and removable dental work should be removed and safely stored prior to the test. Sedation is necessary only in cases of extreme anxiety. |
front 23 Following a surgical procedure, a pneumatic compression device is applied to the adult client. The client reports that the device is hot and the client is sweating and itching. Which of the following steps should the nurse take? (Select all that apply.) Collaborate with health care provider for anti-embolism stockings to be worn under the sleeves of the device Explain that the health care provider ordered the device and it cannot be removed Confirm pressure setting of 45 mm Hg Check for appropriate fit Inform the client that removing the device will likely result in the formation of deep vein thrombosis | back 23 Collaborate with health care provider for anti-embolism stockings to be worn under the sleeves of the device Confirm pressure setting of 45 mm Hg Check for appropriate fit In any situation in which a client has discomfort associated with a medical device, the nurse should ensure it is applied correctly and functioning safely. The usual safe and effective pressure range is 35 to 55 mm Hg. Explanations to the clients should support their informed decision-making capabilities and should not be phrased to intimidate or remove client autonomy. Applying anti-embolism stockings under the disposable sleeves of the device may help with the sweating and itching. |
front 24 The order states: acetaminophen suspension 6 mL by mouth four times a day. The label on the container states: acetaminophen 80 mg per 5 mL. How many milligrams will the nurse administer? | back 24 96mg. 6 mL/1 x 80 mg/5 mL = 480/5 = 96 mg Or Ratio: |
front 25 A client diagnosed with Raynaud's disease and hypertension is prescribed nifedipine (Procardia). Which finding would indicate that the client may be having a side effect of the medication? Facial flushing Cyanosis of the lips Decreased urinary output Increased pain in fingers | back 25 Facial flushing Treatment for Raynaud’s and for hypertension is the use of a vasodilator such as nifedipine. As a result of the vasodilating effect facial flushing can occur. Cyanosis of the lips is not a documented finding. The urinary output may increase due to the vasodilation and the resulting increased blood flow through the kidneys. The pain in the fingers should decrease. |
front 26 A client receives 3 units of insulin lispro at 11:00 am to cover a blood glucose finger stick of 322 mg/dL (17.89 mmol/L). When can the nurse expect this type of insulin to begin to act? 12 noon 3:00 pm 1:00 pm 11:15 am | back 26 11:15 am The onset of action and peak for lispro (Humalog), a rapid-acting insulin is about 10 to 15 minutes. Other rapid-acting insulins are insulin aspart (NovoLog) and insulin glulisine (Apidra). |
front 27 A client has been taking alprazolam for three days. Data collection by the nurse should reveal which expected effect of the medication? Sedation, analgesia Relief of insomnia, phobias Diminished tachycardia, tremors associated with anxiety Tranquilization, numbing of emotions | back 27 Tranquilization, numbing of emotions |
front 28 A client calls the clinic and states to the triage nurse: "I had an upset stomach and took Pepto-Bismol and now my tongue looks black. What's happening to me?" What would be the nurse's best response? "This is a common and temporary side effect of this medication." "Are your stools also black?" "How long have you had an upset stomach?" "Come to the clinic so you can be seen by the health care provider." | back 28 "This is a common and temporary side effect of this medication." The best response would be to explain that a dark tint of the tongue is a common and temporary side effect of bismuth subsalicylate (Pepto-Bismol). Although it may also turn stools a darker color, do not confuse this with black, tarry stools, which is a sign of bleeding in the intestinal tract. After addressing the client's initial concern and the reason for the call, the nurse can ask about the upset stomach and then ask the client to come to the clinic if necessary. |
front 29 A nurse notes an abrupt onset of confusion in an 85 year-old client. Which recently ordered medication would most likely have contributed to this change in mental status? Anticoagulant Antihistamine Beta blocker Thrombolytic | back 29 Antihistamine Older adults are susceptible to the side effect of anticholinergic medications, such as antihistamines. Antihistamines often cause confusion, especially at higher doses. In fact, first-generation antihistamines are included in the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. |
front 30 A client is recovering from hip replacement and is taking acetaminophen with codeine (Tylenol No. 3) every three hours for pain. Which finding associated with opioid analgesics does the nurse anticipate when assessing the client? No bowel movement for three days Itching and bruising at the incision site Dry, unproductive cough Elevated serum glucose | back 30 No bowel movement for three days Side effects of opioid analgesic use include respiratory depression, sedation and constipation. The incision site may be bruised after surgery and it may itch, pull or feel numb, but this is unrelated to oral opioid use. Dry mouth is a possible side effect of acetaminophen with codeine, but not necessarily dry cough. |
front 31 An older adult client is to receive IV gentamicin. What diagnostic finding indicates the client may have difficulty eliminating this medication? Reduced peristalsis Gastric acid reflux Protein deficiency Borderline renal function | back 31 Borderline renal function |
front 32 The hospice nurse is visiting an 85 year-old client diagnosed with end-stage cancer. What should the nurse understand about chronic malignant pain management? Maximum doses of analgesics are needed Heart rate, respirations and blood pressure will be elevated Pain therapy is based on a client's report of pain Relief of temporary pain should be achieved quickly | back 32 Pain therapy is based on a client's report of pain Every person’s unique pain experience must be assessed, understood and treated. Because older adults have a slower metabolism and a greater ratio of body fat to muscle fat than younger people do, smaller doses of analgesics may be sufficient to relieve pain and may be effective longer. Therefore, the amount of medication needed is dependent on the client's needs and reports of pain relief; the nurse should not automatically give the maximum ordered dose. Immediate pain relief relates more to acute pain than chronic pain management. |
front 33 The nurse is assigned to a client diagnosed with a deep vein thrombosis who has been on heparin therapy for five days. The nurse notes that enoxaparin is added to the medication administration record (MAR). Which action should the nurse take? Plan to check the aPTT result after the enoxaparin is given Stop the heparin and begin the enoxaparin 30 minutes later Notify the charge nurse that the client is already receiving heparin Monitor the urine, stool and skin for bleeding | back 33 Notify the charge nurse that the client is already receiving heparin Enoxaparin (Lovenox) and heparin should not be given together because of the increased anticoagulant effect. Enoxaparin can be given 30 minutes after the heparin is discontinued. The aPTT lab is not routinely assessed while a client is taking enoxaparin. |
front 34 The nurse receives an order for several medications for a client. Which combination of medications would require the nurse to contact the provider to discuss the orders? (Select all that apply.) Finasteride (Propecia, Proscar) Amlodipine (Norvasc) Lithium (Eskalith, Lithobid) Furosemide (Lasix) Insulin Verapamil (Calan, Covera, Isoptin, Verelan) | back 34 Lithium (Eskalith, Lithobid) Lithium generally should not be given with diuretics. Furosemide may reduce excretion of lithium, which could result in lithium toxicity. Additionally, side effects of lithium are polyuria and polydipsia. The nurse should clarify the order before administering lithium and furosemide together. |
front 35 The nurse receives an order to give a client iron by deep injection. What does the nurse understand about the reason for using this method of administration? Prevents the medication from tissue irritation Enhances absorption of the medication Provides more even distribution of the drug Ensures that the entire dose of medication is given | back 35 Prevents the medication from tissue irritation Deep injection, or Z-track, is a special method of giving medications via the intramuscular route. Use of this technique prevents irritating or staining medications from being tracked through tissue. Use of Z-track does not affect dose, absorption, or distribution of the medication. Oil-based or thick medication is commonly given in this manner for the same reason. |
front 36 A nurse is reviewing and order that reads: administer conjugated estrogen 1.25 mg daily. The only available tablet strength is 625 mcg. How much medication will the nurse administer? | back 36 2tablet(s). 1.25 mg = 1250 mcg: 1250 mcg/625 mcg = 2 or 2 tablets. Using Dimensional Analysis: Tablet = (1.25 mg/625 mcg) X (1000 mcg/1 mg) = 2 |
front 37 A client is prescribed trimethoprim/sulfamethoxazole for recurrent urinary tract infections. Which comment by the nurse is correct about this medication? "It is safe to take with oral contraceptives." "Drink at least eight glasses of water a day." "Stop the medication after five days." "Be sure to take the medication with food." | back 37 "Drink at least eight glasses of water a day." Trimethoprim/sulfamethoxazole (Bactrim, Septra, Sulfatrim) is a highly insoluble medication and requires a large volume of fluid intake. This medication can be taken with or without regard to food. The full prescribed amount should be taken at evenly spaced intervals until the medication is finished. Unlike many other antibiotics, trimethoprim/sulfamethoxazole does not seem to affect hormonal birth control such as pills, the patch or ring. |
front 38 A nurse is reinforcing instruction to a client diagnosed with osteoporosis. What is the most important approach to exercise the nurse should reinforce for this client? Incorporate daily exercise to reduce weight Avoid exercise activities that increase the risk of fracture Exercise to strengthen muscles with a protection of the bones Exercise by doing weight-bearing activities | back 38 Exercise by doing weight-bearing activities |
front 39 On the burn unit, the nurse is assigned to a child who weighs 30 kg. Which observation best indicates adequate fluid replacement? Moist oral mucus membranes Urinary output of 32 mL per hour Normal skin turgor No reports of being thirsty | back 39 Urinary output of 32 mL per hour For children, the expected urine output is about 1 mL/kg/hour of urine. For a child who weighs 30 kg, 32 mL/hour is adequate urinary output. You will note that since the question is indirectly asking about intake (fluid replacement), the best response will probably have something to do with output. |
front 40 A nurse is caring for a client with an unstable spinal cord injury at the T-7 level. Which nursing intervention should be a priority for this client? Maintain caloric intake for nutritional balance Place client on a pressure-reducing mattress Increase fluid intake to prevent dehydration Use skin care products designed for use with incontinence | back 40 Place client on a pressure-reducing mattress The client with a spinal cord injury is risk for skin breakdown due to immobility and decreased sensation. A cushion should be used on the wheelchair and the bed should have a foam pad, air mattresses or a pressure-reducing mattress. Reducing the risk of skin breakdown also includes repositioning the client, using skin care products to protect the skin and adequate liquid and nutritional intake. |
front 41 A client has been diagnosed with mild dysphagia. What is the appropriate nursing intervention for this client? Alternate clear liquids with more solid foods Tilt head back to facilitate the swallowing process Position client in an upright position while eating Offer finger foods such as crackers or pretzels | back 41 Position client in an upright position while eating An upright position facilitates proper chewing and swallowing. To prevent aspiration, thicker foods should be offered or thickening should be added to liquids. Tilting the chin down helps swallowing. Dry foods such as crackers or pretzels may increase the risk for choking. |
front 42 The nurse is preparing to manually remove the fecal impaction on an 80 year-old client. What information is the most important to understand before performing this procedure? The procedure should be done prior to a bath Increased dietary fiber, fluids and activity can minimize fecal impaction The presence of hemorrhoids is a contraindication for manual removal of the impaction The client may experience bradycardia during the procedure | back 42 The client may experience bradycardia during the procedure Cardiac dysrhythmias, including bradycardia, can result from vagal nerve stimulation during fecal impaction removal. The risk is higher in older adults or clients who have had cardiac surgery. Although it is correct that removing a fecal impaction should be done prior to a bath and that diet, exercise and fluids can help prevent an impaction, these are not the priority for this client in this situation. The presence of hemorrhoids is not a contraindication for manually removing fecal impactions. |
front 43 A client has a nasogastric tube draining bile-colored liquids. Which nursing intervention will provide the most comfort to the client? Swab the mouth using glycerin swabs Allow the client to melt ice chips in the mouth Perform frequent oral care Provide mints to freshen the breath | back 43 Perform frequent oral care Frequent cleansing and stimulation of the mucous membrane is important for clients with a nasogastric tube to prevent development of lesions, infection and to promote comfort. Ice chips or mints may be contraindicated and need to be ordered specifically when NG tubes are present. Lemon and glycerin swabs have no mechanical or cleansing value and should not be used. |
front 44 A 3 year-old child who is diagnosed with celiac disease attends a day care center. Which of the following foods would be an appropriate snack? Vanilla cookies Peanut butter sandwich Cheese crackers Potato chips | back 44 Potato chips |
front 45 Upon examining the mouth of a 3 year-old child, the nurse discovers that the teeth have chalky white-to-yellowish staining with pitting of the enamel. Which condition would most likely explain these findings? Ingestion of tetracycline within the past year Excessive oral iron therapy over the past six months Recent poor dental hygiene Excessive fluoride intake on a regular basis | back 45 Excessive fluoride intake on a regular basis |
front 46 The RN has provided care instructions to the parents of a toddler diagnosed with atopic dermatitis. Which of these actions will the LPN/VN now reinforce to the parents? Wrap the child's hand in mittens or socks to prevent scratching Clean the affected areas with tepid water and antibacterial soap Keep the child away from other children for the duration of the rash Dress the child warmly to avoid chilling | back 46 Wrap the child's hand in mittens or socks to prevent scratching Toddlers with atopic dermatitis need to have fingernails cut short and hands covered so they will not be able to scratch the skin lesions. Prevention of new lesions is important due to the risk of possible secondary infections. The clue in the stem is that the client is a toddler. Because toddlers have a short attention span and minimal self-control, and dermatitis is inflammation of the skin, the best response is to place the child's hands in mittens or socks to prevent scratching. |
front 47 The client is diagnosed with coronary artery disease (CAD). What information should the nurse emphasize when reinforcing nutritional information to this client? Avoid heavy, large meals Eat three well-balanced meals a day Add complex carbohydrates and proteins Limit sodium to 5 grams per day | back 47 Avoid heavy, large meals Controlling portion size is important for a heart-healthy diet. Eating large, heavy meals can pull blood away from the heart for digestion, possibly resulting in angina. Thus, it increases the risk of myocardial infarction. The client should also reduce sodium intake to about 2,300 mg/day (or less). Clients should also limit unhealthy fats and cholesterol; select low-fat protein sources; and eat more fruits, vegetables and whole grains. |
front 48 A couple experiences intense anxiety after their home is destroyed by a fire. One of the partners escaped from the fire with only minor injuries. The nurse knows that the most important initial intervention should be to take which approach? Suggest that the clients rent an apartment with a sprinkler system Explore with the couple the feelings of grief associated with the loss Provide a brochure on methods to promote relaxation Determine available community and personal resources | back 48 Determine available community and personal resources |
front 49 A teenaged client is paralyzed after being in a car accident. Which statement used by the client would indicate that the client is using "repression" as an ego-defense mechanism? "I'm not ready to talk about it right now." "It's all his fault! He was going 90 miles an hour on the freeway." "My mother is heartbroken about this situation." "I don't remember anything about what happened to me." | back 49 "I don't remember anything about what happened to
me." |
front 50 The client diagnosed with paranoid-type schizophrenia sits alone alertly watching the activities of other clients and staff. The client is hostile when approached with medication and asserts that the medication controls the mind. Which option might best explain the reason for the client's behavior? Feelings of increased anxiety related to paranoia Sensory perceptual alteration related to withdrawal from environment Impaired verbal communication related to impaired judgment Social isolation related to altered thought processes | back 50 Social isolation related to altered thought processes |
front 51 After the death of a client, the family approaches a nurse and requests that a family member be allowed to perform a ritual bath on the deceased prior to moving the body. What would be the most appropriate response by the nurse? "These procedures have to be carried out by our staff." "A ritual bath will have to wait until after postmortem care" "Is there anything you need from me to perform the ritual bath?" "I will have to check on hospital regulations and policies." | back 51 "Is there anything you need from me to perform the ritual bath?" Rituals are processes that allow the bereaved to acknowledge the reality of death. Religious rituals specifically offer meaning and provide hope within the context of the particular faith tradition. Nurses should inquire about rituals or observances following death and respect these. The other options are inappropriate and culturally insensitive. |
front 52 The interdisciplinary team is reviewing charts for potential candidates for hospice care. Which of the following clients meet the criteria for hospice care? (Select all that apply.) 72 year-old with prostate cancer metastasized to the bone,
who is receiving palliative radiation therapy 91 year-old with Alzheimer’s disease, who is no longer able to eat or drink oral fluids 53 year-old client with chronic, unrelieved pain, who is addicted to narcotics following a back injury 46 year-old with end stage liver disease, on a wait list for a donor organ | back 52 72 year-old with prostate cancer metastasized to the bone, who is
receiving palliative radiation therapy Hospice care provides services for clients who are at the end of their life, usually with less than 6 months to live. There are no age requirements. Palliative care is provided by a multi-disciplinary team in a variety of settings, including the home, hospital or extended-care facilities. Clients actively seeking a cure or treatment for their disease do not meet the criteria for hospice care. |
front 53 The postpartum Hispanic client refuses hospital food because it is "cold." What action should the nurse take initially? Send the food to be reheated Ask the client what foods are acceptable Encourage the client to eat for strength Consult with the dietitian as soon as possible | back 53 Ask the client what foods are acceptable Many Hispanic clients subscribe to the rebalancing of "hot" and "cold" in the postpartum period. After giving birth, when a woman has lost blood, she is considered to be in a cold state; therefore, she needs to restore her humoral balance. What defines "cold" and "hot" can best be explained by the client and this needs to be incorporated into the plan of care. Note that the correct response is a “data collection” response, which allows for client feedback about what the client is really saying about the food. Notice that it is the only client-centered option. |
front 54 The nurse is working to establish a therapeutic relationship with a client. A therapeutic nurse-client interaction occurs when the nurse takes which approach? Advises about resources for resolving problems Interprets any covert communications Praises the client for appropriate behavior Clarifies the meaning of client communication | back 54 Clarifies the meaning of client communication Clarification is both a facilitating and therapeutic communication strategy. Approval, changing the focus or subject, and advising are non-therapeutic or barriers to effective communication. |
front 55 A client has just been diagnosed with breast cancer. As the nurse enters the room, the client states "You are stupid." Which approach by the nurse would be the most therapeutic? Make no comment or response Explore what is going on with the client Accept the client’s statement Tell the client that the comment is inappropriate | back 55 Explore what is going on with the client The nurse should assist this verbally aggressive client to put angry feelings into words and then to engage in problem solving. The client exhibits being in the angry stage of loss. |
front 56 A client is admitted to the hospital following an automobile accident. Upon admission the client's blood alcohol concentration was 0.18%. Twelve hours after admission the client is diaphoretic, tremulous, and irritable; pulse and blood pressure measurements are elevated. The client states: "I have to get out of here." What is the most likely cause for these findings? Early stage of alcohol withdrawal Dissatisfaction with hospital care Shock related to the injuries Anxiety related to being hospitalized | back 56 Early stage of alcohol withdrawal This client's blood alcohol concentration is more than twice the legal limit in most states. After a period of heavy or prolonged alcohol use, people will experience alcohol withdrawal symptoms, such as insomnia, tremors, hyperactivity, hypertension, tachycardia and diaphoresis. The client must be treated immediately to prevent progression to more severe alcohol withdrawal symptoms, including seizures (which may begin 6-48 hours after cessation of alcohol intake) and delirium tremens (DTs). |
front 57 During a meeting with the nurse at the community clinic, an individual being battered in the home tells the batterer, "I need a little time away." How might the nurse expect the batterer to respond? With acceptance and understanding that the relationship is in trouble With fear of rejection resulting in increased rage toward the battered individual With relief and anticipation of a separation as a way to have some personal time With a new commitment to seek counseling to assist with problems | back 57 With fear of rejection resulting in increased rage toward the battered individual In the absence or potential absence of the battered individual, the fear of rejection and loss only serve to increase the batterer’s rage at the partner. Behaviors that are common in the batterer include extreme jealousy, refusing to take responsibility for the abuse and denying or minimizing the seriousness of the violence and its effects on the victim. |
front 58 The client is diagnosed with post-traumatic stress disorder (PTSD). What are the some of the more common treatment options for PTSD? (Select all that apply.) Opioid analgesics Eye movement desensitization and reprocessing (EMDR) Selective serotonin reuptake inhibitors (SSRIs) Cognitive behavioral therapies | back 58 Eye movement desensitization and reprocessing (EMDR) |
front 59 A 14 year-old boy with a history of hemophilia A was admitted after a fall while playing basketball. In understanding his behavior and assisting in planning care for this client, what should the nurse recognize concerning the behavior of adolescents with a chronic disease? Need to have structured activities Often take part in active sports Avoid physical risks after bleeding episodes Share information about disease limitations with peers | back 59 Often take part in active sports Adolescent hemophiliacs should be aware that contact sports may trigger bleeding. However, developmental characteristics of adolescents, such as impulsivity, inexperience and peer pressure, often place them in unsafe situations. Adolescents do not want to appear differently to their peers and would probably not willingly offer information about their disease to others. |
front 60 A home health nurse is making an initial visit to a 70 year-old client. What should be the first action to meet the client's health needs? Identify learning needs Assist with meal planning Discuss past health history Review the list of medications | back 60 Identify learning needs With the focus on health promotion, the nurse should first identify any learning needs. Once learning needs are identified, the nurse would know if meal planning assistance is needed. Reviewing medications and discussing health history are part of the initial assessment. Helpful hint: since this is a very general question, you should look for a response that's more general. |
front 61 The registered nurse is preparing a client and her healthy newborn for discharge and provides information about hormonal effects in newborns. The licensed practical nurse understands that which finding in the newborn is due to the maternal hormones? Edema of the scrotum Enlargement of the breasts Mongolian spots Lanugo on the extremities | back 61 Enlargement of the breasts Of all the options, the most commonly expected physical finding due to maternal hormones is breast engorgement. This can occur in both boys and girls. Mongolian blue spots commonly appear at birth or shortly thereafter; they are flat, blue, or blue-gray skin markings near the buttocks. The newborn scrotum can be filled with clear fluid (which was squeezed into the scrotum during the birth process); it will be reabsorbed over the next few months. Lanugo is the fine downy hair that may be present on the backs and shoulders of newborns, particularly premature infants. |
front 62 The nurse is discussing modifiable cardiac risk factors with a group of adults. Which topic should the nurse reinforce as the priority intervention? Smoking cessation Stress management Physical exercise Weight reduction | back 62 Smoking cessation Stopping smoking is the priority for clients at risk for cardiac disease because of the effects of reduced oxygenation and constriction of blood vessels. Notice that three of the options are all actions that indirectly reduce cardiac risk factors. Ask yourself which of the options should happen first or which one would have an immediate impact on the body: weight, stress, exercise or smoking? |
front 63 The nurse practices in a long-term care facility and understands that older adults are at greater risk for experiencing adverse effects from medications. What physiologic changes could contribute to these adverse effects? Decrease in blood flow to the kidneys and increase in kidney mass Decrease in total body water and an increase in proportion body fat Increased peristalsis and increased production of gastric acid Increase in blood flow to the liver and decrease in liver mass | back 63 Decrease in total body water and an increase in proportion body fat Because older clients have a decline in lean body mass and changes in total body water in which to distribute medications, more medication remains in the circulatory system with potential for medication toxicity. Increased proportion of body fat results in greater amounts of fat-soluble medications being absorbed, leaving less in the circulation, and thus increasing the duration of action of the medication. |
front 64 The nurse is measuring blood pressure at a community health fair. When the nurse tells someone that his blood pressure is 160/96 mm Hg, he states, “My blood pressure is usually much lower.” What is the best response to this statement? "Check your blood pressure again in a few months." "Get your blood pressure checked again within the next 48 to 72 hours" "Make an appointment to see your health care provider next week" "See your health care provider immediately." | back 64 "Get your blood pressure checked again within the next 48 to 72 hours" The blood pressure reading is moderately high and should be rechecked within a few days. Since the client states it is "usually much lower" the elevated BP could be a concern but it is not clear what the client considers to be a "much lower" BP. The nurse should measure the blood pressure in the other arm and compare the two readings. Waiting two or three weeks for follow-up is too long. |
front 65 The nurse is providing care for an adolescent. Which intervention best demonstrates the nurse's sensitivity to an adolescent's need for autonomy? Explore an adolescent’s feelings of resentment to identify causes Provide discussion of concerns without the presence of parents or guardians Express identification of feelings about body image Allow young siblings to interact via various communication routes | back 65 Provide discussion of concerns without the presence of parents or guardians While the family is an important component in the care of an adolescent, it is also important to spend time alone with the adolescent. This is an opportunity for the nurse to hear the teen's perspective and to really listen to his/her concerns. |
