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331 terms
Terms | Definitions |
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| Elderly Mr. Thomas comes into the Urgent Care Clinic. He states "I tripped and fell down the stairs in my house." When the doctor visits the patient, the LPN/LVN describes the injury as exhibiting pain with movement, swollen, and ecchymotic. When Mr. Thomas asks what "ecchymotic" means, the best response from the nurse would be: (A) Fractured (B) Blanched (C) Edematous (D) Bruised | (D) Bruised Rationale: Ecchymosis describes a discoloration of the skin, usually black and clue in color. Ecchymosis is another word for bruise. This is caused by blood dispersing into the skin after rupture of small blood vessels. A fractured ankle would have to be diagnosed most likely by x-ray, not nursing assessment. Blanched skin refers to skin that is pale. Edema is accumulation of fluid in the tissue or swelling. |
| The LPN/LVN observes a nursing assistant applying a client's antiembolism stockings. What is the appropriate routine for these stockings? (A) The nursing assistant is applying the stockings just after assisting the patient with ROM leg exercises (B) The nursing assistant is applying the stockings just before assisting the patient out of bed in the morning (C) The nursing assistant is applying the stockings at night as the patient is getting ready to go to sleep (D) The nursing assistant is applying the stockings after observing the color and temperature of the skin | (B) The nursing assistant is applying the stockings just before assisting the patient out of bed in the morning Rationale: The correct and best time for application of antiembolism stockings is in the morning, before the client gets out of bed or after the legs have been elevated for an amount of time. The client's lower extremities should be in a non-dependent position during application to prevent trapping venous blood. Antiembolism stockings are usually worn continuously and should only be removed for the nurse to assess the skin. |
| Mr. Stone is a 32 year-old who recently underwent ORIF (open reduction, internal fixation) surgery for a fractured femur. Over the past few hours the client has started to call the nurse frequently. Mr. Stone has also become more irritable and restless. The best nursing response to this behavior would be: (A) Encourage the patient to use relaxation techniques to aid with pain management (B) Notify the doctor of the patient's behavior (C) Ask the patient if there is something on his mind that he'd like to talk about (D) Check on and interact with the client frequently until he is calm, and then increase the intervals as he starts to develop trust in the staff | (B) Notify the doctor of the patient's behavior Rationale: Subtle personality changes, restlessness, irritability, or confusion in a patient who has recently sustained a fracture are indications of possible fat emboli that have migrated to the lungs. The physician should be immediately notified of any of these changes to allow for further and immediate testing and evaluation. Encouraging relaxation, therapeutic communication, and methods to improve trust are interventions that do not deal with the dangerous condition that the symptoms suggest. |
| Mr. Godfrey, a warehouse worker, presented to the Emergency Department with an acute onset of severe lower back pain, muscle spasms, and radiation of pain into the buttocks and leg. The physician suspects that Mr. Godfrey has a herniated lumber intervertebral disk. During assessment, the nurse asks Mr. Godfrey to describe the characteristics of the pain. Which of the following is an aggravating factor of the condition suspected by the physician? (A) Sneezing (B) Chewing (C) Talking (D) Bed rest | (A) Sneezing Rationale: Pain associated with a herniated intervertebral disk is aggravated by actions that increase intraspinal pressure such as bending, lifting, or straining. Sneezing or coughing involves an amount of straining. The movement associated with chewing and talking does not usually affect this condition. Although bed rest can aggravate symptoms of other conditions, it is usually a relieving factor for herniated disk pain. |
| The LPN/LVN is assessing a client's halo traction to ensure it is applied appropriately. Which of the following observations indicates proper use of this device? (A) The client states his pain is "bearable." (B) The client is able to wiggle his toes comfortably. (C) The client is not able to turn his head from side to side. (D) There is a finger-width space between the client's skin and the traction device. | (C) The client is not able to turn his head from side to side. Rationale: Halo traction is used to keep the neck neutrally aligned and immobilized. The best confirmation that the halo traction is applied properly is that the client is unable to turn his head from side to side. Traction does not control pain. The patient should be medicated for pain as appropriate. Traction fits each person differently. Although it should fit in a way that avoids compromising the patient's skin integrity, there is no rule for the distance between the device and the skin or body part. |
| Mrs. Fischner, a 55 year-old client, presents to her physician that she has stiffness and pain in her joints that "never seems to go away." After laboratory tests, the physician diagnoses rheumatoid arthritis. The results of which laboratory test most likely led to the physician's diagnosis? (A) Serum creatinine (B) Erythrocyte sedimentation rate (ESR) (C) International normalized ration (INR) (D) Fasting lipid panel | (B) Erythrocyte sedimentation rate (ESR) Rationale: Erythrocyte sedimentation rate (ESR) is the best diagnostic indicator of rheumatoid arthritis. ESR is a nonspecific test that indicates the presence of an inflammatory disease when elevated. Rheumatoid arthritis is one of a number of disease processes that will elevate this serum level. Serum creatinine is used to evaluate kidney function. International normalized ratio (INR) tests the effectiveness of anticoagulation therapy, usually with the drug Warfarin (Coumadin). A fasting lipid panel measures the cholesterol and lipid levels and ratios that are present in the blood when the levels are not affected by recent food ingestion. |
| Mrs. Fischner's physician diagnosed that she has rheumatoid arthritis. With this condition, the client's chief complaint is persistent joint pain and stiffness. Pain and stiffness associated with rheumatoid arthritis is most often first noticed in the joints of which of the following? (A) Hands (B) Arms (C) Legs (D) Neck | (A) Hands Rationale: Clients with rheumatoid arthritis usually experience discomfort in the proximal finger joints of the hands before any other joints of the body. Although rheumatoid arthritis can eventually spread to any or every joint, the symptoms of rheumatoid arthritis usually are noticed in the finger and hand joints prior to the joints of the arms, legs and neck. |
 The physician prescribes the following for a patient with rheumatoid arthritis: aspirin 5 g po daily. The pharmacy informs the LPN/LVN that the dosage strength of aspirin is 5 grains. How many tablets should be distributed for this patient in each 24-hour period?(A) 5 (B) 10 (C) 15 (D) 20 | (C) 15 Rationale: One gram (g) contains approximately 15 grains. Therefore, 5 grams contain 75 grains (5 X 15 = 75). Solve for x tablets using the following ratio method: 1 tablet/5 grams = x tablets/75 grains 5x = 75 x = 75/5 x = 15 tablets |
| Mrs. Wilkins, is a 60 year-old client with advanced diabetic neuropathy, is two days post-op from a right-above-the-knee amputation. During assessment, the LPN/LVN asks the client if she is experiencing any pain. Mrs. Wilkins replies. "I've been afraid to mention it. I know my right foot isn't there anymore, but I feel it aching." Which of the following is the most accurate explanation for this sensation? (A) "You may feel pain in the tissues near the incision site, which is known as referred pain." (B) "You may be experiencing a psychosomatic pain response as a result of the loss you are experiencing." (C) "You may be experiencing intractable pain, which can be controlled with the appropriate narcotics." (D) "You may be experiencing a sensation called 'phantom pain' from the site of the amputation." | (D) "You may be experiencing a sensation called 'phantom pain' from the site of the amputation." Rationale: Phantom pain is a real sensation that some people feel after loss of a limb or other body part. This can be felt differently by different individuals. Many have described it as burning, cramping, or itching. Some people sense that the limb is still there. referred pain is the sensation of pain localized in an area distant from the actual injury or area of pathology. Psychosomatic pain or illness is a discomfort or array of symptoms caused by mental processes or emotional responses as opposed to physiological causes. Intractable pain is an often unexplained, severe, and unrelenting pain. Combined therapies are usually necessary to treat intractable pain. |
| Mrs. Wilkins is in her second post-op day with a right-above-the-knee amputation. She asks the nurse why her stump must be rewrapped every day with an elastic bandage. Which of the following is the most appropriate reason for this procedure? (A) "The bandage absorbs drainage and blood from the incision site." (B) "The bandage helps shape the stump and shrinks the stump size." (C) "The bandage prevents dehiscence of the incision caused by movement." (D) "The bandage helps increase circulation to the incision site." | (B) "The bandage helps shape the stump and shrinks the stump size." Rationale: The site of a new amputation will develop a large amount of edema. Stump wrapping with an elastic bandage shrinks and shapes the stump for prosthesis construction. Therefore, answer (B) is correct. The prosthesis will not be sized and constructed until the stump is cone shaped and the size is no longer changing. Gauze bandages are used to absorb blood and drainage. Dehiscence is the separation of the edges or reopening of a closed incision. With appropriate suturing, normal movement should not cause dehiscence. Antiembolism stockings are used to aid circulation in uncompromised limbs. |
| A client has just returned to the hospital room from a liver biopsy. Which of the following is a complication that the LPN/LVN should be aware could occur within the first few hours following this procedure? (A) Hemorrhage (B) Infection (C) Tension pneumothorax (D) Anaphylaxis | (A) Hemorrhage Rationale: The most common complications following a liver biopsy is bleeding, which can lead to severe hemorrhage. This is because of the vascular nature of the liver and the possibility for escape of blood through the needle insertion site. The correct answer is (A). Infection could occur at the puncture site, but this complication occurs gradually, not within a few hours. A tension pneumothorax occurs when air enters the pleural cavity and becomes trapped after the lung has been punctured or lacerated. This would induce immediate symptoms during the biopsy and would not develop over the hours following the procedure. Anaphylaxis is a severe allergic response. This should not occur with a liver biopsy. |
| Mrs. Jamison has just returned from a biopsy of her liver. Which of the following instructions provided by the nurse is inaccurate for care following this procedure? (A) The nurse tells the client to "avoid coughing or straining for the next few hours, if possible." (B) The nurse instructs the client to "inhale and exhale deeply several times and then exhale and hold your breath at the end of expiration." The client is instructed to repeat this activity every 10 minutes for the first couple hours after the procedure. (C) The nurse instructs the client to lie on [her] right side with a pillow under [her] rib cage. (D) The nurse states that the client will have to "avoid heavy lifting and any strenuous activity for one week following the procedure. | (B) The nurse instructs the client to "inhale and exhale deeply several times and then exhale and hold your breath at the end of expiration." The client is instructed to repeat this activity every 10 minutes for the first couple hours after the procedure. Rationale: This answer refers to the instructions the nurse would give to a client during the liver biopsy procedure. Holding the breath immobilizes the diaghram and chest wall to avoid perforation of the diaghram during insertion of the biopsy needle. Following a liver biopsy, coughing or straining could lead to straining of the puncture site and escape of blood. Lying on the right side compresses the puncture site against the chest wall to impede bleeding at the site, and leaning on a pillow will provide comfort in this position for a longer time period. Cautious activity reduces the risk fro blood escaping from the biopsy puncture site. |
| The LPN/LVN is providing blood pressure readings at a local convenience store for members of the community. For which of the following client should the nurse recommend follow-up with the client's primary doctor within a period of two months? (A) 114/78 (B) 120/82 (C) 134/97 (D) 138/89 | (C) 134/97 Rationale: Normal blood pressure readings range between 100 to 140 systolic and 60 to 90 diastolic. The Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (2003) recommends that if either a systolic reading between 140 and 149 or a diastolic reading of 90 to 99 is obtained, the client's blood pressure should e rechecked in 2 months following the initial reading. The correct answer is (C). In this answer the diastolic reading is above the normal range. All other answers are within normal blood pressure range. |
| The LPN/LVN caring for Mr. Braxton, a 69 year-old client admitted to the extended stay facility, notices that he has an unsteady gait. Select each of the following that are appropriate nursing actions for the LPN/LVN in this situation (Choose all answer choices that apply): (A) Ensure the client's room is free of clutter or obstacles. (B) Provide adequate lighting to the client's room (C) Make sure the call light stays on the nightstand at all times (D) Place throw rugs around the client's room (E) Have the client sit in a chair with a vest restraint applied (F) Keep the client's bed in its lowest position with all four side rails up | (A) and (B) Ensure the client's room is free of clutter or obstacles, Provide adequate lighting to the client's room. Rationale: (A) and (B) are the only correct answers to this question. Removing obstacles and clutter from the client's room decreases the risk that the client will trip over an item. Adequate lighting ensures the client can see appropriately when moving around the room. It may not be appropriate for the call light to be on the nightstand if it is not within the client's reach. The client should be able to reach the call lights at all times. Throw rugs are not permanently fixed to the floor surface and are therefore fall hazards. Keeping the bed in its lowest position is appropriate, but keeping all of the side rails up increases the distance a client could fall when trying to get out of bed. |
| During routine vital signs, the LPN/LVN auscultates a BP of 180/98. How long should the LPN/LVN wait before inflating the cuff to recheck this reading? (A) 15 seconds (B) 30 seconds (C) 1 minute (D) 2 minutes | (D) 2 minutes Rationale: The American Heart Association (AHA) recommends waiting 2 minutes before repeating a blood pressure reading at the same site. This is to decrease venous congestion. The correct answer is (D). All of the other answers give too short of a time span between cuff inflations. |
| The LPN/LVN walks into the client's room and observes that the client immediately begins to display grand mal seizure activity. Select all of the following nursing actions that should be performed at this time: (A) Turn the client onto her side with her neck flexed (B) Apply soft wrist restraints fro the duration of the seizure (C) Maintain an airway by inserting a tongue depressor into the client's mouth (D) Trigger the facility's procedure for emergency response (E) Raise the side rails (F) Remove any loose items from the client's bed | (A), (D), (E) and (F) Turn the client onto her side with her neck flexed, Trigger the facility's procedure for emergency response, Raise the side rails and Remove any loose items from the client's bed. Rationale: Client safety is the top priority during a convulsion. Important actions to maintain safety include placing the client in a side lying position to allow drainage of oral secretions, activating emergency response, removing all items from the bed that could cause bodily harm, and raising and padding the side rails. During a seizure a client will be experiencing strong spasms that cause muscle contractions. Restraining a client could cause injury to the musculoskeletal system. Muscle contractions in the jaw cause the client's teeth to clench. Never attempt to insert anything into clenched teeth. Doing so may cause injury to the teeth and lips. |
| Mrs. Palmer, a client with Parkinson's disease, is admitted to an extended-stay nursing facility. Up until this point she has been living on her own. Which of the following assessments is the most significant in developing the plan of care? (A) Mrs. Palmer states she dislikes beef nut will eat it once in a while if it is cooked well (B) Mrs. Palmer talks frequently about how much she misses living on her own (C) Mrs. Palmer has a difficult time eating at dinner due to tremors (D) Mrs. Palmer states her only living relative is her daughter who lives across the state and seldom visits | (C) Mrs. Palmer has a difficult time eating at dinner due to tremors Rationale: Although it is important to consider all client needs holistically, the highest concern in establishing a plan of care is the physiological needs of the client. Physiological needs include ADLs (activities of daily living). ADLs are basic needs, such as eating, moving, dressing, toileting and other personal hygiene. Answer (C) is the correct answer because it is the only assessment that indicates a physical hindrance to a physiological need. |
| Which of the following is a correct initial nursing action to be performed by the LPN/LVN when a client with a physician-written DNR order goes into cardiac arrest? (A) Notify the physician (B) Initiate the emergency response system (C) Perform rescue breathing and chest compressions (D) Move the crash cart into the room beside the client's bed | (A) Notify the physician Rationale: A DNR or "Do Not Resuscitate" order indicates that in the case of cardiac or respiratory arrest, no lifesaving treatment will be initiated. I order for DNR procedures to stand, a written physician's order must be documented in the medical record. Initiating the emergency response system is not necessary for a client with a DNR order. Emergency actions, such as rescue breathing and chest compressions, will not be performed. A crash cart containing emergency medications and a defibrillator will not be used on this client. The physician should be notified of the client's status. |
| During an assessment of a client, the LPN/LVN palpates the radial pulse and notices an irregular pattern of beats. How would the nurse best describe this assessment in documentation? | Dysrhythmia or arrhythmia Rationale: Either dysrhythmia or arrhythmia would be correct answers for this question. A dysrrhythmia/arrhythmia is an abnormality to a rhythmic pattern that is usually steady. Therefore, these words can be used to describe irregular rhythm in a client's heart rate. |
| Mrs. Strobell is walking in the hallway with the nursing assistant. She experiences sudden onset of angina. Which of the following should be the first action taken by the LPN/LVN? (A) Call the physician immediately (B) Instruct Mrs. Strobell to relax and discontinue all muscle movement (C) Tell the nursing assistant to help Mrs. Strobell walk back to her bed slowly and lie down (D) Retrieve a wheelchair and an oxygen tank from the supply room and transport Mrs. Strobell back to her room | (B) Instruct Mrs. Strobell to relax and discontinue all muscle movement Rationale: Angina is pain in the chest that is caused by an insufficient flow of oxygen to the cardiac muscle. Muscle activity that occurs with movement increases the oxygen demand of the cardiac muscle. Discontinuing all movement will decrease the oxygen demand of the muscle. It is important to administer supplemental as soon as possible, and the client should not walk or stand any more than necessary while experiencing angina. While a wheelchair and an oxygen tank are being retrieved, the nurse can instruct the client to remain still and relax as much as possible. Of the answer choices, answer (B) is the correct initial action. Once back in her room, Mrs. Strobell can be assisted to bed to lie down. |
| Mrs. Garner is visiting her obstetrician at 12 weeks gestation. Which of the following laboratory findings would indicate the need for interventions in the client's prenatal care? (A) Serum glucose of 96 g/dL (B) White blood cell count of 13 mm3 (C) Hematocrit of 30% (D) Hemoglobin of 12 g/dL | (C) Hematocrit of 30% Rationale: In pregnancy, a client's hematocrit should be between 32 and 465. A hematocrit of 30% indicates slight anemia. Normal serum glucose in pregnancy is 65 to 110 g/dL. Normal white blood cell count in pregnancy is 9 - 15 mm3. Normal hemoglobin in pregnancy is 11 to 13 g/dL. |
| Which of the following should be initiated for a client suspected of having meningitis? (A) Standard precautions (B) Contact precautions (C) Droplet precautions (D) Airborne precautions | (C) Droplet precautions Rationale: The correct answer is droplet precautions. Most forms of meningitis are transmitted from the secretion droplets of those who are infected. Standard precautions are used with all clients, whether or not they are known or thought to be infected with a transmittable disease. Airborne and contact precautions would not be effective in preventing transmission of this pathogen. |
| Which of the following assessments is the most important when examining a client who is suspected to be experiencing a CVA (cerebral vascular accident): (A) Vital signs (B) Motor response (C) Integrity of the airway (D) Level of consciousness (LOC) | (D) Level of consciousness (LOC) Rationale: The first thing to assess in a client who displays signs and symptoms of a CVA (cerebral vascular accident) is level of consciousness (LOC). LOC most quickly and accurately indicates the level of brain function. This is also the first assessment in the ABCs of emergency response procedures. Airway integrity would be assessed after unconsciousness is confirmed. If the client is conscious, vital signs and motor response should then be assessed. Vital sign changes and motor response deficits give further information about the characteristics of the CVA. |
| The LPN/LVN is caring for a one day old male neonate. After feeding the infant 0.5 oz of formula, he is burped and placed in the crib. Which of the following is the ideal position for the LPN/LVN to lay the infant? (A) Right lateral with the crib mattress flat (B) Right lateral with the foot of the crib mattress elevated (C) Left lateral with the foot of the crib elevated (D) Prone with the head of the crib mattress elevated | (A) Right lateral with the crib mattress flat Rationale: The right lateral position promotes gastric emptying and emptying of the oropharynx. Therefore, answer (A) is the best answer. Elevating the foot of the crib mattress would increase the risk of aspiration. The prone position is almost always discouraged for an infant due to research that has connected this position with SIDS (sudden infant death syndrome). |
| The physician writes an order for a client to receive Digoxin 0.08 mg IV q day. The mixture of Digoxin in the vial contains 0.05 mg of medication in 1 mL of solution. The nurse preparing the medication should draw up how much of the solution? | Answer: 1.6 mL Rationale: Solve for x mL using the following ration method 0.05mg/1mL = 0.08mg/xmL 0.05x = 0.08 x = 0.08/0.05 x = 1.6mL Or use desired over available Desired 0.08mg Available 0.05mg in 1mL 0.08mg/0.05mg X 1mL 0.08mg/0.05mg = 1.6 X 1mL = 1.6mL |
| The LPN/LVN administers the prescribed dose of NPH insulin to a client at 0700. At what time should the peak effects of this medication be expected to take place? (A) 1700 {5 pm} (B) 2100 {9 pm} (C) 1400 {2 pm} (D) 1100 {11am} | (A) 1700 {5 pm} Rationale: NPH is an intermediate-acting insulin that peaks between 8 and 12 hours after administration. The peak effects of NPH insulin administered at this time would occur between 1500 {3pm} and 1900 {7pm}. Answer (B) is too late for the peak action of this medication to occur. Answers (C) and (D) are too early for the peak action of this medication to occur. |
| The LPN/LVN is preparing to insert a nasogastric tube into the client's gastrointestinal tract. Prior to insertion, the nurse would determine how far to insert the tube by marking the place on the tube that is equal to which of the following distances? (A) The distance from the tip of the nose to the belly button (B) The distance from the top of the head to the top of the ear, to the belly button (C) The distance from the tip of the earlobe to the belly button (D) The distance from the nose to the earlobe plus the earlobe to the sternum | (D) The distance from the nose to the earlobe plus the earlobe to the sternum Rationale: The length of the nasogastric tubing necessary fro each individual client is measured by using the tube to mark off the distance from the tip of the client's nose to the tip of the earlobe and then from the tip of the earlobe to the tip of the sternum. This is approximately the distance from the nares to the stomach, which varies from client to client. The distances of the other answers would not provide an accurate measurement for the desired length. |
| The distance has been determined and marked on the tubing for inserting a nasogastric tube into a client's gastrointestinal tract. Using all answers provided, arrange the following answer choices into the order of steps that would be followed during insertion of a nasogastric tube: (A) Lubricate the tip of the NG tube (B) Wash hands and put on gloves (C) Ask the client to tilt the head forward (D) Check tube placement (E) Ask the client to hyperextend the neck (F) Have the client swallow sips of water while advancing the tube 5 to 10 centimeters with each swallow | (B) Wash hands and put on gloves (A) Lubricate the tip of the NG tube (E) Ask the client to hyperextend the neck (C) Ask the client to tilt the head forward (F) Have the client swallow sips of water while advancing the tube 5 to 10 centimeters with each swallow (D) Check the tube placement Rationale: Prior to any procedure, the nurse should perform appropriate hand-washing procedures and put on gloves. A lubricant is applied prior to insertion to ease movement through the gastrointestinal tract. During initial insertion of the tube, the client should hyperextend the neck to reduce the curvature of the nasopharyngeal junction. Once the tube is past the nasopharyngeal junction, the client should tilt the head forward to prevent the tube from going into the larynx. Once in the esophagus, having the client take sips of water while advancing the tube will make the process more natural and prevent discomfort. Once the desired length of the tube is inserted, it is important to confirm that the tube is placed in the stomach and not in the lungs. |
| Which of the following would provide the best information as to whether hemodialysis (HD) has been effective therapy for a client with renal failure? (A) Checking the client's weight (B) Measuring intake and output (C) Checking the potassium level of the client's blood (D) Monitoring a client's tolerance to exercise | (A) Checking the client's weight Rationale: Hemodialysis (HD) is indicated for clients with excess and electrolyte imbalances. Fluid loss or gain is assessed by checking the client's weight at least once a day as well as before and after HD sessions. The amount of weight loss or gain at these times is used to monitor effectiveness of or further need for HD. Measuring intake and output is important to ensure limited fluid intake for clients with renal failure, but this will not indicate HD effectiveness. Clients with renal failure often experience fatigue with exercise, but factors other than those associated with renal failure could cause fatigue. HD is used to regulate serum electrolyte levels (i.e., potassium), but these levels will not indicate overall effectiveness of HD. |
| Which of the following pressure points is most likely to be at risk for developing a pressure wound while a client is in the prone position? (A) Occiput (B) Elbows (C) Toes (D) Coccyx | (C) Toes Rationale: Prone position involves the client lying with the anterior surface of the body compressed against the bed or lying area. The occiput, elbow and coccyx (also called the tailbone) are all pressure points that would be compromised if the client were to lay with the posterior surface against the bed or lying area. The toes would be compressed against the lying area with the client in the prone position. Therefore, the correct answer is (C). |
| A 49 year old, male client is admitted to the unit for alcohol withdrawal. The client insists that he had his last drink 4 hours prior. Which of the following medications would the LPN/LVN expect to administer to the client? (A) Naloxone hydrochloride (Narcan) (B) Chlordiazepoxide hydrochloride (Librium) (C) Disulfiram (Antabuse) (D) Chlorpromazine (Thorazine) | (B) Chlordiazepoxide hydrochloride (Librium) Rationale: Chlordiazepoxide hydrochloride (Librium) is an antianxiety agent that is used in the treatment of alcohol withdrawal. Naloxone hydrochloride (Narcan) is an antidote for opioids. Narcan is used to reverse the effects of opioid overdose. Disulfiram (Antabuse) is an alcohol deterrent used to treat alcoholism. Antabuse cannot be taken if the client has ingested alcohol in the past 12 hours. Among other uses, chlorpromazine (Thorazine) is most often used to treat psychosis or control nausea and vomiting. |
