Everything Flashcards by BinWen Tang (2024)

A client is prescribed bed rest by the physician after surgery. The nurse that takes care of the patient always avoids putting pressure on the back of the client’s knees. This is done in order to prevent which complication?

A. Cerebral embolism

B. Pulmonary embolism

C. Limb gangrene

D. Coronary vessel occlusion

B. Pulmonary embolism

Once a thrombus is dislodged and travels through the circulatory system, the pulmonary capillary beds are the first small vessels that the embolus will encounter, resulting in pulmonary embolism.

A client is about to go for a CT angiogram, which involves the administration of an intravenous radiopaque dye. In preparing the client for the procedure, the nurse’s responsibility is to educate him by saying:

A. “You should expect some chest tightness during the procedure.”

B. “You should expect a burning sensation at the intravenous site.”

C. “You will likely experience flushing of the face.”

D. “An allergic reaction may cause a decline in your kidney function.”

C. “You will likely experience flushing of the face.”

Flushing of the face is an expected response to the intravenous administration of contrast dye (Iodine). Most patients experience a warm sensation throughout the body shortly after contrast dye infusion. This is more pronounced in the face and throat and moves to the pelvic area after that.

A: Chest tightness may be experienced during a moderate to severe hypersensitivity reaction and is not an expected response.

B: Burning at the intravenous site is not a usual expected response with the use of IV contrast dye.

C: Iodine contrast is toxic to the kidneys, and directly harmful, not an allergy.

A 30-year old female on a cardiac unit states to the nurse, “I’m just not sure my incision is ever going to look right. I don’t want to look like a freak.” What should the nurse say to comfort her?

A. “It will heal fine.”

B. “Why are you worrying?”

C. “What do you think you will look like?”

D. “Tell me more.”

C. “What do you think you will look like?”

This encourages the patient to explain what they think they will look like, which in turn leads to open conversation.

Not A or B

I picked D, but it does not acknowledge the patient’s feelings of disfigurement but only tells the patient to keep talking.

You are caring for a newly admitted obese patient in the ICU. The patient has a history of smoking. She states that her symptoms started early in life and are worse at night. She denies any history of recent fever or chills. You notice wheezing and stridor upon assessment. You expect the diagnosis for this patient will be:

A. Asthma

B. Bronchiectasis

C. Congestive heart failure (CHF)

D. Chronic obstructive pulmonary disease (COPD)

A. Asthma

Asthma typically begins in early life, whereas symptoms of CHF and COPD usually develop later in life.

Asthma symptoms tend to come and go with symptoms being worse at night. There is often a family history of asthma, and it usually occurs in obese patients.

Bronchiectasis typically presents with signs and symptoms of a recent infection, including large amounts of bronchial secretions. (Option B)

Your client is expressing feelings of dread and impending danger. As you allow the client to freely express these feelings, you attempt to determine the cause of these feelings but are unable to identify the source. What is the most likely nursing diagnosis for this client?

A. Fear related to an unidentifiable source

B. Anxiety related to an unidentifiable source

C. Ineffective coping related to a source that is not based on reality

D. Maladaptive coping related to a source that is based on reality

B. Anxiety related to an unidentifiable source

The most likely nursing diagnosis for this client is “anxiety related to an unidentifiable source”. Unlike fear, anxiety can result from an unidentifiable source as well as one that is identifiable. Fear is related to an identifiable source.

Battery is the intentional touching of a person that is legally defined as unacceptable or occurs without the person’s consent. Many routine actions that are permissible when proper consent is obtained would otherwise be considered medical battery. Furthermore, actions can be considered battery even if no physical injury results.

Ex:
Administering morphine when the nurse tells the client that it’s NS
Inserts a urinary catheter even though a client refuses it

The nurse receives report on 4 clients. Which client should the nurse assess first?

1. Client with end stage renal disease receiving hemodialysis who reports fever with chills and nausea
2. Client taking ibuprofen for ankylosing spondylitis who reports black colored stools
3. Client with altered mental status who is not following commands starts vomiting
4. Client with acute diverticulitis receiving antibiotics who reports increasing abdominal pain

3. Client with altered mental status who is not following commands starts vomiting

This client with altered mental status and not following commands is at risk for aspiration and airway compromise from vomiting. This client should be assessed first; the client needs to be placed in the lateral position with head elevated and may need emergent intubation if airway cannot be protected.

The nurse receives reports on 4 clients, which one should the nurse see first?

1. Client with cellulitis of the right foot, medicated with hydromorphone IV 1 hr ago, reports pain 6/10
2. Client with chronic kiney disease with hgb of 8 and hematocrit of 24% reports s.o.b with activity
3. Client with HF exacerbation and a large pleural effusion with sodium of 132 reports headache
4. Client w/ pneumonia and asthma just relieved nebulized albuterol, now appears to be resting after a sudden decrease in wheezing.

4. Client w/ pneumonia and asthma just relieved nebulized albuterol, now appears to be resting after a sudden decrease in wheezing.

The client with pneumonia and asthma is at risk for problems related to airway management and should be assessed first. Clients with symptomatic asthma will receive inhaled beta agonists (eg, albuterol); however, even after medication, it is a priority to assess this client’s lung sounds, work of breathing, and level of consciousness to determine respiratory status.

A sudden decrease in wheezing may signal the development of silent chest, where airflow is rapidly reduced due to increased bronchial constriction. This scenario can quickly progress to status asthmaticus, respiratory failure, unconsciousness, and death.

Unresolved pain can be checked later (Option 1)
S.o.b after activity is common with anemia (Option 2)
Dilutional hyponatremia < 135 is expected in HF, but a borderline value of 132 does not require immediate attention. (Option 3)

After making initial rounds on all the assigned clients by 8:00 AM, which client should the nurse care for first?

1. Post op client medicated w/ tramadol 50 mg 1.5 hrs ago
2. Post op client w/ pink colored urine after transurethral resection of the prostate (TURP)
3. Client scheduled for discharge today who needs instruction on how to change a sterile dressing
4. Client with adenocarcinoma scheduled for a lobectomy at 9:00 AM was restless and awake all night.

4. Client with adenocarcinoma scheduled for a lobectomy at 9:00 AM was restless and awake all night.

The nurse should care for the client with adenocarcinoma scheduled for a lobectomy at 9:00 AM first. Not being able to sleep the night before surgery is a common manifestation of anxiety and fear; these emotions can negatively affect recovery.

For this reason, it is important to identify and listen to the client’s concerns (eg, diagnosis of cancer, fear of death, pain, anesthesia), teach the client about what to expect following surgery (eg, pain control, tubes, intensive care environment), and provide emotional support to help alleviate the fear and anxiety. The nurse can provide for the physical preparation of the client and complete the preoperative checklist as well.

A client is being discharged with plans to return home alone. The client cannot get up from a chair without help and is very unsteady when standing, even with a walker. The nurse expresses concern, but the primary health care provider is adamant that the client be discharged today. Which team member would be most appropriate to assist the nurse in advocating for this client?

1. Clinical psychologist
2. Occupational therapist
3. Physical therapist
4. Social worker

4. Social worker

The case manager and social worker on the interdisciplinary team have expertise in discharge planning and health care finance. They can assess the adequacy of the discharge setting and support systems, arrange for resources at home, or discharge to an alternate setting, such as a rehabilitation facility. They can also help advocate for safe, effective discharge planning.

The charge nurse on the orthopedic unit has 4 semiprivate room beds available. Which room should the nurse assign to a client being transferred from the post anesthesia recovery unit following a total knee replacement?

1. Client w/ skeletal traction following a fracture of the femur, who has eythema at the pin sites
2. Client w/ cellulitis and osteomyelitis following blunt trauma of the tibia
3. Client with compartment syndrome, 1 day post fasciotomy
4. Client with long leg cast following open reduction of a fractured tibia

A client who is postoperative total knee replacement is at risk for infection. No postoperative client should be assigned to a room with a client who has an actual infection or the potential for infection.

This client should be assigned to room 4 as the client with the cast has the lowest potential risk for infection (Option 4).

(Option 1) This client has erythema at the pin sites; this can be a sign of infection, a complication of skeletal traction.

(Option 2) This client has cellulitis, a bacterial infection of the skin, and osteomyelitis, an infection of the bone.

(Option 3) This client has a fasciotomy wound, which is usually kept open for several days to relieve the pressure in the myofascial compartment. This client is a potential source of infection and is susceptible to infection as well.

Which client event would be considered an adverse event and would require completion of an incident/event/irregular occurrence/variance report? Select all that apply.

1. Admin a 9:00 AM med at 9:30 AM
2. Developed worsening cellulitis after missing antibiotics for 1 day
3. Has a seizure and a hx of epilepsy
4. Slides off the edge of the bed and ends up sitting on the floor
5. Waits 4 hours to be transported for STAT diagnostic CT scan

Answer: 2, 4, 5

Option 2 is a failure to provide appropriate treatment and has a direct correlation for worsening cellulitis.

Option 4 is a fall, although the mechanism probably results in a lesser chance of serious injury. The risk fall assessment should be adjusted.