front 66 A nurse observes a newborn whose Apgar score was 8 at one minute and then 9 at the five-minute evaluation. These scores would be more commonly related to abnormalities in which of these areas? Cry Color Heart rate Muscle tone | back 66 Color Acrocyanosis (blue hands and feet) is the most common Apgar score deduction and is a normal adaptation in the newborn in response to the environment. If the environment is cool, then the hands and feet would display a more bluish discoloration. On average it lasts for about 48 to 72 hours. Recall that the maximum score is 10 for Apgar, so 1 or 2 points lower would suggest a problem that is probably not as severe as a problem related to heart rate, muscle tone or cry (respirations). |
front 67 An anxious parent of a 4 year-old discusses with the nurse how to answer the child's question: "Where do babies come from?" What is the best response by the nurse to the parent? "This question indicates interest in sex beyond this age." "When a child of this age asks a question, give a simple answer." "Children ask many questions, but are not looking for answers." "Full and detailed answers should be given to all questions." | back 67 "When a child of this age asks a question, give a simple answer." During discussions related to sexuality, honesty is very important. However, honesty does not mean imparting every fact of life associated with the question. When children ask one question, they are looking for one answer. When they are ready, they will ask about the other pieces of information by the use of specific questions. |
front 68 A client is forgetful and experiences short-term memory loss. When collecting data about short-term memory loss, which action should the nurse take first? Ask the client to state when he was born Confirm that no hearing loss Observe the client during an activity Suggest the client read from a newspaper | back 68 Confirm that no hearing loss Hearing loss may result in the client answering questions inappropriately, which may be misinterpreted as a short-term memory loss. Asking clients to state their birthdate is used to assess long-term memory. Observing the client during activity may be done for mobility concerns or deficits. Having the client read something can be used to assess vision problems. |
front 69 The nurse is reinforcing information about accidental poisoning in the home to a group of parents. What information should the nurse be sure to include? Do not move the child if a toxic substance is inhaled Empty the child's mouth in any case of suspected poisoning Induce vomiting if the child is suspected of swallowing something poisonous Start treatment before calling the Poison Control Center | back 69 Empty the child's mouth in any case of suspected poisoning Emptying the mouth of the poison prevents any further ingestion. It should be done first to minimize further contact with the substance. Vomiting should never be induced unless told to do so by the Poison Control Center or a health care professional. First aid for inhaling toxic substances is to move the child to fresh air. |
front 70 The nurse is collecting data about the home care for a client with Alzheimer's disease. Which piece of information should be the priority for the nurse to document? The family’s use of respite care Any nutritional intake changes The use of over-the-counter medications The presence of environmental hazards | back 70 The presence of environmental hazards A safe environment for the client with increasing memory loss is a priority focus of home care. Note that the other options would be included in the documentation – with importance being in this order: "environmental hazards,""over-the-counter medications," "intake changes" and then "respite care." The question is asking the reader to prioritize, which usually means that all the responses are correct but one is more important than the rest. |
front 71 An outpatient client is scheduled to receive an oral solution of radioactive iodine. In order to reduce hazards, the practical nurse should reinforce which information? Wash laundry separately and rinse twice in hot water Wait to have guests visit at home for 48 hours after the first dose Urine and saliva will be radioactive for 24 hours after ingestion No solid food may be eaten for six hours after ingestion of the solution | back 71 Urine and saliva will be radioactive for 24 hours after ingestion The client's urine and saliva are radioactive for 24 hours after ingestion. The practical nurse should reinforce the RN's teaching to double flush the commode after use, use disposable utensils, and avoid close contact with children and pregnant women for 48 to 72 hours. Because the treatment may cause nausea, it's best if the client doesn't eat two hours before or after iodine administration. It is not necessary to wash laundry separately or in hot water. |
front 72 At 3 months, the infant has cleft lip and soft palate repair. In the immediate postoperative period for a cleft lip repair, which action is the priority? Initiate clear liquid feedings by mouth when alert and acting hungry Provide written instructions about care of the suture line Remove soft elbow/arm restraints every 2 hours under supervision Position the infant on side or back | back 72 Remove soft elbow/arm restraints every 2 hours under supervision The goal after surgery is to protect the new repair and stitches, which requires some temporary changes in feeding, positioning and activity for the infant. The priority is to wear arm restraints (for the first 10 days after surgery) to keep him from putting his hands in his mouth; the restraints can be removed only for bathing or for exercising the arms. When the infant acts hungry, he will be given a clear liquid feeding using either a syringe fitted with a special soft tubing or a special cleft lip feeder. The infant can be positioned on his side or back to keep him from rubbing his face in the bed. The RN will provide instructions about care of the incision line prior to discharge. |
front 73 The child is newly diagnosed with hepatitis A. Which teaching instructions would the nurse reinforce with the child's parents? Return to daycare two days after starting antibiotic treatment Use gentle cleansers to protect jaundiced skin from breakdown Wash hands thoroughly with soap and warm water after contact with the child Bedrest for several weeks before gradually resuming activity | back 73 Wash hands thoroughly with soap and warm water after contact with the child Hepatitis A virus spreads through contaminated food or water, as well as unsanitary conditions in childcare facilities or schools. The infection resolves spontaneously and symptom relief is usually the only treatment. The child does not have to be confined to bed and s/he can safely return to daycare or school one week after symptoms began. Infants and young children usually do not develop jaundice. |
front 74 The nurse is in a crowded shopping area in an urban setting when a radiologic dispersal device (RDD) explodes scattering radioactive dust and material into the environment. What should the nurse instruct the victims in proximity to the explosion to do first? Keep the nose and mouth covered Remove all exposed clothing right away Stay out of any buildings until help arrives Lie down flat and cover the head with anything available | back 74 Keep the nose and mouth covered An RRD, or "dirty bomb," generates radioactive dust and smoke, which can be dangerous if inhaled. The nurse should initiate measures to limit contamination, instructing victims to cover their noses and mouths. Neither lying down or covering the head does anything to limit exposure. Victims should move into a building where the walls and windows have not been broken and then remove their outer layer of clothing (sealing them in a plastic bag, if available) to help minimize exposure. |
front 75 The client is diagnosed with active tuberculosis (TB) and the case has been reported to the health department. What is the most important reason for notifying the public health department? Contacts need to be traced and screened Treatment options need to be documented The incidence of tuberculosis is tracked Disease statistics need to be maintained | back 75 Contacts need to be traced and screened Active tuberculosis is a reportable disease because people who had contact with the client must be traced, evaluated for the disease, and possibly treated prophylactically. Statistics are kept and trends documented, but that is not the primary reason for required reporting. |
front 76 A severely injured client is moved into an examination area of the emergency department. The family member who accompanied the client to the ED is screaming at the nurse, saying that someone better start doing something right away. What is the best response by the nurse? "I need you to go to the waiting area. You can come back when you're more in control." "I know you are upset. But please control yourself and sit down. Otherwise I will have to call security." "I can't think when you are yelling at me. Talk to me in a normal voice." "I'm going to give you a few minutes alone so you can calm down." | back 76 "I know you are upset. But please control yourself and sit down. Otherwise I will have to call security." Most violent behavior is preceded by warning signs, such as yelling or swearing. The challenge for nurses is to apply interventions that de-escalate a person's response to stressful or traumatic events. The keys to effective limit setting are using commands to express the desired behavior and providing logical and enforceable consequences for noncompliance. Nurses should acknowledge the agitated person's feelings and be empathetic, reminding him or her that they are there to help. |
front 77 A client reports feeling dizzy when getting up from a lying position. Which is the correct action for the nurse to take before assisting the client to ambulate? Support the client in a standing position for several minutes before walking Support the client in a sitting position until the dizziness subsides Encourage the client to stand and slowly move to a chair Apply a gait belt and ask another person to assist with ambulation | back 77 Support the client in a sitting position until the dizziness subsides The findings suggest postural or orthostatic hypotension. The nurse should help the client to sit and dangle on the side of the bed until the dizziness subsides and the blood pressure stabilizes. This will prevent the client from potential injury. |
front 78 The nurse attends an interdisciplinary meeting on the topic of fall prevention. What specific tactics can be used to reduce falls in health care settings? (Select all that apply.) Regularly reorient clients Identify vulnerable clients Raise side rails Use a "two to transfer" policy Use "low beds" for at-risk clients | back 78 Identify vulnerable clients Use a "two to transfer" policy Install and use bed alarms Use "low beds" for at-risk clients Fall prevention involves managing a client's underlying fall risk factors and then implementing strategies to reduce falls. Using restraints, including side rails, can actually increase the risk of fall-related injuries and deaths. Clients with neurocognitive disorders cannot process the information we provide when we attempt to reorient them to our reality. The other techniques listed are used (in combination) to help prevent falls in health care facilities. |
front 79 The adult client is alert and cooperative. The client has a short leg cast and can only partially bear weight on the casted leg. Which technique can be safely used to transfer the client from the bed into a chair? Two caregivers use a friction-reducing device and wide base of support when transferring the client Two caregivers lift the client from the bed and move the client into the chair One caregiver applies a gait belt and transfers the client toward the weak side One caregiver applies a transfer belt and uses the stand-and-pivot technique | back 79 One caregiver applies a transfer belt and uses the stand-and-pivot technique The algorithm for safe client handling and transferring an alert and cooperative client to a chair states: one caregiver applies a gait/transfer belt, uses the stand-and-pivot technique and transfers the client toward the strong side. A friction-reducing device is placed under the client to assist in turning or moving the person in bed, not transferring to a chair. A two person lift is unsafe. |
front 80 A nurse is stuck in the hand by an exposed needle left in a client's bed linens. What immediate action should the nurse take? Contact employee health services Notify the supervisor and risk management Immediately wash hands with vigor Look up the policy on needle sticks | back 80 Immediately wash hands with vigor The immediate action of vigorously washing the hands will help remove any possible contamination. If the site bleeds it will help remove the contaminate. Then, the sequence of actions would be options "notify," "look up" and "contact." |
front 81 The nurse is assessing the client during a home health visit and the client states: "I had physical therapy yesterday. I thought it was supposed to help but my back hurts so much after each visit." The nurse's responsibilities include which of the following actions? (Select all that apply.) Report the client's findings to the physical therapist Offer to help the client make an appointment with the physician about the back pain Tell the client to take the prescribed pain medication Gather more information about the location, duration and intensity of the pain Report the client's findings to the nursing supervisor for further assessment | back 81 Report the client's findings to the physical therapist Gather more information about the location, duration and intensity of the pain Report the client's findings to the nursing supervisor for further assessment The needs of the client can be best addressed by further assessment of the client (collecting more information about the findings of pain) and then communicating the client's needs to the interdisciplinary team members. Before any medication is given or any appointments are made, more information about the pain is needed. |
front 82 A client states: "I do not want to be interrupted for breakfast because it interferes with my meditation time." What is the next action for the nurse to take? Consult with the nurse manager to get suggestions Contact the client's provider Contact the nutritionist or dietitian Talk with the client to work out a mutual plan | back 82 Talk with the client to work out a mutual plan The nurse should talk with the client to determine how the practice of meditation can be incorporated into the morning schedule. Respect for differences must be incorporated into a client's plan of care. |
front 83 An 80 year-old client is hospitalized for a chronic condition. The client informs family members that a living will has been prepared and the client wants no life-prolonging measures performed. The client's condition deteriorates and the client becomes unresponsive. Which of the following nursing actions is most appropriate? Consult the charge nurse and prepare to transfer the client to an intensive care unit Notify the attending physician Contact the family member indicated in the admission forms Call the rapid response team | back 83 Notify the attending physician The first action would be to notify the attending physician for further orders. Then the family member(s) can be contacted about his condition. When a client has an advanced directive, it is not appropriate to perform CPR on him. |
front 84 During a discussion with the nurse manager, a staff nurse confides
that she is attracted to a client regularly assigned to her. Which of
the following actions should be implemented following this
discussion? The nurse reassigns all personal care of the client to the nursing assistant The nurse waits until after discharge to tell the client about her feelings The nurse continues to provide care for the client | back 84 The nurse transfers the care of the client to another nurse Nurses must practice in a manner consistent with professional standards and be knowledgeable about professional boundaries. A nurse’s challenge is to be aware of feelings and to always act in the best interest of the client, avoiding inappropriate involvement. In this case, the nurse did all the right things - aware of her feelings, she consulted with her supervisor and together they decided it would be best if this client were no longer assigned to this nurse. If the nurse had acted on her feelings, this would have been a boundary violation and she could have been subject to board of nursing disciplinary action. |
front 85 The practical nurse has been assigned to four residents. Which resident should be seen first on the initial shift rounds? An 81 year-old female with a history of coronary artery disease (CAD) reporting dyspnea, nausea, and unusual discomfort in the upper back An 86 year-old male diagnosed with hypertension whose last recorded BP was 180/90 after learning that a close friend was hospitalized A 94 year-old female diagnosed with peripheral artery disease (PAD) reporting cramp-like pains in both calf muscles following physical therapy A 70 year-old male with history of heart failure (HF) who reported going to the bathroom "too much" after taking a diuretic | back 85 An 81 year-old female with a history of coronary artery disease (CAD) reporting dyspnea, nausea, and unusual discomfort in the upper back These findings suggest a myocardial infarction (MI). Older adults and women of any age may not always have the classic findings of chest, inner arm, or jaw pain, numbness or tingling of the left arm. The stress of a tragic event can elevate BP temporarily; the nurse can retake the client's BP at a later time. Increased urinary output is an expected finding after taking a diuretic and intermittent claudication is a common and expected finding in PAD. |
front 86 A registered nurse in a charge position is reinforcing goals to the health care team. Which of these items best describes the goal of continuous quality improvement (CQI) in a health care setting? Conduct chart audits for common error discovery Improve the quality of care in a proactive manner Create a flow chart of department or staff interactions Perform actions based on reactive problem solving | back 86 Improve the quality of care in a proactive manner Continuous quality improvement is used to identify ways to correctly do the right thing at the right time. It involves proactive problem-solving. The overall goal of CQI is to improve health care. |
front 87 The client who recently experienced a stroke has an order to ambulate with assistance. Which statement by the nurse provides the best instructions to the unlicensed assistive person (UAP) to assist the client to ambulate? "If the client gets dizzy when walking, ask the client to stop and take 10 fast, deep breaths." "Have the client lift and move the walker out at arms length then walk into the walker.” "As you assist the client to the chair, let me know if the client uses the quad cane correctly." "Stand on the client's strong side when you assist the client to the bathroom.” | back 87 "Have the client lift and move the walker out at arms length then walk into the walker.” The nurse should give clear and concise information to the UAP about what is expected to safely complete any task, which is why the option about using the walker is correct. The person assisting the client to ambulate should walk on the client's weak, not strong, side. UAP cannot assess or evaluate a client ("let me know if the client uses the quad cane correctly"; only nurses can perform the steps of the nursing process. If a client gets dizzy, the UAP should assist the client to sit (or ease the client to the floor is s/he begins to fall.) |
front 88 When walking past a client’s room, the nurse hears an unlicensed assistive person (UAP) talking to another UAP. Which of these statements requires further intervention by the nurse? "This client seems confused, we need to watch the client closely." "I’ll come back and make the bed after I go to the lab." "If we work together we can get all of the client care completed." "Since I am late for lunch, would you perform my client's blood glucose test?" | back 88 "Since I am late for lunch, would you perform my client's blood glucose test?" Only registered nurses (RNs) and licensed practical or vocational nurses (LPN/VNs) can assign tasks and activities. UAPs cannot re-assign tasks or activities to other UAPs. Nurses are accountable for all nursing care; if UAPs cannot complete assignments, they should notify the nurse, who will reassign the task. |
front 89 A 90 year-old is readmitted to the hospital, less than 2 weeks after
being discharged, for the same health concern. What factors contribute
to hospital readmissions among older adults? (Select all that
apply.) Excellent primary care Poor communication among providers Family preferences Reconciliation of medications | back 89 Client health status Poor communication among providers Family preferences Avoidable hospitalization, especially among older adults living in skilled nursing facilities, usually results from multiple system failures. The reasons most often cited include inadequate primary care (including inadequate discharge planning and lack of reconciliation of medications), poor care coordination, poor skilled nursing facility quality of care, poor communication among providers and even family preferences. Not all illnesses can be anticipated and clients with more complex health issues are readmitted more often, regardless of quality or coordination of care. |
front 90 A client with a diagnosis of bipolar disorder has been referred to a halfway house to be considered for placement. A social worker telephones the hospital unit and asks for information about the client’s mental status and adjustment. What must the nurse understand in order to respond to this request for information? The request for information can be given to the social worker in the case of a referral Only the health care provider can give referral information Information can be released if there is written consent from the client Information about a client is never given to anyone by telephone | back 90 Information can be released if there is written consent from the client HIPAA guidelines are strict as to who has access to and can relay information. In order to release written, verbal or electronic information about a client there must be a signed consent form (unless the client is a threat of harm to self or others). In addition, a written request for information is commonly asked for prior to release of any client information. |
front 91 The nurse is using the SBAR technique to communicate with the health care provider. Which of the following phrases would be associated with "B-Background"? "Vital signs are..." "I'm not sure what the problem is, but the client's condition is deteriorating." "I would like you to..." "The client's treatments are..." | back 91 "The client's treatments are..." The correct option gives the health care provider background information about the client, including age, primary diagnosis, treatments, etc. Stating that the client's condition is deteriorating is the situation (S). Stating, "I would like you to..." is the request or recommendation (R). Vital signs are part of the assessment (A). Using SBAR is an effective technique used to improve communication with other members of the health care team. This, in turn, helps to foster a culture of safety. |
front 92 A nurse must use an interpreter to collect data from a client. Which action should the nurse take to help communicate with the client? Face the client while asking questions as the interpreter translates the information Include a family member and direct comments to that person Talk to the interpreter in advance and leave the client and interpreter alone for discussion Speak directly to the interpreter while asking questions | back 92 Face the client while asking questions as the interpreter translates the information Communication is important, especially when the nurse and client do not share the same cultural heritage. Even if the nurse uses an interpreter, it is critical that the nurse use conversational style and spacing, personal space, eye contact, touch, and orientation to time strategies that are acceptable to the client. Therefore, the nurse should face the client and allow the interpreter to translate the content. Facing the client allows nonverbal communication to take place between the client and nurse. Notice that only one option includes the content of this question (collecting data from a client). The other options focus on the “interpreter or the family.” Usually, the client-centered option is the best choice. |
front 93 The nurse, who is caring for a client with complex and unique health needs, describes the nature of the illness in an online social forum for nurses. Neither the client's real name nor any other personal identifiers are used. What, if any, consequence could result from posting this information online? There won't be any consequences because the information was posted on a website for nursing professionals There won't be any consequences because the client's real name was not used The nurse could be fired for breach of confidentiality The nurse could be reprimanded for not clearing the information first with hospital administration | back 93 The nurse could be fired for breach of confidentiality Even though the client was not identified by name, someone could probably figure out who the nurse was writing about. Many health care facilities have adopted a social media policy; it is important to understand that nurses can be fired for posting personal information about clients online, because this is an invasion of privacy. In addition to being a HIPAA violation, the Health Information Technology for Economic and Clinical Health Act (HITECH Act) gives states attorneys the right to pursue violations of patient privacy. |
front 94 Which nursing practice best reduces the chance of communication errors that might otherwise lead to negative client outcomes? Speak using a professional tone on the telephone Maintain respectful working relationships with all staff Use standardized forms for client handoffs Document nursing care at the end of the shift | back 94 Use standardized forms for client handoffs Standardized forms improve information for communication between caregivers. Most problems/poor outcomes involve some element of poor communication. The options of keeping good working relationships and using a professional tone of voice on the phone is good practice but not as useful for minimizing the chance of errors. Documenting at the end of the shift is incorrect practice and may lead to poor communication, as critical findings may be forgotten and not recorded. |
front 95 The client states to the nurse: "I am ready to stop all of these treatments. I just want to go home and enjoy my family for the little bit of time I have left." Which action is most appropriate? Tell the family members that the client's preference is to go home to die No action is needed at this time unless the client repeats the statement to another caregiver Encourage the client to discuss this decision with the health care provider and family Call in a referral to a social worker and explain that the request will need to be discussed in more detail at a later time | back 95 Encourage the client to discuss this decision with the health care provider and family The client has the right to stop treatment and should be supported in clearly communicating this decision with the health care provider and family. The nurse needs to act as an advocate for the client. It is factually incorrect to wait until the request is repeated; clients should not need to express their wishes repeatedly before caregivers listen to them. The nurse should not be the one to share sensitive information with the family; the client controls that information. Social services may get involved but time is of the essence for those who are terminally ill. |
front 96 Two members of the interdisciplinary team are arguing about the plan of care for a client. Which action could any one of the members of the team use as a de-escalation strategy? Bring the communication focus back to the client Adjourn the meeting and reschedule when everyone has calmed down Interrupt, apologize for interruption, and change the subject Tell the violators they must calm down and be reasonable | back 96 Bring the communication focus back to the client Bringing the subject of the communication back to the client refocuses attention on the client's care, instead of the manner of communication. It is the most effective strategy because it is an example of collaboration. The other options are non-productive and may even make matters worse. |
front 97 During a discussion about a living will with a 75 year-old client and the client's son, the son says, “I do not understand the need for a living will.” Which of these statements would be accurate and appropriate for the nurse to say in a response to this question? “Specific instructions are listed for specific diseases.” “Health care decisions can be made based on the client's wishes." “Do-not-resuscitate orders (DNR) are automatic under these conditions.” “A designated family member can make all decisions.” | back 97 “Health care decisions can be made based on the client's wishes." Health wishes are written in a legal document such as a living will or advanced directives. These wishes are obtained when clients are medically and cognitively able to do so. Such instructions are to be followed if clients are no longer able to make decisions because of cognitive impairment or unconsciousness. One incorrect response defines a health care surrogate or a durable power of attorney. Another incorrect response defines medical directives and not part of a living will. The final incorrect response is associated with the DNR, which may be predetermined by the client as written in a legal document. |