| Eighty year old Mr. Lewis visits the physician at the clinic for his routine check-up. Following the doctor's orders, Mr. Lewis has been taking Amphogel for the past two weeks. Which of the following side effects should the LPN/LVN assess for? (A) Constipation (B) Diarrhea (C) Dizziness (D) Pruritis | (A) Constipation Rationale: Aluminum hydroxide (Amphogel) is used for the treatment of ulcers by neutralizing gastric acid. A frequent side effect of this medication is constipation, answer (A). It is uncommon for clients to experience diarrhea, dizziness, or pruritis (itching) from the use of Amphogel. |
| Which of the following are appropriate steps that are involved in irrigating a client's eye? (A) Have the client tilt his/her head toward the opposite eye (B) Wash hands and put on gloves (C) Irrigate with the solution until the eye is no longer reddened (D) Place the drops of solution into the center of the eye (E) Place the drops of solution into the inner corner of the eye (F) Offer a tissue to the client | (B) Wash hands and put on gloves (E) Place the drops of solution into the inner corner of the eye (F) Offer a tissue to the client Rationale: Standard precautions, such as hand washing and applying gloves are used any time a health-care worker will come in contact with a patient, especially when handling body orifices or fluids going into or secreted from a patient. The solution should be dropped into the conjunctival sac at the inner canthus (inside corner of the eye). Applying the solution directly to the center of the eye could damage the cornea. A tissue is offered for the client to absorb solution that flows out of the eye. The client should be instructed to tilt his/her head toward the eye being irrigated. The chemical composition of the solution will cause the eye to redden, as would any foreign object that is introduced to the eye. |
| What is the most appropriate position for a client to assume when receiving a rectal suppository? | Answer: Lying on the left side with the right knee flexed Rationale: The left side-lying or Sims' position with the right knee flexed allows medication to be inserted into the natural curve of the sigmoid colon. Assuming this position will decrease discomfort during the procedure and also reduce the risk of injury to tissue surrounding the rectum and colon. |
| Of the following symptoms, which would indicate that a client has a deficiency of riboflavin? (A) Ecchymosis (B) Dry, cracked lips and mouth (C) Night blindness (D) Anorexia, weight loss, and fatigue | (B) Dry, cracked lips and mouth Rationale: Insufficient amounts of Riboflavin (or Vitamin B2) leads to development of dry skin lesions, usually found in or around the mouth. Riboflavin is not stored in the body, and therefore must be restored through dietary supply. Foods that contain riboflavin include dairy products, eggs, whole-grain enriched breads and cereals, liver, and green leafy vegetables. Ecchymosis (bruising) is a result of a decrease in essential clotting factors in the blood, as in Vitamin K deficiency. Night blindness is a result of Vitamin A deficiency. Anorexia, weight loss and fatigue are symptoms of Thiamin (or Vitamin B1) deficiency. |
| During hospitalization, Mrs. Granger is diagnosed with peptic ulcer disease (PUD). The physician has ordered her discharge home. After reviewing the discharge instructions with Mrs. Granger, which of the following statements indicates to the LPN/LVN that further teaching is needed? (A) "I am going to cut back on milk and cream consumption and start eating other dairy products instead." (B) "I'm going to remove coffee and any food or drinks that contain caffeine from my diet." (C) "I will make aspirin my pain reliever of choice." (D) "I'm scheduled to go out to a smoking cessation group this Tuesday." | (C) "I will make aspirin my pain reliever of choice." Rationale: Aspirin irritates the mucosal lining of the gastrointestinal tract and is not recommended for use by clients with peptic ulcer disease, making answer (C) correct. It is suggested to client's with peptic ulcer disease to avoid a diet rich in milk and cream, which stimulate acid secretion. Coffee, even decaffeinated forms, stimulates acid secretion also. Smoking causes decreased secretion of bicarbonate into the duodenum from the pancreas. Bicarbonate decreases the acidity in the GI tract. Therefore, clients with PUD should be encouraged to stop smoking. |
| A neonate is delivered after a full term pregnancy with an intact omphalocele. Which of the following is NOT an intervention for the management of the omphalocele prior to surgical repair? (A) Apply saline-soaked pads to the sac (B) Insert a nasogastric tube (C) Cover the defect and the abdomen in a plastic wrap (D) Offer a pacifier to the infant | (D) Offer a pacifier to the infant Rationale: Omphalocele is the herniation of abdominal contents through the umbilical cord ring. Protection from infection and rupture of the sac are vitally important to the infant's safety prior to repair. Wrapping the sac in saline-soaked pads keeps the area moist, which helps prevent infection. Covering the sac with saline pads and wrapping the abdomen with plastic wrap help protect the defect. A nasogastric tube is inserted to decompress the gastrointestinal tract and reduce the bowel. The correct answer is (D). A pacifier is offered after surgery for oral gratification. |
| Mrs. Strachand was severely burned in an automobile accident. The burns cover her entire anterior chest and right arm. Using the Rule of Nines, the LPN/LVN would calculate the body surface area (BSA) that is burned to be: (A) 9% (B) 18% (C) 27% (D) 36% | (C) 27% Rationale: The Rules of Nines is a method that uses percentages to calculate the amount of body surface area (BSA) that has been burned. The body is divided into nine sections, each calculated as a percentage that is a multiple of nine. Together, the head and neck make up 9% of the BSA. Each arm is 9% of the BSA. Each leg is 18% of the BSA. The posterior chest (including the back and buttocks) is 18% of the BSA. The perineum, the only exception to the "nine" rules, is 1% of the BSA. Using this information, the correct answer is 27% or answer (C). The right arm is 9% and the anterior chest is 18%. |
| While looking over a client's laboratory findings, the day shift LPN/LVN notices that the serum potassium of the client is 4.1 mEq/L. Which of the following is the most appropriate nursing action after discovering this information? (A) Document this normal finding in the medical record (B) Call the physician immediately for an order to increase this dangerously low potassium level (C) Check that the client is oriented. This reading is critically high and could cause confusion (D) This value is a little low. Encourage the client to drink 12 oz of orange juice and eat a banana to increase the serum level | (A) Document this normal finding in the medical record Rationale: The normal range for serum potassium is 3.8 to 5.0 mEq/L. The client's potassium level is within normal range. The correct nursing action would be to document this finding, answer (A). There is no need for the physician to be notified immediately, and further interventions are not necessary for a normal finding. |
| The LPN/LVN is preparing to administer Vancomycin 1 gram mixed in 500 mL of IV solution. The medication is to be administered over 90 minutes. At what rate should the medication be set at in drops per minute with a drop factor of 15 gtt/mL? (A) 15gtt/min (B) 33 gtt/min (C) 56 gtt/min (D) 83 gtt/min | (D) 83 gtt/min Rationale: The formula to calculate this problem is: x gtt/min = volume/time (in minutes) X drop factor. x gtt/min = volume/time 15gtt/90min = 500/1 x gtt/min = 83 Or use 15gtt/90min X 500mL/1min 15 X 500 = 7500 90 X 1 = 90 7500/90 = 83gtt/min |
| Follow a drop of blood as it circulates through the right side of the heart, using all of the following cardiac structures: (A) Tricuspid valve (B) Vena cava (C) Right ventricle (D) Right atrium (E) Pulmonic valve (F) Pulmonary artery | (B) Vena cave (D) Right atrium (A) Tricuspid valve (C) Right ventricle (E) Pulmonic valve (F) Pulmonary artery Rationale: The blood enters the right atrium of the heart via the superior vena cava. From the right atrium, blood goes through the tricuspid valve to the right ventricle. The blood then continues out of the right side of the heart into the pulmonary artery by way of the pulmonic valve. |
| Mr. Greene is a client in a long term nursing facility who requires tube feedings via his PEG (percutaneous endoscopic gastrostomy) tube. Which of the following would the LPN/LVN know to watch for as the most common complication of tube feedings? (A) Constipation (B) Loose, watery stools (C) Vomiting (D) Excessive belching | (B) The most frequent complication of tube feedings, whether through nasogastric or PEG (percutaneous endoscopic gastrostomy) tube, is diarrhea or loose, watery stools. This is a reaction caused by intolerance to the formula solution or the rate that the formula is being given. Constipation can occur any time food is passed through the gastrointestinal tract, but it is not the most common condition caused by tube feedings. Vomiting could also indicate intolerance to the tube feeding rate, but it is less common than diarrhea. Belching is not a side effect known to be caused by tube feeding. |
| Which of the following pathogens is most commonly found in an infection of the bladder and urinary tract? (A) Streptococcus pyogenes (Group A Strep) (B) Salmonella (C) Staphylococcus aureus (S. aureus) (D) Eschericha coli (E. coli) | (D) Eschericha coli (E. coli) Rationale: The correct answer is Eschericha coli (E. coli), (D). Streptococcus pyogenes (Group A Strep) and Staphylococcus aureus (S. aureus) are pathogens commonly found in the upper respiratory tract, the skin, and the hair. Salmonella is found in the lower gastrointestinal tract. |
| The physician diagnoses a client with septicemia. Which of the following assessment findings would support this diagnosis? (A) Bilateral knee pain (B) Reddened tissue surrounding an injury site (C) Drainage from an injury site (D) Temperature of 101 degrees F | (D) Temperature of 101 degrees F Rationale: Septicemia is the invasion of pathogenic bacteria into the blood stream. Symptoms of septicemia include temperature elevation, backache, headache, elevated pulse, elevated respiratory rate, nausea, vomiting, diarrhea, chills and general malaise. The correct answer is (D), temperature 101 degrees F. Pain, redness or drainage from an injury site suggests local, rather than systemic, infection or inflammation. |
| A male client with diagnosed bipolar disorder is hospitalized on the psychiatric unit. At a community activity, the client becomes disruptive and is seen flirting with female clients. Which of the following is the most appropriate intervention for this behavior? (A) Pull the client aside to remind him of the unit rules and set boundaries for his behavior (B) Tell the other clients to ignore the flirtatious actions of the male client (C) Avert the attention of the male client and lead him to his room (D) Have the client return to his room immediately because of his inappropriate behavior | (C) Avert the attention of the male client and lead him to his room Rationale: The most appropriate response to this behavior would be to avoid confronting and/or threatening the client while removing the inappropriate behavior. Distraction is a good approach to ease removal of the client, making answer (C) correct. Averting the client's attention and escorting him to his room is neither confrontational nor threatening. Pulling the client aside and/or reprimanding him, as in answers (A) and (D), are both confrontational and threatening to a client. This could cause agitation. Having the other clients ignore the behavior will not remove the potentially hazardous situation. |
| The nursing assistant runs out of a hospital room yelling that the patient fell to the floor. The LPV/LVN is rehearsing in her mind the order of nursing actions that should be performed when at the client's side. Arrange the following into the correct order of priority, with the highest priority action listed first: (A) Assess airway patency (B) Assess for injury (C) Move the client into bed (D) Check heart rate and blood pressure (E) Call the client's physician | (A) Assess airway patency (D) Check heart rate and blood pressure (B) Assess for injury (C) Move the client into bed (E) Call the client's physician Rationale: Assessing airway patency is the primary concern upon initiating emergency actions. If the airway is obstructed, CPR steps would be continued (i.e. Heimlich maneuver, rescue breathing, chest compressions, etc.). If the airway is patent, cardiopulmonary stability status is stable, the client can be assessed for any injuries caused by the fall. Moving the client to bed is not a top priority above assessing cardiopulmonary status. If the client could be further injured during the transfer process, this should be avoided until the safest transfer method is available. The physician should be notified once assessment and necessary interventions have been initiated. |
| Which of the following are conditions associated with Cushing's syndrome? Select all that apply. (A) Easy bruising (B) Buffalo hump (C) Hyperglycemia (D) Excessive scalp hair growth (E) Hyponatremia (F) Trunk obesity | (A) Easy bruising (B) Buffalo hump (C) Hyperglycemia (F) Trunk obesity Rationale: Clinical manifestations associated with Cushing's syndrome include: easy bruising, moon face, buffalo hump, hyperglycemia, hypokalemia, sodium retention, thinning of scalp hair, increased body and facial hair, acne, muscle wasting, poor wound healing, and mood changes. Excessive scalp hair growth and hyponatremia are not associated with Cushing's syndrome. |
| A client visiting the physician's office for an annual physical is about to perform a visual acuity test using the Snellen chart. Which statement is most accurate when explaining the examination to the client? (A) "This exam tests your ability to read small print from a close distance." (B) "This exam tests your peripheral vision." (C) "This exam tests your ability to see colors." (D) "This exam tests your visual acuity from far distances." | (D) "This exam tests your visual acuity from far distances Rationale: The visual acuity exam involving the Snellen chart tests long distance vision. The client is asked to read letters form 20 feet away. The letters become consecutively smaller progressing down the chart. Jaeger's chart is used to test close distant vision. A tangent screen is used to test peripheral vision by gradually bringing an object into the peripheral view and having the patient indicate when they see and object in their field of vision. Ishihara's plates are used to test for color vision. |
| Which of the following is the most important information obtained from the client that presents to the physician's office with right calf tenderness? (A) High levels of work related stress (B) Use of oral contraceptives (C) Left femur fracture 18 months prior (D) Plays in a soccer league | (B) Use of oral contraceptives Rationale: The client is displaying a characteristic symptom of a DVT (deep vein thrombosis). DVTs are dangerous as they can lead to pulmonary emboli if the thrombus becomes mobile and travels to the lungs. Risk factors for developing a DVT include: history of varicose veins, cardiovascular disease, pregnancy, oral contraceptive use, immobility, or recent surgery/injury. Stress is not a factor associated with a DVT. An injury 18 months ago is no longer a threat for developing a DVT. Playing soccer could cause shin splints, which would cause calf tenderness. However, a DVT should be ruled out before any other explanation is given for the calf tenderness. |
| Ms. Winters is visiting the pediatrician with her newborn baby girl, Emily. Ms. Winters has breastfed Emily since birth and wonders when Emily will be able to eat other foods. What age is the earliest that introduction of other foods into the infant's diet could begin? | Answer: 4 months Rationale: Until 4 months of age, breast milk provides the nutrients necessary for infant growth and metabolism. Infant rice cereal is recommended as the first food to introduce. Any food introduced any earlier than 4 months might be dangerous to the infant's developing gastrointestinal system. |
| Mrs. foster thinks she might be pregnant and visit's the physician's office. a urine sample pregnancy test is performed. The evaluation of which of the following hormones in the urine would indicate that Mrs. Foster is indeed pregnant? (A) Human growth hormone (hGH) (B) Human chorionic gonadotropin (hCG) (C) Estrogen (D) Oxytocin | (B) Human chorionic gonadotropin (hCG) Rationale: Human chorionic gonadotropin (hCG) is released by the trophoblast, outer cell layer of the developing fetus in the zygote stage. hCG can be detected in the blood and urine as early as 10 to 14 days after conception, indicating early pregnancy. Human growth hormone (hGH) is responsible for the growth of bones, muscles and other organs. Estrogen is important for maintaining pregnancy, but it is not used to diagnose pregnancy. Estrogen elevation does not occur until the seventh week of gestation. Oxytocin promotes uterine contractility and the stimulation of milk ejection from the breasts. During pregnancy oxytocin assists the labor process that results in birth. |
| During her visit to the clinic, testing is performed that confirms Mrs. Foster's suspected pregnancy. Mrs. Foster states that her last menstrual period (LMP) began on March 12. Using Nagele's rule, what would the LPN/LVN calculate Mrs. Foster's estimated date of confinement (EDC) to be? (A) December 11th of that year (B) January 2nd of the following year (C) December 27th of that year (D) December 19th of that year | (D) December 19th of that year Rationale: Nagele's rule calculates the estimated date of confinement (EDC) using the following formula: the first day of the last normal menstrual period (LMP) minus 3 months, plus seven days, plus one year. Three months before the date of Mrs. Foster's LMP is December 12th of the previous year. December 12th plus 7 days is December 19th of the previous year. Therefore, the EDC is December of that year, answer (D). |
| Two days ago the physician prescribed changes to the insulin regimen of a diabetic client. The new regimen involves the following order: Humulin 70/30 15 units sc BID at 9:00 At midnight the client complains of "not feeling right." The client's skin is cool and clammy. Which of the following nursing actions is appropriate for the LPN/LVN assigned to the client to include in the client's care for next 24 hours? (A) Encourage an hs snack (B) Hold the a.m. insulin dose (C) Decrease the a.m. insulin dose to 10 units (D) Give the client Humulin R insulin instead of Humulin 70/30 | (A) Encourage an hs snack Rationale: Encouraging an hs (hour of sleep) snack will help avoid hypoglycemia in the middle of the night caused from peaking effects of the p.m. insulin dose. Without a written physician's order. a nurse may not adjust the prescribed amount or dosage of a medication. Holding or decreasing the a.m. dose will not affect hypoglycemia that occurs at midnight. Humulin R is regular insulin. Regular insulin is fast-acting. Humulin 70/30 contains a 70% to 30% mixture of NPH (intermediate-acting) insulin to Humulin R (regular or fast-acting) insulin. Giving 15 units alone without a serum glucose that can sustain the effects of the dose can be fatal to a client. |
| Prescription of which of the following medications to a client with glaucoma should alert the LPN/LVN to clarify the order with the physician prior to admission? (A) Nalbuphine (Nubain) (B) Aspirin (C) Benazepril (Lotensin) (D) Atropine sulfate (Sal-Tropine) | (D) Atropine sulfate (Sal-Tropine) Rationale: Glaucoma is a condition of the eye that involves an increase on intraocular pressure. Untreated glaucoma can lead to permanent blindness. Use of atropine sulfate (Sal-Tropine) causes pupil dilation, which can obstruct the drainage of aqueous humor from the eye and lead to an acute attack of increased intraocular pressure. Nalbuphine (Nubain) is an opioid analgesic. Nubain does not affect intraocular pressure. The use of aspirin for any therapeutic effect is not contraindicated for clients with glaucoma. Benazepril (Lotensin) is used to lower blood pressure in hypertensive patients. Benazepril (Lotensin) is safe for use by clients with glaucoma as well. |
| Mr. Sanders, an 83 year old client, presents to the clinic complaining of a persistent "whistling sound" in his ears. How would the LPN/LVN document this complaint in the medical record? | Answer: Tinnitus Rationale: Tinnitus is defined as a sound heard in one or both ears. The sound could be described as ringing, buzzing or whistling and occurs without an external stimulus. Causes of tinnitus include an ear infection, side effects of certain medications, a blockage in the eustachian tube, or an injury to the head. Further assessment and patient history should be reviewed to determine the cause of the client's symptom. |
| The LPN/LVN is preparing for a sterile procedure that requires using sterile 4 X $ gauze. Which of the following would indicate contamination of the open 4 X $s? (A) The LPN/LVN pours sterile saline onto the sterile 4 X 4s that are sitting on the bedside table (B) The LPN/LVN opens the 4 X 4s just prior to use to avoid prolonged air exposure (C) The 4 X 4s remain within the sterile packaging borders on a bedside table that is positioned at or above waist level (D) The 4 X 4s are picked up with sterile forceps | (A) The LPN/LVN pours sterile saline onto the sterile 4 X4s that are sitting on the bedside table Rationale: Keeping the 4 X 4s within sterile packaging borders on a surface that is at or above waist level and avoiding prolonged exposure to air are principles used to maintain sterility of equipment and supplies. To prevent contamination, the 4 X 4s should not be touched with any materials that have failed to maintain sterile technique themselves. It is proper to use sterile forceps or hands with properly applied sterile gloves to move sterile 4 X 4s while maintaining sterility. The correct answer (A), allows contamination through capillary action of the 4 X 4s. As the saline solution contacts the surface of the bedside table, the sterility is compromised because bacteria from the table travel through the fluid to contact the 4 X 4s. |
| Which of the following would be the most appropriate room assignment for a child with lymphatic leukemia who is being admitted to the unit? (A) A semiprivate room with another child with leukemia (B) A semiprivate room with a child who is diagnosed with FUO (C) A private room on the pediatric medical floor (D) A private room in the intensive care unit | (C) Until the degree of leukemia involvement is determined in the child, it is best to keep the child away from other children as much as possible. The white blood cells of a client with leukemia are ineffective. This causes decreased immunity. Infection from another child or person could be detrimental to a child with this condition. A semiprivate room is not recommended at this time. Unless the child is in critical condition, assignment to an intensive care bed is not necessary. |
| A physician schedules a client for a stress electrocardiogram. The client asks the LPV/LVN why this test is needed. The most accurate explanation from the nurse would be: (A) "The test will determine the heart rate you want to achieve during exercise." (B) "The doctor will be able to tell how much exercise you need to add to your daily routine in order to stay healthy." (C) "The doctor is looking to see how exercise affects your heart." (D) "The test will tell if you are likely to suffer from a heart attack in the next year." | (C) "The doctor is looking to see how exercise affects your heart." Rationale: A stress electrocardiogram monitors the heart while the client progressively increases exercise levels. The physician will read the electrocardiogram, a graph of the client's heart function, to determine if cardiac dysfunction occurred during exercise. The physician is looking to see how the stress of exercise affects the client's heart. The "target heart rate" or rate that the client should reach during normal exercise is determined based on the client's age and gender. The test may indicate if a client needs to alter his/her daily exercise routine, but this is not the purpose of performing the test. An ECG will not determine the likelihood of a client suffering from a heart attack. |
| What effect on a client's pulse rate would the LPV/LVN expect to occur from taking the medication propranolol (Inderal)? | Answer: The client's heart rate should be slower than it was prior to taking the medication. Rationale: Propranolol (Inderal) is a beta-adrenergic blocker. "Beta blockers" interfere with the effects of the naturally occurring epinephrine in the body. These medications reduce the heart rate. Therefore, once the client has started taking propranolol (Inderal), the client's heart rate should slow down compared to the rate prior to taking the medication. |
| Mr. Dwindell is admitted to the unit with severe dehydration caused by persistent nausea, vomiting and diarrhea. Which of the following fluids would the physician most likely start the client on? (A) 0.45% sodium chloride with added potassium (B) 0.9% sodium chloride with added potassium (C) 3% sodium chloride with added potassium (D) 0.9% sodium chloride | (A) 0.45% sodium chloride with added potassium Rationale: The client in this case needs a hypotonic solution to help the dehydrated cells pull in and regain fluid. 0.45% sodium chloride or 1/2 normal saline is an example of a hypotonic solution. Potassium is lost along with the body fluids expelled through diarrhea and vomiting. Adding this to the fluid solution will replenish the body with this essential electrolyte. 0,9% sodium chloride or normal saline is an isotonic solution. The constituents in isotonic solutions are similar to the fluid in the blood. Using this type of solution would not change the dehydrated state since it will not add or remove fluid from the body cells. 3% sodium solution would lead to further dehydration by pulling fluid from the cells. |
| J. Cramer is a 17 year old client with sickle cell anemia. Which of the following is NOT a common treatment and care modality for a client with this condition? (A) Pain management (B) Preventing infection (C) Fluid restriction (D) Red blood cell transfusion | (C) Fluid restriction Rationale: Acute pain can be very severe during a sickle cell crisis due to hypoxia caused by inadequate blood flow to various tissues or organs. Pain management during crisis includes analgesics, relaxation techniques and distraction. Techniques are used to prevent reoccurrence of symptoms once acute pain is controlled. Clients with sickle cell anemia are usually susceptible to infection. Fluid is encouraged for sickle cell clients in order to promote dilution of the blood, which prevents clumping of sickled cells. Red blood cell transfusions are common therapy used to prevent complications from sickle cell anemia. |
| Mrs. Stanley is a neutropenic client in the medical unit of the hospital. As the lunch trays are being passed out, the LPN/LVN would carefully examine the foods on the tray to be sure they are appropriate for the client. Which of the following would NOT need to be removed from the tray by the LPN/LVN prior to bringing the tray into the room? (A) Garden salad with packaged low sodium dressing (B) Celery with bleu cheese dressing (C) Apple slices (D) Canned peach halves | (D) Canned peach halves Rationale: Neutropenia is a condition where the number of circulating white blood cells (WBCs) in the client's blood is decreased. The risk for infection is very high for clients with this condition. Raw fruits and vegetables may be contaminated with microbes and should not be included in the diet of a neutropenic client. Garden salad, celery and apples are all raw vegetables. Thoroughly cooked or canned fruits and vegetables are considered safe for a client with neutropenia. |
| The physician has written an order for a client to be weighed daily. Which of the following instructions provided by the LPN/LVN to the nursing assistant is most important for obtaining accurate daily results? (A) The client should be weighed at the same time every day (B) The client should not have had anything to eat or drink for 30 minutes prior to weighing (C) The client should remove slippers from their feet prior to being weighed (D) If using an internal bed scale, it is important to subtract 5 lbs from the results to account for the linen on the bed | (A) The client should be weighed at the same time every day Rationale: In order to obtain the most accurate results, a client should be weighed at the same time every day. Eating or drinking prior to weighing should not dramatically affect the results. The same amount of clothing should be worn with each daily reading. If an internal bed scale is used, the scale should be zeroed with the linens on the bed prior to the client getting into the bed. The same linens should be on the bed with each reading as were on the bed when the scale was zeroed. A bedside scale is zeroed prior to each use. |