Option 5 is an avoidable delay in application of a test, which will affect timely diagnosis. The nurse should advocate for a more timely completion of the test.

An 84-year-old client with oxygen-dependent chronic obstructive pulmonary disease is admitted with an exacerbation and steady weight loss. The client has been in the hospital 4 times over the last several months and is “tired of being poked and prodded.” Which topic would be most important for the nurse to discuss with this client’s health care team?

1. Need for discharge to a skilled nursing facility
2. Nutritional consult with instructions on a high-calorie diet
3. Option of palliative care
4. Physical therapy prescription to promote activity

3. Option of palliative care

This client with advanced chronic obstructive pulmonary disease is approaching the end of life. The client has expressed the desire to avoid further tests, treatments, and hospitalizations. The goals of care should be consistent with the client’s wishes and emphasize comfort and quality of life.

Therefore, palliative care is most important who wish to focus on quality of life instead of prolonging life. (Option 3)

An 84-year-old client with oxygen-dependent chronic obstructive pulmonary disease is admitted with an exacerbation and steady weight loss. The client has been in the hospital 4 times over the last several months and is “tired of being poked and prodded.” Which topic would be most important for the nurse to discuss with this client’s health care team?

1. Need for discharge to a skilled nursing facility
2. Nutritional consult with instructions on a high-calorie diet
3. Option of palliative care
4. Physical therapy prescription to promote activity

3. Option of palliative care

This client with advanced chronic obstructive pulmonary disease is approaching the end of life. The client has expressed the desire to avoid further tests, treatments, and hospitalizations. The goals of care should be consistent with the client’s wishes and emphasize comfort and quality of life.

A Critical pathway documentation system

Case management refers to the process of organizing the patient care throughout an episode of illness so that certain clinical and financial outcomes are achieved within an assigned time frame.

Case management uses a critical pathway documentation system as a form of patient care delivery and documentation.

Critical pathways are time-oriented multidisciplinary plans of care that are established and approved by the interdisciplinary team.

The nurse manager is completing an annual performance apprasial/evaluation on a staff nurse. Which elements should the nurse manager include when completing the evaluation? Select all that apply.

A. The nurses’ bar-code medication administration scan rate

B. The number of times the nurse has been absent or tardy

C. The nurse achieving a national certification

D. The nurses’ performance compared to other staff nurses

E. The number of medication errors the nurse has self-reported.

Answer: A, B, C

The performance appraisal/evaluation goal is to provide a broad review of the employee’s performance with minimal evaluator bias. The more objective the evaluation, the less the bias.

Objective metrics such as bar-code medication administration rate, attendance, and national certifications are logical elements to include in the appraisal.

The nurse notes that the physician has entered a do not resuscitate [DNR] order. However, there is no advanced directive by the patient present on the patient’s chart. Which is the appropriate nursing action?

A. Notify the physician about the need for a living will to validate this order.

B. Verify that the physician consulted with the patient and/or family.

C. Accept the order as written, no other documentation is needed.

D. Notify the nurse supervisor and risk management about the DNR order.

B. Verify that the physician consulted with the patient and/or family.

For a DNR, an advanced directive is not required. Neither is a living will.

So the best action would be to verify with the physician they have consulted with the family before

The nurse notes that the physician has entered a do not resuscitate [DNR] order. However, there is no advanced directive by the patient present on the patient’s chart. Which is the appropriate nursing action?

A. Notify the physician about the need for a living will to validate this order.

B. Verify that the physician consulted with the patient and/or family.

C. Accept the order as written, no other documentation is needed.

D. Notify the nurse supervisor and risk management about the DNR order.

B. Verify that the physician consulted with the patient and/or family.

For a DNR, an advanced directive is not required. Neither is a living will.

So the best action would be to verify with the physician they have consulted with the family before

When a nursing assessment is not done in a timely manner, according to the established policy and procedure, this is referred to as a:

A. Nursing fault

B. Medical error

C. Variance

D. Deviance

C. Variance

According to the established policy and procedure, when a nursing assessment is not done promptly, this is called a variance.

It’s not a nursing fault! Nor is it a medical error. Medical error is if the wrong med was given, wrong patient surgery, wrong site surgery.

Deviance is not used to describe this.

The nurse is caring for assigned clients. Which of the following clients would be appropriate for the nurse to refer for an interdisciplinary conference? A client with

Select all that apply.

A. pulmonary tuberculosis with multiple prescriptions.

B. ischemic stroke who has left-sided hemiplegia.

C. hyperthyroidism and is scheduled for a thyroidectomy.

D. stage one Alzheimer’s disease who lives with family.

E. fractured tibia and fibula and is homeless.

F. end-stage-renal disease who refuses dialysis.

Answer: B, E

A client with an ischemic stroke with hemiplegia will require interdisciplinary care such as occupational and physical therapy. –> Rehabilitation

A client with a fractured tibia and fibula will require physical therapy along with consultation with social services to assist the patient with housing.

The nurse is caring for assigned clients. Which of the following clients would be appropriate for the nurse to refer for an interdisciplinary conference? A client with

Select all that apply.

A. pulmonary tuberculosis with multiple prescriptions.

B. ischemic stroke who has left-sided hemiplegia.

C. hyperthyroidism and is scheduled for a thyroidectomy.

D. stage one Alzheimer’s disease who lives with family.

E. fractured tibia and fibula and is homeless.

F. end-stage-renal disease who refuses dialysis.

Answer: B, E

A client with an ischemic stroke with hemiplegia will require interdisciplinary care such as occupational and physical therapy. –> Rehabilitation

A client with a fractured tibia and fibula will require physical therapy along with consultation with social services to assist the patient with housing.

A client in the medical ward is adamant to go home regardless of what the medical team is telling him. The nurse understands that in order for all healthcare team members to be protected from liability when the client goes home, the nurse must first initiate which action?

A. Have the client sign a consent form.

B. Have the client sign an ‘Against Medical Advice’ form.

C. Procure the client’s Medicare card.

D. Assess the client’s mental and neurological status.

D. Assess the client’s mental and neurological status.

The FIRST thing to do would be to assess to see if the client is legally competent to make decisions regarding his care before signing the Against Medical Advice form.

While working in the emergency department. A patient has a cardiac arrest. The nurse caring for the patient quickly defines the necessary tasks and assigns them to each member of the team responding. This nurse demonstrated which of the following leadership styles?

A. Autocratic

B. Situational

C. Democratic

D. Laissez-faire

A. Autocratic

This nurse has demonstrated an autocratic leadership approach. She retained all authority and delegated tasks to be accomplished. This approach is useful in emergencies or crises.

A medication error has occurred in the medical ward. After a thorough investigation was performed, the nurse manager posts a memorandum regarding changes in medication administration to be implemented immediately. The nurses on the unit recognized this management style as:

A. Autocratic

B. Democratic

C. Participative

D. Laissez-faire

A. Autocratic

In autocratic leadership, decisions are made with little or no staff input. The manager makes all the decisions in the unit.

The nurse is educating staff on adult basic life support. It would be appropriate to include which of the following?

Select all that apply.

A. Carotid pulse check should not take more than 20 seconds.

B. The rate of chest compressions should be 100-120 per minute.

C. Chest compression depth should be 2 inches on the center breastbone.

D. Chest tube insertion should be prepared after five minutes of CPR.

E. Early defibrillation is essential in the survival of ventricular fibrillation.

Answer: B, C, E

High-quality CPR involves a compression depth of two inches on the center breastbone. The rate of the compressions should be 100-120 per minute. The nurse should utilize early defibrillation as it is the most effective treatment of ventricular fibrillation.

Carotid pulse check should not exceed 10 seconds
A chest tube is not indicated for this type of scenario

When experiencing conflict with another nurse (that is not resolvable between the parties), what is the most appropriate action for the nurse moving forward?

A. Report the conflict to the director of nursing over the unit.

B. Report the conflict to the nurse manager of the unit.

C. Report the conflict to the assigned charge nurse of the unit.

D. Discuss the conflict with another nurse to attempt resolution of the issue.

C. Report the conflict to the assigned charge nurse of the unit.

It is essential to follow the appropriate chain of command in a professional setting and not to overstep any levels when moving the issue up the ladder.

So not the nursing unit manager, not the director of nursing.

The conflict shouldn’t be discussed with another nurse for resolution.

Aplastic anemia is suspected in a 23 y/o client. Laboratory values reflect anemia, and the client is advised for a bone marrow biopsy. The client refuses to sign the consent and states, “Come on, just get the doctor to give me a transfusion and let me go. Spring break begins this weekend, and I’m leaving for Florida.” The nurse’s most significant concern at this time would be:

A. The possibility that the client may contract an infection from being exposed to large crowds during spring break.

B. The client does not understand the full impact of her condition.

C. The client may need a transfusion before leaving for spring break.

D. The causative agent needs to be identified and the treatment should be started.

B. The client does not understand the full impact of her condition.

The most significant concern at this point is the fact that the client does not fully grasp the gravity of her condition. She must be educated and be allowed to verbalize her feelings about her situation.

I picked A, thinking that the patient already knows about her condition.

Always educate the patient first!