front 98 The client is admitted with a diagnosis of hyperglycemia and poor glycemic control. Which task can the nurse assign to an unlicensed assistive person (UAP)? Reinforce findings of hypoglycemia when the client asks Measure blood pressure, pulse and respirations Check sensation in the extremities Observe for mental status changes every four hours | back 98 Measure blood pressure, pulse and respirations UAP can perform standard tasks with predictable outcomes, such as measuring vital signs. They are trained to assist the client with activities of daily living. UAPs cannot assess, plan, teach or evaluate clients. |
front 99 The licensed practical nurse (LPN) is reassigned to work on an acute care unit. Which of these clients would be most appropriate for the LPN to accept? A client, admitted for a possible stroke, with unstable neurological findings A trauma victim with multiple lacerations requiring complex dressings A confused client whose family complains about the nursing care given after the client’s surgery An older adult client diagnosed with cystitis who has an indwelling urethral catheter | back 99 An older adult client diagnosed with cystitis who has an indwelling urethral catheter LPNs who are reassigned to work on a different unit should be assigned to clients who are stable. The older adult diagnosed with cystitis is the most stable and the outcomes for care are fairly predictable. The other clients have more complex problems, as well as a higher risk for instability. LPNs should not accept an assignment that is beyond their knowledge or skills. |
front 100 The nurse is named in a lawsuit. Which of these factors will offer the best protection for the nurse in a court of law? Complete and accurate documentation of assessments and interventions Above-average performance reviews prepared by nurse manager Sworn statement that health care provider orders were followed Clinical specialty certification by an accredited organization | back 100 Complete and accurate documentation of assessments and interventions The medical record is a legal document. Documentation should include all steps of the nursing process; it must be complete, accurate, concise and in chronological order. Inaccurate or incomplete documentation will raise red flags and may indicate the nurse failed to meet the standards of care. The attorney will review the medical record with the nurse before giving a deposition (sworn pretrial testimony.) Above-average performance reviews could be considered supporting information. Certification is an "extra" based on the nurse's initiative; it is, however, unrelated to accurate charting. |
front 101 The client had a colon resection two days ago. Which statement should the nurse use when assigning an unlicensed assistive person (UAP) to help ambulate this client? "If the client is dizzy upon standing, ask the client to look up and hold onto you." "When you help the client to walk, ask if the pain increases or decreases." "Have the client sit on the side of the bed for three to five minutes before standing." "Help the client to sit in a chair in the room as often as desired." | back 101 "Have the client sit on the side of the bed for three to five minutes before standing." It is important to give clear and concise information when assigning a task or activity to the UAP. The nurse should also ask the UAP to report client concerns after completing the task but the UAP cannot assess the client; only nurses can assess, plan and evaluate client care. |
front 102 A LPN complains to the charge nurse that an unlicensed assistive person (UAP) consistently leaves the work area untidy and does not restock supplies. What is the best initial response by the charge nurse? Write down potential solutions to the problems today by shift's end Add this concern to the agenda of the next unit meeting Assure the staff nurse that the complaint will be investigated Explore for further identification about the nature of the problem | back 102 Explore for further identification about the nature of the problem Helping staff manage conflict is part of the charge nurse's role. It is appropriate to work with the LPN in order to work out problems with minimal intervention from administration when possible. Further definition of the problem and associated issues would be a first step. The nursing process can be used to collect more data before plans or interventions are made. |
front 103 A newly licensed nurse is concerned about time management. Which action should be most effective in the initial development of a time management plan? Ask for additional assistance when necessary to complete tasks Keep a time log for what was done during the hours worked Complete each task before beginning another activity Set daily goals with the establishment of priorities | back 103 Keep a time log for what was done during the hours worked The first step in planning for time management is to establish what tasks were done and when they were completed. This provides a baseline for needed changes in any activities and time use log. The key words in this question are “time management," “most effective," and “initial development.” Remember the first step in the nursing process is data collection - this applies to both caring for clients and developing management skills. |
front 104 The nurse manager identifies that time spent charting is excessive. The nurse manager states that "staff will form a task force to investigate and develop potential solutions to the problem and then report on this at the next staff meeting." What is the nurse manager's leadership style? Transformational Autocratic Dynamic Affiliative | back 104 Transformational A transformational style of management involves staff members in the decision-making processes. Staff members review current policies and provide feedback to their leader in the pursuit of the common good. |
front 105 The health care provider has written an order for "morphine sulfate 2 mg IV push every 3 to 4 hours as needed for pain" for a 75 year-old client in an extended care facility. The licensed practical nurse (LPN) in charge has no other licensed persons working that shift. Which action should the LPN take first? Hold the medication and contact the health care provider Administer the prescribed dose as ordered Give the medication orally and follow up with the health care provider Check with the pharmacist | back 105 Hold the medication and contact the health care provider LPNs do not give IV push medications. The LPN will need to contact the health care provider and ask to have the medication delivered by another route. |
front 106 A client diagnosed with schizophrenia states, "I don't need medication. It makes me sleepy." The client insists that the nurse explain the use and side effects of the medication. What should the nurse understand before responding to the client? A decision to reinforce or not reinforce information about medications should be made by the nurse Clients have a right to know about any prescribed or over-the-counter medications It is dangerous for clients who are diagnosed with schizophrenia to know about their medications A referral needs to be sent to the psychiatrist with a request for discussion of the client’s medication | back 106 Clients have a right to know about any prescribed or over-the-counter medications Clients diagnoses have no influence on their right to know about the medications that they are prescribed. Clients have a right to refuse treatment and to be informed about the use and side effects of their medications. |
front 107 Information about case management and the role of the case management nurse is presented during an orientation session for new nurses. Which statement correctly describes an important fact about case management? The interdisciplinary team makes all the decisions for the
client and family Case management strategies focus on the client's needs during hospitalization Physicians are responsible and accountable for client outcomes | back 107 Case management is a collaborative process designed to meet complex client needs Case management is a collaborative process of organizing and coordinating resources and services within and across multiple settings. The focus is on cost-savings as well as quality and continuity of care. Case management nurses work closely with physicians, nurses, social workers to meet the complex health needs of the client, Case management is "client-centric" and all members of the team, including the client, work together to achieve desired outcomes. Cases that involve high-risk diagnoses (such as AIDs/HIV, cancer, people with cognitive deficits) or high-volume cases (such as total hip or total knee replacements) are often selected for case management. |
front 108 A client refuses to take the medication prescribed because the client prefers to take an herbal preparation. What is the first action the nurse should take? Report the behavior to the charge nurse Discuss with the client to find out about the preferred herbal preparation Explain the importance of the medication to the client Contact the client's health care provider about the refusal | back 108 Discuss with the client to find out about the preferred herbal preparation Remember, the collection of additional data is typically the initial approach when problems arise. Although the client has the right to refuse the medication, it's possible that the herbal preparation does not have the intended purpose of the prescribed medication or may even have unintended side effects |
front 109 The licensed practical nurse (LPN) who is in charge hears a health care provider loudly criticizing one of the unlicensed assistive persons (UAP) within the earshot of others. The UAP does not react or respond to the health care provider's complaints. What should be the charge nurse's first action after hearing this? Request an immediate private meeting with the health care provider and the UAP Walk up to the health care provider and quietly state: “This unacceptable behavior has to stop.” Allow the UAP to handle this situation without interference for the next few minutes Notify the nursing administrator and chief of the medical staff within the hour about the breach of professional conduct | back 109 Request an immediate private meeting with the health care provider and the UAP Assertive communication respects the needs of all parties to express themselves in a private location, but not at the expense of others. The PN charge nurse needs first to protect clients and other staff from this display of inappropriate behavior and come to the assistance or defense of the employee. |
front 110 The nurse asks another staff nurse to sign for a wasted narcotic, which was not witnessed by anyone. This type of request seems to be a recent pattern of behavior for this nurse. What is the appropriate initial action of the second staff nurse? Confront the nurse about suspected medication misuse Sign the narcotic sheet but document the request by an incident report Counsel the colleague about the risky behaviors Report this immediately to the nurse manager | back 110 Report this immediately to the nurse manager |
front 111 The nurse, who is located in a large urban area, uses telecommunications to provide health care and education to clients in remote locations. What is the best reason for using telehealth? Empowers clients to take a greater interest in their illness Standardizes electronic data sharing of health information Reduces health care costs Removes time and distance barriers from the delivery of care | back 111 Removes time and distance barriers from the delivery of care |
front 112 The LPN/VN assists the RN in evaluating the plan of care for clients. What action does the LPN focus on during the evaluation phase? Selection of interventions that are measurable and achievable Achievement or status of progress related to prior goals Establishment of goals to ensure continuity of care Identification of any findings of physical and psychosocial stressors | back 112 Achievement or status of progress related to prior goals Evaluation process of the clinical problem-solving process (the nursing process) should focus on the clients' status, progress toward goal achievement and ongoing re-evaluation of the plan of care. LPN/VN's gather, observe, record and communicate client responses to nursing interventions. |
front 113 A home health nurse is providing care for a client. Which client statement should the nurse consider to be a priority and report immediately to the case manager? "I really don’t want the service of Meals on Wheels. I am just not hungry." "My neighbors just don’t get along with me since I refuse to let them walk across my lawn." "I just didn’t sleep well the last few nights. I have thoughts running through my mind." "When I emptied my urine catheter bag it looked like rusty colored water." | back 113 "When I emptied my urine catheter bag it looked like rusty
colored water." |
front 114 A Bosnian Muslim woman who does not speak English seeks care at a community center. Through physical gestures, the woman indicates that she has pain originating in either the pelvic or genital region. Assuming several people are available to interpret, who would be the most appropriate choice? A female interpreter who does not know the client A female neighbor of the client who is also from Bosnia A Bosnian male, who is a certified medical interpreter The client's adult daughter | back 114 A female interpreter who does not know the client When the nurse and the client do not speak the same language, or have limited fluency, the services of an interpreter is needed. But, it may be inappropriate to have a male interpreter for a female client because the client may not be as forthcoming. The client may also feel it is inappropriate to have private matters interpreted by her daughter (especially if they are of a sexual nature or involve infidelity). To avoid a breach of confidentiality, the nurse should avoid using an interpreter from the same community as the client. The best response is to have a female interpreter who does not know the client. |
front 115 The client has a musculoskeletal disorder and has been newly fitted for a lower limb orthotic. Which activity can be assigned to the unlicensed assistive personnel (UAP)? Assist the client while transfering from the bed to a chair Check the client's skin for any redness or irritation Provide instruction for independent ambulation with the orthotic Monitor the client's response to activity | back 115 Assist the client while transfering from the bed to a chair The UAP can assist with routine activities of daily living, including transferring clients from a bed to a chair or wheelchair. When performed correctly, these routine tasks usually have a predictable outcome. The option about checking the client's skin involves assessment and monitoring the client's response is evaluation, both of which are nursing-only activities. A physical therapist would teach the client to ambulate with an orthotic. |
front 116 During the management of a client's pain, a nurse should consider ethical practice. Which of these items best describes the ethical considerations made by a nurse? The client's self-report of pain is the most important consideration Cultural sensitivity is fundamental to pain management Clients have the right to have their pain relieved Nurses should not prejudge a client's pain based on the nurse's values | back 116 The client's self-report of pain is the most important consideration Pain is a complex phenomenon that is perceived differently by each individual. Pain is whatever the client says it is and when it is. To help answer this question, consider that the correct response is the only one that is client-centered. |
front 117 Upon completing a review of the admission documents, a nurse identifies that an 87 year-old client does not have an advance directive. What action should the nurse take? Record this information on the chart Inform charge nurse and give information about advance directives Assume that the client wishes a full code Refer this issue to social services department | back 117 Inform charge nurse and give information about advance directives For each admission, nurses should verify a copy of the current advance directive. If there is none, the practical nurse should inform the charge nurse and offer written information about advance directives to the client. It is then the client’s choice to sign it. The witness of signature for an advanced directive must be someone not involved in direct care of the client. Social service staff are approved nationwide to witness signatures on advance directives. One option only deals with recording the information and is not sufficient. In another option the nurse should avoid making assumptions that the client has been informed of health care choices. Another option represents an action to be done after written information is given. |
front 118 The home health nurse is visiting a client diagnosed with type 1 diabetes and osteoarthritis. The client has difficulty drawing up the insulin dosage. The nurse should refer the client to which community resource person? Physical therapist Occupational therapist Home health aide Social worker | back 118 Occupational therapist An occupational therapist can assist a client to improve the fine motor skills needed to prepare an insulin injection. An occupational therapist works with the tasks that are needed for smaller movements to maintain activities of daily living or for work actions. A physical therapist works with general movement problems, mobility stability, range of motion or strength training exercises. The key terms in this question are "difficulty drawing up the insulin dosage" and "osteoarthritis." Combined, these terms should call to mind the need for fine motor skills. |
front 119 The practical nurse (PN) is assigned to care for several clients on the 7:00 pm to 7:00 am shift. Which client should be checked immediately after getting shift report? The client with pancreatitis who was admitted yesterday The client diagnosed with chronic renal failure who returned from dialysis five hours ago The client diagnosed with asthma who is scheduled for discharge The client diagnosed with a peptic ulcer who has been vomiting most of the day | back 119 The client diagnosed with a peptic ulcer who has been vomiting most of the day The client with the peptic ulcer should be checked immediately and findings reported to the charge nurse and/or health care provider. A perforated peptic ulcer could cause nausea, vomiting and abdominal distention, and may be a life-threatening situation. |
front 120 Before the client signs a surgical consent form, the nurse must ensure the client has the ability to understand the information in the document. T/F | back 120 True The nurse reviews the information in the consent form with the client and witnesses the client's signature. The nurse verifies the client has the capacity to make choices and understands the consequences prior to the client signing the consent. |
front 121 Nurses participate in quality improvement activities which are intended to promote safety and improve quality of care. T/F | back 121 True |
front 122 Negligence involves any action or inaction that results in unintended harm to a client. T/F | back 122 True |
front 123 Nurses rarely participate in the organ donation process with clients’ families. T/F | back 123 False |
front 124 The nurse has a legal duty to abide by the scope of practice set forth in the nurse practice act/nursing act. T/F | back 124 True |
front 125 Nurses should only access client information for those clients directly under their care. T/F | back 125 True |
front 126 The nurse has a legal duty to provide nursing care to clients. T/F | back 126 True |
front 127 The nurse is responsible for reporting any breach of client privacy or confidentiality. T/F | back 127 True |
front 128 The nurse has an obligation to carry out the health care provider’s written orders, whether the orders are appropriate for the client or not. T/F | back 128 False |
front 129 Advance directives are required for all clients. | back 129 False |
front 130 Which situation requires handwashing? (Select all that apply.) Before having direct contact with a client After making a chart entry Prior to eating After cleaning a wound | back 130 Before having direct contact with a client Prior to eating After cleaning a wound After contact with inanimate objects in the immediate vicinity of the client Handwashing is still the simplest and most effective strategy to prevent the spread of infection. It is necessary to wash one's hands to protect oneself prior to eating, after removing gloves following any client procedure, and even after having contact with intact skin or objects in the client's room. However, it is not necessary to wash hands after handling every chart (although using an alcohol-based hand rub would be advisable). |
front 131 The client, who is diagnosed with dementia, wanders throughout the long-term care facility. How can the nurse best ensure the safety of a client who wanders? Attach a monitoring band to the client's wrist Apply a restraint to keep keep the client in a chair when awake Explain the risk of walking with no purpose Frequently reorient the client to time, person, place | back 131 Attach a monitoring band to the client's wrist A wander management system is used to give people with dementia and other "at risk" clients the ability to move freely where they live. The sensor in the bracelet trips an alarm that's attached to exterior doors if the client attempts to leave the facility. It is inappropriate to use restraints or other restrictive devices to keep clients in chairs or beds (unless they are potentially harmful to themselves or others.) Reality orientation is inappropriate for someone with dementia. |
front 132 A practical nurse (PN) is having difficulty reading a health care provider's written order from the prior shift. What action should the nurse take? Leave the order for the oncoming staff to follow up or interpret Call the pharmacy for assistance in the interpretation Contact the manager to report the problem with the
legibility of the order | back 132 Ask the registered nurse (RN) to notify the health care provider for clarification The nurse should clarify the order with the person who wrote the illegible or confusing order. If the PN reports to an RN, then the RN should obtain written clarification. In some states PNs may write verbal or telephone orders and in other states this is not allowed by the state’s nurse practice act. |
front 133 A 76 year-old client is admitted to the unit after reportedly falling at home. The client begins to seize and loses consciousness. What action by the nurse is appropriate to do next? Place an oral airway in the mouth and suction the mouth Stay with client and observe for airway obstruction Collect pillows and pad the side rails of the bed Announce a cardiac arrest and assist with intubation | back 133 Stay with client and observe for airway obstruction For the client’s safety, the client should not be left unattended. The nurse must remain at the bedside, observe respirations and type of seizure activity, and prepare to clear the airway if it's obstructed. The nurse should not not place anything in the client’s mouth. A code is called only if pulse or respirations are absent after the seizure |
front 134 During a 12-hour night shift, the nurse has a "near miss" and catches an error before giving a new medication. Which statement might explain the reason for the near miss? (Select all that apply.) The nurse is sleep-deprived The unit is short-staffed The nurse has worked on the same unit for 5 years The nurse works in the intensive care unit (ICU) | back 134 The nurse is sleep-deprived The nurse works in the intensive care unit (ICU) There are a number of reasons for near misses and making medication errors, including heavy workload and inadequate staffing, distractions, interruptions, and inexperience. Fatigue and sleep loss are also factors, especially for nurses working in units with high acuity clients. |
front 135 The nurse listens to report about a newly admitted client who has a skin ulcer that’s tested positive for MRSA (methicillin-resistant Staphylococcus aureus). What precautions must be taken for this hospitalized client? (Select all that apply.) Perform hand hygiene after direct contact with the client
and before leaving the room Wear mask when providing routine care to the client Place the client in a single room | back 135 Perform hand hygiene after direct contact with the client and before leaving the room Keep all equipment in the client’s room for his/her sole use Keep the door to the room closed, with a notice for visitors Place the client in a single room Contact precautions are recommended in acute care settings for MRSA when there’s a risk for transmission or wounds that cannot be contained by dressings. The client should be in a single room, with the door closed; the sign on the door instructs visitors to report to the nurse before entering the room. All equipment, such as stethoscopes and blood pressure devices, should be for the client’s sole use and kept in the room. Health care workers must perform hand hygiene (wash hands with soap and water) after direct contact with the client and his/her environment and before leaving the isolation room. Contact precautions require health care workers to wear gloves and a gown; a face mask is not necessary for routine care. |
front 136 The mother of an infant who is being treated for pesticide poisoning asks, “Why is activated charcoal used?” What is an appropriate response by the nurse? "Activated charcoal binds with the poison to limit absorption from the digestive tract." "When it is absorbed into the blood stream, activated charcoal neutralizes the poison." "Activated charcoal stimulates bowel evacuation." "This liquid causes vomiting, which eliminates the poison from the body." | back 136 "Activated charcoal binds with the poison to limit absorption from the digestive tract." Activated charcoal binds to the poison through the entire GI tract; it is estimated that it reduces absorption by almost 60%. Activated charcoal is a fine, black powder that is odorless, tasteless, and nontoxic. It is often used after gastric lavage in the emergency treatment of certain kinds of poisoning. |
front 137 The nurse is discussing safety precautions with the parents of a child. Which activity would be most hazardous to an 18 month-old child? Riding in a car Jumping on a bed Eating whole peanuts Playing around electrical outlets | back 137 Riding in a car Car accidents are a leading cause of death in infants and children, as well as a major cause of permanent brain damage and spinal cord injury. Although all the other options pose a danger to young children, drowning is actually the second most common cause of accidental death among children. |
front 138 A client is admitted to an inpatient crisis unit with the diagnosis of acute mania and has been placed in seclusion. The nurse is assigned to observe the client at all times. It is now time for the client’s dinner. What action should the nurse take next? Accompany the client to the dining area and maintain observation Hold the meal until after the seclusion order has been discontinued Obtain a contract for safe behavior before accompanying the client to the dining area Serve the dinner in the seclusion room, maintaining observation | back 138 Serve the dinner in the seclusion room, maintaining observation |
front 139 A child is admitted with a diagnosis of suspected meningococcal meningitis. Which admission orders should the nurse implement first? Monitor and record vital signs every 30 minutes Seizure precautions Droplet precautions Notify of changes in neurologic status | back 139 Droplet precautions Meningococcal meningitis is an infection caused by the bacteria Neisseria meningitis. The first action for nurses to take is to initiate droplet precautions. The initial therapeutic management of acute bacterial meningitis includes droplet precautions, anti-infective therapy (a cephalosporin or penicillin), monitor neurological status along with vital signs, institute seizure precautions, and maintain optimum hydration. |
front 140 A school nurse plans to reinforce information about the most effective methods to prevent the spread of head lice in school-age children when speaking at a teacher’s conference. The nurse should plan to include which information? The classroom should be sprayed with an insecticide before winter and spring vacations The heads of children should be checked monthly for nits (lice eggs) Each child should wash his or her hands after recess break Children should not share or wear other children's coats, hats and scarves | back 140 Children should not share or wear other children's coats, hats and
scarves |
front 141 Parents of a 7 year-old child call a clinic nurse because their child was sent home from school due to a rash. The child, seen the day before by the health care provider, was diagnosed with fifth disease (erythema infectiosum) and is otherwise in good health. What would be the appropriate action by the nurse? Refer the school officials to printed materials about this viral illness Inform the school that the child is receiving antibiotics for the rash Explain that this rash is no longer contagious and does not require isolation Tell the parents to bring the child to the clinic for further evaluation | back 141 Explain that this rash is no longer contagious and does not require isolation Fifth disease is a viral illness with an uncertain period of communicability (perhaps one week prior to and one week after the onset). Children are not contagious after the appearance of the rash, which gives a "slapped cheek" appearance. Isolation of the child with fifth disease is not necessary except in cases of hospitalized children who are immunosuppressed or having aplastic crises. The parents may need written confirmation of this from the health care provider to give to the school. Notice that two of the options focus on the content of this question (a rash); the other options do not. Note the word “antibiotics” in one option, but there is nothing in the question to indicate there's an “infection.” |