| The physician prescribes atorvastatin (Lipitor) for a client with elevated cholesterol levels that have not been sufficiently reduced with lifestyle changes. The LPN/LVN provides teaching about this medication to the client. Which of the following would the LPN/LVN explain as a potential side effect of taking this medication? (A) Confusion (B) Anemia (C) Muscle pain (D) Drowsiness | (C) Atorvastatin (Lipitor) is a lipid-lowering agent that lowers total and low density lipoprotein (LDL) cholesterol in the body. Lipitor also helps increase high density lipoprotein (HDL) cholesterol. The most common side effects associated with taking Lipitor include abdominal cramps, diarrhea, heartburn and skin rashes. Other side effects that could be caused by taking Lipitor are joint pain (arthralgia), and muscle pain and weakness (myalgia). Confusion, anemia and drowsiness are not side effects that are associated with the use of Lipitor. |
| The LPN/LVN is preparing to give a subcutaneous injection of Procrit 5,000 units. Which of the following needles would be appropriate for this type of injection? (A) A 5/8 inch, 25 gauge needle (B) A 1 inch, 22 gauge needle (C) A 1.5 inch, 25 gauge needle (D) A 1.5 inch, 18 gauge needle | (A) A 5/8 inch, 25 gauge needle Rationale: An all gauge needle is used to administer a subcutaneous injection to decrease the trauma caused by the needle puncture. The length of the needle selected for subcutaneous administration of a medication should be less than one inch, depending on the client's body mass. Needles most commonly come in 3/8 inch and 5/8 inch lengths. |
| A client is admitted to the unit with deep partial thickness burns on bilateral lower extremities. The LPN/LVN knows that deep partial thickness burns would exhibit which of the following characteristics? (A) The burns involve the epidermis and dermis (B) The burns involve the epidermis, dermis and subcutaneous tissue (C) The burns involve all skin layers and destruction of nerve endings (D) Necrosis is evident in the burned areas | (A) The burns involve the epidermis and dermis Rationale: Deep partial thickness burns involve the epidermis and dermis. The client will experience sever pain due to nerve injury, but the burns do not penetrate deep enough to destroy nerve endings. Vesicles will develop from deep burns. Superficial partial thickness burns, such as sunburns, affect only the epidermis. Full thickness burns involve the epidermis, dermis, subcutaneous tissue and destroy nerve endings. Necrosis is seen in full thickness burns. |
| The LPN/LVN is evaluating the arterial blood gas results of a client, which read as follows: pH = 7.30, HCO3 = 26 mEq/L, PaCO2 = 49 mmHg. Which of the following acid-base disturbances do these results represent? (A) Respiratory alkalosis (B) Metabolic alkalosis (C) Respiratory acidosis (D) Metabolic acidosis | (C) Respiratory acidosis Rationale: Normal values for arterial blood pH are 7.35 to 7.45. Normal values for arterial blood HCO3 level are 22 - 26 mEq/L. Normal values for PaCO2 levels are 35 - 45 mmHg. Respiratory acidosis is a disorder in which the arterial blood has a below normal pH and a higher than normal PaCO2. HCO3 may be either normal or high. In respiratory alkalosis, arterial blood pH is high, PaCO2 is low and HCO3 may be either normal or low. In metabolic alkalosis, arterial blood pH is low, HCO3 is high and PaCO2 may be either normal or high. In metabolic acidosis, arterial pH is low, HCO3 is low and PaCO2 may be either normal or low. |
| A client is on heparin therapy while being hospitalized for new onset atrial fibrillation. What laboratory test will the LPN/LVN check regularly to monitor the effects of this medication? | Answer: Partial thromboblastin time (PTT) Rationale: Heparin is an anticoagulant. It is used for clients who are at high risk for thrombus formation. In order to regulate the therapeutic levels of heparin, partial thromboblastin time (PTT) of the client's blood is tested periodically. PTT is the most accurate test for monitoring the effects of heparin therapy. |
| A client is being discharged from the hospital after treatment for new onset atrial fibrillation. The client was started on warfarin (Coumadin). The LPN/LVN reviews the client's discharge instructions. Select all of the following foods that should be limited in a client's diet while on warfarin (Coumadin). (A) Kale (B) Spinach (C) Green beans (D) Broccoli (E) Brussels sprouts (F) Celery | (A) Kale (B) Spinach (C) Green beans (D) Broccoli (E) Brussels sprouts Rationale: Warfarin is an anticoagulant used to prevent thromboembolic events for at risk clients. Vitamin K reverses the effects of warfarin (Coumadin). Good dietary sources of vitamin K include green leafy vegetables, broccoli and green beans. Celery contains very low sources of vitamin K. |
| Mrs. Friedma, a client at the community clinic, has been diagnosed with tuberculosis (TB). Mrs. Friedman's medication regimen includes a combination of the medications rifampin (Rifadin) and isoniazid (INH). The client asks the LPN/LVN why she must take two medications for the same illness. Which of the following would be the most accurate response? (A) "The rifampin (Rifadin) is given to minimize unpleasant side effects that isoniazid (INH) can cause." (B) "When given together, the doses of each medication can be lowered to reduce the effects on the body." (C) "Rifampin (Rifadin) kills the disease in your body and isoniazid (INH) will make sure that you cannot be infected with TB in the future." (D) "Combining these medications keeps the TB from becoming a form that is resistant to treatment." | (D) "Combining these medications keeps the TB from becoming a form that is resistant to treatment." Rationale: If a single medication is used at one time, the tuberculosis pathogen can mutate to resist the medication. Combination therapy slows down this mutation process and allows the medications to be effective against the original TB pathogen. One medication is not given to reduce or prevent side effects of the other medication. Both medications fight the TB pathogen. The medication doses are not changed when given in combination. Both medications fight the pathogen that is already existent in the body. |
| Which of the following are symptoms associated with pernicious anemia? Select all that apply. (A) Sore tongue (B) Diarrhea and upset stomach (C) Insomnia (D) Paresthesias (E) Arthralgia (F) Weakness and fatigue | (A) Sore throat (B) Diarrhea and upset stomach (D) Parasthesias (F) Weakness and fatigue Rationale: Pernicious anemia is an autoimmune disease in which the intestines are unable to absorb enough vitamin B12 to meet the needs of the body. Symptoms include the following: weakness and fatigue; tingling and numbness in the extremities (paresthesias); sore and reddened tongue; diarrhea, nausea and vomiting; pallor; abdominal pain; confusion; and loss of proprioception (sense of position). VitaminB12 is supplemented by means outside of the gastrointestinal tract to correct the deficiency. Insomnia and arthralgia (joint or bone pain) are not associated with pernicious anemia. |
| A concerned mother brings her 3 year old son to the pediatric clinic after discovering a rash that started on his face and progressively spread down his entire body. The LPN/LVN describes the rash to the physician as pin point sized reddened marks. Which of the following do these symptoms indicate that the child is infected with? (A) Chicken pox (B) Mumps (C) Rubella (D) Whooping cough | (C) Rubella Rationale: Rubella (German measles) involves a pinpoint rash that spreads quickly starting on the face and traveling down the body. Chicken pox usually appears first on the trunk as well as the scalp. The rash is described as macular to papular in appearance, and the vesicles crust over. Mumps does not involve rash formation. Symptoms of mumps include fever, headache, malaise and swollen salivary glands. Whooping cough or pertussis does not involve rash formation. Symptoms include coryza (inflammation of nasal mucosa), sneezing, watery eyes, cough that develops a "whooping" sound, fever and vomiting. |
| The physician has written an order for a client to receive 0.45% NaCl (1/2 normal saline) intravenously at a rate of 75mL per hour. The drop factor of the tubing set is 20 drops per mL. The LPN/LVN should calculate the flow rate to be: (A) 20 (B) 25 (C) 50 (D) 75 | (B) 25 Rationale: The formula to calculate this problem is: x gtt/min = volume/time (in minutes X drop factor. x gtt/min = 75mL/60 min X 20 gtt/min 75/60 = 1.25 1.25 X 20 = 25 gtt/min |
| Upon removing a breakfast tray from a room, the LPN/LVN calculates the client's intake. The client consumed the following: 4 oz of pudding, 6 oz of coffee, half of a 6 oz container of grape juice and used 4 oz of milk over cold cereal. In milliliters, what should the nurse record as the client's intake for this meal? (A) 480 mL (B) 390 mL (C) 510 mL (D) 600 mL | (B) 390 mL Rationale: Oral fluid intake is being calculated. Oral fluid intake for this meal would include any consumed fluid or solid food that becomes liquid at room temperature. Pudding does not fit the category for oral intake. Oral Fluid Intake Calculation: 6 oz of coffee, 3 oz of grape juice, 4 oz of milk multiplied by 30 mL/oz = (6=3=4) X30 = 390 |
| Which of the following routes of administration takes effect most rapidly? (A) IV (B) IM (C) PO (D) Topical | (A) IV Rationale: The most rapid route of administration is intravenous (IV). IV administration puts the medication directly into the blood stream, which generally produces immediate effects. Intramuscular (IM) injection is slower than IV administration. Oral (PO = by mouth) administration is the most common but often does not take effect quickly. Topical administration is usually the slowest route of administration. |
| The physician has prescribed promethazine (Phenergan) 12.5 mg IM q 4 hours prn for a chemotherapy client with severe nausea. The vial reads 50 mg of medication per mL of solution. How much solution should the LPN/LVN draw into the syringe for IM administration? (A) 0.125 mL (B) 0.25 mL (C) 0.75 mL (D) 1 mL | (B) 0.25 mL Rationale: Solve for x mL using the following ration method. 50mg/1mL = 12.5mg/xmL 50x = 12.5 x = 12.5/50 x = 0.25mL Or use desired over available: 12.5mg/50mg X 1mL = x mL 12.5 divided by 50 = 0.25 0.25 X 1 mL = 0.25 ML |
| A client with severe peptic ulcer disease undergoes a Billroth II surgical procedure. Which of the following best describes the alterations made to the gastrointestinal tract with this procedure? (A) Antrectomy with anastomosis to the duodenum (B) Antrectomy with anastomosis to the jejunum (C) Vagus nerves are severed (D) Resection of the large bowel | (B) Billroth II, also known as gastrojejunostomy, begins with the removal of the lower section of the antral portion of the stomach. This is the part of the stomach that secretes gastrin, which stimulates the secretion of gastric acid. A small portion of the duodenum and pylorus are also removed. The remaining stomach is then attached with an opening (anastomosed to the jejunum of the small intestines. Answer (A) represents a Billroth I procedure. The severing of vagus nerves, answer (C), describes a vagotomy. Answer (D) describes a colon resection. |
| Mrs. Tracy has been diagnosed by x-ray to have a large bowel obstruction. The cause involves movement of a portion of the bowel into another. Also called "telescoping," what is the medical term for this manifestation? | Answer: Intussusception Rationale: Intussusception occurs when one part of the intestine slips into another part of the intestine. This is called "telescoping' because it looks like a telescope when it is shortened. This manifestation blocks intestinal flow and is a life threatening condition. The blood supply can be cut off causing the intestines to be strangulated and tissue death to occur. |
| Mr. Peters is admitted to the unit for a cardiac arrhythmia. The LPN/LVN knows that this involves a malfunction in the electrical conduction of the heart. Arrange the following in the correct order to represent normal electrical conduction of the heart. (A) Atrioventricular (AV) node (B) Bundle of His (C) Bundle branches (D) Purkinje fibers (E) Sinoatrial (SA) node | (E) Sinoatrial (SA) node (A) Atrioventricular (AV) node (B) Bundle of His (C) Bundle branches (D) Purkinje fibers Rationale: Normal electrical conduction within the heart begins with stimulation of the SA node. The SA node is called the heart's pacemaker because it maintains the normal heart rate of 60 to 100 bpm for an adult. The SA node sends the electrical impulse to the AV node, which transmits the electrical impulse through the bundle of His to the right and left bundle branches. The signal ends in the Purkinje fibers, located in the outside muscle layers of the heart. |
| The LPN/LVN is evaluating a 6 second long electrocardiogram (ECG) strip. Which of the following represents depolarization of the ventricular muscle? (A) P wave (B) T wave (C) QRS complex (D) PR interval | (C) QRS complex Rationale: Depolarization of the ventricular muscle of the heart is represented by the QRS complex on the electrocardiogram (ECG) strip. The P wave represents atrial depolarization. The T wave represents ventricle muscle repolarization. The PR interval is the distance from the beginning of the P wave to the center of the R wave in the QRS complex. This interval represents the time used to stimulate the SA node, depolarize the atria, and conduct the impulse through the AV node prior to ventricular depolarization. |
| Ms. Stafford comes to the clinic complaining of a severe headache and general malaise. Urinalysis results show hematuria. The client also has blood pressure of 169/92 and peripheral edema. Ms. Stafford visited the clinic two weeks ago with strep throat. Which of the following diagnoses do these findings support? (A) Acute glomerulonephritis (B) Congestive heart failure (C) Pulmonary edema (D) Hypertensive encephalopathy | (A) Glomerulonephritis is inflammation of the capillaries of the glomeruli of the kidneys that often is preceded by a streptococcal infection, such as strep throat. This disease can be very vague and mild. However, symptoms can be very severe including hematuria, proteinuria, decreased urine output, fluid retention/edema, hypertension, headache, malaise and flank pain. Fluid retention could lead to circulatory overload with dyspnea, engorged neck veins, cardiomegaly and pulmonary edema. Acute glomerulonephritis may lead to serious conditions such as congestive heart failure (CHF), pulmonary edema and hypertensive encephalopathy. |
| Diuretics are often prescribed for treatment of acute glomerulonephritis to treat fluid overload and hypertension. Which of the following is least likely to be prescribed for this purpose in glomerulonephritis? (A) Bumex (B) Lasix (C) Demadex (D) Aldactone | (D) Aldactone Rationale: Loop diuretics are most commonly used to treat fluid overload and hypertension because of their effectiveness. Bumex, Lasix and Demadex are all loop diuretics. Aldactone, a potassium sparing diuretic, is very weak in comparison to loop diuretics. Unless the client's potassium level is dangerously low, this medication is not usually prescribed. Sometimes potassium sparing diuretics are used along with lower doses of other diuretics to help conserve the body's potassium levels. |
| A practical nurse student is preparing for an upcoming exam on the reproductive system. Arrange the following in order as they occur in the menstrual cycle and ovulation. (A) Ovulation occurs (B) Estrogen level peaks (C) Endometrium is shed (D) Progesterone level drops (E) Estrogen level drops sharply (F) Estrogen level is low | (F) Estrogen level is low (C) Endometrium is shed (B) Estrogen level peaks (A) Ovulation occurs (E) Estrogen level drops sharply (D) Progesterone level drops Rationale: As the menstrual phase (days 1 to 6) begins, estrogen levels are low. During this phase the endometrium of the uterus is shed. During the proliferative phase 7 to 14 days), the endometrium thickens, estrogen rises and peaks, and the ovum is released (ovulation). The secretory phase (days 15 to 26) involves preparing the uterus for implantation. At this stage, estrogen drops sharply and progesterone dominates. During the final stage, the e=ischemic phase (days 27 to 28), progesterone levels begin to decrease, estrogen levels continue to decrease, blood vessels rupture, and blood escapes into the cells of the uterus in preparation for the cycle to begin again. |
| Education regarding testicular cancer is being provided to male clients at the primary care facility. It is recommended that males begin testicular self examinations (TSE) at what age? (A) 13 to 14 years old (B) 17 to 18 years old (C) 20 years old (D) 40 years old | (A) 13 to 14 years old Rationale: Although testicular cancer is rare, the fatality of this type of cancer is very high. Testicular self examination is recommended to all males starting from ages 13 to 14 and up. This is because testicular cancer is the most common cancer in young men (ages 15 to 35). A male with this type of cancer could be asymptomatic. Therefore detection by palpation is necessary to provide early treatment. |
| The LPN/LVN is teaching a male client how to perform a testicular self examination (TSE). Which of the following is NOT accurate for performing this procedure? (A) "It is best to perform the exam in the shower." (B) "The exam may hurt a little as you apply pressure to the testes." (C) "Use your thumb and first two fingers to palpate the area." (D) "If anything abnormal is detected, call your physician for further examination." | (B) "The exam may hurt a little as you apply pressure to the testes." Rationale: Testicular self examinations should be performed once a month. The best place to perform the exam is in the shower, while scrotal sac is warm and relaxed. Using the thumb and first two fingers, the testicles should be palpated. The testicle is movable and egg shaped. Any lump, hard area, or enlargement of a testicle, whether painful or painless, should be reported to a physician. The examination should be painless. If pain is experienced, too much pressure is being applied. |
| A 16 year old female diagnosed with bulimia nervosa is admitted to an inpatient facility for psychiatric evaluation. Select all of the following that would be included in obtaining the client's initial assessment. (A) Frequency of weighing (B) Menstrual history (C) Serum electrolyte values (D) History of abuse (E) Dieting patterns (F) Use of diuretics (G) Premorbid weight | All answer choices are correct. All of the information would be gathered about this client. Bulimia nervosa is an eating disorder characterized by binge eating followed by self-induced purging of the ingested substance. Clients with this condition may use emetics, diuretics and/or laxatives chronically. This condition also involves an obsession with weight and appearance. During the initial exam of a client with bulimia nervosa, history regarding weight patterns, abuse, menstruation, dieting and medication use will be gathered. Body language will be evaluated. Physical examination includes mental status evaluation and laboratory testing of electrolyte levels and complete blood count. |
| Which of the following is a characteristic physical finding least likely to be found in clients with the eating disorder bulimia nervosa? (A) Maintenance of a steady, normal weight (B) Erosion of tooth enamel (C) Loss of hair (D) Electrolyte imbalance | (C) Loss of hair Rationale: Bulimia nervosa is a condition in which a client has an obsession with food and body weight. Clients with this disorder often binge on high calorie foods and then experience a high amount of guilt that leads to purging of the food by self inflicted vomiting or diarrhea. The cycle of binging and purging often leads to maintenance of a steady and normal weight. Due to frequent vomiting episodes, clients with this disorder often have eroded tooth enamel and multiple dental caries from contact with acidic stomach contents. Electrolyte imbalances occur as a result of electrolyte loss caused by emesis and diarrhea. Hair loss caused by malnutrition is commonly seen in clients with anorexia nervosa, a condition that involves complete food aversion. |
| The LPN/LVN at a clinic answers a phone call from an 18 year old rape victim. The nurse tells the victim to go to the emergency room for a medical examination. Which of the following additional instructions for the victim is of highest priority? (A) Gather belongings that might be necessary for a short hospital stay (B) Write down every remembered detail from the incident (C) Call a support person immediately (D) Do not take a shower before going to the hospital | (D) Do not take a shower before going to the hospital Rationale: Rape is any form of sexual violence or assault on an unwilling victim. A thorough physical exam will be performed at the hospital. Evidence may only be available on the victim or the victim's clothes. The victim should be advised not to shower, brush teeth, drink or eat, douche, change clothes, or manipulate any surface or body orifice that could contain evidence against the perpetrator. The victim can wait to tell the details of the incident to medical professionals at the hospital as opposed to writing them down. Gathering belongings and/or calling a support person may be helpful, but these actions are not high priorities in this situation. |
| A client is hospitalized due to complications of lung cancer 2 weeks after initial diagnosis. The client's husband frequently yells at the LPN/LVN and staff as they perform necessary and normal actions. Which of the following is the best response to this behavior from the nurse? (A) Kindly ask the husband to act more appropriately or he may need to leave the facility. (B) Understand that anger is a normal response to this type of circumstance and offer support as the husband works through his grief. (C) Tell the husband that being angry is not going to make the disease go away. (D) Report the behavior to the charge nurse and ask for an assignment change. | (B) Understand that anger is a normal response to this type of circumstance and offer support as the husband works through his grief. Rationale: The husband of this client is experiencing grief from the thought of losing his wife very soon. These behaviors represent the client in the anger stage of the grieving process. The reaction from the nurse should be to understand that the husband's anger is a normal response to feelings of loss and help him move through the grieving process. Withdrawal or retaliation should be avoided, and the staff should not take the behavior personally. Other responses that might help a person in this circumstance would be to help him deal with any underlying needs, provide structure and security, and allow as much control as possible over the situation. |
| The LPN/LVN assigned to a homosexual male is responsible for relaying positive HIV test results to the client. Which of the following responses would the nurse expect initially? (A) Disbelief (B) Acceptance (C) Anger (D) Depression | (A) Disbelief Rationale: Initial response to receiving sad or bad news is disbelief or denial. Grief is a normal response to loss or feelings of powerlessness. When people experiencing grief, they must work through the stages of changing emotions, which usually progress as follows: disbelief, anger, bargaining, depression, and eventually acceptance. |
| A client with obsessive-compulsive disorder (OCD) is admitted to the psychiatric facility for treatment. Select all of the following that are included in medical treatment of this disorder. (A) Prescription of selective serotonin reuptake inhibitors (SSRIs) (B) Behavior therapy (C) Prescription of benzodiazepines (D) Imagery (E) Distraction (F) Electroconvulsive therapy (ECT) | (A) Prescription of selective serotonin reuptake inhibitors (B) Behavior therapy Rationale: Treatment of obsessive-compulsive disorder (OCD) includes use of selective serotonin reuptake inhibitors (SSRIs) and behavior therapy. OCD is thought to be caused partially by low levels of serotonin in the brain. SSRIs increase serotonin levels. Behavior therapy involves exposure to a feared object or situation and prevention of carrying out compulsive behavior. Benzodiazepines are not prescribed to treat OCD. Imagery and distraction are relaxation techniques usually used as pain relief measures. Electroconvulsive therapy is used to treat severe depression when other treatment modalities are ineffective. |
| Valium is a type of benzodiazepine. Which of the following is NOT a prescriptive use of benzodiazepines? (A) Treatment of seizures (B) Muscle relaxant (C) Treatment of anxiety (D) Treatment of psychosis | (D) Treatment of psychosis Rationale: Psychosis, a mental disorder that involves a severe loss of contact with reality, is treated with neuroleptic medications such as Haldol and Risperdal. Treatment of seizures, skeletal muscle relaxation, and treatment of anxiety are all valid uses for benzodiazepines. |
| An inpatient client at the psychiatric facility is placed on Haldol for treatment of a psychotic disorder. Which of the following client symptoms should be immediately reported to the physician? (A) Dizziness (B) Tremors (C) Sensitivity to light (D) Constipation | (B) Tremors Rationale: Muscle tremors are a type of serious adverse effects, known as extrapyramidal effects that can occur from neuroleptic drug use. These effects are caused by nerve impulses traveling outside of the normal tracts of the central nervous system. Extrapyramidal side effects include muscular rigidity, tremors, bradykinesia, and difficulty walking. These symptoms often make the client appear to have Parkinson's disease. The physician should be immediately notified if these symptoms appear. Dizziness, sensitivity to light, and constipation are all common, manageable side effects of neuroleptic drug use. |
| A manic-depressive client is placed on Lithium. The LPN/LVN provides instruction to the client regarding this medication. Which of the following is an appropriate statement by the nurse regarding this medication? (A) "You will need to restrict fluid intake while on this medication." (B) "You may skip your dose if you feel well when you wake up in the morning." (C) "You will need to visit your doctor regularly for laboratory blood testing." (D) "This medication may cause you to lose weight. So be sure to eat enough throughout the day." | (C) "You will need to visit your doctor regularly for laboratory blood testing." Rationale: Lithium is a medication used to decrease or prevent acute manic episodes. To ensure therapeutic effects and prevent toxicity, a client on this medication will need to have regular serum Lithium levels drawn. Initially this test is drawn twice weekly. Once therapeutic levels are reached the test is performed every 2 to 3 months. While on this medication, a client is informed to drink a lot of fluid and consume a moderate amount of sodium in the diet. This prevents low sodium levels, which can lead to Lithium toxicity. The client should be instructed never to skip a dose in order to maintain therapeutic levels. Weight gain, not weight loss, is a side effect of this medication. |
| A client on Lithium for antimanic effects comes to the clinic for regular testing of serum Lithium level. Which of the following indicates a therapeutic level of this medication in the blood? (A) 0.45mEq/L (B) 0.78mEq/L (C) 1.6mEq/L (D) 2.0mEq/L | (B) 0.78mEq/L Rationale: The range that indicates therapeutic serum Lithium level is 0.5 to 1.5mEq/L. Any level below this range may not be producing desired effects. A level higher than this is toxic and lethal to a client. 0.45 mEq/L is below therapeutic range. The client's dosage should be increased. Answers C and D indicate toxic levels of Lithium. The medication should be held, and the client should be monitored closely for adverse effects. |
| An 11 year old child is experiencing seizure activity. When reporting the event in the medical record, the LPN/LVN would record all of the following in the medical record, except: (A) Time of seizure onset (B) Duration of the seizure (C) Demographic data of the client (D) Position of extremities before, during and after the seizure | (C) Demographic data of the client Rationale: The nurse will need to record a description of events leading to the seizure activity, time of onset, duration of seizure activity, initial position of body parts (eyes, head, mouth, body, and extremities), any changes in position or lack thereof, skin characteristics, and facial expressions. These assessments will help in determining any details that contribute to or are associated with the client's seizure activity. The child's demographic data should be recorded elsewhere in the medical record and does not need to be repeated with every new entry. |
| The LPN/LVN walks into the room just prior to the client suddenly becoming unconscious for approximately 20 seconds followed by uncontrolled jerking movements of the client's entire body. Which of the following types of seizures ahs the nurse just witnessed? (A) Atonic seizure (B) Tonic-clonic seizure (C) Myoclonic seizure (D) Absence seizure | (B) Tonic-clonic seizure Rationale: A seizure that begins with the loss of consciousness, usually including muscle stiffness, followed by jerking movements caused by alternating muscle contraction and relaxation is known as a tonic-clonic seizure. Atonic seizures are characterized by sudden and momentary loss of muscle tone. Myoclonic seizures involve convulsive episodes followed by muscle contractions. Absence seizures involve brief loss of consciousness with little or no muscle tone changes. |