The charge nurse is planning patient care assignments for a registered nurse (RN) and licensed practical/vocational nurse (LPN/VN). Which of the following patients would be most appropriate to assign to the LPN?

Select all that apply.

A. A patient receiving antibiotics for lower extremity cellulitis.

B. A patient newly admitted with an exacerbation of myasthenia gravis.

C. A patient with a chest tube and receiving mechanical ventilation.

D. A patient requiring a referral for an outpatient support group.

E. A patient needing to receive intramuscular RhoGAM.

F. A patient needing scheduled tube feedings and colostomy irrigations.

Answer: A, F

Antibiotics can be given by the LPN, Tube feedings and colostomy care are also within the LPN’s scope of practice.
These two clients are also low acuity, they may be cared by the LPN.

Newly admits, mechanical ventilation, referrals, blood products (RhoGAM - Rh Immunogobulin) are within the RN’s scope of practice.

The nurse is supervising an LPN in the psychiatric ward. Which statement by the LPN would warrant attention by the nurse?

A. “I bathed the client already this morning”

B. “I will be attending a team meeting in the next hour.”

C. “I already gave the client his intravenous Olanzapine.”

D. “I will be joining the clients with their games today in the day room.”

C. “I already gave the client his intravenous Olanzapine.”

Here, the LPN needs to be reminded that he/she cannot deliver any medication (except saline and heparin flushes) by direct IV push technique.

Soaking the foot in hot water will break down the skin of the foot of a diabetic client. This will introduce infection on the foot so it should be avoided!

Instead the foot can be cleaned with a wet cloth and dried with a dry cloth, make sure to keep the feet dry!

Active = use of muscles

Passive = use of joints

The nurse in the family clinic is checking the vital signs of clients. Which client should the nurse prioritize?

A. A 9-month-old baby with a pulse rate of 148

B. A 2-year-old with a respiratory rate of 30

C. A 24-week pregnant woman with a blood pressure of 148/96 mmHg

D. A 40-year-old man with a temperature of 37.8 °C

C. A 24-week pregnant woman with a blood pressure of 148/96 mmHg

This woman has a high BP (normal 90-140 / 60-85). She may have pregnancy induced HTN, would need follow up assessment.

HR of 148 is normal (HR norm: 100-160) for a infant
Toddlers have a normal RR of 20-30, 30 is not concerning
The client may have a fever, but not the priority

A client with Addison’s disease was admitted with nausea and vomiting two days ago. His symptoms are now resolved and his vital signs are stable. The client is receiving intravenous glucocorticoids. Which action by the nurse takes priority?

A. Checking the client’s blood sugar level.

B. Measuring intake and output.

C. Checking the client’s sodium and potassium levels.

D. Taking daily weights.

A. Checking the client’s blood sugar level.

Clients on IV corticosteroids are at risk of hyperglycemia, the nurse should prioritize checking the client’s BG to monitor and prevent hyperglycemia.

Since the client is stable and the symptoms of N/V resided, glucose monitoring should be the priority (Option B)

If the client is on mineralocorticoids, then there’s a risk for hypokalemia and hypernatremia (Option C)

Daily weights would be appropriate due to the weight gain side effects of corticosteroids, but hyperglycemia is the more concerning priorty (Option D)

Which of the following is an appropriate intervention for a client who is at risk for otitis media?

Select all that apply.

A. Avoid secondhand smoke

B. Have audiogram yearly

C. Only clean the external ear

D. Be current on immunizations

Answer: A, C, D

A: Smoking weakens the immune system
C: Only the external portion of the ear should be cleaned, the inner ear should be cleaned by the HCP
D: Immunizations prevents infections such as pneumococcal bacteria that cause otitis media

The nurse assesses the following telemetry strip for a client on a medical-surgical unit. Based on the rhythm, It is a premature ventricular contraction (PVC). What is the first priority action for the nurse to take?

A. Prepare for synchronized cardioversion

B. Administer Atropine via IV push

C. Review the most recent labs

D. Ask the patient about palpitations

C. Review the most recent labs

PVCs are the most common type of arrhythmia, can occur in healthy individuals, and are typically not concerning in an otherwise normal rhythm. However, they can be a warning sign of electrolyte imbalance (hypokalemia, hypomagnesemia), hypoxemia, acid-base imbalances, or myocardial ischemia.

Therefore the nurse should review the lab values to determine if there is any apparent physiological cause for the arrhythmia.

I picked D, but it is not helpful or important of determining the need for treatment. Not a high priority.

The nurse in the clinic is caring for a 10-year-old with asthma. The child uses an albuterol multi-dose inhaler before engaging in exercise. The nurse should educate the child and parents that potential side effects of this short-acting beta-2 agonist (SABA) are:

Select all that apply.

A. Tachycardia

B. Hypotension

C. Headache

D. Hypoglycemia

Answer: A, C

Potential side effects of all the SABAs include tachycardia, headache, hypertension, hyperglycemia, tremors, hypokalemia, and increased lactic acid accumulation.

Which of the following findings would lead you to suspect non-accidental trauma in your 1-year-old burn victim patient?

Select all that apply.

A. Scalding on the anterior trunk

B. Circumferential burns on the feet

C. Same thickness of skin damage throughout the burn

D. Burns to the soles of the feet

Answer: B, C

Circumferential burns on feet are full thickness burns affecting the entire circumference of an area. It’s unlikely a 1 y/o would inflict circumferential burn on themselves.

Same thickness of skin damage means the damage is persistent throughout the skin. In an accident, an accident where something such as boiling water was spilled, the water will cool as it moves and leaves different levels of burns on the tissue.

For A: It’s possible to experience anterior trunk burning (Scalding) as the infant pulls on a cloth and something hot drops on them

For D: Burns on the feet are possible as the 1 y/o is beginning to walk

The nurse is administering digoxin to an infant when she notes that her pulse is 85 beats per minute. What should be the nurse’s most appropriate action?

A. Administer the medication.

B. Extract blood for serum digoxin levels.

C. Withhold the medication and check again after an hour.

D. Administer the medication intramuscularly.

C. Withhold the medication and check again after an hour.

If the pulse is less than 90 beats/min in an infant, the nurse should withhold the medication and check again in an hour. A consistently low pulse rate may indicate digoxin toxicity.

Your client, who has chronic pancreatitis and gastroparesis, is complaining of a migraine headache. The doctor has ordered butorphanol orally as needed for pain. What would you do?

A. Call the doctor and suggest transnasal butorphanol because the client has gastroparesis.

B. Call the doctor and suggest rectal butorphanol because the client has pancreatitis.

C. Administer the butorphanol orally as ordered.

D. Administer the butorphanol transdermally for pain.

A. Call the doctor and suggest transnasal butorphanol because the client has gastroparesis.

This client with chronic pancreatitis and gastroparesis is complaining of a migraine headache.

Butorphanol is available in the oral form, transnasal form, transdermal, and parenteral form. Butorphanol PO is contraindicated due to gastrparesis. You would call the doctor and suggest transnasal butorphanol.

The nurse is collecting the health history from a pregnant patient. Which of the following conditions would not put this patient at an increased risk of developing preeclampsia?

A. Obesity

B. Chronic hypertension

C. Frequent urinary tract infections

D. Multifetal gestation

The nurse is collecting the health history from a pregnant patient. Which of the following conditions would not put this patient at an increased risk of developing preeclampsia?

A. Obesity

B. Chronic hypertension

C. Frequent urinary tract infections

D. Multifetal gestation

The nurse receives a call from her mother who tells her that her father is having sudden and severe chest pain but is refusing to go to the hospital. What should be the nurse’s initial action?

A. Tell her mother to call 911.

B. Ask her mother to let her father chew an aspirin.

C. Ask what her father ate recently.

D. Ask her mother if she can talk to her father.

B. Ask her mother to let her father chew an aspirin.

ASA reduce the size of the MI and improve survival.
Calling 911 would be the second step.

A 34-year-old female arrives at the emergency department after developing pain in her left calf. What are the important questions to ask this patient while assessing her?

Select all that apply

A. Is your left calf bigger than your right calf?

B. Are you pregnant?

C. Have you been on any long car or plane rides recently?

D. Do you take any birth control?

E. Do you take any antidepressants?

Answer: A, B, C, D

All of those four are risk factors for developing DVT

The nurse is teaching a group of students about medications and fall prevention. The nurse would be correct to identify which of the following medications that can increase the risk for falls?

Select all that apply.

A. Naproxen

B. Alprazolam

C. Bumetanide

D. Verapamil

E. Allopurinol

F. Thiamine

Answer: B, C, D

Alprazolam = benzodiazepine (sedative)Bumetanide = Ends in ide --> diuretic --> decrease BPVerapamil = CCB lowers BP 

Naproxen (NSAID), Allopurinol (gout/uric acid treatment), Thiamine (Vitamin B1 for alcohol) do not increase risk for falls

Which of the following findings may indicate a change in mental status?

Select all that apply.

A. Asymmetrical movements

B. Lethargy

C. Disheveled appearance

D. Rapid speech

Answer: B, C, D

An alteration in mental status refers to general changes in brain function, such as confusion, amnesia (memory loss), loss of alertness, disorientation (not conscious of self, time, or place), defects in judgment or thought, unusual or strange behavior, poor regulation of emotions, and disruptions in perception, psychom*otor skills, and practice.