front 142 The nurse is caring for a client diagnosed with hepatitis C. When reviewing the client's health history, which of the following findings does the nurse recognize as the most likely cause for developing hepatitis C? Eating raw shellfish last week Receiving blood product transfusions prior to 1992 Getting a tattoo three months ago at a licensed tattoo parlor Recent travel to Central America | back 142 Receiving blood product transfusions prior to 1992 The client who was transfused prior to blood screening for hepatitis C (1992) may show findings of hepatitis C many years later. Raw shellfish ingestion and travel to foreign countries with poor sewage control can increase the risk of developing hepatitis A, but not hepatitis C. Most commercial tattoo parlors are licensed and follow standard safety precautions, so the likely cause of developing hepatitis B or C after a tattoo or a piercing is very low. |
front 143 The parents of a toddler ask, "How long will our child have to sit in a car seat when riding in a car?” What would be the best response by the nurse? "Until the child is about 2 years-old." "When the child is 50 inches tall." "Whenever the child is content to sit in a booster seat." "When the child weighs 40 pounds." | back 143 "Until the child is about 2 years-old." The American Academy of Pediatrics now recommends that infants and toddlers remain in rear-facing car safety seats until age 2 years (or when they physically outgrow the limits of the seat.) They can then transition to sitting in belt-positioning booster seats when they have reached about 4 feet 9 inches tall and are between 8 to 12 years-old. Children under age 13 years should ride in the back seat of the car. |
front 144 The nurse is setting up a client's dinner tray. When the nurse turns her back to the client, the client grabs the nurse's buttocks and states he is hungry for much more than dinner. Which of the following responses by the nurse is indicated? Call the health care provider Complete an incident report Quickly leave the room and ask the UAP to assist the client Ignore the behavior | back 144 Complete an incident report To keep the therapeutic relationship intact, a nurse needs to set limits on appropriate behavior and not ignore bad behavior. Sexual harassment is a form of violence and is never part of the job. The nurse should report the incident to her supervisor and complete an incident report. The nurse has the right to ask not to be assigned to this client. |
front 145 The nurse observes a nursing assistant using antiseptic hand rub and rubbing the hands vigorously after leaving the room of a client diagnosed with Clostridium difficile. Which action is most appropriate by the nurse? Tell the client to ask caregivers if they have washed their hands Require the nursing assistant to wash hands again with soap and water Ensure that visitors wash hands thoroughly before and after visiting Praise the nursing assistant for proper use of antiseptic hand rub | back 145 Require the nursing assistant to wash hands again with soap and water Anyone who is hospitalized should be encouraged to ask caregivers if they washed their hands and to remind visitors to wash their hands. However, it is the nurse's responsibility to supervise the nurse assistant and to correct practice errors as needed. Clostridium difficile (C. diff) is one of the few pathogens that require soap and water for cleansing the hands. Since antiseptic hand rub is ineffective against the hardy spores produced by this bacterium, the nurse should require the nursing assistant to wash his/her hands with soap and water, especially after providing care for this client. |
front 146 The health care team is planning discharge for a 90 year-old client diagnosed with musculoskeletal weakness. Which intervention would be the priority to help prevent falls in the home? Take calcium and vitamin D supplements Wear eyeglasses and hearing aid Begin therapy for muscle strengthening and balance Place night lights in the bedroom and bathroom | back 146 Place night lights in the bedroom and bathroom Family members and the client should understand the simple actions they can take to help prevent falls in the home. More falls occur in the bedroom than in any other location; a simple environmental change would be to add night lights in the bedroom and bathroom. Muscle strengthening and balance exercises, taking calcium and wearing glasses may be all indicated for this client, but using night lights is an immediate and effective action to help prevent falls. |
front 147 The 4 year-old needs to have several vaccines prior to starting kindergarten. However, the nurse determines that the MMR vaccine should not be given. What is the best reason why the MMR should not be given to this child? Low-grade temperature and a runny nose The child is too old for the second dose of the MMR Previous life-threatening allergic reaction to the antibiotic neomycin Known allergy to peanuts | back 147 Previous life-threatening allergic reaction to the antibiotic neomycin According to the CDC, if a person has experienced a life-threatening reaction to the antibiotic neomycin or gelatin s/he should not get the MMR. Vaccines can be given to children with mild cold symptoms, but it might be better to wait until they feel better. There is no relationship between the MMR and an allergy to peanuts. The CDC recommends administering the first MMR between 12 and 15 months and the second dose between 4 to 6 years of age. |
front 148 The nurse is attending an in-service about healthcare-associated infections (HAIs). Which factor is identified as the most common cause of HAIs in the acute care setting? Presence of an indwelling urinary catheter Decreased mobility for a week or longer Existence of an intravenous access device Inadequate fluid intake over 72 hours | back 148 Presence of an indwelling urinary catheter Catheter-associated urinary tract infections is the most common HAI in the acute care hospital setting. Surgical site infections, bloodstream infections and pneumonia are the other categories of infections. |
front 149 Four clients are admitted to an adult medical unit on the same shift. The nurse should expect to implement airborne precautions for the client with which of the following diagnoses? Confirmed AIDS with cytomegalovirus (CMV) Suspected viral pneumonia Positive Mantoux test with an abnormal chest x-ray Advanced carcinoma of the lung | back 149 Positive Mantoux test with an abnormal chest x-ray The client who must be placed in airborne precautions is the client with a positive Mantoux test (also called PPD) and an abnormal chest film because these could be suspicious tuberculin lesions. The client would be placed in a private room. Health care workers would have to use a HEPA filter respirator when in the room providing care for the client. Although the CMV virus is not highly communicable, it can be spread from person to person by direct contact; the virus is shed in the urine, saliva, semen and to other body fluids. |
front 150 Standard precautions also includes respiratory hygiene/cough etiquette. T/F | back 150 True |
front 151 You should quickly remove contaminated clothing by pulling it over your head. T/F | back 151 False |
front 152 The three elements of radiation protection are time, distance and shielding. T/F | back 152 True |
front 153 Sensor pads may be used on the beds of individuals who are a fall risk. T/F | back 153 True |
front 154 Restraints can be ordered “as needed” (PRN) by health care providers. T/F | back 154 False |
front 155 Newborns are fitted with tamper-proof security sensors during their stay in the hospital. T/F | back 155 True |
front 156 Disaster triage differs from routine emergency department triage. T/F | back 156 True |
front 157 Hands can be cleaned with an alcohol-based hand rub after caring for a client with Clostridium difficile (CDI). T/F | back 157 False |
front 158 If a draining wound tests positive for Staphylococcus aureus (MRSA), the client is placed on contact precautions. T/F | back 158 True |
front 159 Assistive devices are used when a caregiver is required to lift more than 35 lbs (15.9 kg). T/F | back 159 True |
front 160 The school nurse is observing a group of children. The nurse should be aware that which of these psychosocial needs are more commonly found in adolescents? Attention, competition, being right Social competencies, respect, sense of humor Privacy, autonomy, peer interaction Independence, confidence, narcissism | back 160 Privacy, autonomy, peer interaction Adolescents display the need for privacy, autonomy, and peer interaction concurrent with an evolving sense of identity. |
front 161 A nurse is observing children playing in the hospital playroom. The nurse should expect to see 4 year-old children playing in which manner? Alone with hand-held computer games Competitive board games with older children Cooperatively with other preschoolers With their own toys alongside with other children | back 161 Cooperatively with other preschoolers Cooperative or associative play is typical of the preschool period. School-age children would play board games, toddlers engage in side-by-side or parellel play, and adolescents would be more likely to play the hand-held computer games. |
front 162 The nurse is asked about chiropractic treatment for illnesses. The nurse should know that it focuses on which approach? Electrical energy fields Mind-body balance Spinal column manipulation Exercise of joints | back 162 Spinal column manipulation The underlying theory of chiropractic medicine is that interference with transmission of mental or electrical impulses between the brain and the body organs produces diseases. Such interference is caused by misalignment of the vertebrae. Manipulation reduces the subluxation or misalignment. Notice that this is a specific question, which means it requires a specific response. Eliminate the two general options (electrical energy fields and mind-body balance). Now pay attention to the word “manipulation” in one option and the word "exercise" in the other remaining option. Return to the question to look for a clue to help with the choices. Focus on the words "treatment for illness" rather than "chiropractic" and go with what is known. An educated guess for "treatment of illness" is more likely to be "manipulation." |
front 163 The clinic nurse is performing the intake assessment for a 74 year-old male. The client has a history of benign prostatic hypertrophy (BPH) and reports having trouble voiding. After the client uses the bathroom to void, how would the nurse best assess the bladder for retention? Check for rebound tenderness Palpate for rounded swelling above the symphysis pubis Scan the bladder using a portable ultrasound scanner Insert an intermittent urinary catheter | back 163 Scan the bladder using a portable ultrasound scanner Urinary retention and incomplete bladder emptying can result from urethral obstruction, as seen in BPH. The nurse can palpate the area from the umbilicus towards the symphysis pubis; an empty bladder rests behind the symphysis pubis and should not be palpable. The nurse can also percuss this area; a urine-filled bladder produces a dull sound. But a bladder ultrasound the most effective technique since it will digitally register bladder volume. Routine catheterization to check for post void residual is not recommended; but if bladder distention is greater than 200 mL, the client may need to be catheterized. |
front 164 The geriatric social worker is working with the nurse to assess the client's ability to perform instrumental activities of daily living (IADL). Which of the following skills are considered instrumental activities of daily living? (Select all that apply.) Ability to bathe self Ability to cook meals Ability to write checks Ability to eat independently/feed self Ability to take medications | back 164 Ability to cook meals Ability to write checks Ability to take medications Activities of daily living (ADLs) are basic self-care tasks, such as feeding, toileting, grooming, bathing, putting on clothes. Instrumental activities of daily living (IADLs) are slightly more complex skills and include a series of life functions necessary for living independently, such as the ability to use a telephone, shopping, doing housework, preparing meals, handling finances, and being responsible to take medications. ADLs and IADLs are part of an older adult's functional assessment. |
front 165 While performing an initial assessment on a newborn following a breech delivery, the nurse suspects hip dislocation. Which of these findings is most suggestive of this abnormality? Negative Ortolani response Lengthened leg of affected side Flexion of lower extremities Irregular hip symmetry | back 165 Irregular hip symmetry Early assessment of irregular hip symmetry alerts the nurse and the provider to a correctable congenital hip dislocation. The leg is shortened on the affected side. One check for hip dislocation is the Ortolani click; if it is found, it is called a positive response. |
front 166 A nurse who works in a high school is reinforcing information to a group of unwed pregnant students. What is the most important action the nurse should stress so that each girl can deliver a healthy child? Get adequate sleep and frequent rest Stay in school to keep normal activities Maintain good nutrition Keep in contact with the child's father | back 166 Maintain good nutrition Nurses can play a pivotal role in reinforcing nutritional education. Weight gain during pregnancy is one of the strongest predictors of infant birth weight. Pregnant teens who gain between 26 and 35 pounds have the lowest incidence of low birth-weight babies. Specifically, teens need to increase their intake of protein, vitamins and minerals (including iron.) |
front 167 A 38 year-old female client is admitted to the hospital with an acute exacerbation of asthma. This is her third admission for asthma in seven months. She describes how she doesn't really like having to use her medications all the time. Which of the following long-term consequence of uncontrolled airway inflammation should the nurse reinforce? Lung remodeling and permanent changes in lung function Frequent pneumonia Degeneration of the alveoli Chronic bronchoconstriction of the large airways | back 167 Lung remodeling and permanent changes in lung function While an asthma attack is an acute event from which lung function essentially returns to normal, chronic under-treated asthma can lead to lung remodeling and permanent changes in lung function. Increased bronchial vascular permeability leads to chronic airway edema which leads to mucosal thickening and swelling of the airway. Increased mucous secretion and viscosity may plug airways, leading to airway obstruction. Changes in the extracellular matrix in the airway wall may also lead to airway obstruction. These long-term consequences should help the nurse when reinforcing the need for daily management of the disease, regardless if the client "feels better" or not. |
front 168 The nurse is giving the pneumovax vaccination to clients in a community health clinic. The nurse should not administer the vaccine to which of the following clients? The client who received a flu shot the week before The client who reports feeling achy all over about two days ago The client with a temperature of 99 F (37.2 C) The client who had chemotherapy for cancer four days ago | back 168 The client who had chemotherapy for cancer four days ago Immunization with this vaccine is contraindicated with clients that are immunosuppressed. The pneumovax vaccine is to be given at least a week apart from other vaccines. The other two options do not warrant suspicion of immunological problems. |
front 169 A newly pregnant woman asks the nurse what to expect in the early stages of pregnancy. The major developmental task that a woman must accomplish during the first trimester of pregnancy is the acceptance of which issue? The potential risk for a termination of the pregnancy The fetus as a separate and unique being The satisfactory resolution of fears related to giving birth The pregnancy and the physical changes that are involved | back 169 The pregnancy and the physical changes that are involved During the first trimester the maternal focus is directed toward acceptance of the pregnancy and adjustment to the minor discomforts. Ambivalence is a normal, expected emotion. You should be able to determine that two of the options occur later in the pregnancy. The option about the potential risk for termination of the pregnancy is unrelated to the question being asked |
front 170 A newborn born prematurely is to be fed breast milk through a nasogastric tube. Why is breast milk preferred over formula for premature infants? Has less fatty acids Is higher in calories/ounce Contains less lactose Provides antibodies | back 170 Provides antibodies Breast milk is ideal for the preterm baby who needs additional protection against infection through maternal antibodies. It is also much easier to digest. Therefore, less residual is left in the infant's stomach. |
front 171 A 75 year-old client is admitted with the diagnosis of possible dehydration. The nurse should understand that older adults are at risk for dehydration due to which of the following factors? Reduced gastric emptying Weakened urinary sphincter Decreased sensation of thirst Reduction in lean body mass | back 171 Decreased sensation of thirst Older adults do not drink because they do not feel as thirsty as younger people. Other risk factors for minimal ingestion of fluids in older adults may include fear of incontinence, inability to drink fluids independently or it's simply too painful to get up from a chair. |
front 172 A healthy 18 year-old is entering college in the fall. Which immunization would the health care provider recommend prior to college? (Select all that apply.) Meningococcal conjugate vaccine (MCV4) Pneumococcal polysaccharide vaccine (PPSV23) Seasonal influenza vaccine Shingles vaccine Human papillomavirus (HPV) vaccine | back 172 Meningococcal conjugate vaccine (MCV4) Seasonal influenza vaccine Human papillomavirus (HPV) vaccine Adults older than age 50 should get the shingles vaccine. The PPSV23 is given to adults older than age 65. (The pneumococcal vaccine PCV13 is routinely given to infants/children.) An 18 year-old who is going to college should receive the TDAP, MCV4 and seasonal influenza vaccine. He or she should also receive the HPV vaccine if s/he has not already received it. |
front 173 A client is in the third month of her first pregnancy. During the interview, she tells a nurse that she has several sex partners and is unsure of the identity of the baby's father. Which of these nursing interventions is best at this time? Request the RN to counsel the woman to consent to HIV screening Refer the client to a family planning clinic Refer her for testing for sexually transmitted infections Discuss the risk for cervical cancer | back 173 Request the RN to counsel the woman to consent to HIV screening The client's behavior places her at high risk for HIV. While it would be a good idea to draw blood to test for STDs, this can't be done without informed consent of the client. Since the woman is already at a clinic seeking health care, it would be best to provide information (and possibly begin treatment) now, instead of simply referring her to another health care facility. The best response is for the RN to provide information and counsel the woman to consent to HIV screening. |
front 174 According to Piaget, which finding indicates that a child has attained the stage of concrete operations? Makes the moral judgment that "stealing is wrong" Explores the environment with the use of sight and movement Reasons that homework is time-consuming yet necessary Thinks in mental images or word pictures | back 174 Makes the moral judgment that "stealing is wrong" The stage of concrete operations is depicted by logical thinking and moral judgments. This stage is associated with school-aged children from ages 7 to about 11. It is a time when children develop transitive thinking and reversibility concepts. They do well with inductive logic, which involves going from a specific experience to a general principle. They do not do well with deductive logic, or the use of a general principle to determine an outcome of a specific event. |
front 175 A client referred for a mammography asks the nurse about the cancer risks from radiation exposure. What is an appropriate response by the nurse? "A chest x-ray gives you more radiation exposure.” "The radiation from a mammography is equivalent to one hour of sun exposure." "Exposure to mammography every two years is not dangerous." "You have nothing to worry about; it is less than tanning in the nude." | back 175 "The radiation from a mammography is equivalent to one hour of sun exposure." A client would have to have numerous procedures during the course of a year to be at risk for cancer. The correct response is concise and gives the client a point of reference. The other options are either judgmental and nontherapeutic ("tanning in the nude"), inaccurate and having the potential for causing more concern (getting more radiation from a chest x-ray), or do not address the client's concern (it's "not dangerous"). |
front 176 The client is an adult who was recently diagnosed with type 1 diabetes. Which action would be the best strategy for a nurse to use when reinforcing insulin injection techniques? Ask the client questions during practice sessions Listen to client’s verbalized understanding Observe a return demonstration Ask the client questions after practice sessions | back 176 Observe a return demonstration Because injecting insulin is a psychomotor skill, observing a return demonstration is the best strategy to know or evaluate whether the client has learned the proper technique. |
front 177 During the physical inspection of a client, the nurse notes a pulsating mass in the client's periumbilical area. Which action is appropriate for the nurse to take to gather more data about the mass? Auscultate the area Percuss the area Measure the length of the mass Palpate the area | back 177 Auscultate the area Auscultation of the abdomen will find a bruit, which will confirm the presence of an abdominal aneurysm. The other actions would be contraindicated because placing pressure on the area might cause the aneurysm to leak or rupture. |
front 178 A nurse is working with family members of an 80 year-old client newly diagnosed with Alzheimer's disease. Which intervention would be helpful? Have the family feed the client Role play communication strategies Demonstrate an active-passive exercise routine Assist the family to bathe the client | back 178 Role play communication strategies Because Alzheimer's disease is a progressive chronic illness that challenges caregivers, the nurse can be of great assistance in helping the family to identify changes in language, as well as ways to communicate with their loved one that will help avoid or minimize difficult behaviors. The client should feed and bathe him or herself as long as physically possible. Exercise is important for Alzheimer's victims, but walking or enjoying other physical activities are more important than specific exercise routines. |
front 179 Parents are asking for information about how they will know if their toddler is ready for toilet training. What should the nurse understand before reinforcing information about toilet training? Neuronal impulses are interrupted at the base of the ganglia The child learns voluntary sphincter control through repetition Myelination of the spinal cord is completed during the toddler years The toddler can understand cause and effect | back 179 Myelination of the spinal cord is completed during the toddler years Voluntary control of the sphincter muscles can be gradually achieved due to the complete myelination of the spinal cord, which occurs sometime between the ages of 18 to 24 months. The other options are incorrect. Notice that both the question and the correct option has the word “toddler” in them. |
front 180 The adolescent's spine is straight and posterior ribs are symmetrical when the client bends forward. Abnormal finding(s) or Expected finding(s) | back 180 Expected finding(s) The adolescent client should be assessed for scoliosis by asking the client to bend forward and touch his or her toes. The client's spine should be straight and without curvature or asymmetry. |
front 181 An 84-year-old has decreased muscle strength in his bilateral upper extremities. Abnormal finding(s) or Expected finding(s) | back 181 Expected finding(s) |
front 182 A 5-month-old has a sunken anterior fontanel. Expected finding(s) | back 182 Abnormal finding(s) |
front 183 A client can tell you her name, but does not know the day of the
week. or Expected finding(s) | back 183 Abnormal finding(s) Normal mental function includes orientation to person, place and time. |
front 184 A 60-year-old male has a left scrotal sac that is slightly lower than the right. Abnormal finding(s) or Expected finding(s) | back 184 Expected finding(s) |
front 185 Auscultation reveals bowel sounds in two of the four abdominal
quadrants. Expected finding(s) | back 185 Abnormal finding(s) |
front 186 During a female client's breast exam, you see a cluster of very tiny
dimples near one nipple. or Expected finding(s) | back 186 Abnormal finding(s) |
front 187 A 42-year-old breathes 30 times per minute. or | back 187 Abnormal finding(s) |
front 188 The client is able to stand on one foot, with eyes shut, for five seconds. Abnormal finding(s) or | back 188 Expected finding(s) |
front 189 When you examine the mouth, you see that the soft palate is moist and
pink with whitish spots. | back 189 Abnormal finding(s) |
front 190 Reflecting back on life | back 190 Older Adult Integrity vs. Despair (approximately age 65 years & older) |
front 191 Exploring independence; developing a sense of self | back 191 Adolescence Identity vs. Role Confusion (approximately age 12-18 years) |
front 192 Exploring and developing close, committed relationships | back 192 Early Adulthood Intimacy vs. Isolation (approximately age 18-40 years) |
front 193 Developing a greater sense of personal control. | back 193 Early Childhood Autonomy vs. Shame & Doubt (approximately 18 months to 3 years) |
front 194 Building career and family. | back 194 Adulthood Generativity vs. Stagnation (approximately age 40-64 years) |
front 195 Developing trust. | back 195 Infant Trust vs. Mistrust (approximately birth to 18 months) |
front 196 Developing a sense of pride in accomplishments. | back 196 School Age Industry vs. Inferiority (approximately age 6-11 years) |
front 197 Play, imagination and initiating activities with others. | back 197 Preschool Initiative vs. Guilt (approximately age 3-5 years) |
front 198 The safest time for the fetus is to give the mother analgesia when her cervix is dilated 8 to 10 centimeters. T/F | back 198 False |
front 199 A woman cannot become pregnant when she is breastfeeding. T/F | back 199 False |
front 200 Common issues on the first postpartum day include afterpains and episiotomy discomfort and swelling. T/F | back 200 True |
front 201 About 5 days after delivery, lochia is pink-brown in color. T/F | back 201 True |
front 202 A baby tapped briskly on the bridge of the nose will close both eyes. T/F | back 202 True |
front 203 An APGAR score of 2 for appearance means the newborn's fingers and toes are bluish in color. T/F | back 203 False The normal color all over for the newborn is pink; a pink baby earns a score of 2. A baby who is pink with pale blue toes/feet and fingers/hands will receive a score of 1 on the APGAR test. |
front 204 A gravida 3, para 3 woman should be rushed to the delivery room once engagement has occurred. T/F | back 204 False |
front 205 The fetus receives more oxygenated blood when the laboring mother lies on her side. T/F | back 205 True |
front 206 Chloasma is the first milk the new mother produces. T/F | back 206 False |
front 207 The nurse will give Rh immune globulin (RhoGAM®) to a Rh negative women after a miscarriage (spontaneous abortion). T/F | back 207 True |
front 208 One of the first signs of pregnancy is Chadwick's sign, which is the softening of the cervix. T/F | back 208 False |
front 209 Most pregnancy tests measure the level of estrogen in the woman's blood. T/F | back 209 False Pregnancy tests measure the hormone human chorionic gonadotropin (hCG) in the urine or in the blood. Levels can be first detected about 12 to 14 days after conception and peak in the first 8 to 11 weeks of pregnancy. |
front 210 When the fetus is active, its heart rate should increase by about 15 beats per minute. T/F | back 210 True |
front 211 The fourth stage of labor is placental separation and expulsion. T/F | back 211 False |
front 212 Fetal movement count during the third trimester should be at least 5 movements per day. T/F | back 212 False |
front 213 While interviewing a client, the nurse notices that the client is shifting positions, wringing the hands, and avoiding eye contact. What initial action should the nurse take? Change the focus of the discussion to a less anxiety-provoking topic Recognize the behavior as a side effect of medications Ask the client about current feelings or thoughts Check the client for the possibility of auditory hallucinations | back 213 Ask the client about current feelings or thoughts The initial step in anxiety intervention is observing, identifying and validating anxiety. The behaviors suggest that the client may be anxious or nervous about the topic being asked about in the interview. |
front 214 The nurse is assisting a client who has a substance use disorder. Which response by the nurse would best help the client to deal with issues of guilt? "You’ve caused a great deal of pain to yourself, the family and close friends. It will take time to undo anything you’ve done." "Let's not focus on your guilty feelings. These feelings will only lead you to more drug and alcohol use." "Addiction usually causes people to feel guilty. It is a typical response due to your drinking behavior." "What have you done that you feel most guilty about? What steps can you begin to take to help you deal with your feelings of guilt?" | back 214 "What have you done that you feel most guilty about? What steps
can you begin to take to help you deal with your feelings of
guilt?" |