| An LPN/LVN is volunteering at the community clinic administering influenza vaccinations. Which of the following is the most important information to gather prior to administering the vaccine> (A) Does the client have an allergy to eggs or egg products? (B) Did the client receive an influenza vaccination last year? (C) When was the last time the client received a pneumococcal vaccination? (D) Has the client experienced flu-like symptoms following an influenza vaccination? | (A) Does the client have an allergy to eggs or egg products? Rationale: Influenza vaccinations are made up of a small amount of influenza virus administered via injection to promote antibody production and prevent development of the full-fledged viral infection. The virus is cultured in egg albumin. If a client is allergic to eggs or egg products, reaction to the albumin in the vaccine may be experienced. It is recommended for members of the general public to receive the influenza vaccine once a year. Pneumococcal vaccination, used to prevent bacterial pneumonia, does not interfere with influenza vaccination. It is common to experience mild flu-like symptoms following vaccination against influenza, as this vaccine is made from a strain of the influenza virus. |
| A client is receiving Robitussin 1200 mg 12 hours for treatment of a productive cough associated with pneumonia. The bottle reads 100mg/5mL. How many ounces would the client receive with each dose? (A) 30 (B) 10 (C) 6 (D) 2 | (D) 2 Rationale: 100mg/5mL = 1200 mg/x mL = 6000/100 = 60 mL. There is 30 mL per ounce of fluid. 30 mL/1 oz = 60 mL/x oz = 60/30 = 2. Therefore, the client would receive 2 oz of Robitussin with each dose. |
| A client is diagnosed with having a left-sided pleural effusion. the procedure most commonly used to correct this problem is called? | Answer: Thoracentesis Rationale: Pleural effusion is the existence of fluid in the pleural space of the thoracic cavity. This can cause difficulty breathing and may lead to cardiovascular difficulties. Thoracentesis is a procedure that involves puncturing the chest wall with a needle to aspirate the fluid from the pleural cavity. The aspirated fluid may be sent for laboratory testing. |
| A client complaining of constipation is prescribed lactulose (Cephulac) 20 g p.o. BID. The nurse preparing the morning dose reads the constitution of medication to syrup solution as 10 g/15 mL. how many mL will the nurse prepare for the client? (A) 10 (B) 15 (C) 20 (D) 30 | (D) 30 Rationale: Solve for x mL using the following ration method: 10 g/15 mL = 20 g/x mL 10x = 300 x = 300/10 x = 30 mL or desired over available: 20 g/10 g X 15 mL = x 20/10 = 2 2 X 15 = 30 mL |
| The LPN/LVN is teaching Mr. Elbridge how to insert his new hearing aid. Arrange the following choices in the correct order for completing this task. (A) Turn the hearing aid on and turn the volume up (B) Line up the earmold with the corresponding parts of the ear (C) Slightly rotate the earmold forward (D) Rotate the earmold backward (E) Insert the ear canal portion of the earmold (F) Turn the hearing aid off and the volume all the way down | (F) Turn the hearing aid off and the volume all the way down (B) Line up the earmold with the corresponding parts of the ear (C) Slightly rotate the earmold forward (E) Insert the ear canal portion of the earmold (D) Rotate the earmold backward (A) Turn the hearing aid on and turn the volume up Rationale: Prior to inserting the hearing aid, it should be turned off with the volume all the way down. Next, locate the parts of the ear and the corresponding parts of the hearing aid and align them. Prior to inserting the ear canal portion of the earmold, it should be slightly rotated forward. As the earmold is guided into the ear canal, it is rotated backward. Once the earmold is snugly in place, turn the eharing aid on and volume according to the client's needs. |
| Accuracy of orders | just bc the doc gives an order doesn't mean the nurse should carry it out. We are legally responsible for are mistakes for this reason we must determine the accuracy of the order we must think critically and always be alert for potential errors great blood flow vs reducing circulation. |
| Drip | D- diagnostic test Ex allergy to shellfish, liver biopsy (bleeding) some are contraindicated R- right procedure make sure its the right body part I- interpretation of order call if u cant read the order clarify P- pharmacology is the top reason for alterations in client safety in hospitalization. In order to understand the accuracy of orders the nurse must understand the action of the drug in the desired outcome of the med. Must understand drug to drug, food to drug interactions, and medical conditions that may result in complications from specific meds Our client must be able to trust us to think about every incident. Put urself in the clients shoes. The most important gift the we can give our client is our full att and brain power. Think about what u are doing. The accuracy of orders will likely determine the clients well being. Have the courage to clarify and verify any orders that maybe inaccurate. |
| Cover ur assets (CYA) | one of the most important assets we have as a nurse is our nursing license. We have to have credentials to take care of the sick and we must CYA to keep it. Med errors can cause us to lose are licenses. we must have in order for restraints and to manage them appropriately. Do and document neuro checks. Document when the restraints were removed to allow for mobility and skin assessment. Lack of Confidentiality is a big problem. Assigning client to impaired staff (involved with drugs or alcohol) can turn into a crisis. Broken equipment that allows injury is serious trouble. Being very present, paying attention to everything, caring, and CYA can keep us out of a "mess". Mess M- medication errors/manage restraints E- ensure confidentiality and identity S- safe equipment (prevent falls) S- safe staff/safe delegation |
| The 8 rights to med administration | 1) right route-where 2) right client- who 3) right drug- what 4) right rationale- why 5) right dose- which ----------------------------------------------------------- 6) right time- when 7) right documentation- write 8) right to know- refuse Nurses must not just implement the top 5 rights but also understand the rationale for the client receiving the medication. if a client is receiving a anti-hypertensive medication in just came from dialysis with symptoms of hypovolemia then it would be inappropriate to administr this medication. The medication must be documented accurately on the medication chart (7th right). Cilents must be taught how to saftly take the medication,the action of the medication, and have the opportunity to refuse the medication (8th right). Medication errors are a major challenge for clients in hospitals. It is imperative that we initiate these (8th right) in order to practice safe medication administration. |
| Universal precautions | Gloves G- gloves L- lather up something as simple as washing hands can significantly decrease nosocomial infections. Clients, family members, and health care workers must understand (give explanation) the importance of infections O- orifices meticulous attention to aseptic technique when cleaning is effective in decreasing infections V- very special handling of secretions, used equipment, needles, soiled linens. E- everyone may be infected. treat everyone as if they have a disease S- sharps when giving shots, starting IV's, or assisting with invasive procedures, meticulous attention must be paid to needles THE KEY TO PRACTICING UNIVERSAL PRECAUTIONS IS TO REMEMBER THE IMPORTANCE OF SAFELY HANDLING BLOOD AND BODY FLUIDS. (GLOVES,HANDWASHING,AND ALCOHOL GEL) |
| Methicillin-Resistant Staphylococcus Aureus (MRSA) | M-many cultures must be done to id the problem. Pathogens such as respiratory,skin,and urinary infections. The nurse is not always able to tell the client is infected. R- requires gown, gloves,goggles should be worn (standard precaution) gloves must be worn when touching substances, mucous membranes, non-intact skin, and items that are contaminated. Linen should be changed frequently after contact with infected material. Gowns should be worn if soiling is likely. mask/face shield should be worn if splashing is to occur. Hand washing before and aftercare. S-social isolation if infections is in the respiratory tract Private room is necessary (droplet precaution). There should be 3 feet of space between client/resident and visitors. Client must ware mask when transporting in the hospital. Linen must be bagged to prevent contamination. trash must be discarded to prevent contamination to self, environment, or outside a bag. masks/face shild for staff and visitors who are within 3 feet of client. Noncritical care equipment should be limited to a single client. A- active infection treatment is tetracycline, bactrim, bacamycin, MRSA is a common drug resistant organism found in health care facilities. Is spreed primarily by direct and indirect contact. Sometimes transmitted thru thr respiratory and urinary tracts. Standard precaution will prevent the spread particularly in the skin and urine infections. If in the wound or urine contact precaution are used and if in the respiratory tract then droplet precautions are used. Hands must always be washed after the gown,gloves, ect have been removed. Trash and linen stays in room (special bagging). Leave stethoscope in room. patient will have ^ tempt, ^ WBC(initally when given drug) I&O(renal function) 30 mins prior to 3rd dose rudolph the redneck reindeer had an adverse side effect from the drug vancomycin got to do peak and trough or go deaf must keep all labs in check caution with renal failure hearing loss and allergies take a temp and blood cultures specially a CBC |
| kInfection prevention ; negative pressure | Negative pressure keeps germs in the room ex; TB verruca and measles the nurse needs to wear respiratory protection face shield or face mask there need to be limited transportation and moment of the client from the room |
| Infection prevention; positive pressure | pushes air out of the room people who are in nutropinic precassions or at high risk for infection from burns or imino compromise will need to be protected from any organism P'-Positive P-Pressure P-Positively P-Prevents P-Patient infection by P-Pushing air out |
| Fever | Fever is the point heat production passes heat loss Ice pack on the head contemplate a temped bath Take acetaminophen or ibuprofen to prevent a rapid rise that may cause seizure If none of these work at 100.4 F can be tolerated can rise to dangerous levels especially in the afternoon. F-Fahrenheit Greater 100.4-100.8(38C) E-Endogenous Pyrogens Reset the hyperventilate system V-Volume needs increase secondary to heat loss ex; increase metabolism shivering sweating evaporation and vazo dilation E-Evaluate the source via labs; CBC with differential a urinalysis a blood culture and chest x-ray R-Risk factors viral or bacterial illness environmental factors tissue damage and biological agents and endocrine system disorders Greater than 107F equals death or irreversible brain damage. These patients are at high risk of dehydration due to sweating. Give a lot of fluids fever peaks in late afternoon |
| Difference between viral and bacterial infections | Viral will have no change in white blood cells tell to go home and get plenty of fluids and bed rest Bacterial there is going to be change in white blood cells so you will give them antibiotics |
| Culture Aspects | S-Soul Food foods that are comfort foods for us are important to or forbidden by are culture or religion P-Products such as blood products have different conotations to differents culturs and religious groups ex; Johanna Witnesses refuse blood products and transfusions give alternate fluids and autologus transfusions may be acceptable. I-Interactions in communication differ many cultures ex; south African people may love to entertain with song and dance while Asians are shy and reserve , native Americans may be offended by direct eye contact. Interpreters may need to be utilized to have effective communications when people are ill. R-Rituals are part of every culture birth weddings and funerals and are time honored ex; some cultures choose to burn umbilical chord when it falls off the infant to prevent sins of the mother to reach the baby I-In transition from the body of life to the spiritual life is important for the nurse ex; Muslim should only be cared by another man. T-Teaching may be challenging to many cultures that may value voodoo Chinese herbs and medicine men our goal is to is to determine the cultural issues to complete compliance Muslim or Jewish no pork Jahovas no blood products (arogam shot) Asian wont look you in eye Muslim female to female and male to male Chinese bury or burn umbilical chord Scientology no alcohol or tobacco Orthodox Jew no organ transplant unless rabbi consents. Visitation is a requirements and a man wont touch a women unless wife or daughter and only eat kosher food |
| Tools physical assessment | 1 Inspection use of eyes to gather data careful observations can provide clues such as respiratory system muscle skeletal and nero system skin integrity and emotional/mental status 2 Osculation listen to sounds by the organs and tissues of the body frequently used to asses the heart lung neck and abdomen. These sounds are characterized according pitch intensity and duration 3 Percussion is used for assessing the size position and density of underlying structures. Use sharp tapping produces vibrations and subsequent sound waves that interpretive as air fluid or solid material 4 Palpation use of hands fingers to gather data through touch. The characteristics of body texture temperature size shape and movement may be distinguished by different parts of the hands and fingers. 5 The palm and ulnar surfaces are used to distinguish vibrations in the dorsal side is the best for temperature. Bi manual technique uses both hands to entrap an organ or mass between the fingertips to better asses the size and shape. |
| The Stethoscope | is indispensable for determining the sounds inside the body. The diaphragm is used to hear high pitch sounds such as S1 and S2 murmurs of the mitral valve regurgitate pericardia and abdominal friction rub sounds. The bell is used to here low pitch heart sounds such as S3 and S$ an a murmur of the aortic stenosys The diaphragm listen to bowl heart sounds and blood pressure |
| Vital Signs | L- Listen I- Inspiration /exportation F- Feel skin (temperature) E- Evaluate pulse, pain |
| Blood Pressure | Blood Pressures- Is the force exerted by the blood against the walls of the blood vessels. Systolic Dystolic Normal <120 <80 Prehypertension 120-139 80-89 200/100 is stroke territory Hypertension 140-159 90-99 Stage 1 Hypertension ≥160 ≥100 Stage 2 If the BP cuff is too small then it will give a false high reading but if the cuff is too big it will give a false low reading. Be cautious when taking BP from people who are on blood thinners. LOC is very important bc they may have normal readings but are hard to arrouse. Respiratory/Heart Rates Neonate R-40 HR-140 Toddler(2-4) R-30 HR-120 Child(6-10) R-20 HR-100 Adult R-12-18 HR-60-100 If a patient has a high respiratory rate they might not be exchanging air. If they are having trouble breathing they may have a scared look on their face or become restless. They my be using accessory muscles or neck muscles to help them breath. Skin assessment determines if they r hot, dry, cold, or clammy. Is a conformation of how they feel. Touching them can show them we care about how they feel and may calm them down. Pulse- Feeling the pulse can determine if it is irregular, regular, bounding, thready, strong, or weak. Abnormal pulse is a high nursing priority action. Pain is known as the 5th vital sign. It may result in VS changes. When in pain their RR and pulse increases. Pulse is a good indicator of pain medication effectiveness. |
| Cardiac Sounds | S1 is ordinarily heard in the beginning of the cardiac cycle(systole) over the tricuspid/mitral sites. "Lubb" S2 is over the pulmonic/aortic site at the end of the cardiac cycle (diastole). "Dubb" S3 over the apex in the left side lying position. Early diastole.'kentucky". May indicate heart failure. S4 over the apex in the left side lying position. Late diastole. "Tennessee" May indicate hypertension. The PMI is usually heard midline at the 5th intercostal space. "Lubb" closure of the mitral and tricuspid valves "Dubb" closure of the aortic and pulmonic valves |
| Breath Sounds | they are catagorized by intensity pitch and duration of the inspatory and the expetory phase bronchial sounds are heard manubirum (if heard at all) exportation sounds are longer louder and higher pitch than inspatory sounds. If heard in the minubrium they are considered abnormal and may be considerded low bar pneumonia. Broncular vassicular sounds are heard in the first or second interspaces interially between the scapula. The intspulatory and explatory sounds are equal in length and are intermediate. Pitch and intensity differences are easilly assesd during exporation if heard in any other location then air fillled long may have been replaced by fluid or solid lung tissue..Vassicular sounds are heard over most of the lungss. Inspatory sounds are longer than expatory sounds. Vassicular sounds are soft and low pitch. Breast sounds should be soft pitch Right side has 3 lobes and let side has 2 Egophony (EE) Bronchaophony (99) Whispered 99 or 123 lung sound is normal and filled with air words are indistinct and muffled. EE is heard when airless lungs with pneumonia 99 are lowder and clearer EE is heard as AY whisper words are louder and clearer. |
| Cranial Nerves | 1 Olfactory God gave us one nose Smell 2 Optic God gave us two eyes to see with 3,4,6 Ocular motor trocular and abducns makes my eyes do tricks 3 is assessed by pupil constriction assess PERLLA 4 Asses eye movement 6 Asses lateral eye movement 5 Trigeminal rhymes with 5 and tri hot and cold 7 Facial 8 Acoustic assess hearing and balance 9,10 Glossopharyngal Vagus is under my chin Gag reflex 11 Spinal accessory shrug the shoulder 12 Hypoglossal tounge movement |
| Nuero Checks PERLMAE | Clients remain alert and oriented P- Pupils E- Equal R- Reactive L- Light M- Moving A- All E- Extremities to commands Compare to last nuero check is the client easy to arouse Squeeze your hands Left side of brain controls right body Right side of brain controls left body If CVA on right left affected If Hemi on right right is affected Strong side allways leads ex hemi on left side put chair on right side CVA on left put chair on left side |
| Infantsy | Trust v mistrust Ericson theory First three months recliner sleeps 20 hours a day bonding very important his head lags 2 months lift head and chest off bed totally dependant provide toys that are soft cuddely and colorful 3-6 months sitter with assistance starts rolling over six months can sit for short time leaning forward on hands "high roller" can turn quickly with heads way up birth weight may double at six months 6-9 months there a bouncer or crawler can pull self to sitting position they start crawling 8-9 months everything goes in mouth and have saftey percaussions 9-12 months cruizer or walker they walk with help. Birth weight triples and length doubles at 12 months shows stranger anxiety and clings to mother continue solitary play and can entertain self for short period of time. Fotenel posterior closes at three months and anterior closes at 18 months |
| Toddlers 1-3 years PRAISE | P- Push pull toys / parallel play autononimiss like playing side by side but not sharing R- Rituals and routines / regression must have constituency regression may occur during hospitalization praise appropriate behavior A- Autonomy v shame and doubt / accidents they like to help dress and undress themselves accidents are leading cause of deaths ex poisoning or drowning I- Involved Parents parents can comfort them S- Separation Anxiety allow parents to stay with child E- Elimination / Explore toilet training is a major milestone browses on extremities from climbing Make sure to keep poisons out of reach and childproof your home |
| Poison Control | P- Promote Stability asses condition and provide airway support and provide IV site if necessary O- Off / Out wash off if radioactive remove contaminated clothing if has pill in mouth take out eyes may need to be flushed out antidotes may be necessary for drug overdose ingested substances may be taken out of body by emisis, lavadge, absorbant (activated charcoal) catharticis Emithis is contra indicated if a person is comatose in shock experience a seizure or has loss of gag reflex. If a low viscosity hydrocarbon or strong corrosive (acid or alcheine ) has been ingested immises is contra indicated I- Identify the toxin S- Support the client both physically and psychologically parents may feel guilty support is imperative O- Ongoing safety education regarding poison control N- Notify they poison control center facility or provider care for immediate consolation. |
| Preschool (3-6) | Have an active imagination and ask "WHY". M- mutilation they fear. A associative play/abandoment they go from parallel play to cooperative play. Have an active imagination and they pretend. Abandoment-are afraid of being left G- guilt they feel they did something bad to cause this event to occur. I- initiative/imaginary playmate/imagination vs guilt child is very creative and may have an imaginary friend C curious about factual info regarding the world. "WHY" |
| School Age (6-12) | Dimple D- death bogeyman. Be honest with them about death and funerals. Encourage ventilation of thoughts and feelings I- industry vs inferiority/immunizations "chum" may enjoy collecting things and playing sports M- modesty more concerned with modesty and privacy. Pull curtains and close doors. P- peers begin to mix with opposite sex L- loss of control hospitalization is seen as loss of control. Let them help with decision making E- explain procedures use terms they can understand |
| Adolescents (12-18) | Adolescents (12-18) P- peer group- select activities involving their peers. Individualize if on isolation or on bedrest A- altered body image dont want to be seen as different. PEER PRESSURE. Health promotion. Ex drugs and STDs I- identity/image struggle with their identity and make choices regarding college or career R- role diffusion who are they and what r their goals. Educate families to help with struggles S- separation from peers encourage peers to visit while in the hospital |
| Immunizations- | should be done prior to school starting. If allergic to eggs cant do mumps, measles, rubella, I-Immunization status- what has been done before M- MMR made with eggs dont give with allergy to neomycin M- must be without fever U- update with the new ones available. Prevnar, a pnneumoccal vaccine, is now on the market N- never give in the gluteals(thighs and deltoids) I- immune supression disqualifies Z- "Zeisure" disorders must be controlled before administration E- evaluate sites for local reaction D- document-site, lot #, parental consent, and RN signature Patient with HIV, leukemia, or is receiving steriods wait 3 months after therapy has stopped before giving measle vaccine |
| A 49-year-old woman was admitted to a physical rehabilitation unit 2 weeks before surgery for a below-the-knee amputation on her right leg. She asks, "why do I have to keep wrapping my stump?" The nurse's best response is: 1. "You will have to shrink and shape the residual limb to fit the prosthesis." 2. "You want to increase the size of the residual limb to fit the prosthesis." 3. "You need to because it is what your physical therapist wants." 4. "You need to speak to your doctor." | 1. Shrinking the residual limb and shaping it into a conical form help to ensure the comfort and fit of the prosthetic device; wrapping helps to shrink the size. |
| Humulin NPH insulin is administered at 7am. At what time would the nurse anticipate the peak action to take place? 1. 9am 2. 12 noon 3. 5pm 4. 11pm | 3. NPH is an intermediate-acting insulin. The peak action takes place 8-12 hours after administration. If NPH was given at 7am, the peak would occur between 3pm and 7pm. |
| What is the minimum time established for a health-care worker to properly wash the hands? 1. 10 seconds 2. 30 seconds 3. 45 seconds 4. 60 seconds | 1. Proper handwashing by health-care workers reduces the risk of nosocomial infections. Ten seconds of vigorous handwashing will remove most transient flora and is the minimum amount of time one should spend washing. |
| Which of the following is the usual adult daily sode of digoxin? 1. 0.025mg 2. 0.25mg 3. 2.5mg 4. 25mg | 2. The usual dose of digoxin is 0.25mg (250mcg) for adults daily. |
| According to the American Heart Association (AHA), which of the following is the most prevalent form of cardiovascular disease? 1. Stroke 2. Coronary Artery Disease (CAD) 3. Hypertension 4. Rheumatic heart disease | 3. The AHA states the most prevalent form of cardivascular disease is hypertention, followed in descending order by CAD, rheumatic heart disease, and stroke. |
| Which of the following is the best site to assess for edema in a client confined to bed? 1. Ankles 2. Pretibial 3. Hands 4. Sacrum | 4. The sacrum is the most dependent area of the body for the client confined to bed rest. Edema accumulates in a dependent area first. |
| A wife whose husband has suffered an MI states, "My husband's favorite foods are fried chicken and french fried potatoes. Would it be okay for me to bring him some?" The nurse's best response is: 1. "That's a good idea; he has a hearty appetite." 2. "If you bring him only a small amount, it will be ok." 3. "First let's speak to the dietician about his diet." 4. "No, you can't bring food into the hospital." | 3. The client and his wife need diet instruction. A diet high in fat and cholesterol will further contribute to the CAD process. |
| When assessing a client after a stroke, the nurse notes that there is an impairment of the ability to read, write, speak, listen, and comprehend. The nurse identifies this as: 1. Ataxia 2. Aphasia 3. Dysphagia 4. Agnosia | 2. Aphasia is the inability to express oneself through speech and language. |
| The nurse is preparing a 42-year-old man for hospital discharge after an MI. Which of the following statements indicates the need for further teaching? 1. "I will take my medications as prescribed" 2. "I will follow a low-cholesterol, low-fat diet" 3. "I can exercise as much as I want" 4. "I can have a small glass of wine with the evening meal" | 3. Although exercise is recommended after MI, it is usually done in a cardiac rehabilitation program where the client is monitored. Exercise is gradually increased over several weeks. |
| To prevent felxion contraction of the hip after a below-the-knee amputation, the nurse should encourage the client to be: 1. In supine position with a pillow between the legs 2. In a semi-Fowler's position most of the day 3. In supine position with a pillow under the knees 4. In prone position | 4. Lying prone stretches the flexor muscles and prevents felxion contraction of the hip. |
| A friend calls and states that he has taken three nitroglycerin tablets for his chest pain, but the pain is still there. The nurse advises him to: 1. Call his doctor 2. Drive to the nearest emergency room 3. lie down and rest to see if the pain goes away 4. Call 911 | 4. A rescue squad is best equipped to give emergency treatment. |
| A 47-year-old client is in acute CHF after an MI. The goal of highest priority for this client at this time is to: 1. Decrease workload of the heart 2. Breathe easily 3. Decrease edema 4. Know his medications | 1. Decreasing any strain on the heart is the highest priority in restoring the health of the client at this time. |
| This is the second post-op day for a 54-year-old client who had a CABG. At 8am her BP is normal; the pulse rate is 123 bpm (normally 82 bpm) and weak. The client is cold, clammy, and confused. Her respiratory rate is 44/min; bowel sounds are absent, and urinary output is 22mL/hr. The nurse prepares for the treatment of: 1. CHF 2. MI 3. Shock 4. Cardiac tamponade | 3. The signs are classic for shockl the BP can be normal. |
| CN III | A trauma nurse is caring for a patient that sustained trauma to the head. She notices that the patient has a "blown pupil" (one pupil is fixed a dilated). This is caused by intracranial swelling and brain herniation. A blown pupil is caused by disruption of which cranial nerve? |
| Place a tongue-blade in the patient's mouth to prevent blockage of the airway. | A patient in the hospital for observation after a presumed seizure is found thrashing about in his room. Which of the following would be an improper intervention? |
| The patient should be placed on droplet precautions. | You are working in the emergency department when a college freshman is brought in by his roommate. The freshman has a severe headache, stiff neck, subjective fever and his roommate had to pull over en route to the hospital to let the patient vomit. The lights of the ER triage area seem to bother his eyes. Which of the following is an important part of caring for this patient? |
| Parkinson's disease | A gentleman from Peru is brought by his wife to the clinic. He does not speak English and she is translating for him. You learn that he was a manganese miner for over twenty years. This gentleman is at particular risk of developing symptoms of which of the following diseases? |
| Equal pupillary constriction in response to light | You are the nurse assigned to perform an eye assessment on an 80-year-old client. Which of the following findings during the assessment is considered normal? |
| Loss of lens elasticity | Which of the following physiologic changes would be expected in a patient with presbyopia? |
| "The lens is normally transparent | A patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry? |
| Artificial tears | A patient with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse? |
| Encouraging compliance with drug therapy to prevent loss of vision | A client with history of glaucoma was diagnosed by the community nurse as experiencing Visual Sensory/Perceptual Alterations R/T increased intraocular pressure. The plan of care should focus on: |