Asymmetric movements may relate to a stroke or change in neurological status

The definition of a “nonverbal” client in the context of pain assessment can include the clients:

A. Reluctance to report pain.

B. Inability to speak because of intubation.

C. Absence of consciousness.

D. Expressive verbal aphasia.

C. Absence of consciousness.

The description of “nonverbal” in the context of pain assessment is the inability to self-report pain, the failure to be adequately assessed using a numerical pain scale, and the inability to be adequately evaluated using a pictorial pain assessment scale.

I picked B - but the client is still able to communicate using the pictorial pain scale, so they are not considered “nonverbal” in pain assessment

Which of the following are risk factors for Respiratory Syncytial Virus (RSV)?

Select all that apply.

A. Prematurity

B. Smokers in the home

C. Age 7-10 years

D. Trisomy 21

Answer: A, B, D

A: Premature babies have weakened immune system
B: Smoking will increase risk for respiratory infections
D: Trisomy 21 clients have weakened immunity, higher risk for infection

C: Children aged 7-10 are not a risk factor. Children aged < 2 years old are at most risk for developing respiratory syncytial virus (RSV).

Which of the following nursing diagnoses is the most appropriate for a client who just came back from bronchoscopy?

A. Risk for impaired skin integrity related to immobilization

B. Risk for infection related to an invasive procedure

C. Risk for bleeding related to diagnostic bronchoscopy

D. Lack of knowledge regarding postoperative care related to inexperience with diagnostic bronchoscopy as evidenced by frequent queries about the postoperative routine

C. Risk for bleeding related to diagnostic bronchoscopy

The most common complication of a diagnostic bronchoscopy is bleeding.

The nurse is caring for a client with acute myocardial infarction (AMI). Which diagnostic intervention should the nurse anticipate?

A. Exercise electrocardiography

B. Computed tomography (CT) of the chest with contrast

C. Percutaneous coronary intervention (PCI)

D. Echocardiogram

C. Percutaneous coronary intervention (PCI)

A PCI involves inserting a catheter into the femoral or radial artery to access the coronary arteries. This test diagnose narrowing in the coronary arteries and intervene with angioplasty and stenting.

I picked B: But Archer said: A chest CT may assist in diagnosing an occlusion in the coronary artery, but this test does not allow for intervention. The question was asking for a diagnostic intervention?

You are caring for a 33-year-old male client at the end of life. This married client has two children; the son is 14-years-old and the daughter is 8-years-old. Both of these children are being prepared for their father’s imminent death. Which consideration should be incorporated into your explanations of death with these children?

A. Children before the age of 12 view death as terrifying so the nurse should not discuss death with these young children.

B. Children before the age of 12 do not have any perspectives about death, its meaning, and its finality or lack thereof.

C. The cognitive development of young children impacts their understanding of death.

D. The cognitive development of young children before 12 has no impact on their understanding of death.

C. The cognitive development of young children impacts their understanding of death.

The cognitive development of young children impacts their understanding of death. Since the meaning of death and the finality of death vary according to the age of the child, the nurse should listen to and support these children according to their level of understanding.

When instructing a post-surgical patient with an abdominal incision on deep breathing and coughing, the nurse explains that the patient should be sitting up for these activities because:

A. It is physically more comfortable for the patient

B. Helps the patient to support their incision with a pillow

C. Loosens respiratory secretions

D. Allows the patient to observe their area and relax

B. Helps the patient to support their incision with a pillow

This position allows the patient to support his incision with a pillow, providing abdominal support when coughing. It also allows the lungs to expand more fully because it enables the diaphragm to move downwards under gravity.

The nurse is supervising a nursing student to teach a pregnant client about a scheduled chorionic villus sampling (CVS) test. Which statement, if made by the nursing student, would require follow-up?

A. You will need to provide both a urine and blood sample for this test.

B. Drink plenty of water prior to this test and do not empty your bladder.

C. An ultrasound will be used during this procedure to guide the needle.

D. It is okay to eat and drink on the day of the procedure.

A. You will need to provide both a urine and blood sample for this test.

A urine and blood sample is not needed because a chorionic villus sample is taking a a small sample of the placenta for prenatal genetic diagnosis.

Chorionic villus sampling is a test that may be performed as early as ten gestational weeks to determine if the fetus has any chromosomal abnormalities.

The CVS uses ultrasound, and a full bladder allows for an acoustic window to ensure accurate imaging. No eating or drinking restrictions are in place during preprocedure. The client may eat and drink normally.

The nurse preceptor is orienting a newly hired nurse caring for a client with advanced polycystic kidney disease (PKD). Which of the following actions by the newly hired nurse would require follow-up by the nurse preceptor?

A. Requesting a prescription for ketorolac to help relieve the client’s pain.

B. Instructing the client on how to use guided imagery as a comfort strategy.

C. Applying dry heat to the client’s abdomen or flank for pain relief.

D. Provides the client with foods high in fiber and low in salt.

A. Requesting a prescription for ketorolac to help relieve the client’s pain.

For a client with advanced PKD, NSAIDs should be avoided.

I picked C, but pain control can be achieved for a client with PKD by applying dry heat to the abdomen or flank.
Guided imagery may help with pain as it is relaxation / meditation.
Low sodium puts less stress on the kidneys

You are completing a health history of a 4-year-old male at the primary care office. When checking with his mother about milestones in fine motor development. You would expect that the 4-year-old is able to do which of the following?

Select all that apply.

A. Complete a puzzle with 5 or more pieces

B. Copy a triangle onto a piece of paper

C. Dress himself

D. Use a fork to eat dinner

Choices A, B, C, and D are all correct.

These are all fine motor skills that are expected in preschool-age children, who are 3 to 5 years old. Other fine motor developmental milestones include: pasting things onto paper, completing puzzles with 5 or more pieces, cutting out simple shapes with scissors, and brushing their teeth.

Which of the following best describes the primary purpose of referrals?

A. Ensure that the continuum of care is a seamless transition.

B. Ensure the completeness and appropriateness of the client care.

C. Establish the registered nurse as the center of client care.

D. Establish the client or a group of clients as the center of client care.

The nurse is performing a physical assessment. When assessing a client’s eyes for accommodation, which of the following actions would the nurse perform?

A. Bring a penlight from the side of the client’s face and briefly shine the light on the pupil.

B. Ask the client to gaze at a distant object and then at a test object.

C. Obtain a tuning fork and place it in the middle of the client’s forehead.

D. Have the client stand twenty feet away from a Snellen chart.

B. Ask the client to gaze at a distant object and then at a test object.

For accommodation, the nurse ask the client to gaze at a distant object and then at a test object held closer to the client’s face. The pupils converge and accommodate by constricting when looking at close objects.

Think: The eyes accommodate by changing its dilation.

Which of the following meals would be appropriate for a nurse to assign to a client of Orthodox Judaism faith on a kosher diet?

A. Pork belly roast, rice, vegetables, mixed fruit, milk

B. Crab salad on a croissant, potato salad, milk, vegetables with dip

C. Sweet and sour chicken with rice and vegetables, juice, mixed fruits

D. Fettuccini Alfredo with shrimp and vegetables, salad, mixed fruit, iced milk tea

C. Sweet and sour chicken with rice and vegetables, juice, mixed fruits

In judaism, the dairy-meat combination is unacceptable (ex: milk + crab, milk + shrimp, milk + pork). Only fish that have scales and fins are allowed.

When using the Critical Care Pain Observation Tool (CPOT), the nurse understands that the best indicator of the patient’s pain is:

A. Facial expression

B. Body movements

C. Compliance with the ventilator

D. Muscle tension

Facial expression is the best indicator of the patient’s pain since this is often the first change the nurse might notice and is least likely to be under the control of the patient.

Muscle tension is the second-best indicator of the patient’s pain. (Option D)

Body movements and compliance with a ventilator are not the best indicators for the patient’s pain. (Option B and C)

Analyze the following ABG: pH 7.44, CO2 52, HCO3 42

A. Compensated metabolic alkalosis

B. Uncompensated metabolic acidosis

C. Compensated respiratory acidosis

D. Uncompensated respiratory alkalosis

pH 7.44, Elevated, but not over the pH normal
CO2 52, Elevated
HCO3 42, Elevated

ROME - Metabolic equal –> pH and HCO3 are in the same direction. Therefore, this is a Metabolic Alkalosis. Since the pH is within normal, it is Compensated.

An emergency room nurse is assigned to triage. Four people check-in at the same time. Which patient should receive priority care?

A. A 29-year-old female two-week post-cesarean section that complains of a headache and leg swelling

B. An 8-year-old female with LLQ pain for three days

C. A 55-year-old male with RUQ pain & a history of pancreatitis

D. A 3-year-old female with pain upon urination

The nurse is assessing a patient with diabetic ketoacidosis (DKA). Which of the following would be an expected finding?

Select all that apply.