front 215 A nurse is collecting data on a client suspected of being in an abusive relationship. Which statement by the client is most indicative that this individual is in an abusive relationship? "I am determined to leave my house in a week." "I have only been in this relationship for two months." "No one else in the family has been treated like this." "I have tried leaving in the past, but have always gone back." | back 215 "I have tried leaving in the past, but have always gone
back." |
front 216 A client who lives in an assisted living facility tells the nurse, “I am so depressed. Life isn't worth living anymore.” What is the best response by the nurse to this statement? "Think of the many positive things in life today." "Did you tell any of this to your family?" "Have you thought about hurting yourself?" "Come on, it is not that bad." | back 216 "Have you thought about hurting yourself?" It's important to determine if someone, who has voiced thoughts about death, is considering a suicidal act. This response is most therapeutic under the circumstances. To respond by saying things are not so bad, denies the validity of the client’s statement. To ask if the family or anyone knows of these feelings lacks focus on the client and would also be in violation of the rights of the client. Many times, when there doesn't seem to be an urgent physiologic need, look for a response that focuses on the safety of the client. |
front 217 Stages of the grieving process | back 217 The phases of loss or the grief process according to Dr. Kubler-Ross are: denial, anger, negotiation, depression and acceptance. |
front 218 The nurse is caring for a client who has a history of heavy alcohol use. Which behaviors would indicate the client is experiencing delirium tremens (DTs)? An excited state accompanied by disorientation, hallucinations and tachycardia Disorganized thinking and feelings of terror with nonpurposeful behaviors Tremors or jerking movements caused by rapidly contracting muscles or tremors A generalized shaking of the body accompanied by repetitive thoughts and movements | back 218 An excited state accompanied by disorientation, hallucinations and tachycardia Delirium tremens (DTs) is a severe form of alcohol withdrawal that usually occurs within 72 hours after the last drink. During DTs, the person experiences both physical and mental hyperexcitability. Common findings include agitation, confusion, disorientation and hallucinations. The physical component of DTs includes diaphoresis, tachycardia, hypertension, tremors, fever, and eventually, if not treated, grand mal seizures, severe dehydration and death. |
front 219 The nurse works with clients diagnosed with dementia and recognizes that this disorder involves impairment and loss. What type of impairments are expected for clients with dementia? Learning, creativity and judgment Endurance, strength and mobility Hearing, speech and sight Balance, flexibility and coordination | back 219 Learning, creativity and judgment Dementia is not a single disease but a general term used to describe symptoms such as impairments to memory, communication and thinking. There are many causes of dementia and although we generally associate dementia with aging, we know that it is due to degenerative changes to the brain. The other options include expected changes due to aging but are not necessarily due to cognitive impairment related to dementia. |
front 220 A client diagnosed with schizophrenia first speaks animatedly, with clarity of pronunciation. The client is then observed mumbling to self and speaking to the radio. A desirable outcome for this client’s care should include which action by the client? Demonstrate improved social relationships Accurately interpret events and behaviors of others Express feelings appropriately through verbal interactions Engage in meaningful and understandable verbal communication | back 220 Engage in meaningful and understandable verbal communication The data supports impaired verbal communication. The outcome must be related to the diagnosis and supporting data. So the most appropriate outcome would be for the client to engage in meaningful and understandable verbal communication. When trying to narrow the options down, look at the two similar but dissimilar answers. That would lead to options that both focus on “verbal” communication and interaction. Notice the word “feelings” in one option and ask: Are feelings in the stem of this question? Because no data is presented about feelings or to thinking processes, the option about expressing feelings would not be an appropriate outcome. Remember, content cannot be in your answer that is not in the question. |
front 221 The client is an 80 year-old diagnosed with a neurocognitve disorder. The nurse is discussing with family members the best type of care for their mother. To assist the family with decision-making, what question should the nurse ask first? "Are you able to assist with the care of your mother in any manner?" "What type of assistance does your mother require?" "What is your opinion of nursing homes or assisted living facilities?" "Is your mother taking any over-the-counter or prescription medications at the present time?" | back 221 "What type of assistance does your mother require?" The initial question should focus on the client's needs, as the family sees them. Because the client is cognitively impaired, the client is not a reliable source of information for decision making. The sequence of questioning after this would be to ask if the family is able to care for the client, to determine what medications the client is taking, and then to ask the family's opinion of other living arrangements, such as assisted living facilities or nursing homes. |
front 222 The nurse works in an inpatient psychiatric setting. What would be the best reason why the nurse should limit touch to a handshake with a client? Clients may misconstrue touch as an invitation to more intimate behavior Refusing to touch a client indicates a lack of concern Touching a client can set off a violent episode Shaking hands allows the use of touch in a professional manner | back 222 Shaking hands allows the use of touch in a professional manner The therapeutic use of touch is a basic part of the nurse-client relationship. However, in a psychiatric setting, the extent of physical contact should be limited to handshakes. Some facilities may even have a no-touch policy, especially when working with clients who have a history of sexual trauma. Even reassuring touching can be misinterpreted by the client |
front 223 A nurse is caring for a client diagnosed with end-stage heart failure. The family members are distressed about the client's impending death. Which action should the nurse do first? Ask about the family's religious affiliation and practices Recommend an easy-to-read book on grief Explore the family's past patterns for dealing with death Explain the stages of death and dying to the family | back 223 Explore the family's past patterns for dealing with death When a problem is identified, it is important for the nurse to collect accurate data. This is crucial to ensure that the client and the family's needs are addressed. But because the question is addressing the family's distress, the initial action should be directed at the family, and not the client. You should also notice that the word “death,” which is used in the question, only appears in the correct response ("exploring the family's past patterns for dealing with death.") |
front 224 The client reports seeing spiders crawling on the walls, over the bed, and on the food tray, but denies feeling spiders crawling on the skin. The nurse determines that there are no spiders in the room. Which of the following assessments should the nurse use to document these findings? (Select all that apply.) Spiders reported to be crawling on client Delusional thinking Visual hallucinations Spiders reported to be crawling on surfaces Incoherent speech Tactile hallucinations Spiders not found in the room | back 224 Visual hallucinations Spiders reported to be crawling on surfaces Spiders not found in the room Charting should be factual and not judgmental. It is important to evaluate the client's statements. The nurse looks to see if there are indeed spiders in the room surfaces. When the client sees something that is not present, this is called a visual hallucination. Because this client did not feel crawling spiders, tactile hallucinations is not an acceptable answer. |
front 225 A nursing assistant asks the nurse to explain the beliefs of a client who is a Christian Scientist and refuses admission to the hospital after being involved in a motor vehicle accident. The best response by the nurse should emphasize that the "believer" has which guiding principle? Dietary practices Spiritual healing Meditation Fasting with prayer | back 225 Spiritual healing For many Christian Scientists, they may decide to pray first about a challenge, including health issues. For the believer, medical treatments may interfere with drawing closer to God. Notice that two of the options are both associated with religion. The word “healing” in one option is a hint if it is associated with the words in the stem “motor vehicle accident.” |
front 226 The nurse is caring for a mother who has just delivered a stillborn baby. What would be the most therapeutic comment by the nurse to this grieving mother? "Tell me about your pregnancy experience." "You are young and will have other children." "You have an angel in heaven watching over you now." "Nature has a way of getting rid of the imperfect." | back 226 "Tell me about your pregnancy experience." The nurse must help the mother actualize the loss by encouraging her to talk about it. Advice and clichés are inappropriate and not comforting. |
front 227 A client of Chinese descent is admitted with the diagnosis of generalized anxiety disorder. The client is unable to provide self-care. Based on the cultural belief of yin and yang, to what should the nurse expect the client’s family to attribute this illness? Yin, the negative force that represents darkness, cold, and emptiness Yang, the positive force that represents light, warmth and fullness A failure to use homeopathy correctly Too many hot spicy foods and herbs | back 227 Yin, the negative force that represents darkness, cold, and emptiness According to Chinese folk medicine, health is represented as a balance of yin and yang. Yin is the negative female force characterized by darkness, cold and emptiness; excessive yin predisposes one to nervousness. Notice that the content of this question “yin and yang” appears in two of the options. Because the client is experiencing more negative items (“anxiety” and “cannot care for self”), eliminate the “positive force” in the one option and select the "negative force" option as the correct answer. |
front 228 A client talks about being upset after electroconvulsive therapy (ECT) because of the side effect of confusion. In the post ECT phase, the client reports losing money and an inability to remember telephone numbers. What would be the most therapeutic response by the nurse? "The confusion will clear up within 48 to 72 hours each time." "I can understand that the confusion is upsetting to you." "Your illness indicates that you needed the treatments." "We will develop a plan to prevent money and memory loss." | back 228 "I can understand that the confusion is upsetting to you." Communicating caring and empathy while acknowledging the client's feelings is the most appropriate and therapeutic response. Developing a plan for dealing with the effects of memory loss can be done later if it is agreed upon by the client. |
front 229 An Hispanic couple confides in the nurse about their concern with staff giving their newborn the "evil eye." What should the nurse communicate to the other personnel who are involved in the care of this family? Bless the newborn while speaking to the child Avoid touching the newborn Touch the newborn after looking at the child Look only at the parents and not the newborn | back 229 Touch the newborn after looking at the child In many cultures, an "evil eye" is cast when looking at a person without touching. Thus, the spell is broken by touching while looking or assessing. Remember that quotations in the stem of the question are often the most important content in the question (evil eye). You should make the association between the words “looking” and “seeing” (eye). Also note that the answer needs to refer to the newborn, not the parents (“give the newborn the evil eye”). |
front 230 The nurse is caring for a client who is being treated for major depressive disorder. During which period of time would the nurse expect the client to be at the highest risk for attempting suicide? Within 72 hours after admission, while in one-to-one observation When the client refuses to participate in group therapy sessions while hospitalized After an angry outburst with family members over some
insignificant issue | back 230 Within one to two weeks after initiation of antidepressant medication
and psychotherapy |
front 231 The nurse observes a client with a diagnosis of obsessive-compulsive disorder on an inpatient unit. Which behavior is consistent with this medical diagnosis? Repetitive, involuntary movements Verbalized suspicions about thefts on the unit Preference for consistent caregivers Repeatedly checking that a door is locked | back 231 Repeatedly checking that a door is locked Obsessive-compulsive disorder is characterized by repetitive, unwanted, intrusive thoughts (obsessions) and irrational, excessive urges to perform certain actions (compulsions.) People know their thoughts and behaviors don't make sense, but they are often unable to stop them. Verbalized suspicions reflect a paranoid thought process. Repetitive, involuntary movements are characteristic of some antipsychotic medication side effects. |
front 232 The child with this disorder has difficulties with social interaction and verbal and nonverbal communication and also exhibits repetitive behaviors. | back 232 A child with autism spectrum disorder (ASD) has difficulty with social interactions and verbal and nonverbal communication; the child also exhibits repetitive behaviors. ASD is considered a neurodevelopmental disorder. |
front 233 This disorder includes Alzheimer’s disease, traumatic brain injury and Huntington’s disease. | back 233 This group of disorders was formerly referred to as “dementia, delirium, amnestic and other cognitive disorders." |
front 234 Malabsorption syndrome and Wernicke-Korsakoff syndrome are associated with this disorder. | back 234 Nutritional deficiencies are common among clients who suffer from chronic alcohol abuse and are related to malabsorption of fat, nitrogen, sodium, water, thiamine, folic acid and vitamin B12. Wernicke-Korsakoff syndrome (also called Wernicke encephalopathy) is caused by a lack of thiamine (vitamin B1). |
front 235 A client with this disorder experiences hallucinations and delusional thoughts. | back 235 A client with schizophrenia experiences hallucinations and delusional thoughts. There are different types of schizophrenia, but often the client is unable to think rationally, communicate properly, make decisions or remember information. |
front 236 A client with this disorder recognizes their behavior is excessive and unreasonable but cannot stop the behavior. | back 236 Clients with obsessive compulsive disorder (OCD) cannot control their obsessions and/or compulsions, even though they recognize that they are unreasonable or excessive. |
front 237 “Drug holidays” are sometimes used in the management of this disorder. | back 237 A drug holiday refers to the deliberate interruption of pharmacotherapy for a defined period and for a specific clinical purpose. Sometimes a clinician will give a child with attention deficit hyperactivity disorder (ADHD) a "vacation" from medications on weekends or during summer break from school. |
front 238 A client with this disorder may experience drastic changes in mood accompanied by extreme changes in energy, activity, sleep and behavior. | back 238 Clients with bipolar disorder may experience mood swings ranging from mania to depression, with periods of normal mood and activity in between. Sometimes the mood swings can be unusually intense or extreme; at other times, they are less extreme. |
front 239 Russell’s sign is observed with this disorder. | back 239 A person who repeatedly self-induces vomiting will have scraped or raw areas on the knuckles. Bulimia nervosa is a type of eating disorder that involves binging (eating large amounts of food) and purging (vomiting). |
front 240 Electroconvulsive therapy (ECT) is used to treat a severe form of this disorder. | back 240 ECT can be used as a treatment for severe depression when medication does not ease the symptoms of clinical depression. ECT is not a cure for depression. ECT can also be used to treat clients with symptoms of delusions, hallucinations or suicidal thoughts. |
front 241 The only FDA-approved type of medications used to treat this disorder are selective serotonin reuptake inhibitors (SSRIs.) | back 241 Sertraline (Zoloft) and paroxetine (Paxil) are FDA-approved to treat PTSD. Other medications may be used off-label or as adjunct treatment. For example, prazosin (Minipress) may be used to decrease nightmares. |
front 242 Religious beliefs influence decisions about health. T/F | back 242 True |
front 243 Nurses must be aware of their own cultural values and beliefs to avoid biases when providing care to clients. T/F | back 243 True |
front 244 The nurse should write everything down for the client with Wernicke's aphasia. T/F | back 244 False |
front 245 Mental health disorders and substance use disorder rarely occurs together. T/F | back 245 False |
front 246 Liquid medications are best for clients who are on suicide
precautions. | back 246 True |
front 247 Stress activates the parasympathetic nervous system. T/F | back 247 False |
front 248 Primitive defense mechanisms are very effective for long-term use. T/F | back 248 False People use defense mechanisms to protect themselves from things they don't want to think about or deal with. Primitive defense mechanisms, such as denial, regression, acting out and projection, are often used by children and can have short-term advantages, but become less effective when used long term. |
front 249 The grieving process lasts for approximately one year. T/F | back 249 False |
front 250 Only young clients suffer from abuse. T/F | back 250 False |
front 251 The nurse-client relationship is a mutually defined, social relationship. | back 251 False |
front 252 The client had a long leg hinged cast applied following surgery to realign a fractured tibia. When the client returns from surgery, what initial intervention to increase mobility will be reinforced? Full active range of motion of the knee Muscle-setting exercises Partial weight-bearing exercises with crutches Call for assistance before transferring to the wheelchair | back 252 Muscle-setting exercises The client will use crutches (or a walker) and will be non-weight bearing for up to 12 weeks or until the tibia fracture has healed. Active and passive range of motion exercises will be prescribed, but initially, the nurse should encourage the client to perform basic isometric exercises like quadriceps setting, wiggling the toes and ankle exercises. When the cast is dry, the client can be allowed up in a chair or wheelchair with the leg elevated. |
front 253 The nurse is caring for a client who is paralyzed. What observation of the client would indicate the probable presence of a fecal impaction? Semisoft to liquid stools Oozing liquid stool Continuous rumbling flatulence Absence of bowel movements | back 253 Oozing liquid stool When the bowel is impacted with hardened feces, there is often a frequent seepage of brownish liquid around the obstruction. This is often mistaken for uncontrolled diarrhea. Be careful to report only the objective facts; for example, the the client is oozing brownish liquid from the rectum. |
front 254 The nurse is caring for an infant with six teeth. What is the best way for the nurse to give mouth care to this infant? Brush with a little toothpaste and floss each tooth Offer a bottle of water for the infant to drink Swab the teeth and gums with a flavored mouthwash Use a moistened soft brush or cloth to clean the teeth and gums | back 254 Use a moistened soft brush or cloth to clean the teeth and gums The nurse should use a soft cloth or soft brush to perform mouth care so that the infant can adjust to the routine of cleaning the mouth and teeth. You will note that two of the options refer to "brush" the teeth, but that the word "soft" is used in the correct option (which would make sense because the client is an infant). Based on the number of teeth, this infant is most likely between 8 and 12 months of age. |
front 255 A 69 year-old client states that he experiences the passage of hard dry stools at least twice a week. To improve bowel function, the nurse should suggest that the client take which of these actions first? Use a chemical laxative occasionally Increase fiber intake to include 20 to 30 grams daily Avoid binding foods such as cheese and chocolate Monitor the balance between activity and rest | back 255 Increase fiber intake to include 20 to 30 grams daily Incorporating high-fiber foods, especially whole grains, fruits and vegetables, into the diet is the first step in improving bowel function. For someone eating 2000 calories a day, this would work out to be about 25 grams of fiber. The client should also increase fluid intake. Changing a person's diet should reduce the need for chemical laxatives. |
front 256 A nurse is providing care to a 75 year-old adult client diagnosed with bilateral pneumonia. Which intervention will best promote the client’s comfort? Increase oral fluid intake Keep conversations short Monitor vital signs frequently Encourage visits from family and friends | back 256 Keep conversations short Keeping conversations short will promote the older adult client’s comfort by decreasing the demands on the client’s breathing and energy. Increased intake of fluids is not related to comfort. While the presence of family is supportive, demands on the client to interact with the visitors may interfere with the client’s rest. Monitoring vital signs is an important assessment but not related to promoting the client’s comfort. |
front 257 A 2 year-old child is brought to the pediatrician's office with a report of mild diarrhea for two days. Nutritional counseling by the nurse would reinforce which information? Place the child on clear liquids and gelatin for 24 hours Place NPO for 24 hours, then rehydrate with liquids Give bananas, apples, rice and toast as tolerated Continue with a regular diet and include oral electrolyte replacement drinks | back 257 Continue with a regular diet and include oral electrolyte replacement
drinks |
front 258 The client is grimacing, crying and reports having pain. What is the first step the nurse should take when collecting data about the client's pain? Ask the client to indicate the location of the pain Accept the client’s report of pain Have the client identify coping methods Determine the severity and duration of pain | back 258 Accept the client’s report of pain Although all of the actions are correct, the first and most important piece of information for data collection is to accept what the client is telling about the pain, i.e., “the client’s report.” |
front 259 During a 12-hour shift, a client who underwent a transurethral
resection of the prostate (TURP), had an IV intake of 1200 mL, oral
intake of 400 mL, continuous bladder irrigation of 2400 mL, 2 syringe
flushes of 50 mL each, and indwelling urinary catheter output of 3000
mL. | back 259 4100mL. (1200 mL + 400 mL + 2400 mL + 100 mL) = 4100 mL. The amount of irrigation fluid must be included in intake; only the urine collected from the indwelling urinary catheter is considered output. |
front 260 The client is diagnosed with Ménière's disease. The nurse should reinforce that the client modify the diet by avoiding foods high in which substance? Carbohydrates Fiber Calcium Sodium | back 260 Sodium The client with Meniere's disease has an excess accumulation of fluid in the inner ear. A low sodium diet will aid in reduction of the fluid. If you are not sure about which answer to select, look at the "similar/dissimilar" options; in this case, it's the two minerals: calcium and sodium. Then you should consider which mineral is typically restricted in diets: calcium or sodium? |
front 261 A client diagnosed with heart failure has been instructed about proper nutrition associated with the disease process. The selection of which lunch items by the client indicates that the client has learned about sodium restriction? Leftover turkey on a sandwich and fresh pineapple Mushroom pizza and ice cream Grilled cheese sandwich with a glass of 2% milk Cheeseburger and baked potato chips | back 261 Leftover turkey on a sandwich and fresh pineapple A turkey sandwich using leftover turkey (as opposed to sliced lunch meat) is appropriate because it is not a highly processed food and fresh pineapple has low sodium. Any food with more than 480 mg of sodium per serving should be considered a high-sodium food. A sodium restricted diet should consist of less than 2 grams of sodium per day. A regular diet should include 4 to 6 grams of sodium per day. All the other choices contain one or more high-sodium foods. |
front 262 The nurse is reviewing proper nutrition with a client who has a history of emphysema. Which action should the clinic nurse emphasize to the client? Cleanse the mouth of dried secretions to reduce the risk of infection Perform exercises after respiratory treatments to enhance appetite Eat foods high in sodium to increase sputum liquefaction Use oxygen during meals to minimize oxygen deficits | back 262 Use oxygen during meals to minimize oxygen deficits |
front 263 The nurse is reinforcing foot care instructions to a client with a history of arterial insufficiency of the legs. The nurse should identify which client's statement as incorrect? "I will trim corns and calluses regularly." "I will ask a family member to help inspect my feet." "I can only wear cotton socks." "I should not go barefoot around my house." | back 263 "I will trim corns and calluses regularly." Clients who have diabetes mellitus, and/or have arterial peripheral vascular disease, often have decreased circulation and sensation in one or both feet. With older adults vision may also be impaired. Therefore, these clients need to be taught to examine their feet daily or have someone else do so. They should wear cotton socks that have not been mended and always wear shoes or slippers when out of bed. They should not cut their toenails, corns and calluses by themselves; they should have them trimmed by providers who specialize in foot care. |
front 264 The client is diagnosed with type 2 diabetes. What information about diet should the nurse reinforce with the client? Keep a candy bar available for hypoglycemic episodes Continue the same caloric intake but cut down on complex carbohydrates Reduce intake of carbohydrates to 30% and intake of protein to 15% Improve food choices but continue a regular schedule of meals and snacks | back 264 Improve food choices but continue a regular schedule of meals and
snacks |
front 265 An 82 year-old client reports being unable to completely empty the bladder and feeling bloated and uncomfortable. What additional finding does the nurse expect and need to report to the health care provider right away? Inadequate fiber in the diet Excess abdominal fat Acid reflux and indigestion Fecal impaction | back 265 Fecal impaction |
front 266 The client is diagnosed with cystic fibrosis (CF). The nurse would expect the client to be treated with oral pancreatic enzymes and which type of diet? Dairy-free Gluten-free, low fiber Sodium-restricted High fat, high-calorie | back 266 High fat, high-calorie |
front 267 The mother of a 3 month-old infant tells the nurse, “I want to change from formula to whole milk and add cereal and meats to my infant’s diet.” What should be emphasized as the nurse reinforces information about correct infant nutrition? Solid foods should be introduced at three to four months Tap water with fluoride should be used to dilute the milk Supplemental apple juice can be used between feedings Whole milk is difficult for a younger infant to digest | back 267 Whole milk is difficult for a younger infant to digest |
front 268 A 14 month-old child had cleft palate surgical repair several days ago. Which lunch selected by the parents is the best example of an appropriate meal? Baked chicken, applesauce, cookie, milk Peanut butter and jelly sandwich, chips, pudding, milk Soup, blenderized soft foods, ice cream, milk Hot dog, carrot sticks, gelatin, milk | back 268 Soup, blenderized soft foods, ice cream, milk In a child with cleft palate repair, the parents should prepare soft foods and avoid those foods with particles that might traumatize the surgical site. The key to answering this question is to pay attention to the age of the child. Also, focus on the words "best" and "cleft palate repair several days ago." Only the correct answer has all "soft" foods in the response. |
front 269 An obese client tells the nurse: "I just started a diet and I am eating no more than 800 calories a day." What information is most important for the nurse to know in order to therapeutically respond to this statement? This diet is classified as low calorie and adequate if balanced with 1 meat, 1 fruit, and 2 fat exchanges Very low-calorie diets often have severe and irreversible side effects A very low-calorie diet is never a successful weight loss program and should be discouraged Individuals following a very low-calorie diet need professional monitoring | back 269 Individuals following a very low-calorie diet need professional
monitoring |
front 270 The nurse is caring for a preschooler who has the left leg in balanced skeletal traction. Which activity would be an appropriate diversional activity? Play electronic hand-held games Play "Simon Says" Kick balloons with right leg Throw bean bags | back 270 Play electronic hand-held games Immobilization with traction must be maintained until bone ends are in satisfactory alignment. Activities that increase mobility interfere with the goals of treatment. |