| Hypogeusia | A patient has a normal sensory change that results in diminished sense of taste. How would this be documented |
| CN IX and CN VII | A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved |
| Damage to cranial nerve I | A 78-year-old client is admitted to the Emergency Department (ED) via emergency medical service (EMS) with complaints of severe diarrhea with resultant weakness and signs of dehydration. Discussion with the significant other reveals that the patient continually eats spoiled foods. Which of the following might be most directly related to this patient's behavior? |
| Reposition the client to avoid neck flexion | An 18-year-old client is admitted with a closed head injury sustained in a MVA. His intracranial pressure (ICP) shows an upward trend. Which intervention should the nurse perform first? |
| Rapid dilantin administration can cause cardiac arrhythmias | A client with a subarachnoid hemorrhage is prescribed a 1,000-mg loading dose of Dilantin IV. Which consideration is most important when administering this dose? |
| Evaluate urine specific gravity | A client with head trauma develops a urine output of 300 ml/hr, dry skin, and dry mucous membranes. Which of the following nursing interventions is the most appropriate to perform initially? |
| Immobilize the client's head and neck | A client comes into the ER after hitting his head in an MVA. He's alert and oriented. Which of the following nursing interventions should be done first? |
| Raise the head of the bed immediately to 90 degrees | A 22-year-old client with quadriplegia is apprehensive and flushed, with a blood pressure of 210/100 and a heart rate of 50 bpm. Which of the following nursing interventions should be done first? |
| To immobilize the surgical spine | A client with a cervical spine injury has Gardner-Wells tongs inserted for which of the following reasons? |
| Laceration of the middle meningeal artery | A client is admitted to the ER for head trauma is diagnosed with an epidural hematoma. The underlying cause of epidural hematoma is usually related to which of the following conditions? |
| Check the fluid for dextrose with a dipstick | A 23-year-old client has been hit on the head with a baseball bat. The nurse notes clear fluid draining from his ears and nose. Which of the following nursing interventions should be done first? |
| A client with a high cervical spine injury | Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia? |
| Noxious stimuli | A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia? |
| Put the client in the high-Fowler's position | During an episode of autonomic dysreflexia in which the client becomes hypertensive, the nurse should perform which of the following interventions? |
| "Wake him every hour and assess his orientation to person, time, and place | An 18-year-old client was hit in the head with a baseball during practice. When discharging him to the care of his mother, the nurse gives which of the following instructions? |
| Dopamine | Which neurotransmitter is responsible for may of the functions of the frontal lobe? |
| Activity of the brain | The nurse is discussing the purpose of an electroencephalogram (EEG) with the family of a client with massive cerebral hemorrhage and loss of consciousness. It would be most accurate for the nurse to tell family members that the test measures which of the following conditions? |
| Epidural hematoma | A client arrives at the ER after slipping on a patch of ice and hitting her head. A CT scan of the head shows a collection of blood between the skull and dura mater. Which type of head injury does this finding suggest? |
| Quadriplegia with gross arm movement and diaphragmic breathing | After falling 20', a 36-year-old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect |
| Epidural hematoma | The nurse is caring for the client in the ER following a head injury. The client momentarily lost consciousness at the time of the injury and then regained it. The client now has lost consciousness again. The nurse takes quick action, knowing this is compatible with |
| Limiting bladder catherization to once every 12 hours | A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse would avoid which of the following measures to minimize the risk of recurrence? |
| Inability to elicit a Babinski's reflex | The nurse is evaluating neurological signs of the male client in spinal shock following spinal cord injury. Which of the following observations by the nurse indicates that spinal shock persists? |
| Unequal pupil size | A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor? |
| Slow, irregular respirations | Which of the following respiratory patterns indicate increasing ICP in the brain stem? |
| Encourage the client to hyperventilate | Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg? |
| Decrease in LOC | A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition? |
| Wrap her hands in soft "mitten" restraints | A client who is regaining consciousness after a craniotomy becomes restless and attempts to pull out her IV line. Which nursing intervention protects the client without increasing her ICP? |
| Back arched; rigid extension of all four extremities. | Which of the following describes decerebrate posturing? |
| Call the physician while another nurse checks the vital signs and ascertains the patient's Glasgow Coma score | A client receiving vent-assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate? |
| Dilated non reactive pupils | A client has been pronounced brain dead. Which findings would the nurse assess? |
| Decorticate | abnormal posturing that involves rigidity, flexion of the arms, clenched fists, and extended legs. |
| true | seizures are divided into two broad categories: generalized and partial (also called local or focal). |
| true | Generalized seizures are produced by electrical impulses from throughout the entire brain |
| true | partial seizures are produced (at least initially) by electrical impulses in a relatively small part of the brain. |
| "Grand Mal" or Generalized tonic-clonic | Unconsciousness, convulsions, muscle rigidity |
| Absence Seizure | short loss of consciousness (just a few seconds) with few or no symptoms. The patient, most often a child, typically interrupts an activity and stares blankly. These seizures begin and end abruptly and may occur several times a day. Patients are usually not aware that they are having a seizure, except that they may be aware of "losing time." |
| Myoclonic Seizure | sporadic jerks, usually on both sides of the body. Patients sometimes describe the jerks as brief electrical shocks. When violent, these seizures may result in dropping or involuntarily throwing objects. |
| Clonic Seizure | repetitive, rhythmic jerks that involve both sides of the body at the same time. |
| Tonic Seizure | Muscle stiffness, rigidity |
| Atonic Seizure | sudden and general loss of muscle tone, particularly in the arms and legs, which often results in a fall. |
| Linear skull fractures | blunt trauma |
| Depressed skull fractures | high-energy transfer, such as a blow from a baseball bat |
| Basilar skull fractures | Caused by a blow to the back of the head, characteristic signs: blood in the sinuses; a clear fluid called cerebrospinal fluid (CSF) leaking from the nose or ears; raccoon eyes |
| Intracranial hemorrhages | dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments |
| Subdural hemorrhage | gap between the dura and the cortical surface of the brain. |
| 4 things that protect the brain | meningies, csf, blood-brain barrier, skull |
| nsg intervention for spinal injury | vitals/turn freq/call light close/ ROM |
| acceleration injury | head is suddenly forced to stop or start moving, or to turn rapidly. |
| deceleration injury | collision between a rapidly moving body part and a stationary object |
| Hyperflexion injuries | whiplash - shaken baby |
| Prioritizing (FIRST) | F-Find Hypoxia O2 is an always immediate concern can be a result of cardiac or respiratory complications VS skin color or capillary refill are a few assessments a nurse would anticipate, also increased anxiety and confusion. I-Imunno Compromised receiving kimo, or has aids R-Real Bleeding Hemmer age from trauma or surgery changes in VS skin color temperature and urine output will result in alteration in organ or tissue confusion S-Safety at risk for injury from IICP or confusion form delirium or dementia T- Try Infection client who is septic with a high fever and has order for blood cultures and antibiotics, obtain blood cultures before starting antibiotics |
| Seven W's with med errors | Who- What- Which- When- Why- Where- Write down- |
| MANAGERS | M-Med errors #1 problem A- Areas of danger ex: fires, falls, hazardous material(O2, Waste, Sharp Needles) N- Nurture Relationships A- Arrest infection before it starts G- Give strong documentation E- Educate continually R- Room assignment S- Staff delegation |
| STAR | S- Strength to grow help and allow others to grow T- The happiness factor comfortable in her own shoes is not a victim and does not blame A- A visionary that can think out of the box R- Reactive last Proactive first. |
| RACE | R- Rescue A- Activate Alarm C- Confine the fire E- Evacuate / Extinguish |
| Delegation | Delegates task but not the responsibility tells his colleague how to be helpful to him, you have to practice excellent communication skill before we tell something to do something we are legally responsible for the outcome. |
| TELL (Delegation) | T- Taught Has the person been taught the skill treatment or assessment E- Evaluate You have to evaluate just because they were taught how to do something does not mean they are competent to do it, has there return demonstration been performed and documented. L- Licensee Does the individual have or need a licensee to do this task and is this in the scope of there practice. L- Lists What lists of standards of cares (agency policies are written regarding this task) |
| PART - LPN (delegation) | P- Plan and isolation of RN LPN's collaborate with RN's , The current LPN standard is not to push IV meds. A- Asses initially LPN's will participate in ongoing assessments but the RN is responsible for the initial assessment Analyze LPN's do not make nursing diagnosis or analyze nursing care R- Review and evaluate and isolate the RN The LPN is responsible for collaborating with the RN during the evaluation process T- Teach initially while LPN's maybe involved in the teaching process the RN is responsible for the initial teaching the LPN may reinforce teaching |
| CNA's (delegation) CCANT | C- Cant irrigate a Foley the CNA's should not conduct this intervention C- Cant make clinical decisions CNA's but can make observations A- Anticipate Clinical Changes N- No Invasive Procedures CNA's should not be accountable for any invasive procedures or specialized procedures T- Teach CNA's are not responsible for teaching |
| CNA's (delegation) BART | B- Baths (routine and uncomplicated0 if the client is in acute distress or has any complications such as an alsure the nurse may implement the bath due to ongoing clinical assessment A- Ambulation if there are any complications like hypotension or syncopy or post op implication the nurse must be present R- Routine Tasks does not require critical thinking ex: obtaining a urine sample stool for blood the nurse will make clinical decisions based on the data T- Tasks that do not require critical thinking |
| Room Assignments RISK | R- Radiation this client should be put in isolation to prevent injury to other clients I- Infection / Isolation Remember consider infection with the selection of roommates for a client. ex:TB Variclla or Measles airborne transmission precautions are important neissseria menengities, mycoplasma pneumonia, strep group a infection or pertussis it is important to follow droplet percussion GI respitory skin or wound should be placed in private room and have contact precautions. immino compromise should be placed in appropriate isolation S- Safety / Sex Female with Female and Male with Male unless married never place a combative or a manic client with a depressed client. A preaclamntic patient the room should be a low stimulation enviroment. K- Know growth and development Two clients should be same developmental age. |
| Safe use of equipment SAFE | S- System must be without problems for client safety A- Accident Prevention can be achieved at 100% of the time when the nurse is functioning to prior use F- Functions properly prior to using ex: there will never be a client death if the nurse checks the PCA pump prior to usage E: Evaluate the effectiveness checking the equipment is of paramount importance in providing safe care |
| Cost effectiveness SAVE | S- Staff if an LPN able to provide the nursing care safely and efficiency it is not financially wise to assign RN to same client A- Avoid duplication Share staff members V- View infection An ounce of prevention is worth a pound of cure, infections are expensive wash hands and practice universal precautions E- Educate discuss the budget with the nursing staff an informed manager can be a smart manager. |
| Disaster Plan ABC | A- Ambulatory The priority is to evacuate the largest amount clients initially B- Bed Ridden The bed ridden clients will be next to evacuate ambulatory group my be able to assist. C- Critical Care Last group to be evacuated this involves the ultimate objective is to evacuate volumes of clients |
| HIPPA Privacy | H- How to release information to health care professionals that need to know I- Impermissible uses and disclosures results in lawsuits. P- Protect Privacy of individually identifiable health information P- Plan for sharing info with families in a discrete way A- Access by client to medical records including the right to see a copy |
| Legal Aspects | Due Process is following correct procedures and if any steps are skipped there are legal issues of negative proportions. Decision are arbitrary is like not letting a bad looking family see a client Deprivation of property is like don't go through client stuff other than psychiatric patients Deprivation of confidentiality the nurse discusses client care with another nurse |
| A client with pulmonary tuberculosis (TB) asks the nurse how this disease was contracted. The nurse replies that TB is commonly spread by which of the following methods? 1. Sneezing 2. Shaking hands 3. Contact with stool 4. Contact with urine | 1. Sneezing Rationale: TB is spread by droplet nuclei, which become airborne when the infected client laughs, sings, sneezes, or coughs. An individual must inhale the droplet nuclei for the chain of infection to continue. Therefore it is not spread by shaking hands or contact with stool or urine. |
| A nurse is collecting data about the lethality risk of a suicidal client. Which of the following is the best question for the nurse to ask the client? 1. "Do you have a death wish?" 2. "Do you wish your life was over?" 3. "Do you ever think about ending it all?" 4. "Have you ever thought of killing yourself?" | 4. "Have you ever thought of killing yourself?" Rationale: A lethality assessment requires direct communication between the client and nurse. It is important to provide a question that is directly related to lethality. Options 1, 2 and 3 do not directly address the subject of the question. Option 4, is the most direct option. |
| A physical assessment of the suicidal client is performed on admission to the inpatient unit. The nurse reviews the findings and recognizes that this is an important part of the admission process because it alerts the nurse to: 1. Baseline data 2. Abnormalities 3. Existing medical problems 4. Evidence of physical self-harm | 4. Evidence of physical self-harm Rationale: The physical assessment of a suicidal client should be thorough and should focus on the evidence of self-harm or the formulation of a plan for the suicide attempt. Although all of the options are correct, option 4 is the most appropriate for the suicidal client. Clients with a history or evidence of self-harm are greater suicide risks. |
| A nurse is collecting information from a client about the client's suicide risk. The nurse should ask the client which most significant question? 1. "Why do you want to hurt yourself?" 2. "Do you have a plan to commit suicide?" 3. " Has anyone in your family committed suicide?" 4. Can you describe how you are feeling right now?" | 2. "Do you have a plan to commit suicide?" Rationale: When collecting information about suicide risk, the nurse must determine if the client has a suicide plan. Clients who have a definitive plan pose a greater risk for suicide. Options 1, 3 and 4 do not directly provide this information. |
| A client is admitted to a long-term care facility with a diagnosis of Parkinson's disease. The nurse gives information about the client's condition to a visitor assumed to be a family member. The nurse has violated which legal concept of the nurse-client relationship? 1. Incompetency 2. Invasion of privacy 3. Communication techniques 4. Teaching/Learning principles | 2. Invasion of privacy Rationale: Discussing a client's condition without the client's permission violates the client's right and places the nurse in legal jeopardy. This is an invasion of privacy and affects client's confidentiality. Incompetence could lead to negligence, but this legal concept is not related to the subject identified in the question. Communication techniques relate to the nurse-client relationship. Teaching/learning principles are considered concepts of standard practice. |
| A client has an order for valproic acid (Depakene) 250 mg once daily. To maximize the client's safety, the nurse plans to schedule the medication: 1. With lunch. 2. At bedtime. 3. After breakfast. 4. Before breakfast. | 2. At bedtime Rationale: Valproic acid is an anticonvulsant that causes central nervous system (CNS) depression. Its side effects include sedation, dizziness, ataxia and confusion. When the client is taking this medication as a single dose, administering it at bedtime negates the risk of injury from sedation and enhances client safety. |
| A client with a synthetic cast on the right leg tells the nurse that he wants to take a shower. Based on the review of the data related to the injury and type of cast, which of the following is the best response to ensure a safe environment? 1. "The cast padding will never dry." 2. "It may lead to a serious problem." 3. "Hot water may soften the synthetic cast." 4. It is not safe for you to shower at this time." | 4. "It is not safe for you to shower at this time." Rationale: It may be unsafe for a client to shower with a cast the leg because the client could slip and fall. Water does not damage the synthetic cast; however, the client should know that it may take a while for the cast padding to dry. Water may soften a plaster cast but has no effect on a synthetic cast. A shower will not cause an infection. |
| A client is prepared to receive elective cardioversion to treat atrial fibrillation. Which of the following is an unsafe preprocedure observation? 1. The client's digoxin has been withheld for the last 48 hours. 2. The synchronizer on the defibrillator is turned on and set at 50 joules. 3. The client has received an intravenous (IV) dose of midazolam (Versed). 4. The client is wearing a nasal cannula delivering oxygen at 2 liters per minute. | 4. The client is wearing a nasal cannula delivering oxygen at 2 liters per minute. Rationale: Digoxin may be withheld for up to 48 hours before cardioversion because it increases ventricular irritability and may cause ventricular dysrhythmias after countershock. The client typically receives an IV dose of a sedative or antianxiety agent. The defibrillator is switched synchronizer mode to time the delivery of the electrical impulse to coincide with the QRS complex and avoid the T wave, which should cause ventricular fibrillation. Energy level is typically set at 50 to 100 joules. During the procedure any oxygen is removed temporarily because oxygen supports combustion, and a fire could result from electrical arcing. |
| A nurse administers a fatal dose of digoxin (Lanoxin) to a client. During the subsequent investigation of error, it is determined that the nurse did not note the client's heart rate of 45 beats per minute before administering the medication. Failure to adequately collect all data in this event is addressed under which function of the Nurse Practice Act? 1. Defining the specific educational requirements for licensure in the state 2. Describing the scope of practice of licensed and unlicensed care providers 3. Identifying the process fro disciplinary action if standards of care are not met 4. Recommending specific terms of incarceration for nurses who violate the law | 3. Identifying the process for disciplinary action if standards of care are not met Rationale: In this event, acceptable standards of care were not met (the nurse failed to adequately assess the client before administering a medication). Option 3 refers specifically to the event described in the question. Options 1, 2 and 4 do not relate to the event described in the question. |
| A nurse is observing a nursing assistant talking to a client who is hearing impaired. The nurse should intervene if which of the following were performed by the nursing assistant during communication with the client? 1. The nursing assistant is speaking in a normal tone 2. The nursing assistant is speaking clearly to the client 3. The nursing assistant is facing the client when speaking 4. The nursing assistant is speaking directly into the impaired ear | 4. The nursing assistant is speaking directly into the impaired ear. Rationale: When communicating with a hearing impaired client, the nurse should speak in a normal tone to the client and should not shout. The nurse should talk directly to the client while facing the client and speak clearly. If the client does not seem to understand what is said, the nurse should express the statement differently. Moving closer to the client and toward the better ear may facilitate communication, but the nurse should avoid talking directly into the impaired ear. |
| Which statement made by a nursing student indicates an understanding of the concepts associated with suicide and suicide intentions? 1. "Only psychotic individuals commit suicide." 2. "Suicide attempts are just attention-seeking behaviors." 3. "Suicide runs in the family, so there is nothing that health care personnel can do about it." 4. "Many individuals who really do kill themselves have talked about their intentions to others." | 4. "Many individuals who really do kill themselves have talked about their intentions to others." Rationale: Most people who commit suicide have given definite clues or warnings about their intentions. The individual who is suicidal is not necessarily psychotic or even mentally ill. A suicide attempt is not an attention-seeking behavior, and each act should be taken seriously. Suicide is not an inherited condition; it is an individual condition. |
| A rehabilitation center nurse is planning the client assignments for the day. Which of the following clients should the nurse assign to the nursing assistant? 1. A client who had a below-the-knee amputation 2. A client on a 24-hour urine collection who is on strict bed rest 3. A client scheduled for transfer to the hospital for an invasive diagnostic procedure 4. A client scheduled to be transferred to the hospital for coronary artery bypass surgery | 2. A client on a 24-hour urine collection who is on strict bed rest. Rationale: The nurse is legally responsible for client assignments and must assign tasks based on the guidelines of nursing practice acts and the job description of the employing agency. A client who had a below-the-knee amputation, is scheduled for an invasive procedure, or is scheduled to be transferred to the hospital for coronary artery bypass surgery has both physiological and psychological needs. The nursing assistant has been trained to care for a client on bed rest and urine collections. The nurse provides instructions, but the tasks required are within the role of a nursing assistant. |
| A nurse has administered a dose of diazepam (Valium) to the client. The nurse should take which most important action before leaving the client's room? 1. Draw the shades closed 2. Give the client a bedpan 3. Put up the side rails on the bed 4. Turn the volume on the television set down | 3. Put up the side rails on the bed Rationale: Diazepam is a sedative/hypnotic with anticonvulsant and skeletal muscle relaxant properties. The nurse should institute safety measures before leaving the client's room to ensure that the client does not injure himself or herself. The most frequent side effects of this medication are dizziness, drowsiness and lethargy. Therefore the nurse puts the side rails up on the bed before leaving the room to prevent falls. Options 1, 2 and 4 may be helpful measures that provide a comfortable, restful environment; however, option 3 is the only one that provides for the client's safety needs. |
| A client with acquired immunodeficiency syndrome (AIDS) who has cytomegalovirus retinitis is receiving ganciclovir sodium (Cytovene). The nurse should plan to do which of the following while the client is taking this medication? 1. Monitor blood glucose levels for elevation 2. Administer the medication on an empty stomach only 3. Apply pressure to venipuncture sites for at least 2 minutes 4. Provide the client with a soft toothbrush and an electric razor | 4. Provide the client with a soft toothbrush and an electric razor Rationale: Ganciclovir sodium causes neutropenia and thrombocytopenia as the most frequent side effects. For this reason, the nurse monitors the client fro signs and symptoms of bleeding and implements the same precautions that are used for a client receiving anticoagulant therapy. These include providing a soft toothbrush and electric razor to minimize risk of trauma that could result in bleeding. The medication may cause hypoglycemia, but not hyperglycemia. The medication does not have to be taken on an empty stomach. Venipuncture sites should be held for approximately 10 minutes. |
| A client is scheduled to have insertion of an inferior vena cava (IVC) filter. The nurse should place highest priority on determining whether the surgeon wants which of the following medications held in the preoperative period? 1. Furosemide (Lasix) 2. Famotidine (Pepcid) 3. Multivitamin with minerals 4. Warfarin sodium (Coumadin) | 4. Warfarin (Coumadin) Rationale: The nurse is careful to question the surgeon about whether warfarin sodium should be administered in the preoperative period before insertion of an IVC filter. This medication is often withheld during the preoperative period to minimize the risk of hemorrhage during surgery. The other medications may also be withheld if specifically ordered, but usually they are discontinued as part of an NPO (nothing by mouth) after midnight order. |
| A client has cognitive-perceptual difficulties and problems with fine motor coordination. The nurse working with this client should read the progress notes from which of the following health team members to obtain suggestions for working with him or her? 1. Social worker 2. Speech pathologist 3. Recreational therapist 4. Occupational therapist | 4. Occupational therapist Rationale: The occupational therapist focuses on the development or relearning of fine motor skills. Social workers, speech pathologists and recreational therapists do not address these types of client problems. |
| A postpartum client has been diagnosed with endometritis. The nurse who is reinforcing teaching about how to prevent the spread of infection to the newborn should tell the mother to: 1. Keep the newborn in the Isolette 2. Ask visitors not to hold the newborn 3. Wear a mask to prevent spread of airborne droplets 4. Wash hands carefully before picking up the newborn | 4. Wash hands carefully before picking up the newborn Rationale: Infectious diseases can be transmitted through contaminated items such as hands and bed liners in clients with endometritis. Hand washing is one of the most effective methods to prevent transmission of this infectious disease because it breaks the chain of infection. Options 2 and 3 are not related to the route of transmission of this infection. Option 1 is unnecessary. |
| A 2 month-old is admitted to the hospital. The nurse should take which of the following actions to maintain the infant's safety and to reduce the risk of sudden infant death syndrome (SIDS)? 1. Make sure that only plastic bottles and toys are used 2. Place the infant in a supine position in preparation for sleep 3. Take the pacifier out of the mouth before the infant falls asleep 4. Cover the crib with netting when the child is not being directly observed | 2. Place the infant in a supine position in preparation for sleep Rationale: The American Academy of Pediatrics recommends the supine position for sleep to reduce the risk of SIDS. Plastic bottles and toys are not needed yet because a 2 month-old cannot hold them. Pacifiers are considered safe and appropriate at this age. Safety netting is not necessary for a 2 month-old because the infant cannot roll over or stand alone. |
| Sertraline (Zoloft) is prescribed to treat depression. The nurse reviews the client's record and consults the physician if which of the following is noted? 1. A history of diabetes mellitus 2. Use of phenelzine sulfate (Nardil) 3. A history of myocardial infarction 4. A history of irritable bowel syndrome | 2. Use of phenelzine sulfate (Nardil) Rationale: Sertraline (Zoloft) is a serotonin reuptake inhibitor and antidepressant medication. Potentially fatal reactions may occur if sertraline is administered concurrently with a monoamine oxidase inhibitor (MAOI) such as phenelzine sulfate, MAOIs should be stopped at least 14 days before sertraline therapy. Conversely, sertraline should be at least 14 days before MAOI therapy. Options 1, 3, and 4 are not concerns of use of this medication. |