A. Thready pulse

B. Jugular venous distention (JVD)

C. Oliguria

D. Tachycardia

E. Orthostatic hypotension

Answer: A, D, E

Dehydration is a common sign and symptom of DKA.
High sugar = high pee = dehydration
Dehydration –> Low fluid volume –> Leads to:

Low BP, Thready pulse (weak pulse)

Increased HR to compensate

The nurse is preparing a client with peptic ulcer disease for a barium study of the stomach and esophagus. What should be the initial nursing action?

A. Have the informed consent signed by the client for the procedure.

B. Teach the client the importance of increased oral fluids after the procedure.

C. Explain to the client that he or she will have to drink a white, chalky substance.

D. Instruct the client not to eat or drink anything before the procedure.

D. Instruct the client not to eat or drink anything before the procedure.

I picked A - but a barium study test is not an invasive test and therefore does not require an informed consent.

A 16-year-old female client has been recently diagnosed with Grave’s disease and is being admitted. The primary health care provider prescribes a few medications. Which of the following prescriptions, if ordered, should the nurse question?

A. Atenolol

B. Propylthiouracil (PTU)

C. Radioactive iodine (I131)

D. Methimazole (Tapazole)

C. Radioactive iodine (I131)

The nurse should question the radioactive iodine because RAI can cross the placenta and affect the developing thyroid gland of the unborn baby.

Therefore, a pregnancy test must be obtained in this 16-year-old woman before initiating RAI.

What is the most appropriate instruction to give a client with osteoporosis regarding exercise?

A. Avoid exercise activities that increase the risk of fractures.

B. Exercise to strengthen muscles and thereby protect bones.

C. Exercise to reduce weight.

D. Exercise doing weight-bearing activities.

D. Exercise doing weight-bearing activities.

Weight bearing means a person is working against the weight of another object. Weight bearing helps with osteoporosis because it strengthens muscles and builds bone.

The nurse in the ICU notes bleeding from the client’s transparent dressing over her peripheral intravenous site, gum bleeding, and frank blood in the urine. The client was originally admitted for sepsis. What should be the nurse’s immediate next action?

A. Assess the client’s hemoglobin and hematocrit level.

B. Check the client’s oxygen saturation

C. Apply pressure to the intravenous site.

D. Call the physician.

D. Call the physician.

The client is manifesting signs of disseminated intravascular coagulation (DIC).

This is a critical complication that often happens in the intensive care unit and usually is secondary to other serious etiologies such as sepsis.

The nurse must call the physician first to initiate medical interventions.
This may include to confirm DIC, transfuse platelets, infuse clotting factors.

When compared to younger adults, the nurse recognizes that the older clients have variations in pulse with:

A. Food intake

B. Heat

C. Respirations

D. Exercise

D. Exercise

Aging adults have a normal pulse range of 60-100 beats/minute. However, the maximum heart rate in older adults is much lesser with exercise.

The pulse rate of older adults takes longer to rise to meet sudden increases in demand, takes longer to return to resting state, and tends to be lower than that of younger adults.

Which of the following educational points are appropriate for your patient being discharged with oral potassium supplements?

Select all that apply.

A. Take on an empty stomach.

B. Commonly causes GI upset.

C. Should only be taken at night.

D. Mix well.

Answer: B, D

The most common side effect of oral potassium is GI upset. Take potassium with food to minimize the GI upset. Teach clients to mix potassium supplements well before administering them (Choice D).

A 90-year-old woman has been bedridden at home for two weeks. Which of the following is not an expected finding due to immobility?

A. A decrease in bone density

B. Loss of short-term memory

C. Atelectasis

D. High serum calcium level

B. Loss of short-term memory

Loss of short-term memory is not an expected complication of prolonged immobility and warrants further assessment. Short-term memory loss may indicate medication effects, Alzheimer’s dementia, or Lewy body dementia, etc.

A hospitalized client tells the nurse that she has a living will prepared and that her lawyer will be bringing the will to the hospital today for witness signatures. The client asks the nurse to help her obtain a witness for the will. Which of the following is the most appropriate response?

A. “Don’t worry, I will sign as a witness to your signature.”

B. “Because it is a legal document, you will need to find a witness on your own.”

C. “Whoever is present at the time will sign as a witness for you.”

D. “I will contact the nursing supervisor for assistance regarding your request.”

D. “I will contact the nursing supervisor for assistance regarding your request.”

Living wills require witness by specified individuals or those who are able to notarize. The nurse of a facility where the client is receiving care can not be a witness. The nurse should notify the nurse supervisor for assistance.

The home health nurse is discussing environmental safety with a 74-year-old patient who lives with her son. Which of the following statements by the patient would indicate that additional teaching is needed?

A. “My son will install grab bars in the bathroom.”

B. “I will wear my indoor shoes while walking inside the house.”

C. “The furniture is arranged so that I can hold onto something if I need it.”

D. “We will remove all small rugs.”

C. “The furniture is arranged so that I can hold onto something if I need it.”

It is not safe for the patient to be using furniture for support during walking. The nurse should discuss the risks associated with this action and evaluate the patient’s need for a mobility aid such as a walker or cane.

The nurse is caring for a client with congestive heart failure (CHF). The nurse should anticipate a prescription for which medication?

A. Enalapril

B. Verapamil

C. Lovastatin

D. Gemfibrozil

A. Enalapril

Enalapril is an ACE inhibitor and this drug class is indicated in the treatment of heart failure to prevent ventricular remodeling.

Option B: Verapamil (CCB) is contraindicated due to its adverse effects on cardiac output (Negative inotropic)

Option C and D: Lovastatin and gemfibrozil reduces cholesterol, not used for HF.

Pheochromocytoma (Tumor on adrenal glands)

Abnormal protein quantification in multiple myeloma

Creatinine clearance

The nurse is caring for a client who is receiving newly prescribed prednisone. Which of the following medications should the client avoid while receiving this medication?

A. Valsartan

B. Naproxen

C. Omeprazole

D. Acetaminophen

B. Naproxen

Naproxen should not be administered with corticosteroids, when taken together, these two meds will increase the risk for GI bleeds!

Acetaminophen is preferred over NSAIDs as it does not induce risk of GI bleeds.

The nurse is caring for a child with nocturnal enuresis that was not responsive to non-pharmacological modifications. The nurse anticipates the primary healthcare provider (PHCP) to provide which medication?

A. Urecholine

B. Desmopressin

C. Prazosin

D. Finasteride

B. Desmopressin

This medication is a synthetic form of antidiuretic hormone.

Think: desmopressin = vasopressin (It’s pressing on to the kidneys to decrease urine output!)

Desmopressin is indicated for the treatment of diabetes insipidus and nocturnal enuresis.

A patient is being evaluated in the clinic for pancreatitis. Besides an elevated white blood cell count and serum lipase levels, which assessment finding indicates a positive finding for pancreatitis?

A. The discoloration of the abdomen and periumbilical area

B. Overactive bowel sounds

C. Low bilirubin levels

D. Bluish discoloration of the soles of the feet

A. The discoloration of the abdomen and periumbilical area

The discoloration of the abdomen and periumbilical area is known as Cullen’s sign and indicates pancreatitis when it occurs in conjunction with other symptoms.

Option B: Bowel sounds are generally diminished or absent

Option C: Bilirubin levels are usually slightly elevated

Option D: Blue feet is not associated with pancreatitis

A patient presents with a round, non-tender nodule on the left wrist that is more pronounced upon flexion. The nurse would recognize this as which of the following conditions?

A. Olecranon bursitis

B. Bouchard node

C. Ganglion cyst

D. Pilar cyst

C. Ganglion cyst

Gnaglion cyst - non tender, exists on wrist, more noticeable with flexion.

Olecranon bursitis - common form of bursitis (fluid filled sac inflammed), it’s large, soft, red, and painful to touch.

Bouchard node - is a hard, non-tender bony overgrowth on the proximal interphalangeal joint, commonly seen in osteoarthritis.

Pilar cyst is a fluid filled cyst that originates in a hair follicle, usually found on the scalp.

A client taking lithium salts (Lithane) for the treatment of manic episodes is talking to the nurse regarding adverse reactions of the drug. Which statement by the nurse is the most appropriate teaching to prevent adverse effects for a client taking lithium?

A. “You must take the medication on time.”

B. “You must take the medication with food or milk.”

C. “You can suck on sugarless lozenges when your mouth dries up.”

D. “You must drink at least 2 liters of water daily.”

D. “You must drink at least 2 liters of water daily.”

The kidneys reabsorb more lithium into the serum during periods of dehydration and sodium depletion.

Maintain hydration while taking the drug prevents lithium toxicity.

A client taking lithium salts (Lithane) for the treatment of manic episodes is talking to the nurse regarding adverse reactions of the drug. Which statement by the nurse is the most appropriate teaching to prevent adverse effects for a client taking lithium?

A. “You must take the medication on time.”

B. “You must take the medication with food or milk.”

C. “You can suck on sugarless lozenges when your mouth dries up.”

D. “You must drink at least 2 liters of water daily.”

D. “You must drink at least 2 liters of water daily.”

The kidneys reabsorb more lithium into the serum during periods of dehydration and sodium depletion.

Maintain hydration while taking the drug prevents lithium toxicity.