front 271 The nurse documents “effective use of guided imagery to change report of pain from a 4 to a 1.” Which definition best describes this technique? Closing the eyes to focus on the back of the eyelids or a blank screen Inhalation to a count of four and exhalation to a count of four Focusing on pleasant mental pictures of a relaxing scene Repetition of a word to oneself while thinking of only the word | back 271 Focusing on pleasant mental pictures of a relaxing scene Guided imagery is a technique that uses pleasant mental visuals of a relaxing scene that can be recalled by the client to reduce stress, anxiety or pain. Repeating a word to oneself describes meditation. Closing the eyes and focusing on a blank screen is also a form of meditation; a person uses a mental picture of a blank black screen and attempts to think of nothing. Counting while breathing is considered slow deep breathing. |
front 272 Neuropathic pain is also called musculoskeletal pain. T/F | back 272 False |
front 273 The client with a sigmoid colectomy will have semi-liquid stool collect in a colostomy bag. T/F | back 273 False |
front 274 A 7-year-old child can be taught to self-catheterize him or herself. T/F | back 274 True |
front 275 Urinary incontinence is a normal part of aging. T/F | back 275 False |
front 276 The nurse will hold a tube feeding when the gastric residual is greater than 100-150 mL. T/F | back 276 False |
front 277 A client with gout is prescribed a pureed diet. T/F | back 277 False |
front 278 The thirst center is located in the parathyroid gland. T/F | back 278 False |
front 279 Complementary & integrated health therapies replace the need for pharmacologic interventions. T/F | back 279 False |
front 280 Iron is one of the macrominerals found in a healthy human body. T/F | back 280 False |
front 281 The client using a cane should hold it on his strong side and move the cane at the same time as the weaker leg. T/F | back 281 True |
front 282 Clients with insomnia either have difficulty falling asleep or staying asleep. T/F | back 282 True |
front 283 Glucose is the only fuel used by brain cells. T/F | back 283 True |
front 284 Less than 4 to 8 wet diapers a day may be a sign of dehydration in a baby. T/F | back 284 True |
front 285 Women who are planning on becoming pregnant need about 200 ug/day of folic acid. T/F | back 285 False |
front 286 Protein is the body's only source of nitrogen. T/F | back 286 True |
front 287 The nurse can use the deltoid muscle, vastus lateralis muscle, ventrogluteal muscle and dorsogluteal muscle to administer an intramuscular injection. T/F | back 287 False |
front 288 Hypovolemia is a risk for the client receiving whole blood products. T/F | back 288 False |
front 289 The nurse can crush the oral medication disopyramide CR and mix it with applesauce. T/F | back 289 False |
front 290 Clients increase their risk of adverse effects if they use herbal supplements along with prescription medications. T/F | back 290 True |
front 291 Lactated Ringer's (LR) solution is a hypotonic fluid. T/F | back 291 False |
front 292 An elderly client is more sensitive to the active substance in a transdermal patch than a younger adult. T/F | back 292 True |
front 293 A nurse should ask a client with emphysema to bear down during the insertion of a non-tunneled central venous catheter (CVC). T/F | back 293 True |
front 294 Examples of Schedule I medications include morphine and secobarbital. T/F | back 294 False |
front 295 Sublingual medications avoid the first-pass effect. T/F | back 295 True |
front 296 The nurse applies mild pressure to the inner canthus of the eye after instilling eye drop medication. T/F | back 296 True |
front 297 Furosemide is a potassium-sparing diuretic. T/F | back 297 False |
front 298 Ondansetron is given to prevent nausea and vomiting caused by cancer chemotherapy. T/F | back 298 True |
front 299 Propofol is a long-acting sedative used for many surgical procedures. T/F | back 299 False |
front 300 For clients at risk for cardiovascular disease, the usual oral daily dose of aspirin is 2 tablets (650 mg total). T/F | back 300 False |
front 301 Calcium channel blockers can cause severe constipation in older adults. T/F | back 301 True |
front 302 Regular insulin intravenous infusions are mixed in 5% dextrose in water. T/F | back 302 False |
front 303 The client should use a dry-powder inhaler as rescue therapy during acute asthma attacks. T/F | back 303 False |
front 304 To help reduce stomach upset, a client can take an antacid at the same time as almost any other oral medication. T/F | back 304 False |
front 305 The client taking chlorpromazine should avoid saunas and temperature extremes. T/F | back 305 True |
front 306 Clients receiving organ transplants are often started on cyclosporine after surgery. T/F | back 306 True |
front 307 The nurse instructs the client to take no more than 2 extra-strength acetaminophen tablets (1000 mg) 4 times a day. T/F | back 307 True |
front 308 The client should take levothyroxine immediately after breakfast. T/F | back 308 False |
front 309 The nurse should check the international normalization ratio (INR) lab results prior to hanging intravenous heparin. T/F | back 309 False |
front 310 Extended-release oral potassium chloride (KCl) should be taken with meals and a full 8-ounce (236 mL) glass of water. T/F | back 310 True |
front 311 Naloxone is used to counteract the respiratory depression associated with barbiturate overdose. T/F | back 311 False |
front 312 What is the drug classification for: | back 312 Bone Resorption Inhibitors bind to hydroxyapatite in bone and inhibit bone resorption by decreasing the number and activity of osteoclasts. They are primarily used in the prevention and treatment osteoporosis in postmenopausal women; they are also used to treat osteoporosis due to other causes, e.g., Paget’s disease of the bone and corticosteroid therapy. |
front 313 What is the drug classification for: | back 313 Some Antirheumatics relieve pain (analgesics), some reduce inflammation (NSAIDs & steroids), while others control the underlying disease (disease modifying rheumatoid arthritis drugs or DMARDs & biologic drugs, like infliximab). DMARDs are used as long-term solutions to control symptoms of rheumatoid arthritis by slowing down joint destruction and preserving joint function. Biologic agents (IM or IV only) target specific components of the immune system; biologic agents may be used alone, but are often given with other DMARDs to increase the benefits and limit potential side effects. |
front 314 What is the drug classification for: | back 314 ACE Inhibitors slow the activity of the enzyme angiotensin converting enzyme (ACE), which decreases the production of angiotensin II. As a result, blood vessels relax and dilate, blood pressure is lowered, and more oxygen-rich blood can reach the heart. They are primarily used to control blood pressure, treat heart failure, and to help prevent strokes. |
front 315 What is the drug classification for: | back 315 Antituberculars have various actions that affect mycobacteria, with most having bactericidal (for example, rifampin) and/or bacteriostatic (for example, isoniazid) actions. They used in the treatment and prevention of tuberculosis (TB). |
front 316 What is the drug classification for: | back 316 Osmotic Diuretics are low-molecular-weight substances that produce a rapid loss of sodium and water by inhibiting their reabsorption in the kidney tubules and the loop of Henle. They also increase the osmolality of plasma, which increases diffusion of water from the intraocular and cerebrospinal fluids. They are mainly used in the management of cerebral edema to decrease intracranial pressure. |
front 317 What is the drug classification for: | back 317 Calcium Channel Blockers (CCBs) slow the rate at which calcium passes into the heart muscle and into the vessel walls; this relaxes the vessels and allows blood to flow more easily through them, thereby lowering blood pressure. They are used to treat hypertension, angina, and abnormal heart rhythms (atrial fibrillation, paroxysmal supraventricular tachycardia). They are also used for client post-MI who cannot tolerate beta-blockers. |
front 318 What is the drug classification for: | back 318 Beta Blockers block norepinephrine and epinephrine from binding to beta receptors on nerves. By blocking the effects of these neurotransmitters, they reduce heart rate and reduce blood pressure by dilating blood vessels. They are used to treat hypertension; heart failure; arrhythmias; angina (but not for immediate relief); glaucoma (ophthalmic); sometimes used in heart attack patients to prevent future heart attacks; also used prophylactically for migraine headaches. |
front 319 What is the drug classification for: | back 319 Minerals/electrolytes/pH modifiers are taken to correct imbalances of substances in the blood (minerals and electrolytes) or to make the urine more alkaline (pH modifiers). They are used in the prevention and treatment of any deficiencies or excesses of electrolytes. Acidifiers and alkalinizers are also used to prevent crystals from forming in the urine and inhibit the formation of kidney stones. Magnesium sulfate is used for pre-eclampsia and eclampsia. Some of these meds are used to neutralize gastric acid. |
front 320 What is the drug classification for: | back 320 Non-steroidal Anti-inflammatory Drugs (NSAIDs) block the cyclooxygenase (COX-1 & COX-2) enzymes and reduce prostaglandins throughout the body, thereby reducing inflammation, pain, and fever. They are used to control mild-to-moderate pain, reduce fever, and to treat various inflammatory conditions, such as osteoarthritis. |
front 321 What is the drug classification for: | back 321 Opioid Analgesics interact with opioid receptors in the central nervous system, acting as agonists of endogenously occurring opioid peptides (eukephalins and endorphins); this action alters perception and response to pain. They can be categorized as long-acting, short-acting, or rapid-onset agents. Fentanyl is a rapid-acting and long-acting Opioid Analgesic approved for cancer breakthrough pain. They are all Schedule II drugs. They are used in the management of moderate-to-severe pain. |
front 322 What is the drug classification for: | back 322 Antivirals are designed to work in one of two ways - they either inhibit the ability to multiply or they mimic the virus attachment protein, disrupting the replication process. They are commonly used in the management, prevention, and/or treatment of viral infections, such as HIV, herpes simplex and cytomegalovirus, pneumonia, measles and mumps, and influenza strains (including swine flu). |
front 323 What is the drug classification for: | back 323 Some Oral Antidiabetic Agents (sulfonylureas and meglitinides) work by stimulating insulin release from the beta cells of the pancreas - glipizide is a sulfonylurea. Other (biguanides) improve insulin’s ability to move glucose into cells, especially muscle cells. Some (thiazolidinediones) enhance insulin effectiveness in both muscle and adipose tissue. Others (alpha-glucosidase inhibitors) block enzymes that help digest starches, slowing the rise in blood sugar. These medications are used to treat type 2 diabetes mellitus. |
front 324 What is the drug classification for: | back 324 Antiplatelet Agents block the formation of blood clots by preventing the clumping of platelets. They are used to treat and prevent thromboembolic events, e.g., stroke, myocardial infarction, peripheral vascular disease. They are used after stent, artificial heart values, and other devices that are placed inside the heart or blood vessels. |
front 325 What is the drug classification for: | back 325 Rapid-acting insulin, such as insulin lispro, covers insulin needs for meals eaten at the same time as the injection. Short-acting insulin covers insulin needs for meals eaten within 30 to 60 minutes. Intermediate-acting insulin covers insulin needs for about half of the day or overnight (and is often combined with rapid- or short-acting insulin). Long-acting insulin covers insulin needs for about one full day. Insulin is used in the treatment of type 1 diabetes mellitus and may be used to treat type 2 diabetes mellitus. |
front 326 What is the drug classification for: | back 326 Thrombolytics convert plasminogen to plasmin, which then degrades fibrin in clots. They are used for the acute management of coronary thrombosis (MI), massive pulmonary emboli, deep vein thrombosis, and arterial thromboembolism. |
front 327 What is the drug classification for: | back 327 Selective Serotonin Reuptake Inhibitors (SSRIs) block the reabsorption (reuptake) of serotonin. They are used primarily to treat moderate-to-severe depression and chronic fatigue syndrome; they may also be used to treat premenstrual dysphoric disorder, obsessive-compulsive disorder, panic disorder, post-traumatic stress disorder, and generalized anxiety disorder. |
front 328 What is the drug classification for: | back 328 Penicillins belong to a group of antibiotics called beta-lactams, which exert bactericidal action by inhibiting bacterial cell wall production. Currently the group includes more than 20 antibiotics. Used in the treatment and prophylaxis of wide range of bacterial infections including streptococcal infections, syphilis and Lyme disease. |
front 329 What is the drug classification for: | back 329 Monoamine oxidase inhibitors (MAOIs) prevent the enzyme monamine oxidase from breaking down the neurotransmitters norepinephrine and serotonin (also known as monoamines) in the brain. They are typically used to treat depression. |
front 330 What is the drug classification for: | back 330 Immunosuppressants inhibit cell-mediated immune responses. Azathioprine can also be categorized as an Antirheumatic. Most of these drugs are used in the prevention of transplantation rejection reactions; others are used in the management of selected autoimmune diseases (for example, nephritic syndrome of childhood and severe rheumatoid arthritis). |
front 331 What is the drug classification for: | back 331 Cephalosporins belong to a group of broad spectrum, semi-synthetic beta-lactam antibiotics derived from the mold Cephalosporium. The mechanism of action is the same as penicillins (they interfere with bacterial cell wall synthesis). An example of a 1st generation Cephalosporin is cephalexin. They are mainly used in the treatment and prophylaxis of a wide variety of bacterial infections, such as respiratory tract infections, skin and soft-tissue infections, and urinary tract infections. |
front 332 What is the drug classification for: | back 332 Some Vascular Headache Suppressants(ergot derivatives) directly stimulate alpha-adrenergic and serotonergic receptors, producing vascular smooth muscle vasoconstriction. Others (5-HT1 or selective serotonin receptor agonists, such as sumatriptan) work by narrowing dilated blood vessels and blocking nerves from transmitting signals of pain to the brain. They are used for the treatment of vascular headaches (migraines and cluster headaches). |
front 333 What is the drug classification for: | back 333 Skeletal Muscle Relaxants act centrally on the spinal cord or brain stem and inhibit neuronal transmission; dantrolene is the only one that acts directly on skeletal muscle. These medications are typically classified by their pharmacologic properties as either antispasticity (baclofen & tizanidine) or antispasmodic (cyclobenzaprine & carisoprodol) agents. These drugs are used to treat spasticity associated with spinal cord diseases (such as cerebral palsy, multiple sclerosis) or lesions; they may also be used as adjunctive therapy in the symptomatic relief of acute painful musculoskeletal conditions |
front 334 What is the drug classification for: | back 334 Non-steroidal Anti-inflammatory Drugs (NSAIDs) block the cyclooxygenase (COX-1 & COX-2) enzymes and reduce prostaglandins throughout the body, thereby reducing inflammation, pain, and fever. They are used to control mild-to-moderate pain, reduce fever, and to treat various inflammatory conditions, such as osteoarthritis. |
front 335 What is the drug classification for: | back 335 Anticoagulants work by inhibiting clotting factor synthesis, inhibiting thrombin, or by interfering with blood platelet formation. Enoxaparin is classified as a low-molecular-weight heparin (LMWH). They are used to prevent or treat blood clots associated with stroke, heart attack, heart valve disease, coronary artery disease, heart failure, arrhythmia, atrial fibrillation, deep vein thrombosis, and pulmonary embolism. |
front 336 What is the drug classification for: | back 336 Nonopioid Analgesics target and block the chemical substances released by the brain in response to injury (particularly prostaglandin) that facilitate the transmission of the pain stimuli to the brain. These drugs are used to control mild-to-moderate pain and/or fever. |
front 337 What is the drug classification for: | back 337 Antineoplastics inhibit or prevent the development, maturation or spread of neoplastic cells by various different mechanisms of action. Many damage the DNA of cancer cells; others interfere with the cancer cell's metabolism or affect cell division (methotrexate is classified as an antimetabolite); still others create an unfavorable environment for cancer cell growth (hormones). Methotrexate is also listed in the drug category: Antirheumatic. They are used in the treatment of various solid tumors, lymphomas, and leukemias. They may also be used in some autoimmune disorders (such as rheumatoid arthritis). |
front 338 What is the drug classification for: | back 338 Antiasthmatics either relax the smooth muscles that line the airway (bronchodilators), block the inflammation that narrows the airways (corticosteroids), counteract substances that cause the air passages to constrict and secrete mucus (leukotriene modifiers), or prevent allergic reactions or asthma symptoms. Montelukastis aleukotriene antagonist; it can also be categorized as a Bronchodilator. They are used in the management of acute and chronic episodes of reversible bronchoconstriction associated with asthma. The goal of therapy is to treat acute attacks (short-term control) and to decrease incidence and intensity of future attacks (long-term control). |
front 339 What is the drug classification for: | back 339 Tetracyclines exert their bacteriostatic effect by inhibiting protein synthesis in bacteria. They are broad spectrum anti-infectives. They are typically used in the treatment of respiratory tract infections, acne and skin infections, genital infections (syphilis, Chlamydia), urinary tract infections, Lyme disease, mycoplasmal infections and rickettsial infections and the infection that causes stomach ulcers (helicobacter pylori). |
front 340 What is the drug classification for: | back 340 Some Anticonvulsants are thought to generally depress central nervous system function. Others (such as GABA inhibitors) are thought to target specific neurochemical processes, suppress excess neuron function, and regulate electrochemical signals in the brain. Clonazepam is also categorized as a Benzodiazepine. They are primarily used to help control epileptic seizures; they are also used to treat neuropathic pain (associated with diabetes, shingles, and fibromyalgia), migraine headaches, and bipolar disorder. |
front 341 What is the drug classification for: | back 341 Sulfonamides are bacteriostatic and have a broad spectrum of activity against both gram-positive and gram-negative bacteria. They are typically used in the treatment of urinary tract infections and also some types of bacterial pneumonia (Pneumocystis Carinii), shigellosis, as well as some protozoal infections. |
front 342 What is the drug classification for: | back 342 Antianginals are vasodilators - they dilate the blood vessels, improving blood flow and allowing more oxygen-rich blood to reach the heart muscle and they also relax the veins. They are used to treat and prevent attacks of (acute) angina. |
front 343 What is the drug classification for: | back 343 Benzodiazepinesde press the CNS, probably by potentiating GABA, which is an inhibitory neurotransmitter. Midazolamcan also be categorized as a Sedative/Hypnotic. These are all Schedule IV drugs. They are primarily used to produce sedation, induce sleep, relieve anxiety and muscle spasms, and to prevent seizures. Midazolam is used as an agent for sedation/anxiolysis/amnesia |
front 344 What is the drug classification for: | back 344 Some Antiarrhythmics slow down the heart (the calcium channel blockers, digoxin, and beta-blockers); other slow the heart’s electrical impulses by blocking the heart’s potassium channels (amiodarone, sotalol, dofetilide). They are generally classified by their effects on cardiac conduction tissue (Class IA, IB, IC, II, III, IV). Flecainide is in Class IC. They are used in the suppression of (potentially lethal) cardiac arrhythmias. |
front 345 What is the drug classification for: | back 345 The action of Macrolides is mainly bacteriostatic. They are used in the treatment of various systemic and local bacterial infections of the respiratory tract, gastrointestinal tract, and soft tissues; they are also effective in treating severe acne and sexually transmitted infections. They are used prophylactically in the prevention of whopping cough and the prevention of endocarditis in dentistry. |
front 346 What is the drug classification for: | back 346 Angiotensin Receptor Blockers block the action of angiotensin II by preventing angiotensin II from binding to angiotensin II receptors on blood vessels. As a result, blood vessels enlarge (dilate) and blood pressure is reduced. They are primarily used to control high blood pressure and treat heart failure. In addition, they slow the progression of kidney disease due to high blood pressure or diabetes. |
front 347 What is the drug classification for: | back 347 Some Antiemetics may inhibit the chemoreceptor trigger zone in the medulla by blocking dopamine receptors; others act by decreasing the sensitivity of the vestibular apparatus. Phenergan has different effects on the brain - both antihistamine and anticholinergic activity. They are used to manage the various causes of nausea and vomiting, including surgery, anesthesia, antineoplastic and radiation therapy, and motion sickness. |
front 348 What is the drug classification for: | back 348 Aminoglycosides are bactericidal; they primarily act by inhibiting protein synthesis in bacteria and compromising the structure of the bacterial cell wall. They are used in the treatment and prophylaxis of severe infections, such as septicemia, severe urinary tract infections, and hospital-acquired respiratory infections, caused by aerobic, gram-negative bacteria, e.g., as Escherichia coli and Klebsiella species. |
front 349 What is the drug classification for: | back 349 Laxatives are typically classified as either bulk-forming agents, osmotics, salines, stimulants (such as bisacodyl) or stool softeners. They are used to treat or prevent constipation or to prepare the bowel for radiologic or endoscopic procedures. |
front 350 What is the drug classification for: | back 350 Antidiarrheals work in a variety of ways. Some slow the passage of stools through the intestines (like loperamide). Others decrease the secretion of fluid into the intestine and inhibit the activity of bacteria (bismuth subsalicylate). They are used to control and to provide symptomatic relief of acute and chronic nonspecific diarrhea. |
front 351 What is the drug classification for: | back 351 Some of these Oral Antidiabetics (sulfonylureas and meglitinides) work by stimulating insulin release from the beta cells of the pancreas. Other (biguanides) improve insulin’s ability to move glucose into cells, especially muscle cells. Some (thiazolidinediones - like rosiglitazone) enhance insulin effectiveness in both muscle and adipose tissue. Others (alpha-glucosidase inhibitors) block enzymes that help digest starches, slowing the rise in blood sugar. These medications are used to treat type 2 diabetes mellitus. |
front 352 What is the drug classification for: | back 352 Corticosteroids mimic the effect of hormones produced naturally by the adrenal glands. When the dose exceeds the body's usual hormone levels, they will suppress inflammation, as well as the immune system; they are also used for their antineoplastic activity. Oral forms are used to treat inflammation and pain associated with arthritis and autoimmune diseases (such as lupus, Crohn's). Inhaled medications are used to treat asthma and allergies. Topical applications help heal skin conditions. The injected forms are used treat the pain and inflammation of arthritis, gout and other inflammatory diseases. |
front 353 What is the drug classification for: | back 353 Bronchodilators relax bronchial smooth muscle. Relaxing these muscles makes the airways larger and allows air to pass through the lungs. Some also increase mucociliary clearance (beta agonists). Albuterol (Proventil) is a short-acting (or rescue) medication and can also be categorized as an Antiasthmatic. Short-acting medications are used as needed as asthma "rescue" medications. Long-acting medications are used every day to control asthma in conjunction with an inhaled steroid. |
front 354 What is the drug classification for: | back 354 Beta Blockers block norepinephrine and epinephrine from binding to beta receptors on nerves. By blocking the effects of these neurotransmitters, they reduce heart rate and reduce blood pressure by dilating blood vessels. The spelling of many beta blockers often end with “lol.” They are used to treat hypertension; heart failure; arrhythmias; angina; glaucoma (ophthalmic); sometimes used in heart attack patients to prevent future heart attacks; also used prophylactically for migraine headaches. |
front 355 What is the drug classification for: | back 355 Antipsychotics work by blocking a specific subtype of the dopamine receptor (the D2 receptor). The 2nd generation of these medications not only block D2 receptors but also a specific subtype of serotonin receptor (5HR2A receptor). Risperidone (Risperdal) is a 2nd generation antipsychotic. They are used in the treatment of acute and chronic psychosis, especially when accompanied by increased psychomotor activity. Off-label uses include Tourette’s syndrome, substance abuse, stuttering, obsessive-compulsive disorder, post-traumatic stress disorder, depression, bipolar disorder and personality disorders. |
front 356 What is the drug classification for: | back 356 Antihistamines compete with histamine for histamine receptor sites and when they occupy the histamine receptor sites, they prevent histamine from causing allergic symptoms. They are used for relief of symptoms associated with allergies (including rhinitis, urticaria and angioedema) and as adjunctive therapy in anaphylactic reactions. Some are used to treat insomnia (diphenhydramine), motion sickness (dimenhydrinate and meclizine), Parkinson-like reactions (diphenhydramine), and other nonallergic conditions. |
front 357 What is the drug classification for: | back 357 Antifungal agents are also called antimycotic agents; they kill or inactivate fungi. They are used to treat systemic, localized, or topical fungal infections (including yeast infections). |
front 358 What is the drug classification for: | back 358 Tricyclic Antidepressants inhibit the nerve cell's ability to reuptake serotonin and norepinephrine, resulting in increased levels of these neurotransmitters in the brain. They also block the action of acetylcholine and histamine (which causes many of the side effects of these meds). They are used to relieve depression and may also be used to treat obsessive compulsive disorder and bedwetting. Off-label uses include panic disorder, bulimia, and chronic pain (migraine, diabetic neuropathy & post herpetic neuralgia). |
front 359 What is the drug classification for: | back 359 Serotonin and Norepinephrine Reuptake Inhibitors (SNRIs) block or delay the reuptake of serotonin and norepinephrine by the presynaptic nerves. The increased levels of these neurotransmitters elevates mood. They are primarily used to treat depression, but are also used to treat anxiety disorder, panic disorder and other mood disorders. |
front 360 What is the drug classification for: | back 360 Some of these Antiparkinson Agents replenish dopamine, while others mimic the role of dopamine or block the effects of other chemicals that cause problems in the brain when dopamine levels drop. Ropinirole (Requip) is a dopamine agonist. They are used to help relieve the symptoms of parkinsonism (such as tremor or trembling in the hands, arms, legs, jaw, and face; stiffness or rigidity of the arms, legs, and trunk; bradykinesia; poor balance and coordination). |
front 361 What is the drug classification for: | back 361 Some of these Anti-Alzheimer's Agents (cholinesterase inhibitors, like donepezil) are thought to prevent the breakdown of acetylcholine by blocking the activity of acetylcholinesterase. Others (NMDA receptor antagonists) helps regulate the activity of glutamate, a chemical involved in the processing, storage and retrieval of information. They are used to treat Alzheimer's disease. |
front 362 What is the drug classification for: | back 362 Thiazide Diuretics are derived from a chemical called benzothiadi(A)zene. They work in the distal convoluted tubule by decreasing the kidney’s reabsorption of sodium and chloride (which results in increased urine production) and they also help dilate blood vessels. They are used alone or in combination with loop diuretics in the treatment of hypertension or edema due to heart failure or other causes. |
front 363 What is the drug classification for: | back 363 Calcium Channel Blockers slow the rate at which calcium passes into the heart muscle and into the vessel walls; this relaxes the vessels and allows blood to flow more easily through them, thereby lowering blood pressure. They are used to treat hypertension, angina, and abnormal heart rhythms (atrial fibrillation, paroxysmal supraventricular tachycardia). They are also used for client post-MI who cannot tolerate beta-blockers. |