| A nurse must give an injection to a client with acquired immunodeficiency syndrome (AIDS). The nurse does which of the following after giving the injection? 1. Breaks the needle and discards it 2. Recaps the needle and discards the syringe in the disposal unit 3. Places the uncapped needle and syringe in a labeled cardboard box 4. Places the uncapped needle and syringe in a labeled, rigid plastic container | 4. Places the uncapped needle and syringe in a labeled, rigid plastic container Rationale: Standard precautions include specific guidelines for handling sharps and needles. Needles should not be recapped, bent, broken or cut after use; they should be disposed of in a labeled, impermeable container specifically used for this purpose. Needles should not be discarded in cardboard boxes because they could puncture the cardboard, causing a needlestick injury. Needles should never be left lying around after use. |
| A licensed practical nurse (LPN) is assisting a registered nurse (RN) to develop a plan of care for a client who will be hospitalized for insertion of an internal cervical radiation implant. Which of the following does the LPN suggest be included in the client's plan of care? 1. Limit visitor's time to 60 minute visits 2. Place a radiation sign on the door of the client's room 3. Place the client in a private room close to the nurses' station 4. Reinsert the implant into the vagina immediately if it becomes dislodged | 2. Place a radiation sign on the door of the client's room Rationale: The client's room should be marked with appropriate signs stating the presence of radiation. Visitors are limited to 30 minutes. The client should be placed in a private room at the end of the hall because this location provides less a chance of radiation exposure to others. A lead container and long-handled forceps should be kept in the client's room at all times during internal radiation therapy. If the implant becomes dislodged, the nurse should pick it up with long-handled forceps and place it in the lead container. It is not reinserted by the nurse. |
| A nurse assigned to care for a 4-week-old infant who is scheduled for a pyloromyotomy. The nurse plans to do which of the following when caring for the infant? 1. Restrain the infant in a high chair 2. Feed the infant in a lying-down position 3. Feed the infant 1 ounce of formula every hour 4. Position the infant prone with the head of the bed elevated | 4. Position the infant prone with the head of the bed elevated Rationale: Before surgery the infant's status is nothing by mouth (NPO), and the infant is stabilized with intravenous fluids and electrolytes. The head of the bed is elevated, and the infant is placed prone to reduce the risk of aspiration. Options 2 and 3 are not accurate during the preoperative period because the infant is kept NPO. An infant is not restrained in a high chair. |
| A nurse employed in a long-term care facility has planned a get-together for clients and their families to celebrate the birthday of a client who is 100 years old. During the party, the nurse takes pictures of some of the clients and plans to develop the pictures and submit the pictures to the local newspaper. Which client right has the nurse violated? 1. Assault 2. Battery 3. Invasion of privacy 4. False imprisonment | 3. Invasion of privacy Rationale: Invasion of privacy takes place when an individual's private affairs are unreasonably invaded. Taking photographs of a client is an example of such a violation. Telling the client that he or she cannot leave the hospital constitutes an example of false imprisonment. Threatening to place a client in restraints is an example of an assault. Performing a procedure without consent is an example of battery. |
| A nurse overhears a client ask the physician if the client the results of a biopsy indicated cancer. The physician tells the client that the results have not returned, when in fact the physician is aware that the results of the biopsy indicated the presence of malignancy. The nurse is upset that the physician has not shared the results with the client and tells another nurse that the physician has lied to the client and that the physician probably lies to all the clients. Which legal tort has the nurse violated by this statement? 1. Libel 2. Assault 3. Slander 4. Negligence | 3. Slander Rationale: Defamation is a false communication or a careless disregard for the truth that causes damage to someone's reputation, either in writing (libel) or verbally (slander). An assault occurs when a person puts another person in fear of a harmful or an offensive contact. Negligence involves the actions of professionals that fall below the standard of care for a specific professional group. Although the physician may be aware of the biopsy results, the physician decides when it is best to share such a diagnosis with the client. |
| A nurse employed in a long-term care facility is preparing to administer medications to an assigned client and notes that order for furosemide (Lasix) is higher than the recommended dosage. The nurse calls the physician to clarify the order and asks the physician to prescribe a dosage within the recommended range. The physician refuses to change the order and instructs the nurse to administer the dose as prescribed. Which of the following actions should the nurse take? 1. Discontinue the order 2. Contact the nursing supervisor 3. Administer the dose as prescribed 4. Call the state medical board and report the physician | 2. Contact the nursing supervisor Rationale: If the physician writes an order that requires clarification, it is the nurse's responsibility to contact the physician for clarification. If there is no resolution regarding the order because the order remains as it was written after talking with the physician or because the physician cannot be located, the nurse should then contact the nurse manager or supervisor for further clarification as to what the next step should be. Under no circumstances should the nurse proceed to carry out the order until clarification is obtained. Option 1 is not within the scope of nursing practice. Option 4 is a premature action. |
| The nurse is administering medications to a client and administers a dose of methyldopa (Aldomet) 250 mg orally instead of the prescribed 125 mg dose. The nurse discovers the error when documenting that the medication has been administered. Which of the following is an inappropriate nursing action regarding the incident? 1. Complete an incident report 2. Monitor the client's blood pressure 3. Make a copy of the incident report for the physician 4. Document a complete entry in the client's record concerning the incident | 3. Make a copy of the incident report for the physician Rationale: An incident report needs to be completed whenever an unusual occurs. The incident report is confidential and privileged information and should not be copied, placed in the chart, or have any reference made to it in the client's record. A complete entry in the client's record should be made concerning the incident. The incident report is not a substitute for such an entry. The client's blood pressure should be monitored because this medication is an antihypertensive. The physician is notified. |
| A new nurse graduate asks another licensed practical nurse (LPN) about the need to obtain professional liability insurance. The appropriate response by the LPN is: 1. "The hospital insurance covers your actions." 2. "Nurses should have their own malpractice insurance." 3. "It is very expensive, and you really don't need it since the hospital covers you." 4. "Lawsuits are filed against physicians and the hospital, so you are safe not to obtain it." | 2. "Nurses should have their own malpractice insurance." Rationale: Nurses need their own liability insurance for protection against malpractice lawsuits. Nurses erroneously assume that they are protected by an agency's professional liability policies. Usually when a nurse is sued, the employer is also sued for the nurse's actions or inactions. Even though this is the norm, nurses are encouraged to have their own malpractice insurance. |
| A licensed practical nurse witnesses an accident in which a victim was hit by a car. The nurse stops at the scene of the accident and administers safe care to the victim, who sustained a compound fracture of the femur. The victim is hospitalized and later develops sepsis as a result of the fractured femur. The victim files a suit against the nurse who provided care at the scene of the accident. Which of the following most accurately describes the nurse's immunity from this suit? 1. The Good Samaritan Law will not protect the nurse 2. The Good Samaritan Law protects lay persons and not professional health care providers 3. The Good Samaritan Law will protect the nurse if the care given at the scene is not negligent 4. The Good Samaritan Law always provides immunity from the suit even if the nurse accepted compensation for the care provided | 3. The Good Samaritan Law will protect the nurse if the care given at the scene is not negligent Rationale: A Good Samaritan law is passed by the state legislature to encourage nurses and other health care providers to provide care to a person when an accident, emergency or injury occurs, without fear of being sued for the care provided. Called immunity from suit, this protection usually applies only if all of the conditions of the law are met, such as the health care provider receives no compensation for the care provided, and the care given is not willfully and wantonly negligent. |
| A nurse working in a long-term care facility responds after hearing someone calling, "Help, the bed is on fire!" On entering the room, the nurse finds an older client slapping at the flames on the bedspread with a pillow. Both hands have been burned. Which action should the nurse take first? 1. Pull the nearest fire alarm 2. Close the door to the room 3. Remove the client from the room 4. Run to get the nearest fire extinguisher | 3. Remove the client from the room Rationale: In a fire emergency, the steps to follow use the acronym RACE. The first step is to remove the victim. The next steps are: activate the alarm, contain the fire, and then extinguish as needed. This is a universal standard that may be applied to any type of fire emergency. Option 3 is correct because it removes the victim from the area. Option 1 would be the next step (alarm). The fire is next contained (option 2) and then extinguished (option 4). |
| An adult client is brought to the emergency room by an ambulance after being hit by a car. The client is unconscious and in shock. A perforated spleen is suspected, and emergency surgery is required immediately to save the client's life. No family members are present. In regard to informed consent for the surgical procedure, the nurse understands that which of the following is the best nursing action? 1. Ask the hospital chaplain to sign the consent form 2. Transport the client to the operating room immediately 3. Call the nursing supervisor to initiate a court order for the surgical procedure 4. Call a family member to obtain telephone consent before the surgical procedure | 2. Transport the client to the operating room immediately Rationale: Generally there are only two instances in which the informed consent of an adult is not needed. One instance is when an emergency is present and delaying treatment for the purpose of obtaining informed consent would result in injury or death to the client. The second instance is when the client waives the right to give informed consent. It is inappropriate to ask the hospital chaplain to sign the consent form. Requesting that the nursing supervisor initiate a court order for the surgical procedure delays the necessary life-saving intervention. Although the family needs to be notified, calling a family member to obtain telephone consent before the surgical procedure also delays necessary life-saving intervention. |
| A nurse is asked to check the corneal reflex on an unconscious client. The nurse should use which of the following as the safest stimulus to touch the client's cornea? 1. Sterile glove 2. Wisp of cotton 3. Sterile drop of saline 4. Tip of a 1 mL syringe | 3. Sterile drop of saline Rationale: The client who is unconscious is at risk of corneal abrasion. The safest way to test the corneal reflex is by using a drop of sterile saline. Options 1, 2 and 4 can cause injury to the cornea. |
| A client tells the nurse that she has seen many articles in the health care section of the newspaper about case management and asks the nurse what this means. To provide the client with accurate information, the nurse tells the client which of the following? 1. "It represents an interdisciplinary health care delivery system." 2. "One nurse takes care of one client and is responsible for that client." 3. "One nurse supervises all of the other employees when they care for clients." 4. "A single case manager plans the care for all of the clients in the nursing unit." | 1. "It represents an interdisciplinary health care delivery system." Rationale: Case management represents an interdisciplinary health care delivery system to promote appropriate use of hospital personnel and material resources to maximize hospital revenues while providing for optimal outcome of care. Case management manages client care by managing the client care environment. Options 2, 3 and 4 are incorrect descriptions. |
| A client is scheduled for a bone marrow aspiration. The nurse plans to bring which of the following skin cleansing agents to the bedside before this procedure for skin cleansing to prevent infection as a result of the procedure? 1. Alcohol swabs 2. Soap and water 3. Povidone-iodine 4. Hydrogen peroxide | 3. Povidone-iodine Rationale: Before bone marrow aspiration, the needle insertion site is cleansed with an antiseptic solution such as povidone-iodine. This helps reduce the number of bacteria on the skin and decreases the risk of infection from the procedure. The other options are incorrect agents because they would not produce this effect. |
| A nurse arrives to work on the day shift and is assigned to care for a client with terminal cancer. The nurse notes that the client has been receiving a narcotic analgesic every 3 hours for pain. When entering the client's room, the client states, "I am so glad you are here. The medicine never works when the nurse who cared for me last night gives it to me." The nurse has previously observed the same occurrence with this client and other clients and suspects that the night nurse is substance impaired. Which of the following actions should the nurse take? 1. Report the information to the police 2. Report the information to a supervisor 3. Call the impaired nurse organization and report the nurse 4. Call the night nurse who gave the medication and discuss the event with the nurse. | 2. Report the information to a supervisor Rationale: The Nurse Practice Act requires reporting the suspicion of impaired nurses. The Board of Nursing has jurisdiction over the practice of nursing and may develop plans for treatment and supervision. The suspicion should be reported to the nursing supervisor who will then report to the Board of Nursing. Option 4 is incorrect and may cause a conflict. Option 1 and 3 are premature actions. |
| A nurse is assisting in providing emergency treatment for a client in ventricular tachycardia. The licensed practical nurse understands that which action by the registered nurse provides for the safest environment during a defibrillation attempt? 1. Places no lubricant on the paddles 2. Performs a visual and verbal check of "all clear" 3. Holds the client's upper torso stable while the defibrillation is performed 4. Hands the charged paddles separately to the person performing the defibrillation | 2. Performs a visual and verbal check of "all clear" Rationale: Safety during defibrillation is essential for preventing injury to the client and to the personnel assisting with the procedure. The person performing the defibrillation ensures that all personnel are standing clear of the bed by a verbal and visual check of "all clear." Charged paddles should never be handed to other personnel. For the shock to be effective, some type of conductive medium (lubricant, gel) must be placed between the paddles and the skin. The client is not touched during the defibrillation procedure. |
| A physician prescribes 1000 mL of normal saline to be infused over 12 hours. The drop factor is 15 drops per milliliter. To administer the infusion safely, the nurse adjusts the flow rate at how many drops? 1. 15 drops 2. 18 drops 3. 21 drops 4. 28 drops | 3. 21 drops Rationale: Use the formula for calculating intravenous (IV) drop rates. Formula: Total volume in mL X drop factor/Time in minutes = Flow rate in drops per minute 1000 mL X 15 drops/720 minutes = 15000/720 = 20.8 or drops 21 drops per minute |
| An adolescent asks a nurse about the procedure to become an organ donor. The nurse most accurately tells the adolescent that: 1. Written consent is never required to become a donor 2. A donor must be 18 years or older to provide consent 3. An individual who is at least 16 years of age can sign to become a donor 4. The family is responsible for making the decision about organ donation at the time of death | 2. A donor must be 18 years or older to provide consent Rationale: Any person 18 years of age or older may become an organ donor by indicating his or her consent in writing. In the absence of appropriate documentation, a family member or legal guardian may authorize donation of the decedent's organs. |
| A nurse employed at a medical unit of a local hospital arrives at work and is told to report (float) to the pediatric unit for the day because there were several pediatric admissions during the night and the pediatric unit needs assistance in caring for the children. The nurse has never worked in the pediatric unit and is anxious about floating to this area. Which of the following is the appropriate nursing action? 1. Call the nursing supervisor 2. Refuse to float to the pediatric unit 3. Ask another nurse to float to the pediatric unit 4. Report to the pediatric unit and identify tasks that can be safely performed | 4. Report to the pediatric unit and identify tasks that can be safely performed Rationale: Floating is an acceptable legal practice used by hospitals to solve their understaffing problems. Legally, a nurse cannot refuse to float unless a union contract guarantees that nurses can work only in specified areas or the nurse can prove the lack of knowledge for the performance of assigned tasks. When faced with this event, the nurse should set priorities and identify potential areas of harm to the client. A nurse cannot refuse an assignment and should not ask another to perform an assignment. The supervisor would be called if the nurse is asked to perform a task he or she could not safely perform. |
| A 22 year-old client who was struck by a car while jogging, is brought to the emergency room by the ambulance team. Emergency measures are instituted but are unsuccessful. The client's fiancee is with the client and tells the nurse that the client is an organ donor. In anticipation that the client's eyes will be donated, which of the following should the nurse plan to implement initially? 1. Ask the fiancee to obtain the client's will from the lawyer 2. Call the National Eye Bank to confirm that the client is a donor 3. Position the deceased client supine and place dry sterile dressings over the eyes 4. Elevate the head of the bed, close the deceased client's eyes, and place a small ice pack on the eyes | 4. Elevate the head of the bed, close the deceased client's eyes, and place a small ice pack on the eyes Rationale: When corneal donation is anticipated, the head of the bed is elevated, the deceased client's eyes are closed, and a small ice pack is placed on the client's eyes. Within 2 to 4 hours the eyes are enucleated. The cornea is usually transplanted within 24 to 48 hours. Options 1 and 3 are incorrect actions. Option 2 is not an initial action. |
| A client with metastatic bladder cancer is admitted to the hospital for chemotherapy. During data collection, the client tells the nurse that a living will was prepared 2 years ago and asks if the will needs to be updated. The most appropriate nursing response is which of the following? 1. "Living wills are valid for 6 months." 2. "The will can't be changed once it is written." 3. "You will have to discuss the issue with your lawyer." 4. "A living will should be reviewed yearly with your physician." | 4. "A living will should be reviewed yearly with your physician." Rationale: The client should discuss the living will with the physician, and it should be reviewed annually to ensure that it contains the client's current wishes and desires. Options 1 and 2 include inaccurate information. Option 3 is not an appropriate response and places the client's question on hold. |
| A licensed practical nurse (LPN) is preparing to suction a client with a diagnosis of acquired immunodeficiency syndrome (AIDS). The LPN should gather which of the following supplies to perform this procedure safely? 1. Gloves, gown and mask 2. Gown, mask, and protective eyewear 3. Gloves, mask, and protective eyewear 4. Gloves, gown, and protective eyewear | 3. Gloves, mask, and protective eyewear Rationale: Standard precautions include the use of gloves whenever there is actual or potential contact with blood or body fluids. During suctioning the nurse wears gloves, a mask, and protective eyewear or a face shield. Impervious gowns are worn in those instances when it is anticipated that there will be contact with a large amount of body fluid or blood. |
| A licensed practical nurse (LPN) employed in a long-term care facility is observing a nursing assistant ambulating a client with right-sided weakness. The LPN determines that the nursing assistant is performing the procedure safely if the LPN observes the nursing assistant: 1. Standing behind the client 2. Standing in front of the client 3. Standing on the left side of the client 4. Standing on the right side of the client | 4. Standing on the right side of the client Rationale: When working with a client, the nurse should stand on the client's affected side. The nurse should position the free hand on the client's shoulder so that the client can be pulled toward the nurse in the event that the client falls forward. The client should be instructed to look up and outward rather than at his or her feet. Options 1, 2 and 3 are incorrect. |
| A nurse is caring for a client who is receiving a dose of an intramuscular antibiotic. The nurse enters the client's room to administer the prescribed antibiotic, and the client tells the nurse that the medication burns and that he does not want to receive it. The nurse tells the client that the medication is necessary and administers the medication. Which of the following can the client legally charge as a result of the nursing action? 1. Assault 2. Battery 3. Negligence 4. Invasion of privacy | 2. Battery Rationale: An assault occurs when a person puts another person in fear of a harmful or offensive contact. For this intentional tort to be actionable the victim must be aware of the threat of harmful or offensive contact. Battery is the actual contact with one's body. Negligence involves actions below the standards of care. Invasion of privacy occurs when the individual's private affairs are unreasonably invaded. In this event, the nurse can be charged with battery because the nurse administers a medication that the client has refused. |
| A licensed practical nurse (LPN) is reinforcing teaching done by a registered nurse (RN) to parents of a child with celiac disease. The LPN reminds the parents to do which of the following to ensure that the diet is safe based on the child's physical needs? 1. Restrict corn and rice in the diet 2. Serve pasta dishes instead of cereals with grain 3. Keep the intake of fresh starchy vegetables to a minimum 4. Read food labels carefully to avoid hidden sources of gluten | 4. Read food labels carefully to avoid hidden sources of gluten Rationale: Gluten is added to many foods such as hydrolyzed vegetable protein derived from cereal grains. Grains are also frequently added to processed foods as thickening or fillers. Because of this, it is important to read food labels. Gluten is found primarily in the grains of wheat and rye. Rice, corn and other vegetables are acceptable in a gluten-free diet. Many pasta products contain gluten and should be avoided. |
| A nurse notes that a child who has been diagnosed with intussusception has a formed brown bowel movement. The nurse should do which of the following at once to ensure that a safe plan of care is implemented for the child? 1. Prepare the child for hydrostatic reduction 2. Ask the child about any increase in abdominal pain 3. Warn the child and her parents that surgery is imminent 4. Report the passage of the normal stool to the registered nurse (RN) | 4. Report the passage of the normal stool to the registered nurse (RN) Rationale: Passage of a formed brown bowel movement usually indicates that an intussusception has reduced itself. The nurse immediately reports this data to the RN, who will in turn report it to the physician. This finding may change the course of the plan of care. Increased abdominal pain is not expected because the child's gastrointestinal tract is more functional. The finding does not indicate the need for immediate surgery. |
| A psychotic client is belligerent and agitated, making aggressive gestures and pacing in the hallway. To ensure a safe environment, which of the following is the nurse's highest priority? 1. Assist other staff in restraining the client 2. Provide safety for the client and other clients on the unit 3. Provide comfort and consolation to other clients on the unit 4. Ask the client politely to calm down and regain control over his or her behavior | 2. Provide safety for the client and other clients on the unit Rationale: A psychotic client who is out of control may require seclusion to ensure the safety of the client and other clients in the unit. The correct option is the only one that addresses the safety needs of both the client and others. Options 1 and 3 do not provide for the client's safety needs or rights, respectively. In addition, specific policies and guidelines must be followed with regard to restraining a client. Option 4 may be ineffective and does not address the safety needs of others in the unit. |
| A client with Bell's palsy is scheduled for a magnetic resonance imaging (MRI). The nurse should implement which of the following standard orders to ensure a safe environment in preparation for this test? 1. Shave the groin area for insertion of a femoral catheter 2. Apply metal-tipped electrodes on the client's chest 3. Remove all objects containing metal from the client 4. Ensure that the client stays NPO for 24 hours before the test | 3. Remove all objects containing metal from the client Rationale: An MRI uses magnetic fields to produce a diagnostic image. All metal objects such as rings, bracelets, hairpins and watches should be removed. The client's history should also be reviewed to determine if the client has any internal metallic devices such as orthopedic hardware, pacemakers and shrapnel. A femoral catheter is not inserted. For an abdominal MRI, the client is usually NPO, but this is not necessary for an MRI of the head. In addition, an NPO status for 24 hours is unnecessary and may be harmful to the client. Metal-tipped electrodes are not used for this test. |
| A nurse assisting in the care of a client who has been in a coma for more than a year is told by the physician to stop the tube feeding that is providing sustenance to the client. The nurse, who is aware of the legal basis needed for carrying out the order, first determines whether which of the following requirements has been met? 1. Institutional Ethics Committee approval 2. A court order to discontinue the treatment 3. A written order by the physician to remove the tube 4. Authorization by the family to discontinue the treatment | 4. Authorization by the family to discontinue the treatment Rationale: The family or a legal guardian can make treatment decisions, generally in collaboration with physicians, other health care workers, and other trusted advisors. The nurse first checks for family authorization to discontinue the treatment. Next, option 3 would be appropriate. Although options 1 and 2 may be necessary in some events, these options are not the first actions in this event. |
| A nurse who is assisting a physician with insertion of a Miller-Abbott tube should do which of the following to ensure a safe environment and decrease the client's risk of aspiration? 1. Place the client in a high-Fowler's position 2. Assist with inserting the tube with the balloon inflated 3. Instruct the client to bear down if there is an urge to gag 4. Ask the client to cough when the tube reaches the nasopharynx | 1. Place the client in a high-Fowler's position Rationale: A miller-Abbott tube is a nasoenteric tube used to correct a bowel obstruction and decompress the intestine. A high-Fowler position decreases the risk of aspiration if vomiting occurs. A physician inserts the tube with the balloon deflated in a manner similar to that used with a nasogastric tube. The client usually sips water to facilitate passage of the tube through the correct nasopharynx and esophagus. Options 2, 3 and 4 are incorrect actions. |