What is the antidote for Anthrax?

A. Acyclovir

B. Zidovudine (Retrovir)

C. Ciprofloxacin

D. Oseltamivir

Anthrax is a bacterial infection treated with antibiotics such as penicillin, doxycycline, and ciprofloxacin.

Acyclovir, Retrovir, Oseltamivir are all antiviral meds

The nurse is caring for a client with heart failure. Which medication should the nurse clarify with the primary healthcare provider (PHCP)?

A. Lisinopril

B. Prednisone

C. Hydralazine

D. Carvedilol

B. Prednisone

Corticosteroids have the side effects of:
Hyperglycemia, osteoporosis, weight gain (Fluid gain), leukopenia

So giving prednisone to a client with HF would exacerbate the fluid overload!

Lisinopirl (ACE-I) is the gold standard for treating HF
Hydralazine and carvedilol both vasodilates the vascular system, easier for blood to be pumped out.

Which question would you ask to assess the family as the basic unit of society as you apply the structural-functional theory of family?

A. What community health promotion resources do you use?

B. Who is the major decision-maker in your family?

C. What community activities does the family enjoy?

D. What support people do you have outside of the home?

B. Who is the major decision-maker in your family?

Structural-functional methods of family address issues like decision-making, intrafamily relationships, family structures, and patterns of communication in the family.

An infant is currently stable but has just been diagnosed with cystic fibrosis. Which of the following would be the priority nursing goal for the family?

A. Stabilize the child

B. Provide emotional support

C. Arrange for financial assistance

D. Formulate long-term goals

B. Provide emotional support

The family needs emotional support when a chronic condition is newly diagnosed in a family.

Financial assistance and formulate long term goals are similar answers as they are long term goals. Plus they are not to be prioritized when a diagnosis has just been informed.

The school nurse is talking to a group of mothers regarding poison prevention and management. Which statement by the mothers indicates a need for further teaching?

A. “I need to properly label the containers of poisonous liquids.”

B. “I need to make my child vomit in the instance he ingests gasoline.”

C. “I can give my child milk or some water to dilute the poison while I rush him to the hospital.”

D. “All poisonous materials should be stored away from children.”

B. “I need to make my child vomit in the instance he ingests gasoline.”

Induction of vomiting when a victim has ingested hydrocarbons is contraindicated.

Vomiting may lead to inhalation of the poison, worsening the situation.

Labeling, diluting the poison with water or milk, storing poisonous materials away from children are all poison prevention.

An unreasonable fear of cats.

Ailurophobia is usually treated with exposure therapy to the object or situation that is causing this unreasonable fear

The nurse is talking to new parents about their toddler. The mother is concerned that the child is getting independent and she wants to tend to the toddler all the time. The nurse’s most appropriate response would be:

A. “Your child will develop mistrust.”

B. “Your child will develop shame.”

C. “Your child will feel guilt.”

D. “Your child will feel inferior.”

B. “Your child will develop shame.”

Infants = Trust / MistrustToddlers = Autonomy / shamePreschooler = Initiative / guilt

The nurse is caring for a client who reports excessive flatulence and abdominal cramping. The nurse anticipates a prescription for

A. simethicone.

B. omeprazole.

C. ferrous sulfate.

D. cimetidine.

Not Omeprazole or cimetidine - Since -prazole = PPI, and -tidine = H2 blockers, both of which reduce gastric ulcers, does not treat gas and abdominal cramping.

Not ferrous sulfate since it treats iron deficient anemia.

Simethicone treats excessive flatulence and discomforts (abd cramps)

A post-coronary artery bypass graft patient developed a fever of 38.8° C. The nurse notifies the physician of the elevated temperature because:

A. The elevated temperature may lead to profuse sweating.

B. It may increase cardiac output.

C. It is a sign of cerebral edema.

D. It is indicative of hemorrhage.

B. It may increase cardiac output.

An increase in temperature leads to increased metabolism and cardiac workload.

A is not reasonable to be calling the MD
Elevated temp does not an early sign of cerebral edema
Blood loss = decreased temp

The nurse is caring for a client with narcolepsy. Which of the following medications would the nurse anticipate the primary healthcare provider (PHCP) prescribe?

A. Aripiprazole

B. Modafinil

C. Ropinirole

D. Quetiapine

B. Modafinil

Not A or D, since A prevents gastric ulcers (PPI), D is an antipsychotic.

Ropinirole - think rolling, pin rolling = parkinson’s med. It is a dopaminergic med.

Modafinil is a psychostimulant used to treat narcolepsy

The registered nurse is working together with the LPN in a psychiatric ward. In a busy day, the nurse understands that it is necessary to delegate tasks to LPNs. Which job would the RN delegate to the LPN?

A. Escorting a client with a serum lithium level of 2.2 mEq/L to the ER.

B. Accompanying a bulimic client for an hour after lunch.

C. Conducting art therapy to a group of clients in the day room.

D. Accompany the client who is talking to her mother on the phone.

B. Accompanying a bulimic client for an hour after lunch.
LPN can be there to prevent client from purging (Vomit)

Not A because lithium toxicity is an acute patient. Not C because LPN is not trained in art therapy
Not D because it is a violation of the patient’s privacy.

The patient is presenting with a fever, nausea, and dysuria. Which action would the nurse take first?

A. Administer as needed antipyretic.

B. Call the physician to obtain an antibiotic order for a suspected UTI.

C. Collect a midstream, clean-catch urine specimen.

D. Collect STAT blood cultures.

C. Collect a midstream, clean-catch urine specimen.

The nurse should recognize that this patient is presenting with symptoms of urinary tract infection (UTI) or pyelonephritis.

A 25-year-old female client is at the emergency department with complaints of severe pain in the right lower quadrant of the abdomen; she was assessed and found to have appendicitis. She is being scheduled for an appendectomy. Which question is most relevant for this presentation?

A. “Are you breastfeeding?“

B. “Have you ever been under general anesthesia?“

C. “Do you have any allergies to medication?”

D. “Is there any chance that you are pregnant?”

D. “Is there any chance that you are pregnant?”

This is the most relevant question because if the client is pregnant, we would want to avoid exposure to radiation from imaging and avoiding putting the client into general anesthesia (as this might complicate the fetus’ HR and health).

A nurse is caring for an 8-month-old infant. The physician notes a low potassium level and prescribes intravenous KCl. Which of the following nursing actions should be performed when administering the medication?

A. Administer the medication immediately

B. Administer the medication within the first hour of the order

C. Assess for adequate urine output

D. Wait until the client’s blood count results are in

C. Assess for adequate urine output

We want to make sure the client does not have any renal impairment before administering the KCl. Otherwise, the client may develop life threatening hyperkalemia!

The nurse suspects a patient on the neurological floor is experiencing autonomic dysreflexia. What action would be the nurse’s priority?

A. Administer sublingual nitroglycerin.

B. Elevate the head of the bed.

C. Obtain a residual volume reading with a bladder scan.

D. Perform a digital examination to assess for the presence of stool.

B. Elevate the head of the bed.

The nurse should first sit this patient up to attempt to reduce blood pressure quickly (Blood flows to legs)
Begin frequent vital checks, loosen restrictive clothing, then assess for full bladder or fecal impaction.

Then the nurse would administer nitroglycerin if those interventions did not work.

The nurse is assessing a 4-year-old client who was sent to the emergency department from urgent care. Assessment reveals tripod positioning, blue lips, mottled skin, inspiratory stridor, and excessive drooling. Vital signs are:

Temp: 39 C
HR: 188
RR: 46
O2: 82 %

What is the priority action for the nurse to take at this time?

A. Keep the child calm and call for emergency airway equipment

B. Obtain IV access

C. Assess the throat for a cherry red epiglottis

D. Place the child on a high flow nasal cannula at 100% FiO2

A. Keep the child calm and call for emergency airway equipment

Based on the presenting symptoms, the nurse suspects that this child has epiglottitis. Any child presenting with excessive drooling, distress, and stridor is highly suspicious to have this medical emergency.

The child also has circulatory compromise (mottling, cyanosis).
The priority option would be to keep the child calm and call for the emergency airway equipment.

I picked D:
D is incorrect. We see the O2 is at 82% and we think giving the child 100% FiO2 is the right intervention. But this addresses the C in ABCs, whereas the A in ABC is the priority! Closing of the trachea! This child is at risk of losing their airway, so all interventions need to wait until there is emergency airway equipment close by.

The nurse is providing education for a patient scheduled for transurethral resection of the prostate (TURP). Which teaching would be appropriate for the nurse to include?

A. The prostate will be removed during this procedure.

B. This procedure will require general anesthesia.

C. Any sign of blood in the urine should be reported to the physician immediately.

D. A urinary catheter will remain in place following this procedure.

D. A urinary catheter will remain in place following this procedure.

This patient should expect to have an indwelling urinary catheter placed during this procedure. The nurse should discuss this intervention with the patient prior to the procedure as well as explain that the pressure of the catheter and balloon typically results in a constant urge to void.