front 364 What is the drug classification for: | back 364 Potassium-sparing Diuretics are used to conserve potassium in clients receiving thiazide or loop diuretics; they decrease sodium reabsorption in the collecting tubules of the kidneys. They are often used in clients with heart failure; they do not significantly lower blood pressure. |
front 365 What is the drug classification for: | back 365 Some of the Antiulcer Agents (PPIs) block the secretion of gastric acid by the gastric parietal cells (one example is pantoprazole). Others (H-2 receptor blockers) stop the action of histamine on the gastric parietal cells, which inhibits the secretion of gastric acid. Remember, the spelling of PPIs often end with "prazole." These drugs are used in the treatment and prophylaxis of peptic ulcer and gastric hypersecretory conditions, e.g., Zollinger-Ellison syndrome and also to manage the symptoms of gastroesophageal reflux disease (GERD). |
front 366 What is the drug classification for: | back 366 Sedatives/Hypnotics are substances that moderate activity and excitement while inducing a calming effect (and may be anxiolytic) or substances that may induce drowsiness and sleep. Most all are Schedule IV drugs. Temazepamis a intermediate-acting benzodiazepine. They are used to provide sedation, usually prior to procedures. Selected agents are useful as anticonvulsants, skeletal muscle relaxants, adjuncts in general surgery and adjuncts for the treatment of alcohol withdrawal syndrome. |
front 367 What is the drug classification for: | back 367 Vasopressors are potent vasoconstrictors, producing a rise in blood pressure (increase in mean arterial pressure). They are used to control blood pressure in hypotensive states, such as (cardiogenic, septic) shock, drug reactions, spinal anesthesia. They can also be used to prolong anesthesia and to treat certain heart rhythm problems, including cardiac arrest. |
front 368 What is the drug classification for: | back 368 Loop Diuretics work in the ascending limb of the loop of Henle (where magnesium & calcium are reabsorbed). Disrupting the reabsorption of these 2 ions brings about increased urine production (which lowers blood volume) and results in lowered blood pressure. They also cause the veins to dilate, which lowers blood pressure mechanically. They are used to treat acute pulmonary edema and manage edema; they can also be used to reduce intracranial pressure and to treat hyperkalemia. |
front 369 What is the drug classification for: | back 369 Antianxiety Agents act at many levels in the CNS to produce anxiolytic effect. They may produce CNS depression and the effects may be mediated by GABA (an inhibitory neurotransmitter). They are used in the treatment of Generalized Anxiety Disorder (GAD) and Panic Disorder; they are also used in the management of anxiety associated with depression. |
front 370 What is the drug classification for: | back 370 ACE Inhibitors slow the activity of the enzyme angiotensin converting enzyme (ACE), which decreases the production of angiotensin II. As a result, blood vessels relax and dilate, blood pressure is lowered, and more oxygen-rich blood can reach the heart. The spelling of many angiotensin-converting enzyme (ACE) inhibitors end with "pril". They are primarily used to control blood pressure, treat heart failure, help prevent strokes. |
front 371 What is the drug classification for: | back 371 Lipid-lowering Agents reduce LDL (“bad”) cholesterol by inhibiting the enzyme in the liver (HMG-CoA reductase) responsible for making cholesterol. Along with diet and exercise, they are used to reduce blood lipids in an effort to reduce the morbidity and mortality of atherosclerotic cardiovascular disease and its sequelae. |
front 372 A nurse is talking to a client diagnosed with chronic renal failure about medications. The client questions the purpose of aluminum hydroxide (Amphojel) in the medication regimen. What is the best explanation for the nurse to give the client for the use of this medication? Reduce serum calcium Control gastric acid secretions Increase urine output Decrease serum phosphate | back 372 Decrease serum phosphate Aluminum binds phosphates in the gastrointestinal tract. Phosphates tend to accumulate in the client with chronic renal failure due to decreased filtration capacity of the kidney. Antacids such as Amphojel and Basaljel are commonly used to lower phosphate levels |
front 373 A client is newly diagnosed with hypothyroidism and takes levothyroxine 50 mcg/day by mouth. What information should the nurse understand about this medication? May decrease the client's energy level Must be stored in a dark container Will decrease the client's heart rate | back 373 Should be taken in the morning |
front 374 A terminally ill client is receiving high doses of an opioid analgesic to manage pain. As death approaches and the client becomes unresponsive to verbal stimuli, what approach to pain management should the nurse now anticipate? A nonopioid analgesic will be prescribed The analgesic will be discontinue The same analgesic dosage will be continued The dosage of the analgesic will be decreased by half | back 374 The same analgesic dosage will be continued Dying clients who have been in chronic pain will probably continue to experience pain even though they are unresponsive. Pain medication should be continued at the same dosage that was considered effective when the client was more alert and responsive. |
front 375 The nurse is discussing medication with a client. Which information should be reinforced by the nurse about captopril (Capoten)? Avoid green leafy vegetables Avoid the use of salt substitutes Take the medication with meals Restrict fluids to 1000 mL/day | back 375 Avoid the use of salt substitutes Captopril is an angiotensin converting enzyme (ACE) inhibitor. Captopril is used to control blood pressure, treat heart failure, and help prevent strokes. Because it can cause an accumulation of potassium (or hyperkalemia), clients should avoid the use of salt substitutes, which are generally potassium-based. The generic names of ACE inhibitors often end with "pril." |
front 376 A clinic nurse assists with a toddler who is diagnosed with a first episode of otitis media. Which reinforcement of information should the nurse include in instructions to the child's parents? Emphasize the importance of a return visit after completing antibiotic therapy Describe the tympanocentesis used to detect persistent infections Demonstrate how the toddler should learn to swallow tablets Provide the parents with a handout describing the purpose of myringotomy tubes | back 376 Emphasize the importance of a return visit after completing antibiotic therapy A liquid suspension, not tablets, will be prescribed for the toddler and the nurse should reinforce how to store and measure the liquid. The child should be examined again after completion of the full course of antibiotics to assess hearing or to check for findings of a persistent infection and/or middle ear effusion. There is no need to discuss surgery or any other treatment at this time. |
front 377 A nurse administers cimetidine to a 75 year-old client diagnosed with a gastric ulcer. Which function may be affected by this medication and should be closely monitored by the nurse? Blood pressure Mental status Liver function Hearing | back 377 Mental status Cimetidine (Tagamet) is a histamine H2-receptor antagonist, used to treat gastric ulcers. Clients over age 50 or who are severely ill may become temporarily confused while taking H2 blockers, especially cimetidine. |
front 378 A postoperative client has a prescription for acetaminophen with codeine. A nurse should recognize that a primary effect of this combination is what action? Prevents tolerance Enhanced pain relief Minimized side effects Faster onset of action | back 378 Enhanced pain relief Combination of analgesics with different mechanisms of action can afford greater pain relief. |
front 379 The client is discharged from the hospital with a new prescription for furosemide. One week later, during a follow-up visit with the health care provider, the client reports experiencing the following findings. Which finding is most important to report to the health care provider? Constipation Muscle cramps Increased urine production Occasional lightheadedness | back 379 Muscle cramps Furosemide (Lasix) is a loop diuretic used to treat edema and hypertension. It can cause dehydration and electrolyte imbalances (hypokalemia and hypomagnesemia), which can result in muscle cramps. This is the most important finding. Dizziness, lightheadedness, or headache may occur as the client adjusts to the medication. The nurse should reinforce that the client should get up slowly when rising from a sitting or lying position but to tell the health care provider if these findings persist or become worse. Increased urine production is an expected action of the medication. Some people experience constipation when taking this medication. |
front 380 The provider ordered 500 mg erythromycin oral suspension every six
hours for a client diagnosed with pneumonia. The client has a
gastrostomy tube. The pharmacy sends up the medication in a liquid
suspension of 250 mg/5 mL. | back 380 10mL. 250 mg/5 mL = 500 mg/X mL 250x = 2500 x = 2500/250 = 10 mL |
front 381 A client has been given a prescription for alendronate. Which of the following statements indicate the client understands how to safely take this medication? (Select all that apply.) "I will notify the health care provider if I have any difficulty swallowing." "I will take the pill immediately preceding weight-bearing exercise." "I will always eat breakfast before taking it." "I will swallow it with 8 ounces of water." "I will stand or sit quietly for 30 minutes after taking it." | back 381 "I will notify the health care provider if I have any difficulty swallowing." "I will swallow it with 8 ounces of water." Alendronate (Fosamax) can cause esophagitis or esophageal ulcers unless precautions are followed. The client must be able to sit upright or stand for at least 30 minutes after taking the tablet. The client should take the tablet first thing in the morning, with a full glass of water, at least 30 minutes before eating or drinking anything or taking any other medication. |
front 382 A client diagnosed with tuberculosis is to begin taking rifampin and isoniazid. Which statement by a nurse is most appropriate to include when reinforcing information about these medications? "You may have occasional problems sleeping." "You may experience an increase in appetite." "You may notice an orange-red color to your urine." "You can take the medication with food." | back 382 "You may notice an orange-red color to your urine." Rifampin can cause reddish-orange discoloration of the urine and other body fluids. It is harmless, but the client needs to be aware of it. The nurse should caution the client not to wear soft contacts while taking this medication. |
front 383 An antibiotic is ordered to be given intramuscularly (IM) to a toddler. The total volume of the injection equals 2 mL. What is the correct nursing intervention? Check with pharmacy to substitute a liquid form of the medication Administer the medication in two separate injections Call the health care provider and request a smaller dosage Give the medication in the dorsal gluteal site | back 383 Administer the medication in two separate injections Intramuscular injections should not exceed a volume of 1 mL for small children. Medication doses exceeding this volume should be split into two separate injections of 1 mL each. In adults the maximum intramuscular injection volume is commonly 5 mL depending on the characteristics of the site. The vastus lateralis of the thigh should be used to administer IM medications to a toddler (12 to 36 months of age). |
front 384 The client is prescribed digoxin as a treatment for heart failure. What side effect can occur if the client develops hypokalemia when taking digoxin? Dyshrythmias Altered level of consciousness (LOC) Oliguria Tingling sensation | back 384 Dyshrythmias Conditions that increase the risk of digoxin-induced dysrhythmias include hypokalemia and increased serum digoxin levels. The nurse should reinforce the importance of eating high-potassium foods (spinach, bananas, potatoes) and report signs of hypokalemia, such as nausea, general muscle weakness and irregular pulse. Tingling or other unusual sensations are associated with hyperkalemia. Altered LOC is not associated with hypokalemia. Persistent hypokalemia can cause polyuria, not oliguria. |
front 385 The order is for ibuprofen oral drops 10 mg/kg of body weight. The client weighs 62 lbs. Motrin oral drops are supplied in bottles containing 40 mg/mL. How many milliliters will the nurse administer? (Report to the nearest whole number.) | back 385 7mL. X mL = 1 mL/40 mg X 10 mg/kg X 1 kg/2.2 lbs X 62 lbs = 620/88 = 7.05 or 7 mL Ratio : |
front 386 A nurse is reinforcing how to use the metered-dose inhaler (MDI) to a client newly diagnosed with asthma. The client asks, “How will I know the canister is empty?” What is the best response by the nurse? “Estimate how many doses are usually in the canister.” “Shake the canister to detect any fluid movement.” “Count the number of doses as the inhaler is used.” “Drop the canister in water to observe floating.” | back 386 “Count the number of doses as the inhaler is used.” Dropping the canister into a bowl of water assesses the amount of medications remaining in a metered-dose inhaler is the old way of checking how much was left in the canister. Now clients should be instructed to calculate how many doses are in each canister and keep track of the number of doses used. Some of the newer canisters have counters. |
front 387 The nurse observes a family member administering a rectal suppository. With the client lying on the left side, the family member pushes the suppository in the rectum, up to the second knuckle. After 10 minutes, the family member helps the client turn to the right side. What is the appropriate comment for the nurse to make? “Did you feel any stool in the intestinal tract?” "Why don’t we now have the client turn back to the left side.” “Let’s check to see if the suppository is in far enough.” “That was done correctly. Did you have any problems with the insertion?” | back 387 “That was done correctly. Did you have any problems with the insertion?” Left side-lying position is the optimal position for the client receiving rectal medications. Due to the position of the descending colon, left side-lying allows the medication to be inserted and move along the natural curve of the intestine and facilitates retention of the medication. The suppository should be somewhat melted after 10 to 15 minutes. The other responses are incorrect because there is no data in the stem to support these comments. |
front 388 A client at risk for developing a deep vein thrombosis is being discharged home on enoxaparin. Which information would be appropriate for the nurse to reinforce before the client leaves the hospital? "You must have your lab tests checked daily." "You will have a special type of temporary IV inserted before discharge." "Massage the injection site after the medication is given." "Notify the health care provider if you notice any unusual bruising on your skin." | back 388 "Notify the health care provider if you notice any unusual
bruising on your skin." |
front 389 The home care nurse is admitting a new client with a diagnosis of COPD, atrial fibrillation and gout. After reviewing the client's medication list, the nurse would arrange for periodic monitoring of blood drug levels for which of the following medications? (Select all that apply.) Beclomethasone inhaled (Qvar) Theophylline (Elixophyllin, Theo-24, Uniphyl) Allopurinol (Aloprim, Zyloprim) Glipizide (Glucotrol) Digoxin (Lanoxin) | back 389 Theophylline (Elixophyllin, Theo-24, Uniphyl) Digoxin (Lanoxin) |
front 390 The nurse is discussing with a client some of the necessary precautions when taking warfarin. The nurse should remind the client to avoid which over-the-counter (OTC) medication? Nonsteroidal anti-inflammatory medications Laxatives containing magnesium salts Cough medicines with guaifenesin Histamine blockers | back 390 Nonsteroidal anti-inflammatory medications Warfarin is indicated in the prophylaxis and treatment of blood clots, atrial fibrillation and cardiac valve replacements. Taking warfarin and a nonsteroidal anti-inflammatory medication, such as ibuprofen, or an antiplatelet medication, such as aspirin, may increase the risk for bleeding. Garlic and ginkgo biloba can also increase the risk of bleeding if taken with warfarin. |
front 391 A client has a new prescription for a selective serotonin reuptake inhibitor (SSRI) antidepressant. Which information would prompt the nurse to contact the health care provider after reviewing the client's admission history and physical? Frequent use of antacids Recent prescribed use of an MAO inhibitor Diagnosis of vascular disease History of obesity | back 391 Recent prescribed use of an MAO inhibitor SSRIs should not be taken concurrently with MAO inhibitors due to serious, life-threatening medical condition called serotonin syndrome. Serotonin syndrome symptoms may occur within several hours of taking a new drug. It may be necessary to allow two to five weeks (or more) between stopping a MAOI and starting the SSRI (or vice versa). |
front 392 There is an order to insert a urinary catheter. The client is an adult female. The nurse slips the catheter approximately 4-5 inches (10-12 cm) into an opening, but no urine is obtained. What is the most probable reason for this outcome? The bladder is overdistended without the ability to empty No urine is present in the bladder The catheter is not inserted far enough into the canal The catheter is located in the vaginal canal | back 392 The catheter is located in the vaginal canal |
front 393 When assessing a client who has just undergone a cardioversion, the nurse finds the respirations are 12 per minute. Which action should the nurse take first? Ask the registered nurse (RN) to assess the vital signs Continue to monitor the respirations Measure the pulse oximetry Try to vigorously stimulate normal breathing | back 393 Continue to monitor the respirations Normal respirations range 12 to 20 BPM; respirations 8 or less are a cause for concern. Vigorous stimulation is not indicated. It is also not necessary to ask the RN to check findings. |
front 394 A client is being prepared for electroconvulsive therapy (ECT). Which x-ray should the nurse anticipate for the client prior to having this procedure? Chest Pelvic Jaw Spinal | back 394 Spinal |
front 395 The nurse is preparing the client for an intravenous pyelogram (IVP) test. Which intervention would the nurse perform? Restrict the client's fluid intake four hours prior to the examination Inform the client that only one x-ray of the abdomen is necessary Administer a laxative to the client the evening before the test Instruct the client to maintain a regular diet 24 hours before the scheduled time | back 395 Administer a laxative to the client the evening before the test Bowel preparation is important to clean out the large intestine to allow for the visualization of the kidney, bladder and ureters. Clients are often given the osmotic bowel preps the night before, such as Colyte, and an enema in the morning of the test. Beginning the day before the test, a clear liquid diet is prescribed and the client is NPO after midnight. |
front 396 A nurse is caring for a client who had a closed reduction of a fractured right wrist, followed by the application of a fiberglass cast about 12 hours ago. Which finding requires the nurse’s immediate attention? Client reports prickling sensation in the right hand Slight swelling of fingers of right hand Skin warm to touch and normally colored Capillary refill of fingers on right hand is three seconds | back 396 Client reports prickling sensation in the right hand A prickling sensation, or paresthesia, may be an indication of compartment syndrome and requires immediate action by the nurse. The client may also report extreme pain, there may be pallor and an absent or diminished pulse on the affected extremity. The nurse should report the findings to the RN charge nurse, who will then split the cast to help relieve the pressure and contact the health care provider. The other findings are normal for a client in this situation. |
front 397 A client is two days postoperative. The vital signs are: BP 120/70, heart rate 100, respiratory rate 30, and temperature 100.4 F (38 C). The client suddenly becomes profoundly short of breath and the skin color is gray. Which vital sign should have alerted the nurse initially to the client's change in condition? Respiratory rate Heart rate Temperature Blood pressure | back 397 Respiratory rate Tachypnea is one of the first clues that the client is not being adequately oxygenated. The compensatory mechanism for decreased oxygenation is increased respiratory rate. To help answer this question, you will notice that the problem in the question is respiratory (short of breath), so you should look for a response with this focus. |
front 398 The client is diagnosed with a tension pneumothorax and has a chest tube inserted. What is the purpose of the chest tube for this client? Increase the intrathoracic pressure to restore it back to
normal Provide the appropriate postoperative treatment for a pneumothorax Drain the purulent drainage from the empyema that caused it | back 398 Remove air out of the pleural space to restore normal intrathoracic pressure With a tension pneumothorax, the lung is collapsed due to air in the pleural space and this trapped air continues to build up; the pressure of this air pushes on and displaces the mediastinum. The classic sign of a tension pneumothorax is a deviation of the trachea away from the side of the tension. This is an emergency situation and is not the result of a surgical procedure. Insertion of a chest tube will remove the air, which will reduce the intrathoracic pressure, and allow the lung to re-inflate. |
front 399 A nurse is preparing a client diagnosed with a deep vein thrombosis (DVT) for a venous doppler evaluation. Which nursing intervention is necessary to prepare the client for this test? Have ready a sedative medication prior to the test No special preparation is necessary for the client Keep the client NPO after midnight Discontinue anticoagulant therapy just before to the test | back 399 No special preparation is necessary for the client This is a noninvasive procedure. Because this is an ultrasound test for the venous circulation, it does not require any special preparation (as compared to an ultrasound of the uterus that requires a full bladder). |
front 400 A nurse is caring for a client who had surgery to remove the gallbladder as well as a common bile duct exploration with the placement of a T-tube. The nurse observes copious amounts of drainage through the T-tube the day after surgery. Which action should the nurse take next? Continue to monitor the drainage Clamp the T-tube for two hours Lower the head of the bed Notify the registered nurse (RN) charge nurse immediately | back 400 Continue to monitor the drainage Several hundred milliliters of drainage can be expected from the T-tube in the initial 24 to 48 hours after a duct exploration. The nurse's responsibility is to continue to monitor the drainage and notify the health care provider if the findings indicate leakage of bile into the peritoneum or a blocked duct. The tube should not be clamped unless there is a specific order to do so (tube is clamped 3 to 4 days postop) while client is eating and for a few hours afterwards to test for duct patency. If nausea and vomiting occur when the tube is clamped, this indicates the duct is not patent and the nurse should remove the clamp. Keeping the head of the bed elevated will help to facilitate drainage. |
front 401 A nurse is caring for an unconscious client. To prevent keratitis, moisturizing ointment should be applied to which site? Perianal area Lower eyelid Tips of fingernails and toenails External ear canal | back 401 Lower eyelid Keratitis is a corneal ulcer or abrasion caused by exposure to the air from lack of or minimal blink reflex. Treatment involves the application of moisturizing ointment to the exposed cornea and a plastic bubble shield or eye patch. |
front 402 A 78 year-old male client had a hernia repair in an outpatient surgery clinic. He is awake and alert, but has not been able to void since he returned from surgery six hours ago. He received 1000 mL of IV fluids. Which action would most likely help this client to void? Wait two hours and have him try to void again Apply Crede’s method to the bladder from the bottom to the top Assist him to stand by the side of the bed to void Have him drink several glasses of water | back 402 Assist him to stand by the side of the bed to void When a male is not able to use a urinal unassisted, the client should stand by the side of the bed to void. This is the most desirable position for normal voiding for male clients. Given the client’s age, he most likely also has some degree of prostate enlargement, which may also interfere with voiding. |
front 403 A client is being treated for diabetic ketoacidosis (DKA). A basic metabolic panel (BMP) was drawn and the nurse notes the client's serum glucose is 650 mg/dL (36.08 mmol/dL). Which other serum lab result should the nurse check? Magnesium Calcium Creatinine Potassium | back 403 Potassium |
front 404 The child diagnosed with thalassemia major has received several blood transfusions during the past three days. What lab value should be monitored closely during this therapy? Red blood cell indices Neutrophil percent Hemoglobin Platelet count | back 404 Hemoglobin Hemoglobin is the oxygen-carrying protein component of the red blood cell. Normal hemoglobin range for children is approximately 11-13 gm/dL. Beta thalassemia, also called Cooley's anemia, is a genetic defect that causes anemia. The only treatment is blood transfusions (every month) or a bone marrow transplant. With frequent blood transfusions, the body is unable to eliminate the excess iron contained in the transfused blood; over time this can result in tissue and organ damage. |
front 405 A client is in the physical therapy room and tells the LPN/VN, "I feel like I'm going to have a seizure." Which intervention is most appropriate for the nurse to implement first? Assist the client to a safe position away from hazards Reduce the noise and dim the lights in the room Instruct a coworker to notify the registered nurse (RN) Stay with the client and document observations | back 405 Assist the client to a safe position away from hazards Clients with seizure disorders (or epilepsy) often experience symptoms that warn them that a seizure is going to happen, called an aura. The most important action to implement in this situation is to place the client in a safe position so that if a seizure occurs, the client will not be injured. The LPN/VN should stay with the client and send someone to notify the RN (who can bring medication to prevent seizure activity). Noise reduction and light dimming may be beneficial in preventing an impending seizure, but they are not the priority. Remember to consider safety first when there isn't an immediate physical need. |
front 406 The cardiac monitor displays a rhythm that appears to be ventricular fibrillation. Which initial nursing action is appropriate? Initiate cardiopulmonary resuscitation Notify the health care provider Prepare to administer IV epinephrine Determine responsiveness of the client | back 406 Determine responsiveness of the client Electrical interference can be mistaken for ventricular fibrillation, in which case the client would respond when checked. Therefore, the most important initial action would be to check to see if the client is responsive or not. It would be inappropriate to initiate CPR or prepare to administer emergency drugs without first determining that the client is unresponsive. |
front 407 A pregnant woman in the third trimester is admitted with a report of painless vaginal bleeding over the last several hours. A nurse should prepare this client for what procedure? Pelvic exam C-section Nonstress test Abdominal ultrasound | back 407 Abdominal ultrasound |
front 408 Following surgery for the placement of a ventriculoperitoneal (VP) shunt as treatment for hydrocephalus of their infant, the parents ask the licensed practice nurse (LPN) to reinforce the registered nurse’s (RN) explanation as to why the infant has a small abdominal incision. What is the best response by the LPN about the abdominal incision? The incision was made in order to insert the catheter into the abdominal cavity The incision was made in order to insert the tubing into the urinary bladder The incision was made in order to insert the catheter into the stomach The incision was made in order to insert the camera for catheter placement | back 408 The incision was made in order to insert the catheter into the abdominal cavity The preferred procedure in the surgical treatment of hydrocephalus is placement of a ventriculoperitoneal (VP) shunt. This shunt procedure provides primary drainage of the cerebrospinal fluid from the ventricles to an extracranial compartment, usually the peritoneum. A small incision is made in the upper quadrant of the abdomen so the shunt can be guided into the peritoneal cavity. |
front 409 The licensed practical nurse (LPN) assists the registered nurse (RN) with suctioning a tracheostomy. What action is taken to prevent hypoxia during the procedure? Apply suction for no more than 10 seconds Lubricate three to four inches of the catheter tip Withdraw catheter in a circular motion Maintain sterile technique | back 409 Apply suction for no more than 10 seconds Applying suction for more than 10 seconds may result in hypoxia, by suctioning oxygenated air out of the airway. The clue was to read the question correctly - it asked about prevention of hypoxia associated with suctioning. Although the other responses are important and correct actions, hypoxia results from actions that decrease the oxygen supply. |