| A nurse who is assisting in the care of a client with cancer is following medication orders to manage the cancer pain. Which of the following strategies should the nurse follow to ensure adequate and safe pain control? 1. Try multiple simultaneous medications for maximum pain relief effect 2. Rely entirely on prescription and over-the-counter medications for pain relief 3. Ensure that the client is kept at a low baseline pain level to avoid sedation or addiction 4. Start with low medication doses and gradually increase to a dose that relieves pain without exceeding the maximal daily dose | 4. Start with low medication doses and gradually increase to a dose that relieves pain without exceeding the maximal daily dose Rationale: The most appropriate approach is to begin with low doses and increase as needed to maintain a dose that relieves the pain. Option 2 ignores the benefits of other options that may relieve pain such as massage, therapeutic touch, or music. Keeping the client at a baseline level is inappropriate practice. Multiple medication interventions do not guarantee effectiveness and can also be unsafe. |
| A licensed practical nurse (LPN) is reinforcing instructions given by a registered nurse (RN) to a client about how to take medications after discharge from the hospital. The LPN should use which of the following approaches to best ensure safe administration of medication in the home? 1. Show the client the proper way to take prescribed medications 2. Tell the client to double up on medications if a dose has been missed 3. Count the number of pills remaining in the prescription bottle once a week 4. Allow the client to verbalize and demonstrate correct administration procedure | 4. Allow the client to verbalize and demonstrate correct administration procedure Rationale: The most effective method of teaching to ensure safe self-administration of medications in the home setting is to have the client verbalize and also demonstrate how to take medications. This ensures that the client has both the knowledge and the physical ability to comply with medication therapy. Option 1 is useful early in the teaching or learning process but is not the best method because it does not allow the client to demonstrate his or her own ability. Option 2 is incorrect because it is dangerous and incorrect statement. Option 3 is unrealistic and does not enhance self-care. |
| A client with thrombophlebitis is being treated with heparin sodium (Liquaemin) therapy. The registered nurse (RN) asks the licensed practical nurse (LPN) to check the medication supply to ensure that the antidote for this therapy is available. The nurse checks the medication supply for which medication? 1. Protamine sulfate 2. Streptokinase (Streptase) 3. Phytonadione (vitamin K) 4. Aminocaproic acid (Amicar) | 1. Protamine sulfate Rationale: Protamine sulfate is the antidote for heparin sodium. Streptokinase is a thrombolytic agent used to dissolve blood clots. Vitamin K is the antidote for warfarin (Coumadin). Amicar is an antifibrinolytic used to prevent the breakdown of clots already formed. |
| A nurse who is assisting in the care of a client with cardiomyopathy should give priority to which of the following to ensure client safety> 1. Administering vasodilator medications 2. Conducting a thorough pain assessment 3. Taking measures to prevent orthostatic changes when the client stands 4. Telling the client about the importance of avoiding over-the-counter medications | 3. Taking measures to prevent orthostatic changes when the client stands Rationale: Orthostatic changes can occur in the client with cardiomyopathy as a result of impaired venous return. These changes could lead to dizziness and client falls. Vasodilators should not be administered. There is no mention of pain in the question, and pain may not directly affect safety in this event. Option 4 is an accurate statement but is not directly related to the subject of the question. |
| A licensed practical nurse (LPN) is reinforcing teaching done by the registered nurse (RN) with a client who has been diagnosed with endocarditis. The LPN explains that it is important for this client to use an electric razor rather than a straight razor for shaving because of which of the following? 1. An electric razor can be sanitized more easily 2. Straight razors harbors too many microorganisms 3. The client is at a higher risk for infection from any nick or cut 4. Any cuts or skin injury should be avoided while taking anticoagulants | 4. Any cuts or skin injury should be avoided while taking anticoagulants Rationale: Clients with endocarditis are at risk for developing thrombi along the walls of the heart, which could become emboli leading to stroke. For this reason, clients with endocarditis are treated with anticoagulant therapy to prevent thrombus formation. Clients on anticoagulants should implement measures to prevent injury and subsequent bleeding, The other options are incorrect because infection rather than bleeding is their primary focus. |
| A licensed practical nurse (LPN) is assisting a registered nurse (RN) in caring for a client who just underwent cardiac catheterization using the femoral artery approach. The nurse should avoid taking which of the following actions in caring for this client because it is unsafe? 1. Resume prescribed medications 2. Have the client sit upright for a meal 3. Encourage the client to drink extra fluids 4. Ask the client to wiggle the toes when collecting data about neurovascular status | 2. Have the client sit upright for a meal Rationale: For 6 hours after cardiac catheterization using the femoral approach (or per physician's orders), the client should not bend or hyperextend the affected leg to avoid blood vessel occlusion or hemorrhage. This means that having the client sit upright would be contraindicated. The precatheterization medications are generally resumed after the procedure. Asking the client to wiggle the toes to determine neurovascular status is acceptable and should be done because vascular status could be impaired if a hematoma or thrombus were developing. Fluids should be increased to aid in eliminating the contrast medium through the kidneys. |
| A nurse is delivering a meal tray to a client with heart failure. The nurse should remove which item from the tray before bringing it to the client's bedside because the food item would be unsafe for the client to consume? 1. Sherbet 2. Green beans 3. Baked chicken 4. Saltine crackers | 4. Saltine crackers Rationale: Clients with heart failure should monitor and restrict sodium intake. Saltine crackers are high in sodium and should be avoided. Green beans and sherbet are low in sodium. Baked chicken would contain only physiological saline because it is an animal product and would not have to be avoided by the client. |
| An older client with diabetes mellitus is vomiting because of gastroenteritis. The nurse should do which of the following to maintain oral intake to safely minimize the risk of dehydration? 1. Give only sips of water until the client is able to tolerate solid foods 2. Withhold all food and fluids until vomiting has ceased for at least 8 hours 3. Restrict the client to clear liquids for at least 3 days to allow for bowel rest 4. Encourage the client to drink up to 8 to 12 ounces of fluid every hour while awake | 4. Encourage the client to drink up to 8 to 12 ounces of fluid every hour while awake Rationale: Small amounts of fluid may be tolerated even when vomiting is present. The client should be offered up to 8 to 12 ounces of liquid containing both glucose and electrolytes hourly. The diet should be advanced to a regular diet as soon as it is tolerated and should include a minimum of 100 to 150 g of carbohydrates daily. Options 1, 2 and 3 are incorrect actions because they will not maintain adequate oral intake. |
| A client who does not have an artificial airway has a new order for a sputum culture. The nurse should avoid doing which of the following to obtain a suitable specimen? 1. Obtaining the specimen early in the morning 2. Having the client take deep breaths before coughing 3. Asking the client to rinse the mouth before expectoration 4. Placing the culture container lid face down on the bedside table | 4. Placing the culture container lid face down on the bedside table Rationale: The lid would be contaminated if it is placed face down on the bedside table, which could lead to inaccurate test results. The client should rinse the mouth or brush the teeth before specimen collection to avoid contaminating the specimen. The client should take deep breaths before expectoration for the best sputum production. The specimen is optimally obtained early in the morning because sputum has a longer amount of time to collect in the airways during sleep. |
| A nurse is implementing measures to prevent the spread of infection to other clients. The nurse understands that which of the following is the best way to prevent the spread of infection? 1. Use proper hand washing techniques 2. Use sterile technique with all procedures 3. Never stop in the middle of performing a procedure 4. Read the policy and procedure manual before performing treatments | 1. Use proper hand washing techniques Rationale: Proper hand washing is the best way to prevent the spread of infection. All procedures do not require sterile technique. Reading the policy and procedure manual does not guarantee that infection will not be spread. It may be necessary in some events to stop in the middle of performing a procedure, but option 3 is not the best way to prevent the spread of infection. |
| A nurse is carrying out an order to obtain a sputum sample, which must be obtained using the saline inhalation method. The nurse guides the client in using the nebulizer safely and effectively by encouraging the client to do which of the following? 1. Hold the nebulizer under the nose 2. Keep the lips closed lightly over the mouthpiece 3. Keep the lips closed tightly over the mouthpiece 4. Alternate one vapor breath with one breath from room air | 2. Keep the lips closed lightly over the mouthpiece Rationale: Inhaling vaporized saline is an effective means to assist a client to cough productively because the vapor condenses on respiratory mucosa, stimulating the cough reflex and the expectoration of secretions. The nurse tells the client to hold gentle pressure between the lips and the mouthpiece. It is not necessary to form a tight seal. The client inhales vaporized saline with each breath until coughing results. The nebulizer is not held under the nose. |
| A client has a tracheostomy with a nondisposable inner cannula. After completing tracheostomy care, the nurse reinserts the inner cannula into the tracheostomy tube immediately after doing which of the following? 1. Suctioning the airway 2. Rinsing it in sterile water 3. Drying it with a sterile cotton ball 4. Tapping it dry lightly against a sterile surface | 4. Tapping it dry lightly against a sterile surface Rationale: The nurse reinserts the inner cannula immediately after tapping it dry against a sterile surface. Once inserted, it is turned clockwise to lock it into place. It should not be dried with a cotton ball, which could leave cotton particles on the cannula. The client's airway is suctioned before doing tracheostomy care. It is rinsed in sterile water before it is tapped. |
| A nurse is assisting in the care of a client with a nasogastric (NG) tube. The nurse understands that which of the following would be the most potentially hazardous method for checking tube placement when giving care to the client? 1. Measuring the pH of gastric aspirate 2. Submerging the NG tube in water to check for bubbling 3. Aspirating the NG tube with a 50 mL syringe for gastric contents 4. Instilling 10 to 20 mL of air into the NG tube while auscultating over the stomach | 2. Submerging the NG tube in water to check for bubbling Rationale: The most potentially hazardous method for checking NG tube placement is to submerge the end of the tube in water to observe for bubbling. This could put the client at risk for aspiration if the client breathed in fluid while the tube was in the lungs. Each of the other methods described is acceptable. The best method of determining tube placement is to verify by x-ray. |
| An older client who has not been hospitalized previously is extremely anxious after hospital admission. To provide a safe environment for the client and minimize the stress of hospitalization, the nurse should do which of the following? 1. Keep visitors to the minimum number possible 2. Keep the door open and room lights on at all times 3. Admit the client to a room far away from the nurse's station 4. Allow the client to have as many choices related to care as possible | 4. Allow the client to have as many choices related to care as possible Rationale: Several general interventions will reduce the hospitalized client's level of stress. These include acknowledging the client's feelings, offering information, providing social support, and letting the client have control over choices related to care. Options 1 and 3 could increase anxiety, whereas option 2 could add to the disruption created by the hospitalization and interfere with the client's sleep pattern. |
| A prenatal client who has acquired the sexually transmitted virus Condyloma acuminatum (human papilloma virus) asks the nurse to explain again the treatment for the infection. The nurse should reinforce additional information about which of the following safe treatments with this client? 1. Laser therapy 2. Interferon therapy 3. Cytotoxic medications 4. No therapy is available | 1. Laser therapy Rationale: For the pregnant client, laser therapy is the most effective method of destroying the virus. This therapy is localized, whereas medications (which are considered toxic to the fetus) would have a systemic effect. The primary neonatal effect of the virus is respiratory or laryngeal papillomatosis, although the exact route of perinatal transmission is unknown. Options 2, 3 and 4 are incorrect. |
| A nurse is assisting in the care of a client in labor who has a history of sickle cell anemia. Knowing that the client has a high risk for sickling crisis during labor, the nurse should give priority to implementing which safe nursing action to prevent a crisis from occurring? 1. Maintain strict hand washing technique 2. Give the client reassurance and encouragement 3. Ensure that the client uses oxygen during labor 4. Remind the client not to bear down for more than 3 seconds | 3. Ensure that the client uses oxygen during labor Rationale: Administering oxygen as needed is an effective intervention to prevent sickle cell crisis during labor. During the labor process the client is at high risk for being unable to meet the oxygen demands of labor and unable to prevent sickling. Option 1 is a safe nursing action, but it does nothing to prevent sickling crisis. Option 4 is not realistic and would not prevent sickling crisis. Option 2 is another generally helpful nursing measure but again is not related to prevention of sickling crisis. |
| A client who is admitted to the labor and delivery unit in active labor has active genital herpes lesions present in the genital tract. The licensed practical nurse should reinforce teaching done by the registered nurse about which of the following immediate plans for the client? 1. Placement on protective isolation 2. Preparation for a cesarean delivery 3. Preparation for spontaneous vaginal delivery 4. Imminent artificial rupture of the membranes | 2. Preparation for a cesarean delivery Rationale: Cesarean delivery reduces the risk of neonatal infection with a mother in labor who has either herpetic genital lesions or ruptured membranes. Options 3 and 4 would expose the fetus to the virus. Standard Precautions are necessary, not protective isolation. |
| A client with possible renal disease is scheduled to undergo diagnostic testing by intravenous pyelogram (IVP). To ensure client safety, the nurse should be certain to collect data from this client about a history of which of the following? 1. Allergy to shellfish 2. Family incidence of renal disease 3. Frequent and chronic antibiotic use 4. Long-term use of diuretic medications | 1. Allergy to shellfish Rationale: A client undergoing diagnostic testing that uses a contrast medium such as IVP should be questioned about allergy to shellfish, seafood, or iodine. This would identify a potential allergic reaction to the contrast dye that may be used in this test. The other items are useful as part of the general health history but are not as critical as the allergy determination. |
| A nurse is carrying out an order for a 24-hour urine collection for a client with a suspected renal disorder. Which of the following actions should the nurse avoid to ensure proper collection technique? 1. Refrigerate the container or place it on ice 2. Save all voidings after the first one in the 24-hour period 3. Ask the client to void at the end time, and add this specimen to the container 4. Ask the client to void at the start time, and place this specimen in the container | 4. Ask the client to void at the start time, and place this specimen in the container Rationale: To collect a 24-hour urine specimen, the nurse should ask the client to void at the beginning of the collection period and discard the urine sample. This is done because the urine in that voiding has been in the bladder for an unknown period of time. All subsequent voided urine is saved in a container, which is placed on ice or refrigerated. The nurse should ask the client to void at the finish time and add this sample to the collection. The nurse then labels the container, places it on fresh ice, and sends it to the laboratory immediately. |
| A licensed practical nurse (LPN) who is assisting a registered nurse (RN) in caring for a client in active labor should do which of the following to best prevent fetal heart rate decelerations? 1. Begin preparations for a cesarean delivery 2. Encourage upright or side-lying maternal position 3. Measure maternal and fetal vital signs every 30 minutes 4. Suggest asking the physician about the advisability of an oxytocin (Pitocin) drip | 2. Encourage upright or side-lying maternal position Rationale: Side-lying and upright positions such as walking, standing and squatting can improve venous return and encourage effective uterine activity, which in turn will reduce the likelihood of fetal heart rate decelerations. Cesarean delivery will not prevent decelerations. Measuring vital signs every 30 minutes will do nothing to prevent decelerations. Oxytocin could aggravate fetal heart rate decelerations because of increased uterine activity and decreased uteroplacental perfusion. |
| A nurse employed in a clinic is assisting in the care of a client with diabetes mellitus who is 36 weeks' pregnant. The results of three previous weekly nonstress tests have been reactive. This week the test was nonreactive after 40 minutes. The nurse should expect that the physician will prescribe which of the following to safely monitor this client? 1. A contraction stress test 2. Admission to the hospital for continuous fetal monitoring 3. Admission to the hospital for immediate induction of labor 4. A follow-up appointment in 3 days to repeat the nonstress test | 1. A contraction stress test Rationale: A nonreactive test requires further follow-up evaluation, indicating the need for a contraction stress test. To send the client home for 3 days could place the fetus in jeopardy. Hospitalizing the client for either induction of labor or continuous fetal monitoring would be a premature intervention without further diagnostic test data. |
| A nurse who begins to administer medications to a client via a nasogastric feeding tube suspects that the tube has become clogged. The nurse should take which safe action first? 1. Aspirate the tube 2. Flush the tube with warm water 3. Prepare to remove and replace the tube 4. Flush with a carbonated liquid such as cola | 1. Aspirate the tube Rationale: the nurse should first attempt to unclog the feeding tube by aspirating it. If this does not work, the nurse should try to flush the tube with warm water. Carbonated liquids such as cola may also be used, but only if agency policy identifies it as acceptable. Replacement of the tube is the last step if others are unsuccessful. |
| A client with depression who was admitted to the psychiatric unit the previous day suddenly begins smiling and stating that the current episode of depression has lifted. The client continues to be talkative and engages in conversation with other clients on the unit. The licensed practical nurse (LPN) consults with the registered nurse knowing that which of the following changes should be made to the client's treatment plan? 1. Allow increased "in room" activities 2. Increase the level of suicide precautions 3. Allow the client to spend time off the unit 4. Reduce the dosage of antidepressant medication | 2. Increase the level of suicide precautions Rationale: A depressed client hospitalized for only 1 day is unlikely to have a dramatic cure. A sudden elevation in mood probably indicates that the client has decided to harm himself or herself. An increase in the level of suicide precautions is indicated to keep the client safe. The other options are not indicated (option 1) or could place the client at increases risk (options 3 and 4). |
| A nurse who is assisting in the care of suicidal clients in a psychiatric nursing unit should plan to implement special precautions at which of the following times of increased risk? 1. Day shift 2. Weekdays 3. Shift change 4. 8 am to 2 pm | 3. Shift change Rationale: During the change of shifts, fewer staff members may be available to observe clients. The staff in a psychiatric nursing unit should increase precautions during shift change for clients identified as suicidal. Other times of increased risk for suicides are weekends (not weekdays), and the night shift (not day shift). |
| A nurse is assisting in the admission of a postoperative client from the postanesthesia care unit to the surgical nursing unit. The nurse should do which of the following for the safety of the client? 1. Ask the client to slide from the stretcher to the bed 2. Move the client rapidly from the stretcher to the bed 3. Put the bed rails up after moving the client from the stretcher 4. Uncover the client before transferring him or her from the stretcher to the bed | 3. Put the bed rails up after moving the client from the stretcher Rationale: Because the client may still be experiencing residual effects of anesthesia, the nurse should raise the side rails after transferring the client from the stretcher to the bed. It is not realistic to ask the client to slide from the stretcher to the bed because of the effects of anesthesia and postoperative pain. Hurried movements and rapid changes in position should be avoided since these predispose the client to hypotension. During the transfer of the client after surgery, the nurse should avoid exposing the client because of potential heat loss, respiratory infection and shock. |
| A nurse is caring for a child with a fever. The nurse implements which safe action when giving this child a tepid tub bath? 1. Add some alcohol to the bath water 2. Let the child soak in the tub for 10 minutes 3. Add cool water slowly to the warmer bath water 4. Warm the water to the same body temperature of the child | 3. Add cool water slowly to the warmer bath water Rationale: Cool water should be added to an already warm bath because this will cause the water temperature to slowly drop. The child will be able to gradually adjust to the changing water temperature and will not experience chilling. The child should be in a tepid tub bath for 20 - 30 minutes to achieve maximum results. To achieve the best cooling results for the child with a fever, the water temperature should be at least 2 degrees lower than the child's body temperature. |
| A nurse is assisting in the care of a child who underwent surgical repair of a cleft lip the previous day. The nurse should implement which safe nursing intervention when caring for the surgical incision? 1. Clean the incision only if serous exudate forms 2. Remove the Logan bar carefully to clean the incision 3. Rub the incision gently with a sterile cotton-tipped swab 4. Rinse the incision with sterile water after using diluted hydrogen peroxide | 4. Rinse the incision with sterile water after using diluted hydrogen peroxide Rationale: The incision should be rinsed with sterile water when it is cleaned with a solution other than water or saline. The Logan bar is intended to maintain integrity of the suture line; removing the Logan bar on the first postoperative day is incorrect because removal would increase tension on the surgical incision. The incision is cleaned after every feeding and when serous exudate forms. The incision should be dabbed and not rubbed to maintain its integrity. |
| A nurse is assigned to care for an older client who has been identified as a victim of physical abuse. In planning care for this client, the nurse's priority is focused toward: 1. Removing the client from any immediate danger 2. Adhering to the mandatory abuse reporting laws 3. Encouraging the client to file charges against the abuser 4. Referring the abusing family member for treatment | 1. Removing the client from any immediate danger Rationale: Whenever the abused client remains in the abusive environment, priority must be placed on determining whether the person is in any immediate danger. If so, emergency action must be taken to remove him or her from the abusing event. Options 2 and 4 may be appropriate but are not the priority. Option 3 is not an appropriate intervention at this time and may produce increased fear and anxiety in the client. |
| A nurse assists in developing a plan of care for a client who will be hospitalized for insertion of an internal cervical radiation implant. Which of the following will the nurse suggest to include in the client's plan of care? 1. Limit visiting time to 60 minutes per visit 2. Place the client in a private room near the nurse's station 3. Reinsert the implant into the vagina immediately if it becomes dislodged 4. Place a sign on the door of the client's room indicating the need to speak to the nurse before entering | 4. Place a sign on the door of the client's room indicating the need to speak to the nurse before entering Rationale: the client's room should be marked with appropriate signs stating the need to speak to the nurse before entering because of the risk of exposure to radiation when in the client's room. The client should be placed in a private room at the end of the hall because this location provides less chance of radiation exposure to others. A lead container and long handled forceps should be kept in the client's room at all times during internal radiation therapy. If the implant becomes dislodged, the nurse should be pick up the implant with long handled forceps and place it in the lead container. The nurse does not reinsert it. Visiting time is limited to 30 minutes per visit. |
| A nurse is observing a nursing assistant talking to a client who is hearing impaired. The nurse should intervene if which of the following were performed by the nursing assistant during communication with the client? 1. The nursing assistant is speaking in a normal tone 2. The nursing assistant is speaking clearly to the client 3. The nursing assistant is facing the client when speaking 4. The nursing assistant is speaking directly into the impaired ear | 4. The nursing assistant is speaking directly into the impaired ear Rationale: When communicating with a hearing impaired client, the nurse should speak in a normal tone to the client and should not shout. The nurse should talk directly to the client while facing the client and speak clearly. If the client does not seem to understand what is said, the nurse should express the statement differently. Moving closer to the client and toward the better ear may improve communication, but the nurse should avoid talking directly into the impaired ear. |
| Ultraviolet light (UVL) therapy is prescribed in the treatment plan for a client with psoriasis. The nurse reinforces instructions to the client regarding safety measures related to the therapy. Which statement made by the client indicates a need for further instructions? 1. "Each treatment will last 30 minutes." 2. "I will expose only the area requiring treatment." 3. "I should wear eye goggles during the treatment." 4. "I will cover my face with a loosely applied covering." | 1. "Each treatment will last 30 minutes." Rationale: Safety precautions are required during UVL therapy. Most UVL treatments require the person to stand in a light treatment chamber for up to 15 minutes. It is best to expose only those areas requiring treatment to the UVL. Placing protective wrap-around goggles prevents exposure of the eyes to the UVL. The face should shielded with a loosely applied cloth if it is unaffected. Direct contact with the light bulbs of the treatment unit should be avoided to prevent burning of the skin. |
| A nurse is assigned to care for a client who sustained a burn injury. The nurse reviews the physician's orders and should question the registered nurse about which order? 1. Monitor weight daily 2. Monitor urine output hourly 3. Maintain the nasogastric tube to intermittent suction 4. Administer morphine sulfate intramuscularly every 3 hours as needed for pain | 4. Administer morphine sulfate intramuscularly every 3 hours as needed for pain Rationale: Oral, subcutaneous and intramuscular routes for administering medications are contraindicated in the burned client because of the poor absorption factor. When fluid balance is stabilized, oral narcotic agents can be used. Options 1, 2 and 3 are all appropriate interventions for the client with a burn. |