TURP involves removal of only the enlarged potion of the prostate. Entirely removing the prostate is an open prostatectomy. Option A

TURP can be performed using general or local anthesthesia

Blood tinged urine or small clots, tissue debris in the catheter is expected findings immediately after removing the catheter as it can causes urethral trauma.

Upon noticing fetal bradycardia, the labor and delivery nurse performs a vagin*l examination on her client in labor. She discovers a pulsatile mass. What is the initial action of the nurse?

A. Prepare for a Cesarean section.

B. Tell the client not to push when contractions arrive.

C. Escort the father out of the room.

D. Place the client in Trendelenburg position.

D. Place the client in Trendelenburg position.

First we have to recognize that the nurse palpates a mass in the vagin* during labour indicates there is a prolapsed cord!

When there’s a prolapsed cord, nurses should:
Call for help

Lift the presenting part (of the baby) off of the cord

Position mom in a face down & ass up OR trendelenburg OR a modified sims position.

Administer O2 8 - 10L / min

Start IV fluids

Prepare for immediate delivery

Which of the following is the reason a patient receives nitrous oxide in addition to thiopental sodium?

A. To provide the additional anesthesia to put him in a sleep-like state

B. To increase the effectiveness of each drug at lower dosages

C. Because thiopental sodium is not effective when used alone

D. Because nitrous oxide is not effective when used alone

B. To increase the effectiveness of each drug at lower dosages

Nitrous oxide may be used together with other general anesthetics, which makes it possible to decrease the dosages of each with greater effectiveness. This method is used during general anesthesia.

After administering the IV agent and the patient loses conciousness, inhaled agents are introduced to maintain the anesthesia.

Which procedures below require a sterile technique?

Select all that apply.

A. Administering medication through a PICC line.

B. Inserting a Foley catheter.

C. Inserting a peripheral IV line.

D. Suctioning an endotracheal tube with in-line suction.

Answer: A and B

Administering medication in a central line requires a sterile technique. Central lines include PICC lines, Broviaks, IJs, EJs, and other lines that terminate in or just above the patient’s heart rather than in a peripheral vein (Choice A).

Inserting a foley catheter requires sterile technique.

A client has sickle cell crisis reports severe generalized pain. Which intervention is a priority for correcting vasoocclusion?

1. Admin high flow IV fluids
2. Apply O2
3. Maintain strict bed rest
4. Transfusing RBC

1. Admin high flow IV fluids

Adequate oxygenation and hydration may reverse the acute sickling response. In the sickled state, RBCs cannot carry enough oxygen from the lungs to the tissues, even with supplemental oxygen. The priority intervention is the administration of IV fluids to reduce blood viscosity and restore perfusion to the areas previously affected by vasoocclusion (Option 1).

Only after IV rehydration reverses vasoocclusion can nonsickled RBCs effectively carry supplemental oxygen to the tissues (Option 2).

Option 3 - bed rest does not resolve vasoocclusion, may cause DVT

Blood transfusions provide client with nonsickled RBCs, increasing O2 capacity in blood. This therapy is reserved for clients who do not respond to rehydration (IV fluids) (Option 4).

The patient who is two days postoperative cesarean section complains of right shoulder discomfort. Which action should the nurse take first?

A. Administer PRN analgesic.

B. Obtain STAT EKG.

C. Encourage ambulation.

D. Discuss the pain with the patient.

D. Discuss the pain with the patient.

We should talk with the patient regarding pain before providing interventions. The pain may be due to referred pain from the C section surgery.

I picked B. Obtain STAT EKG. This would be a priority action.

Assess FIRST before intervention / action!

The emergency department charge nurse was notified of a mass shooting at a nearby shopping mall. The charge nurse should take which action to prepare for the surge in clients? Select all that apply.

A. Work to arrange timely discharge and admission for appropriate clients.

B. Establish a holding area for discharged clients not able to go home.

C. Modify the nurse/client ratio to accommodate the surge levels.

D. Instruct staff to switch from electronic to paper documentation.

E. Prepare to provide frequent updates to local media.

Answer: A, B, C

D: Switching documentation methods from electronic to paper would jeopardize client safety and decrease efficiency.
E: It’s not the nurse’s role to contact the media!

The nurse is assigned to multiple clients with fever. Taking a rectal temperature would be contraindicated in which of the following cases? Select all that apply.

A. A client who had rectal surgery and a post-operative abscess

B. A child who has pneumonia

C. An older client who is post-myocardial infarction (MI)

D. A teenager with leukemia, a neutrophil count of 500/microliter, and is receiving erythropoietin for anemia

E. An adult patient with acute pancreatitis and has disseminated intravascular coagulation (DIC)

Answer: A, C, D, E

I picked A, D, and E.

C is correct because inserting the thermometer in the rectum will cause vagal stimulation. For a post MI patient, that can slow the heart rate.

A 6-year-old child is diagnosed with conjunctivitis. Which of the following discharge instructions should the nurse go over with the family?

Select all that apply.

A. Use warm compresses to lessen the irritation.

B. It is okay to go back to school after 48 hours of antibiotic administration.

C. Avoid sharing towels with family members.

D. Avoid rubbing the eyes to prevent injury.

Answer: C, D

Avoid sharing towels to minimize spread of infection. Avoid rubbing eyes to lessen injuries and spread of infection.

A: Should be cold compresses, not warm
B: It’s okay to send the child back to school after 24 hrs on antibiotics.

Which of the following foods can the nurse recommend to parents of toddlers who have constipation?

Select all that apply.

A. Mac and cheese

B. Whole grains

C. Whole milk

D. Black beans

Answer: B and D

Whole grains and Black beans are a source of high fibre, great for constipation.

Dairy foods are not recommended for constipation

An emergency department nurse is taking care of a 68-year-old female after she fell. The paramedics said that she was on the bathroom floor for approximately 10 hours. The nurse is straight catheterizing the patient for a urine sample when she notices the amount of urine reaches 800 mL. The urine is still flowing heavily. What action should the nurse take and why?

A. Drain the patient’s bladder entirely and place a small amount in a urine specimen cup. This patient needs a urine sample to check for rhabdomyolysis.

B. Continue draining the bladder fully, then place a Foley catheter to monitor for sufficient urine output.

C. Stop draining the patient’s bladder because the patient is at risk for developing bladder spasms.

D. Stop draining the patient’s bladder and consult the physician for further instructions.

C. Stop draining the patient’s bladder because the patient is at risk for developing bladder spasms.

This patient is at risk of developing bladder spasms if the bladder is completely drained. Anything over 800 mL that is drained out at one time puts the patient at risk for developing bladder spasms since there is not enough time to adjust from being abundant to shrinking.

The nurse is caring for a 30-year-old patient who has developed iron-deficiency anemia during pregnancy. Which complication would this patient be at an increased risk for due to iron deficiency anemia?

Select all that apply.

A. Low birth weight

B. Preterm delivery

C. Gestational diabetes

D. Perinatal mortality

Answer: A, B, D

During pregnancy, there is an increased demand for oxygen to supply both the mother and the developing fetus. Iron deficiency anemia occurs as a result of insufficient amounts of iron (needed to make hemoglobin) to meet oxygen demand. Iron deficiency anemia is associated with an increased risk for low birth weight, preterm delivery, and perinatal mortality.

Which part of the laryngeal cartilage is a full circular ring and is the narrowest part of the airway in young children?

A. Hyoid

B. Arytenoid

C. Cricoid

D. Thyroid

C. Cricoid

Think Cricoid - C for Circle

The nurse is administering warfarin. Prior to administering the dose, they review any contraindications that would require holding the medication. Which circ*mstances do not require the nurse to hold the prescribed dose of warfarin?

A. After the patient has tested positive for pregnancy.

B. After the patient has eaten a large kale salad.

C. While the patient is receiving epidural anesthesia.

D. When the patient has a platelet count below 30,000/mcL.

B. After the patient has eaten a large kale salad.

It is fine for the client to eat large kale salad beforehand. Kale salad contains high amount of vitamin K which is antagonizing towards warfarin. However, the nurse can let the physician know and we can monitor the INR levels and titrate the warfarin until therapeutic levels.

I picked C: client is receiving epidural anesthesia. This is wrong. While the client is on epidural, there’s a puncture site at the spine. The puncture site is a location possibly for bleeds. So if the client is on warfarin, the chances of them bleeding there increases.

You are working on a medical unit with an LPN/LVN. The interventions that can be delegated to the LPN/LVN include:

Select all that apply.

A. Tracheostomy care

B. Starting a blood transfusion

C. Irrigating a PICC line

D. Inserting a urinary catheter

Answer: A and D

LPN cannot do anything with blood transfusion or irrigate/ administer PICC line meds.

The school nurse is responding to a child who has suffered a penetrating eye injury on the playground, upon inspection. The nurse notes that a small wood chip is piercing the eye. What is this nurse’s primary intervention?

A. Remove the wood chip immediately

B. Have the student lie flat

C. Attempt to rinse the wood chip from the eye

D. Cover the eyes with a cup and tape it in place

D. Cover the eyes with a cup and tape it in place

The nurse’s first action should be to cover the eye with a cup and tape it in place so that the patient cannot further damage their eye by rubbing or touching the object. After this has been performed, the nurse should immediately contact the patient’s primary health care provider

I picked A, however, the nurse should never remove a penetrating object as it may be holding eye structures in place. The health care provider should perform this procedure.