front 410 The client has been taking isoniazid (INH) and rifampin for several months to treat pulmonary tuberculosis. Which laboratory tests does the nurse anticipate will be ordered for this client. Pancreatic enzymes Kidney function Liver enzymes Cardiac enzymes | back 410 Liver enzymes INH, as well as other long-term by-mouth medications, can cause hepatocellular injury. The nurse anticipates monitoring liver enzymes (ALT, AST and alkaline phosphatase) because these are released into the blood when the liver is damaged. |
front 411 The nurse begins the enteral tube feeding at 8 am at a continuous rate of 40 mL/hour. It is now noon. What action is needed by the nurse? Measure, record and then discard gastric residual (GRV) Flush the feeding tube with 30 mL of warm water Assess bowel sounds and gastric pH Check gastric residual and stop the feeding if the volume is greater than 150 mL | back 411 Flush the feeding tube with 30 mL of warm water The nurse will flush the tube with approximately 30 mL of warm water every 4 hours to maintain patency and check GRV every 4-6 hours (it's best to do both at the same time.) Residuals should be returned to the stomach because they contain electrolytes, nutrients, and digestive enzymes. Current evidence shows that acceptable GRVs range can from 150-500 mL and that a single elevated GRV simply requires ongoing monitoring. Although the nurse will monitor the client's response during the tube feeding, the nurse should have assessed bowel sounds and measured gastric pH (as well as GRV) before starting the feeding. |
front 412 Many clients experience some soreness and shoulder pain following a diagnostic laparoscopy. T/F | back 412 True |
front 413 Pulse oximetry replaces the need to obtain arterial blood gases (ABGs). T/F | back 413 False |
front 414 The nonrebreather mask with reservoir bag can deliver oxygen concentrations near 100%. T/F | back 414 True |
front 415 A client’s hemodynamic status (blood pressure) is continuously monitored during hemodialysis. T/F | back 415 True |
front 416 The nurse should inject approximately 30 mL of air through the nasogstric (NG) tube while auscultating the abdomen to confirm placement of a NG tube. T/F | back 416 False |
front 417 Foam dressings are ideal for draining full-thickness wounds. T/F | back 417 True |
front 418 15 to 30 pounds (6.8 to 13.6 kg) of traction is recommended for
Buck’s skin traction. | back 418 False |
front 419 Pacemakers use high-energy electrical pulses to treat life-threatening arrhythmias. T/F | back 419 False |
front 420 The nurse should frequently suction the airway of clients with pneumonia and bronchitis. T/F | back 420 False |
front 421 The nurse should expect to hear bowel sounds when assessing the client who is one day post-op following colostomy surgery. T/F | back 421 False |
front 422 Clients should remove all metal objects, including any and all piercings, prior to a magnetic resonance imaging (MRI) scan. T/F | back 422 True |
front 423 Clients should fast 8 to 12 hours before having blood drawn for lipid blood tests. T/F | back 423 True |
front 424 An esophageal manometry may be ordered to confirm dysphagia or gastroesophageal reflux (GERD). T/F | back 424 True |
front 425 The ELISA test is used to detect antibodies in the blood. T/F | back 425 True |
front 426 A myelogram is a painless test that measures the electrical activity in muscles. T/F | back 426 False |
front 427 A barium study and a computerized tomography (CT) scan can be completed within 24 to 48 hours of each other. T/F | back 427 False |
front 428 An intravenous cholangiogram (IVC) is an iodine-based contrast study designed to visually study the function of the kidneys. T/F | back 428 False |
front 429 The Schick test is used to test for allergies. T/F | back 429 False |
front 430 Serum bilirubin and urobilinogen measure how well the liver and gallbladder are functioning. T/F | back 430 True |
front 431 The basic metabolic panel (BMP) is a group of 8 specific tests used to determine the status of the kidneys, blood sugar, electrolyte and acid/base balance. | back 431 True |
front 432 The QRS complex of the ECG is when the atria depolarize. T/F | back 432 False |
front 433 A clean catch urine specimen can be used to detect the presence of blood cells, protein and bacteria. T/F | back 433 True |
front 434 Excessive bruising, swollen and painful joints and lengthy bleeding. | back 434 There are several types of hemophilia. All types can cause abnormal or exaggerated bleeding and poor blood clotting. Common sites for bleeding are the joints, muscles and gastrointestinal tract. |
front 435 Hypotension and tachycardia, with muffled heart sounds and jugular vein distention. | back 435 Beck’s triad (hypotension; jugular vein distention; and distant/muffled heart sounds) are the classic symptoms of cardiac tamponade. Cardiac tamponade is where blood or fluid accumulates in the pericardial space and acts to compress and constrict the heart. |
front 436 Fluttering or "thumping" sensation in the chest. | back 436 Atrial fibrillation (AFib) is the most common type of irregular heartbeat. Many clients have no symptoms. A client with AFib is five times more likely to have a stroke than someone without AFib. |
front 437 Anemia, episodes of pain and frequent infections. | back 437 The most common finding of sickle cell disease is pain (sickle cell crisis). This is caused by the characteristic crescent-shaped red blood cells getting stuck and blocking blood vessels. Clients with sickle cell disease often also have anemia and are more prone to infections. |
front 438 Pain, pallor, paresthesia, pulselessness, paralysis or poikilothermia. | back 438 Occlusive arterial disease (also known as peripheral artery disease) is caused by arteriosclerosis. The classic symptoms appear during walking or exercise and are relieved with rest. |
front 439 Sequence of color changes in skin in response to cold or stress. | back 439 Raynaud’s phenomenon is a condition where cold temperatures or strong emotions cause blood vessel spasms, which block blood flow to the fingers, toes, ears and nose. |
front 440 Dyspnea, fatigue and weakness, and edema in legs, ankles and feet. | back 440 Systolic heart failure is when the heart muscle cannot pump/eject the blood out of the heart. Diastolic heart failure is when the heart muscles are stiff and do not fill up with blood easily. As the heart’s pumping action becomes less effective, blood backs up in other areas of the body (congestive heart failure). |
front 441 Bleeding, blood clots, bruising and drop in blood pressure. | back 441 In disseminated intravascular coagulation (DIC), the proteins that control blood clotting become overactive, increasing a client’s risk for serious bleeding. This can be due to inflammation, infection or cancer. |
front 442 Skin redness, swelling, warmth and tenderness over a vein. | back 442 Thrombophlebitis is a swollen or inflamed vein due to a blood clot. |
front 443 ST elevation on ECG. | back 443 STEMI is a type of heart attack when the coronary artery is completely blocked off by an occlusion. The client will experience crushing, non-remitting retrosternal pain, diaphoresis, nausea/vomiting and dyspnea. |
front 444 Cardiomyopathy related to myocarditis. | back 444 Finding |
front 445 Mononucleosis related to myocarditis. Etiology Finding | back 445 Etiology |
front 446 Marfan syndrome related to aortic valve insufficiency. Etiology or | back 446 Etiology |
front 447 Congenital disorder related to pulmonary stenosis. Etiology Finding | back 447 Etiology |
front 448 Aging heart related to aortic stenosis. Etiology Finding | back 448 Etiology |
front 449 Dyspnea, syncope and angina related to aortic stenosis. Etiology | back 449 Finding |
front 450 Narrow or obstructed valve related to pulmonary stenosis. Etiology Finding | back 450 Etiology |
front 451 Peripheral edema related to pulmonary stenosis. Etiology | back 451 Finding |
front 452 Dyspnea, chest pain, and syncope related to pulmonary stenosis. Etiology or | back 452 Finding |
front 453 Dyspnea related to mitral valve regurgitation. Etiology or | back 453 Finding |
front 454 Mitral valve prolapse related to mitral valve regurgitation. Etiology | back 454 Etiology |
front 455 Sharp, stabbing chest pain related to pericarditis. Etiology or | back 455 Finding |
front 456 Upper respiratory infection related to pericarditis. Etiology Finding | back 456 Etiology |
front 457 Rheumatic fever related to endocarditis. Etiology Finding | back 457 Etiology |
front 458 Cardiac murmurs related to endocarditis. Etiology or | back 458 Finding |
front 459 There is a valve between the portal vein and the left atrium. T/F | back 459 False |
front 460 During systole, the pulmonic valve is open but the tricuspid valve is closed. T/F | back 460 True |
front 461 The mitral valve should open during diastole. | back 461 True |
front 462 The aorta is a vein. T/F | back 462 False |
front 463 The septum is a valve between the two ventricles. T/F | back 463 False |
front 464 The arteries stay open when cut. T/F | back 464 True |
front 465 The pulmonary vein takes blood away from the heart to the lungs. T/F | back 465 False |
front 466 Peripheral veins contain valves that keep the blood flowing back to the heart. T/F | back 466 True |
front 467 There are two veins called venae cavae. T/F | back 467 True |
front 468 Blood flows from the ventricles to the atria. T/F | back 468 False |
front 469 The heart muscle (myocardium) gets oxygenated blood via the aorta. T/F | back 469 True |
front 470 The endocardium is a sac that surrounds and supports the heart. T/F | back 470 False |
front 471 The mitral (bicuspid) valve is an atrioventricular valve. T/F | back 471 The mitral valve controls flow between the left atrium and left ventricle. |
front 472 The aorta carries oxygenated blood. T/F | back 472 True |
front 473 Normally, the blood pressure is lower in systole than in diastole. T/F | back 473 False |
front 474 Cough; exertional dyspnea; fatigue; fainting; swelling of feet or ankles | back 474 Cor pulmonale Cor pulmonale is an alteration in the structure and function of the right ventricle caused by a primary disorder of the respiratory system. |
front 475 Barrel chest; chronic cough, shortness of breath, wheezing; weight loss | back 475 Emphysema Emphysema is a chronic and progressive disease of the lungs that causes shortness of breath due to over-inflation of the alveoli. |
front 476 Chest pain; muffled heart and lung sounds; mediastinal shift; respiratory distress | back 476 Tension Pneumothorax A tension pneumothorax occurs when air gets trapped in the pleural cavity and as the pressure increases, it pushes the mediastinum to the other side of the chest, which compresses the other lung. This is a life-threatening condition. |
front 477 Difficulty swallowing; ear pain; fever & chills; headache; sore throat | back 477 Tonsillitis Tonsillitis is an inflammation of the tonsils, due to either viral or bacterial infections or immunologic factors. Findings are similar to pharyngitis (sore throat). |
front 478 Ptosis; difficulty chewing & swallowing; weakness in arms & legs; shortness of breath | back 478 Myasthenia Gravis Myasthenia gravis is a chronic autoimmune neuromuscular disease characterized by varying degrees of weakness of the skeletal muscles. It is caused by a defect in the transmission of nerve impulses to muscles. Muscles that control eye and eyelid movement, facial expression, chewing, talking, swallowing, and breathing are often affected. |
front 479 Cough; difficulty breathing; fatigue; fever greater than 100.4 F (38 C); headache; myalgia | back 479 Severe Acute Respiratory Syndrome (SARS) SARS is a viral infection causing acute respiratory distress and sometimes death. |
front 480 Fever, chills, productive cough, dyspnea, pleuritic pain, use of accessory muscles | back 480 Pneumonia Pneumonia is an inflammatory process that results in edema of the lung tissues. Fluid moves into the alveoli and this can cause hypoxia. Pneumonia is caused by bacteria, viruses, fungi or chemicals. |
front 481 Thick, sticky mucus, wheezing, exercise intolerance, repeated lung infections | back 481 Cystic Fibrosis Cystic fibrosis is a hereditary disorder that causes severe damage to the lungs and digestive systems. It is a disorder that affects the exocrine glands, causing them to produce thick and sticky mucus. |
front 482 Attacks include vertigo, tinnitus, hearing loss | back 482 Ménière's Disease A chronic disorder of the inner ear that usually affects only one ear. It usually develops between the ages of 40-60 years. |
front 483 Blurred vision without pain | back 483 Cataract A clouding of the lens in the eye that affects vision. Most cataracts are related to aging. |
front 484 Loss of (bilateral) peripheral vision, cupping of the optic disk, elevated intraocular pressure. | back 484 Chronic Open-angle Glaucoma The most common type of glaucoma. The increase in pressure is often small and develops slowly. |
front 485 Sudden onset of blurred vision and severe eye pain | back 485 Acute Closed-angle Glaucoma Occurs when fluid is suddenly blocked and can't flow out of the eye, resulting in a quick, severe rise in eye pressure. This is a medical emergency. |
front 486 Bright flashes of light, blurred vision, "floaters" in the eye | back 486 Retinal Detachment Separation of the light-sensitive membrane (retina) from its supporting layers. |
front 487 Guillain-Barré results from an acute infection and inflammation of
the peripheral nerves. | back 487 False |
front 488 Ischemic strokes are the most common type of stroke. T/F | back 488 True |
front 489 A person who has migraine headaches should avoid foods containing monosodium glutamate, tyramine and caffeine. T/F | back 489 True |
front 490 The tonic component of the generalized seizure lasts longer than the clonic component. T/F | back 490 False |
front 491 Sudden onset of fever, headache, photosensitivity and stiff neck are common findings of meningitis. T/F | back 491 True |
front 492 Anticonvulsants and skeletal muscle relaxants are used in the management and treatment of trigeminal neuralgia. T/F | back 492 True |
front 493 Delirium is a chronic condition affecting brain function. T/F | back 493 False |
front 494 The nurse should use open-ended questions during admission of cognitively impaired clients. T/F | back 494 False |
front 495 The pain of cluster headaches comes on slowly and takes days to resolve. | back 495 False |
front 496 Anticholinesterase inhibitor medications should be given 30 to 60
minutes before a meal for clients diagnosed with myasthenia gravis. | back 496 True |
front 497 Parkinson's disease (PD) affects intellectual ability. T/F | back 497 False |
front 498 One of the initial signs of a stroke is weakness on one side of the body. T/F | back 498 True |
front 499 Caused by a bacterial infection, toxins and viruses, this condition can cause inflammation, cirrhosis or cancer of the liver. | back 499 There are several causes of inflammation of the liver, but hepatitis is usually caused by a virus. Hepatitis can heal on its own with no significant consequences or it can progress to scarring of the liver (cirrhosis). |
front 500 Clients may develop this condition after some types of surgery and when using certain drugs, especially narcotics. | back 500 Intestinal obstruction is a partial or complete blockage of the bowel. It is usually due to either a mechanical reason or an ileus (a condition where there is no structural problem causing the bowel not to contract correctly - such as following surgery). |
front 501 Eating a high-fiber diet can help reduce symptoms of this disease. | back 501 A low-fiber diet is the most common cause of diverticular disease. The disease is made up of two conditions: diverticulosis and diverticulitis. |
front 502 A slowly progressing disease in which healthy tissue is replaced with scar tissue, which may result in the need for a transplant. | back 502 Scar tissue from cirrhosis in loss of liver function and can cause: portal hypertension, hepatic encephalopathy, gastrointestinal bleeding, infection, ascites and hepatorenal syndrome. |
front 503 Pain localizes to the right upper quadrant, but may radiate to the right shoulder or scapula. | back 503 Cholecystitis is inflammation of the gallbladder caused by an obstruction of the cystic duct (usually by stones). Clients may experience nausea, vomiting and fever. Risk factors include increasing age, obesity or rapid weight loss, medication and pregnancy. |
front 504 Chronic inflammation extending deep into the lining of the affected part of the GI tract results in abdominal pain, cramping and diarrhea. | back 504 Crohn's disease is an inflammatory bowel disease. Unlike ulcerative colitis, inflammation affects the entire thickness of the bowel wall and can affect any part of the digestive tract (although it most commonly affects the ilium and beginning of the colon). |
front 505 Infection by the bacterium Helicobacter pylori is the most common cause of this condition. | back 505 A peptic ulcer is a sore on the lining of the stomach or duodenum. The bacterium called Helicobacter pylori is a major cause of peptic ulcers; NSAIDs are another common cause of peptic ulcers. |
front 506 This condition may be caused by gallstones, chronic alcohol use, infections, medications and trauma. | back 506 Treatment for pancreatitis includes IV fluids, antibiotics and pain relievers; many clients will require an endoscopic retrograde cholangiopancreatography (ERCP) to examine the bile and pancreatic ducts. |
front 507 Inflammation in the lining of the colon leads to abdominal discomfort and blood or pus in diarrhea. | back 507 Ulcerative colitis is a disease that causes inflammation and sores (ulcers) in the lining of the rectum and colon (large intestine). |
front 508 Barrett's esophagus is a complication of this condition. | back 508 Complications of GERD include bronchospasm, chronic cough or hoarseness, dental problems, esophageal ulcer and Barrett's esophagus (a change in the lining of the esophagus that can increase the risk of cancer). |
front 509 Difficulty starting a urine stream; dribbling after urination; urinary retention. | back 509 Benign Prostatic Hypertrophy An enlarged prostate does not necessarily raise the risk of cancer, but men may develop urinary tract infections, hematuria, bladder stones, and bladder or kidney damage. |
front 510 Hematuria; severe pain in low back/flank pain. | back 510 Renal Calculi Although kidney stones (nephrolithiasis) may be small, passing one can be very painful. Dehydration is a major risk factor for kidney stone formation. |
front 511 Herniation of bladder into the vaginal canal. | back 511 Cystocele This hernia-like disorder occurs when the urinary bladder protrudes through the wall of the vagina. Treatments include estrogen, surgery, or mechanical support by pessary. |
front 512 Chancres, flu-like symptoms, hair loss, palmar rash. | back 512 Syphilis Syphilis is a sexually transmitted disease (STD) with 4 distinct stages. In the primary stage, painless sores appear. Skin rashes and flu-like symptoms occur in the secondary stage. If untreated, syphilis is eventually fatal. |
front 513 Ecchymoses, hyperpigmentation, pruritus. | back 513 Chronic Kidney Disease In addition to pruritus, pigmentary disorders, and ecchymosis, clients with chronic kidney disease may also have xerosis (dry skin), uremic frost, half-and-half nails. |
front 514 CD4 count less than 200; Kaposi's sarcoma; pneumocystosis. | back 514 Acquired Immune Deficiency Syndrome (AIDS) |
front 515 Anxiety, exophthalmos, heat intolerance, restlessness, weakness. | back 515 Graves' disease Graves' disease is an autoimmune disorder that leads to overactivity of the thyroid gland. |
front 516 Facial puffiness; macroglossia; ptosis; coarse, sparse hair; confusion; hypothermia; bradycardia. | back 516 Myxedema coma Myxedema coma/crisis usually affects older women who have long-standing, undiagnosed or undertreated hypothyroidism. The crisis is triggered by a significant stress, such as infection, a systemic disease, certain medications or exposure to a cold environment. |
front 517 Dry, scaly skin; muscle cramps; tingling of the lips, fingers and toes. | back 517 Hypoparathyroidism Hypoparathyroidism is a disorder in which the parathyroid glands do not produce enough parathyroid hormone (PTH). PTH helps control serum levels of calcium, phosphorus, and vitamin D. |
front 518 Abdominal pain; amenorrhea; decreased libido; osteoporosis; sensitivity to cold. | back 518 Hypopituitarism These findings are associated with a deficiency of luteinizing hormone (LH) & follicle stimulating hormone (FSH), which are pituitary hormones. Findings of hypopituitarism are directly related to the missing hormone (thyroid-stimulating hormone (TSH), LH, growth hormone (GH), adrenocorticotropic hormone (ACTH), and/or prolactin). |
front 519 Dehydration; fatigue and muscle weakness; hyperpigmentation of the skin; unintentional weight loss. | back 519 Addison's disease Addison's disease is a disorder that occurs when the adrenal glands do not produce enough hormones (glucocorticoid hormones, mineralcorticoid hormones and sex hormones). |
front 520 Acne; buffalo hump; hirsutism; moon-shaped face; upper body obesity, with thin legs and arms. | back 520 Cushing syndrome Cushing syndrome is caused when the adrenal gland secretes too much cortisol or when someone takes too much corticosteroid medication. |
front 521 Acromegaly is the result of excess growth hormone secretion in children. | back 521 False |
front 522 Central diabetes insipidus may be caused by damage to the pancreas. T/F | back 522 False |
front 523 The water deprivation test is used to diagnose diabetes insipidus. T/F | back 523 True |
front 524 The client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH) should be placed on seizure precautions. T/F | back 524 True |
front 525 Clients diagnosed with hyperosmolar hyperglycemic state (HHS) experience severe ketoacidosis. T/F | back 525 False |
front 526 Management of mild hyperparathyroidism includes increasing oral fluid intake to prevent the development of kidney stones. T/F | back 526 True |
front 527 Type 2 diabetes results when pancreatic beta cells stop producing insulin. T/F | back 527 False |
front 528 Many clients are able to manage type 2 diabetes through diet and exercise. T/F | back 528 True |
front 529 To treat a conscious adult with a serum glucose below 50 mg/dL, the nurse should prepare to administer 1 mg glucagon. T/F | back 529 True |
front 530 Clients should take levothyroxine at bedtime. T/F | back 530 False |
front 531 Osteoarthritis is an autoimmune disease that causes progressive loss of cartilage in the joints. T/F | back 531 False |
front 532 The client with Charcot's joint will benefit from regular aerobic exercise. T/F | back 532 False |
front 533 A progressive exercise routine is the best therapy for the client with chondromalacia patellae. T/F | back 533 True |
front 534 Obesity is a risk factor for the development of rheumatoid arthritis. T/F | back 534 False |
front 535 A stress fracture is an example of a pathological fracture. T/F | back 535 False |
front 536 Clients diagnosed with systemic lupus erythematosus (SLE) should avoid exposure to sunlight and ultraviolet light. T/F | back 536 True |
front 537 Rheumatoid nodules are the same thing as Heberden's nodes. T/F | back 537 False |
front 538 Clients diagnosed with systemic lupus erythematosus (SLE) should avoid exposure to sunlight and ultraviolet light. T/F | back 538 True |
front 539 Some symptoms of osteomalacia include kyphosis, difficulty walking, deformation of weight-bearing bones and pain in the low back and hips. T/F | back 539 True |
front 540 A woman is more likely to develop type 1 osteoporosis if she is postmenopausal, smokes, drinks alcohol and is not taking hormone replacement therapy. T/F | back 540 True |
front 541 Estrogen, calcitonin, bisphosphonates and bone-forming agents can reverse the damage of osteoporosis. T/F | back 541 False |
front 542 Paget's Disease (neuropathic joint disease) is characterized by overactive osteoclasts. T/F | back 542 True |
front 543 An indication for total hip replacement is peripheral vascular disease associated with uncontrolled diabetes. T/F | back 543 False |
front 544 X-rays should be taken both before and after a closed reduction of a fracture. T/F | back 544 True |
front 545 An overweight client who has been newly diagnosed with gout should be advised to lose weight as quickly as possible. T/F | back 545 False |
front 546 Complications of orthopedic surgery include deep vein thrombosis, fat embolism, pulmonary embolism, thrombophlebitis, hemorrhage and wound infection. T/F | back 546 True |
front 547 The nurse should use alcohol or iodine-based products to clean around the pins used in skeletal traction. T/F | back 547 False |
front 548 The nurse should assist a client with an above the knee amputation to lie in the prone position several times a day. T/F | back 548 True |
front 549 When the nurse suspects compartment syndrome, the casted limb should be elevated about the level of the heart. T/F | back 549 False |
front 550 Sarcomas are cancers that begin in the cells of the immune system. T/F | back 550 False |
front 551 In the TNM classification (staging) system, the 'M' stands for metastasis. T/F | back 551 True |
front 552 One monoclonal antibody drug can be used to attack a variety of different types of cancer. T/F | back 552 False |
front 553 The most curable form of cancer is Hodgkin disease. T/F | back 553 True |
front 554 The human papillomavirus 9-valent vaccine, recombinant (Gardasil®9) can prevent cervical cancer. T/F | back 554 True |
front 555 The lower legs and upper back are the most common sites for melanoma in fair-skinned women. T/F | back 555 True |
front 556 Colon cancer may develop from adenomatous polyps. T/F | back 556 True |
front 557 The prognosis for childhood cancers is generally poor. T/F | back 557 False |
front 558 Breast cancer is the most common cause of death in women. T/F | back 558 False |
front 559 External beam radiation is used to damage cancer cell DNA. | back 559 True |
front 560 A priority for septic shock is to treat the cause of infection. | back 560 True |
front 561 The sequence of actions in the initial assessment for trauma care is:
airway, cervical spine stabilization, breathing and then circulation. | back 561 True |
front 562 Medical management of hypovolemic shock includes rapid fluid replacement. T/F | back 562 True |
front 563 Hypotension is a finding of the initial stage of shock. | back 563 False |
front 564 Acute myocardial infarction (MI) is the most common cause of
cardiogenic shock. | back 564 True |
front 565 Cardioversion is used in the emergency treatment of ventricular fibrillation. T/F | back 565 False |
front 566 Paradoxical chest wall movement is a key assessment finding in the client with a flail chest. T/F | back 566 True |
front 567 Altered level of consciousness (LOC) is often a late sign in a client with increased intracranial pressure (ICP). T/F | back 567 False |
front 568 An infant with spina bifida may have a meningocele and neurological
deficits and may experience seizures. | back 568 False |
front 569 A common cause of increased intracranial pressure (ICP) in infants is hydrocephalus. T/F | back 569 True |
front 570 Cyanotic heart defects are more dangerous than acyanotic defects. T/F | back 570 True |
front 571 Respiratory distress syndrome (RDS) in infants is caused by weakness
or underdevelopment of chest muscles. | back 571 False |
front 572 Treatment for bronchiolitis almost always involves surgery. T/F | back 572 False |
front 573 Ventilator support in infants can lead to bronchopulmonary dysplasia (BPD). T/F | back 573 True |
front 574 Apnea is a symptom of any number of different etiologies. T/F | back 574 True |
front 575 Croup syndromes are treated with antibiotics and cool air/mist. T/F | back 575 False |
front 576 A low protein and low calorie diet is indicated for children with cystic fibrosis (CF). T/F | back 576 False |
front 577 Hypothyroidism is a congenital disease that may manifest in children as lethargy, constipation, feeding problems and slow growth. T/F | back 577 True |
front 578 Neonates with tracheoesophageal fistula (TEF) may develop copious amounts of fine white frothy bubbles of mucus in the mouth and nose. T/F | back 578 True |
front 579 An abnormal immune reaction to gluten damages the small intestine in people with celiac disease. T/F | back 579 True |
front 580 A classic finding of Hirschsprung's disease is diarrhea. T/F | back 580 False |
front 581 Primary enuresis develops several years after a person has learned to control his or her bladder. T/F | back 581 False |
front 582 The infant born with bladder exstrophy will most likely experience additional congenital defects. T/F | back 582 True |
front 583 Anemia, thrombocytopenia and acute renal failure are the classic findings of acute hemolytic-uremic syndrome (HUS). T/F | back 583 True |
front 584 Children's bones are more brittle than those of adults, because the bones have not yet fully calcified. T/F | back 584 False |
front 585 Infantile osteochondritis of the hip occurs when the infant's femur is insecurely seated in the acetabulum. T/F | back 585 False |
front 586 To screen for scoliosis, look at the child's silhouette and note asymmetries in the trunk and legs. | back 586 True |
front 587 Juvenile idiopathic arthritis is best managed by diet, hormones and range-of-motion exercises. T/F | back 587 False |
front 588 The treatment for frostbite includes massaging the affected skin. T/F | back 588 False |
front 589 The first sign of mild hypothermia is shivering. T/F | back 589 True Cold-induced shivering is stimulated when body temperatures drop below the set point (which is governed by the hypothalamus). Shivering is activated to raise the body temperature. |
front 590 Findings of a partial thickness burn include moist, red skin that's painful to the touch. T/F | back 590 True For a superficial partial thickness burn, the skin is red, moist and has blisters; the skin is very painful to the touch. There may be no blisters with a deep partial thickness burn. |
front 591 The skin of a client with heat stroke is pale and moist. T/F | back 591 False |
front 592 One way to treat heat exhaustion is to get the client into a cool place. T/F | back 592 True |