| A nurse is caring for an older client who had a hip pinned after being fractured. In planning nursing care, the nurse should avoid which of the following to minimize the chance for further injury? 1. Leaving the side rails down 2. Keeping the call bell in reach 3. Answering the call bell promptly 4. Ensuring that the night-light is working | 1. Leaving the side rails down Rationale: Safe nursing actions intended to prevent injury to the client include keeping the side rails up, keeping the bed in low position, and providing a call bell that is within the client's reach. Responding promptly to the client's use of the call light minimizes the chance that the client will try to get up alone, which could result in a fall. Night-lights are built into the lighting systems of most facilities, and these bulbs should be routinely checked to ensure that they are working. |
| A nurse has reinforced instructions to a parent regarding the safe methods to prevent Lyme disease. Which statement made by a parent would indicate the need for additional instructions? 1. "We should wear hats when we go on our hiking trip." 2. "Wearing long-sleeved tops and long pants is important." 3. "We should wear closed shoes and socks that can be pulled over our pants." 4. "We should avoid the use of insect repellents because they will attract the ticks." | 4. "We should avoid insect repellents because they will attract the ticks." Rationale: To prevent Lyme disease, individuals should be instructed to use insect repellent on the skin and clothes in areas where ticks are likely to be found. Long-sleeved tops and long pants, closed shoes, and a hat or cap should be worn. If possible, heavily wooded areas or areas with thick underbrush should be avoided. Socks can be pulled up and over pant legs to prevent ticks from entering under clothing. |
| A client with paraplegia has a risk for injury related to spasticity of leg muscles. The nurse avoids which action that would be least helpful in dealing with this problem? 1. Using restraints to immobilize the limbs 2. Administering a PRN order for a muscle relaxant 3. Removing potentially harmful objects placed near the client 4. Performing range-of-motion exercises with the affected limb | 1. Using restraints to immobilize the limbs Rationale: Using limb restraints will not alleviate spasticity and could harm the client. Their use should be avoided. Use of muscle relaxants may be helpful if the spasms cause discomfort to the client or pose a risk to the client's safety. Removing potentially harmful objects is a good basic safety measure. Range-of-motion exercises are beneficial in stretching muscles, which may diminish spasticity. |
| A client is admitted to the hospital with severe hypoparathyroidism. The nurse should do which of the following activities to promote client safety? 1. Keep the room slightly cool 2. Institute seizure precautions 3. Keep the head of bed lowered 4. Use a waist restraint continuously | 2. Institute seizure precautions Rationale: Hypoparathyroidism results from insufficient parathyroid hormone, leading to low serum calcium levels. Hypocalcemia can cause tetany, which, if untreated can lead to seizures. The nurse should institute seizure precautions to maintain a safe environment. The other options do nothing to help this health problem or promote a safe environment for this client. |
| A nurse is assisting in preparing a plan of care for a client being admitted to the hospital for insertion of a cervical radiation implant. Which safe activity should the nurse suggest for this client following insertion of the implant? 1. Maintain bed rest 2. Out of bed in a chair only 3. Elevate the head of the bed 45 degrees 4. Maintain the client in the side lying position | 1. Maintain bed rest Rationale: The client with a cervical radiation implant should be maintained on bed rest in the dorsal position to prevent movement of the radiation source. The head of the bed is elevated to a maximum of 10 to 15 degrees for comfort. Turning the client on the side is avoided. If turning is absolutely necessary, a pillow is placed between the knees and, with the body in straight alignment the client is logrolled. |
| A nurse is assigned to care for a client who has returned to the nursing unit after an oral cholecystogram. At this point in time, the nurse should question which of the following physician's orders in the medical record? 1. Assess for nausea and vomiting 2. Monitor the client's hydration status 3. Maintain a clear liquid status for 72 hours 4. Monitor the client for abdominal discomfort | 3. Maintain a clear liquid status for 72 hours Rationale: The client should be able to resume the usual diet once the nurse assured is assured the client that the client's gastrointestinal (GI) function is normal. It is not necessary to keep the client on clear liquids for 72 hours after the procedure. The nurse would monitor the client for complaints of GI discomfort and nausea and vomiting. The nurse would also assess the client's hydration status as part of routine care for the client undergoing a GI diagnostic test. |
| A nurse employed in a physician's office is asked to check the client who is at low risk for contracting tuberculosis for the results of the purified derivative (PPD) implanted 72 hours previously. The nurse reads the PPD as measuring 11 mm induration in diameter. Which action should the nurse take next? 1. Notify the physician 2. Ask the client for permission to repeat the test 3. Document the normal finding in the client's record 4. Tell the client to make an appointment with a pulmonologist | 1. Notify the physician Rationale: An area of induration that measures 10 mm is considered a positive reading and indicates exposure to tuberculosis (TB). The nurse who observes a positive PPD reading notifies the physician immediately. The physician would then order a chest x-ray to determine whether the client has clinically active tuberculosis or old, healed lesions. A sputum culture would then be done to confirm a diagnosis of active TB. Option 3 is incorrect because the reading is not a normal finding. Option 2 is incorrect because the test results are positive. The physician, not a nurse would request a consultation with a pulmonologist. |
| A nurse reinforces information about the disease and recuperation to the client diagnosed with tuberculosis. The nurse determines that the client understands the information presented if the client states that it is possible to return to work when: 1. Five sputum cultures are negative 2. Three sputum cultures are negative 3. The PPD and chest x-ray are negative 4. A sputum culture and a PPD test are negative | 2. Three sputum cultures are negative Rationale: The client must have sputum cultures performed every 2 to 4 weeks after antituberculosis medication therapy. The client may return to work when the results of three sputum cultures are negative because the client is considered noninfectious at that point. One negative sputum culture is not sufficient, and five negative cultures are unnecessary. |
| A registered nurse (RN) tells a licensed practical nurse (LPN) that a client who is suspected of having tuberculosis (TB) is being admitted to the hospital and asks the LPN to prepare a room for the client. The LPN prepares the room, knowing that this client's room needs to provide which of the following? 1. Venting to the roof and ultraviolet light 2. Ultraviolet light and three room air exchanges per hour 3. Ten room air exchanges per hour and venting to the roof 4. Venting to the outside, six room air exchanges per hour, and ultraviolet light | 4. Venting to the outside, six room air exchanges per hour, and ultraviolet light Rationale: The client with tuberculosis must be admitted to a private room that provides at least six air exchanges per hour. The room should provide venting to the outside and have ultraviolet lights installed. Options 1, 2 and 3 are inaccurate and would not provide adequate protection to help prevent transmission of the infection. |
| A nurse is planning to give a subcutaneous injection of insulin. The nurse plans to do which of the following immediately after giving the injection? 1. Break the needle 2. Recap the needle 3. Place the needle and syringe in a labeled cardboard box 4. Place the needle and syringe in a labeled, rigid plastic container | 4. Place the needle and syringe in a labeled, rigid plastic container Rationale: Standard precautions include specific guidelines for handling of sharps. Needles should not be recapped, bent, broken, or cut after use. They should be disposed of in a labeled, impermeable container that is specifically used for this purpose. Needles should not be discarded in cardboard boxes because they could puncture the cardboard, causing needlestick injury. Needles should always be properly discarded after use. |
| A licensed practical nurse (LPN) is asked to prepare a room for a child who will be admitted to the pediatric unit with a diagnosis of tonic-colonic seizures. The LPN prepares the room and plans to place which of the following items at the bedside? 1. Suction apparatus and oxygen 2. A tracheotomy set and oxygen 3. An endotracheal tube and an airway 4. An emergency cart and padded side rails | 1. Suction apparatus and oxygen Rationale: Tonic-clonic seizures cause tightening of all body muscles followed by tremors. An obstructed airway and increased oral secretions are the major complications during and after a seizure. Suction apparatus, oxygen and an airway are helpful to prevent choking and cyanosis. Options 2, 3 and 4 are incorrect. Inserting a tracheostomy or endotracheal tube is not done. It is not necessary to have an emergency cart at the bedside, but a cart should be available in the treatment room or in the nursing unit. |
| An extremely angry and aggressive client in the mental health inpatient unit has been placed in restraints. When working with this client, the nurse should suggest removal of the restraints when the client: 1. Has been sedated and is still experiencing its effects 2. Divulges all of the reasons for the aggressive behavior 3. Apologizes and tells the nurse that it will not happen again 4. Initiates no aggressive acts for an hour after the release of two leg restraints | 4. Initiates no aggressive acts for an hour after the release of two leg restraints Rationale: The best indicator that the client's behavior is under control is when the client refrains from aggression after being partially releases from the restraints. Restraints are initially placed around the waist, wrists, and ankles. The ankle restraints are removed first, one at a time, at regular intervals. The wrist and waist restraints are removed together when the client continues to exhibit nonaggressive behavior. |
| A client who has been admitted to the mental health unit with obsessive compulsive disorder repeatedly cleans the bathroom fixtures. The client has become enraged and has started to bite and kick the roommate for occupying the bathroom. Which of the following actions should the nurse take first? 1. Physically restrain the client 2. Notify the risk management department 3. Provide a safe environment for both clients 4. Administer a medication to provide chemical restraint | 3. Provide a safe environment for both clients Rationale: The first action of the nurse is to provide an environment that is safe for both clients. This may take a variety of forms, depending on the individual circumstance, agency protocols, and written physician orders. Seclusion, chemical restraint, and physical restraint are used only when alternative and less restrictive measures are not effective in controlling the client's behavior. |
| A physician orders a 12-lead electrocardiogram (CG) to be performed on a client. The client is concerned about the safety of the test, and the nurse provides information to the client. Which of the following would indicate that the client understands the test? 1. "I cannot breathe while the ECG is running." 2. I should lie still while the ECG is being done." 3. When the ECG begins, I must take a deep breath." 4. If I move when the ECG begins I will be shocked." | 2. "I should lie still while the ECG is being done." Rationale: good contact between the skin and electrodes is necessary to obtain a clear 12-lead ECG printout. Therefore the electrodes are placed on the flat surfaces of the skin just above the ankles and wrists. Movement may cause a disruption in that contact and artifact, which makes the ECG printout difficult to read. The client does not have to hold the breath or take a deep breath during the procedure. The client should be reassured that the procedure will not produce a shock. |
| A nurse is assisting in planning the discharge of a client with chronic anxiety and assists in selecting the goals that will promote a safe environment at home. The appropriate maintenance goal should focus on which of the following? 1. Ignoring feelings of anxiety 2. Identifying anxiety-producing events 3. Continuing contact with a crisis counselor 4. Eliminating all anxiety from daily events | 2. Identifying anxiety-producing events Rationale: Recognizing events that produce anxiety allows the client to prepare to cope with anxiety or avoid a specific stimulus. Counselors will not be available for all anxiety-producing events, and this option does not encourage the development of internal strengths. Ignoring feelings will not resolve anxiety. It is impossible to eliminate all anxiety from daily activities. |
| A nurse is planning to reinforce instructions to a client with chronic vertigo about safety measures to prevent worsening of symptoms or injury. Which safety instruction should the nurse provide to the client? 1. Turn the head slowly when spoken to 2. Remove throw rugs and clutter in the home 3. Drive at times when the client does not feel dizzy 4. Go to the bedroom and lie down when vertigo is experienced | 2. Remove throw rugs and clutter in the home Rationale: The client with chronic vertigo should avoid driving and using public transportation. The sudden movements involved in each could precipitate an attack. To further prevent vertigo attacks, the client should change position slowly and should turn the entire body, not just the head, when spoken to. If vertigo does occur, the client should immediately sit down or grasp the nearest piece of stable furniture. The client should maintain a clutter-free home with throw rugs removed because the effort of regaining balance after slipping could trigger vertigo. |
| A nurse is assigned to care for a client with Parkinson's disease who has recently begun taking L-dopa (levodopa). Which of the following is most important to check before ambulating the client? 1. The client's history of falls 2. Assistive devices used by the client 3. The client's postural (orthostatic) vital signs 4. The degree of intention tremors exhibited by the client | 3. The client's postural (orthostatic) vital signs Rationale: Clients with Parkinson's disease are at risk for postural (orthostatic) hypotension from the disease. This problem worsens when L-dopa is introduced because the medication can also cause postural hypotension, thus increasing the client's risk for falls. Although knowledge of the client's use of assistive devices and history of falls is helpful, it is not the most important piece of data based on the information in this question. Clients with Parkinson's disease generally have resting rather then intention tremors. |
| A nurse is giving a bed bath to a client who is on strict bed rest. To safely increase venous return, the nurse bathes the client's extremities by using: 1. Long, firm strokes from distal to proximal areas 2. Short, patting strokes from distal to proximal areas 3. Firm, circular strokes from proximal to distal areas 4. Smooth, light strokes back and forth from proximal to distal areas | 1. Long, firm strokes in the direction of venous flow promote venous return when the extremities are bathed. Circular strokes are used on the face. Short, patting strokes and light strokes are not as comfortable for the client and do not promote venous return. |
| A nurse is preparing to give an intramuscular (IM) injection that is irritating to the subcutaneous tissues. The drug reference recomends that it be given using the Z-track technique. Which of the following procedural steps would cause tracking the medication through the subcutaneous tissues? 1. Massaging the site after injecting the medication 2. Retracting the skin to the side before piercing the skin with the needle 3. Attaching a new sterile needle to the syringe after drawing up the medication 4. Preparing a 02.mL air lock in the syringe after drawing up the medication | 1. Massaging the site after injecting the medication Rationale: The Z-track variation of the standard IM technique is use to administer IM medications that are highly irritating to subcutaneous and skin tissues. Attaching a new sterile needle is done so that the new needle will not have any medication adhering to the outside that could be irritating to the tissues. Preparing an air lock keeps the needle clean of medication on insertion and, as the air is injected behind the medication, will provide a seal at the point of insertion to prevent tracking through the subcutaneous tissues. The site should not be massaged because this can lead to tissue irritation. |
| A nurse is preparing to transfer an average-sized client with right-sided hemiplegia from the bed to the wheelchair. The client is able to support weight on the unaffected side and the nurse plans to use the hemiplegic transfer technique. The client is sitting upright in bed with the legs dangling over the side. For the safest transfer, where should the wheelchair be positioned? 1. Next to either leg 2. Near the client's left leg 3. Near the client's right leg 4. As space in the room permits | 2. Near the client's left leg Rationale: Although space in the room is an important consideration for placement of the wheelchair for a transfer, when the client has an affected lower extremity, movement should always occur toward the client's unaffected (strong) side. For example, if the client's right leg is affected and the client is sitting on the edge of the bed, the wheelchair is positioned next to the client's left side. This wheelchair position allows the client to use the unaffected leg effectively and safely. |
| A nurse is preparing to suction a client's tracheostomy. To ideally promote deep breathing and coughing, in which position should the client be safely placed? 1. Supine 2. Lateral position 3. High-Fowler's position 4. Semi-Fowler's position | 4. Semi-Fowler's position Rationale: If it is not contraindicated, before suctioning a tracheostomy, the client is placed in semi-Fowler's position to promote deep breathing, maximum lung expansion, and productive coughing. With the client in this position, gravity pulls downward on the diaghram, which allows greater chest expansion and lung volume. Options 1 and 2 would not provide maximum lung expansion. The high-Fowler's position would not allow for easy visualization of the tracheostomy or easy access of the suction catheter. |
| The pregnant client is at full term. The fetal heart rate (FHR) is being monitored for a baseline rate. The nurse is satisfied with the results and tells the client that the baby is safe and that the baby's heart rate is within normal limits. The nurse bases this interpretation on which of the following data? 1. FHR of 80 beats per minute 2. FHR of 90 beats per minute 3. FHR of 140 beats per minute 4. FHR of 170 beats per minute | 3. FHR of 140 beats per minute Rationale: The average FHR is 140 beats per minute. The normal range is 110 to 160 beats per minute; therefore option 3 is the only correct option. |
| A nurse is caring for a client who is dying and is a potential organ donor. The nurse reviews the client's medical record and identifies a contraindication to organ donation if which of the following were documented in the client's record? 1. Age of 38 years 2. Hepatitis B infection 3. Allergy to penicillin type antibiotics 4. Negative rapid plasma reagin (RPR) laboratory result | 2. Hepatitis B infection Rationale: A potential organ donor must meet age eligibility requirements, which vary by organ. For example, age must not exceed 65 (kidney donation), 55 (pancreas and liver), or 40 (heart) years old. The client should be free of communicable disease such as human immunodeficiency virus or hepatitis, and the involved organ may not be diseased. Another contraindication to transplant is malignancy, with the exception of noninvolved skin and cornea. |
| A nurse is assigned to care for a client with cervical cancer who has an internal radiation implant. Which of the following required items should the nurse ensure is kept in the client's room during this treatment? 1. A lead shield 2. A bedside commode 3. A no. 16 Foley catheter 4. Long-handled forceps and a lead container | 4. Long-handled forceps and a lead container Rationale: In the case of dislodgement of an internal radiation implant, the radioactive source is never touched with the bare hands. It is retrieved with long-handled forceps and placed in the lead container kept in the client's room. In many situations the client has a Foley catheter inserted and is on bed rest during treatment to prevent dislodgement. Although a lead shield may be in the room, it is not the required item. Nurses wear a dosimeter badge while in the client's room to measure the exposure to radiation. |
| A client who suffered a severe head injury has had vigorous treatment to control cerebral edema. Brain death has now been determined. The nurse assigned to assist in caring for the client prepares to carry out which of the following orders that will maintain viability of the kidneys before organ donation? 1. Checking respirations 2. Monitoring temperature 3. Frequent range of motion to extremities 4. Administration of intravenous (IV) fluids | 4. Administration of intravenous (IV) fluids Rationale: Perfusion to the kidney is affected by blood pressure, which is in turn affected by blood vessel tone and fluid volume. Therefore the client who was previously dehydrated to control intracranial pressure is now in need of rehydration to maintain perfusion to the kidneys. The nurse prepares to infuse IV fluids as ordered and to continue monitoring urine output. Checking respirations and temperature and frequent range of motion to extremities will not maintain viability of the kidneys. |
| A nurse is assisting in the emergency room of a small local hospital when a client with multiple gunshot wounds arrives by ambulance. The nurse is asked to care for the client's personal belongings, which may be needed as legal evidence. Which of the following actions by the nurse is contraindicated in the proper handling of legal evidence? 1. Giving the clothing and wallet to the family 2. Cutting clothing along seams, avoiding bullet holes 3. Placing personal belongings in a labeled sealed paper bag 4. Initiating a log (custody log) that provides tracking and handling items needed for evidence | 1. Giving the clothing and wallet to the family Rationale: Basic rules for handling evidence include limiting the number of people with access to the evidence, initiating a chain of custody log to track handling and movement of evidence, and carefully removing clothing to avoid destroying evidence. This usually includes cutting clothes along seams, avoiding areas where there are obvious holes or tears. Potential evidence is never released to the family to take home. |
| A nurse working on a medical nursing unit during an external disaster is called to assist with the care of clients coming into the emergency room and is asked to assist the triage nurse. Using principles of prioritizing, the nurse initiates care for a client with which of the following injuries first? 1. Fractured tibia 2. Penetrating abdominal injury 3. Bright red bleeding from a neck wound 4. Open severe head injury in a deep coma | 3. Bright red bleeding from a neck wound Rationale: The client with arterial bleeding from a neck wound is in immediate need of treatment to save the client's life. According to the triage process, the client in this classification would be issued a red tag. The client with the penetrating abdominal injury would be tagged yellow and classified as "delayed," requiring intervention within 30 to 60 minutes. A green or "minimal" designation would be given to the client with a fractured tibia; this client requires intervention but can provide self care if needed. A designation of "expectant" and color code "black" would be applied to the client with massive injuries and a minimal chance of survival. These clients are given definitive treatment last. |
| A nurse is orienting a nursing assistant to the clinical nursing unit. The nurse should intervene if the nursing assistant did which of the following during a routine hand washing procedure? 1. Kept the hands lower than the elbows 2. Washed continuously for 10 to 15 seconds 3. Use 2 to 5 mL of soap from the dispenser 4. Dried the hands from the forearm down to the fingers | 4. Dried the hands from the forearm down to the fingers Rationale: Proper hand washing procedure involves wetting the hands and wrists and keeping the hands lower than the forearms so water flows toward the fingertips. The nurse uses 3 to 5 mL of soap and scrubs for 10 to 15 seconds using a rubbing and circular motion. The hands are rinsed and then dried, moving from the fingers to the forearms. The paper towel is then discarded, and a second one is used to turn off the faucet to avoid hand contamination. |
| A client who is immunosuppressed is being admitted to the hospital on neutropenic precautions. The nurse assigned to care for the client plans to ensure that which of the following does not occur in the care of the client? 1. Admitting the client to a semiprivate room 2. Placing a mask on the client if the client leaves the room 3. Removing a vase with fresh flowers left by a previous client 4. Placing a "See the Nurse before Entering" sign on the door to the room | 1. Admitting the client to a semiprivate room Rationale: The client who is on neutropenic precautions is immunosuppressed and therefore is admitted to a single room on the nursing unit. A sign indicating "See the Nurse before Entering" should be placed on the door to the client's room so that the nurse can ensure that neutropenic precautions are implemented by anyone entering the room. Sources of standing water and fresh flowers should be removed to decrease the microorganism count. The client should wear a mask for protection from exposure to microorganisms whenever he or she leaves the room. |
| A client who received a dose of chemotherapy 12 hours ago is incontinent of urine while in bed. The nurse safely wears which of the following when cleaning the client? 1. Mask and gloves 2. Gown and gloves 3. Mask, gown and gloves 4. Gown, gloves and eyewear | 2. Gown and gloves Rationale: The client who has received chemotherapy will have antineoplastic agents or their metabolites in body fluids and excreta for 48 hours. For this reason, the nurse should wear protection for likely sources of contamination. In this instance, the nurse should wear gloves and a gown to protect the hands and uniform from contamination. |
| A clinic nurse is providing instructions to a mother of a child who was diagnosed with mumps. The mother is concerned about her other children and asks the nurse how the infection is transmitted. The nurse informs the mother that mumps is transmitted by: 1. Fecal oral route 2. Airborne droplets 3. Contact with tears 4. Contact with body sweat | 2. Airborne droplets Rationale: Mumps id transmitted via airborne droplets, salivary secretions, and possibly the urine. Options 1, 3 and 4 are incorrect. |
| A nurse is assisting in preparing a client scheduled for a bone marrow aspiration. The client asks the nurse if the procedure will be painful. To provide the client with accurate information, the nurse should incorporate which of the following in a response to the client? 1. There is no pain from the procedure at all 2. The procedure is painful, but the client will be under anesthesia 3. A local anesthetic is used, but there is some pain during aspiration 4. The procedure is very painful, but the client will be heavily medicated beforehand | 3. A local anesthetic is used, but there is some pain during aspiration Rationale: A local anesthetic is used to anesthetize the skin and subcutaneous tissue to minimize tissue discomfort with needle insertion. The client will feel some pain briefly when the sample is aspirated out of the marrow. Options 1, 2 and 4 are not true statements. |
| A nurse is preparing to assist a client from the bed to chair using a hydraulic lift. The nurse should do which of the following to move the client safely with this device? 1. Position the client in the center of the sling 2. Have three staff members available to assist 3. Lower the client rapidly once positioned over the chair 4. Have the client grasp the chains attaching the cling to the lift | 1. Position the client in the center of the sling Rationale: One person may operate a hydraulic lift. The client is positioned in the center of the sling, which is then attached to chains or straps that connect the sling to the lift. The client is raised from the bed into a sitting position. The lift raises the client off the mattress and lowers the client slowly once the sling is positioned over the chair. |
| An older client in a long-term care facility is at risk for injury because of confusion. Because the client's gait is stable, which method of restraint, if prescribed, would be best used by the nurse to prevent injury to the client? 1. Vest restraint 2. Waist restraint 3. Alarm-activating bracelet 4. Chair with a locking lap-tray | 3. Alarm-activating bracelet Rationale: If the client is confused and has a stable gait, the least intrusive method of restraint is the use of an alarm-activating bracelet, or "wandering bracelet." This allows the client to move about the residence freely while preventing him or her from leaving the premises. A vest or waist restraint or a chair with a locking lap tray is more intrusive than an alarm-activating bracelet. |
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