The nurse should never remove ANY object stuck in the body!

The nurse is explaining immunizations to the parent of a pediatric patient. What type of acquired specific immunity would the Varicella vaccine fall under?

A. Natural active immunity

B. Artificial active immunity

C. Passive natural immunity

D. Passive artificial immunity

B. Artificial active immunity

Artificial = Made by people Natural = Obtained from nature

Active = Active / Live vaccinePassive = Non Live vaccine / dead virus with just the RNA

A community health nurse is evaluating different populations for risks of developing a latex allergy. Which of the following groups is at the highest risk of developing a latex allergy?

A. Kindergarteners

B. The homeless

C. Hospital housekeepers

D. Individuals with a lowered immune system

C. Hospital housekeepers

Reoccurring exposure to latex is responsible for increased risk of developing latex allergy.

Professionals who routinely wear latex gloves, such as housekeepers, nurses, or hairdressers are at a higher risk of developing a latex allergy than other populations.

The nurse is caring for a 5-year-old client whose family is of Orthodox Jewish faith. The mother requests that the client remains kosher while in the hospital. Which of the following actions while assisting the child with lunch would best respect the mother’s request?

A. Finding metal utensils instead of plastic

B. Placing the food on plastic plates instead of paper

C. Helping the child unwrap the plastic utensils from their packaging

D. Allowing the child and his mother to unwrap the eating utensils

D. Allowing the child and his mother to unwrap the eating utensils

It is appropriate to allow the child and the mother to unwrap the eating utensils. This is the only action listed that allows the child and the mother to remain kosher as requested.

When caring for an Amish patient, what does the nurse know to be true?

Select all that apply.

A. They use traditional and alternative health care.

B. Funerals are conducted in the home.

C. The authority of women and men are equal.

D. Many choose to live without health insurance.

E. Health is believed to be a gift from God.

Answer: A, B, D, E

Amish live a life that is generally strictly separate from society. While women are highly respected and valued, men hold the authority in the home. Traditional and alternative health care is appreciated, although many live without insurance. Health is believed to be a gift from God.

Women are respected in Amish society but do not hold authoritative power.

While working in a pediatric cardiac unit, you are assigned to take care of an infant with tetralogy of Fallot. During report, you are told that the infant is having frequent ‘tet spells’. To prepare for your shift, which medication do you ensure is readily available in case of a tet spell?

A. Morphine sulfate

B. Dexmedetomidine

C. Fentanyl

D. Atropine sulfate

A. Morphine sulfate

Morphine sulfate is the drug of choice for use during tet spells. It helps to calm the child down while simultaneously reducing the infundibular spasm that causes right ventricular outflow obstruction and therefore the hypercyanotic tet spell.

After talking to her family, an elderly client says that she wants to change the living will she wrote two weeks ago. The nurse’s most appropriate reply would be:

A. “You can only change your living will a year after it is formulated.”

B. “Let me see if I can find someone to help you.”

C. “You can only make changes to your will after 3 weeks.”

D. “Let’s call your lawyer first and see what he thinks.”

B. “Let me see if I can find someone to help you.”

Living wills can be changed by the client anytime and as many times as they wish as long as they are competent in making decisions. (Option A, C, D)

It is the nurse’s responsibility to be the client’s advocate. She should be responsible for finding someone that can help the client with her request.

After talking to her family, an elderly client says that she wants to change the living will she wrote two weeks ago. The nurse’s most appropriate reply would be:

A. “You can only change your living will a year after it is formulated.”

B. “Let me see if I can find someone to help you.”

C. “You can only make changes to your will after 3 weeks.”

D. “Let’s call your lawyer first and see what he thinks.”

B. “Let me see if I can find someone to help you.”

Living wills can be changed by the client anytime and as many times as they wish as long as they are competent in making decisions. (Option A, C, D)

It is the nurse’s responsibility to be the client’s advocate. She should be responsible for finding someone that can help the client with her request.

The nurse is preparing a 3-year-old child for an incision and drainage of a large left leg abscess. The nurse understands which of the following types of anesthesia will be administered to the child?

A. Peripheral nerve block

B. Spinal anesthesia

C. General Anesthesia

D. Local Anesthesia

C. General Anesthesia

A large leg abscess will need significant time for incision and drainage (I&D). Children who are not yet adolescents are not mature enough to cooperate adequately during such surgical procedures. Children undergoing most surgeries require general anesthesia because this minimizes their fears of intrusive or mutilating procedures. General anesthesia provides necessary sedation so the surgery can be safely performed.

The nurse is preparing a 3-year-old child for an incision and drainage of a large left leg abscess. The nurse understands which of the following types of anesthesia will be administered to the child?

A. Peripheral nerve block

B. Spinal anesthesia

C. General Anesthesia

D. Local Anesthesia

C. General Anesthesia

A large leg abscess will need significant time for incision and drainage (I&D). Children who are not yet adolescents are not mature enough to cooperate adequately during such surgical procedures. Children undergoing most surgeries require general anesthesia because this minimizes their fears of intrusive or mutilating procedures. General anesthesia provides necessary sedation so the surgery can be safely performed.

A nurse is evaluating an 83-year-old client who has been hospitalized after a fall. He has not had a bowel movement for five days, and a possible fecal impaction is suspected. Which assessment finding would be most indicative of fecal impaction?

A. Rigid, board-like abdomen

B. The client has lost the urge to defecate

C. Liquid stool

D. Complaints of abdominal pain

C. Liquid stool

Fecal impaction - the client has the urge to defecate but is unable to do so.

A liquid stool is usually observed as it is the only thing that will be able to pass around the impacted site.

Board like abdomen is associated with a perforated bowel.
Abdominal pain without enlargement is not associated with fecal impaction

The nurse is caring for a client who recently had a dosage increase of prescribed levothyroxine. Which of the following is a priority?

A. Weight

B. Heart rate

C. Activity status

D. Oral temperature

B. Heart rate

Heat rate because there’s a risk for the patient developing tachydysrhythmia. Therefore the HR is the priority.

The nurse is giving discharge instructions to the patient regarding his antihypertensive medication, amlodipine. Which statement by the client would necessitate further teaching from the nurse?

A. “I need to inform my doctor if I want to stop my medication.”

B. “I’ll just eat more whenever I feel nauseous.”

C. “I must take my medication an hour before my meal.”

D. “I don’t need to worry about dizziness because it will just pass after a few days.”

B. “I’ll just eat more whenever I feel nauseous.”

The client is instructed to eat small frequent meals when nausea develops, not eat more substantial meals.

A: This is true, no need for further teaching

C: They need to take 1 hr before their meal or 2 hrs after their meal.

You are selecting a toy to purchase for your 3-year-old niece. Which of the following choices are most appropriate for her age group?

A. Brightly colored foam blocks

B. Detailed coloring books and crayons

C. Lincoln logs

D. Light up mirror toy

C. Lincoln logs

Lincoln logs are an excellent choice for a three-year-old. These building blocks will allow the use of both fine and gross motor skills and imaginative play. The normal three-year-old should be able to assemble these blocks and have a long enough attention span to work on building something with them.

Not A - The blocks are more appropriate for a 12 month old as they develop gross motor skills and pincer grasp

Not B - complex coloring books will be frustrating for a 3 y/o

Not D - More appropriate for a 7 month old as they develop color vision and intrigued by sound and light.

The nurse has just finished administering two units of packed red blood cells (PRBCs) to a client with anemia. Before the blood transfusion, the client’s hemoglobin was 5.5 g/dL and hematocrit was 26%. The nurse would expect which laboratory values upon the next blood count?

A. Approximate hemoglobin of 10.5 g/dL and hematocrit of 32%

B. Approximate hemoglobin of 7.5 g/dL and hematocrit of 32%

C. Approximate hemoglobin of 10 g/dL and hematocrit of 33%

D. Approximate hemoglobin of 13 g/dL and hematocrit of 33%

B. Approximate hemoglobin of 7.5 g/dL and hematocrit of 32%

Each bag of RBCs increase the Hbg by 1 g/dL, and hematocrit of 3%, so two bags should increase the Hbg by 2 g/dL and hematocrit by 6%.

The nurse is caring for several geriatric clients. Which of the following should the nurse include in the teaching plan for older clients with altered immune responses? Select all that apply.

A. It is normal to run a slightly higher than normal temperature.

B. If arthritis pain begins to bother you, the doctor can prescribe something for pain.

C. I’d like to talk to you about ways to manage stress.

D. It is very important to eat a well-balanced diet.

Answer: B, C, D

Chronic pain and continued stress can negatively affect the immune system (Option B and C).
Additionally, the nurse should also educate the elderly clients to maintain a well-balanced diet to promote a healthy immune system. (Option D)

It is not normal to have a slightly higher temp, a low grade fever is still a fever. (Option A)

The nurse is preparing to suction a client to obtain a sputum sample. Before performing this procedure, the nurse should:

A. Hyperoxygenate the client

B. Provide the client with a small snack

C. Initiate NPO status

D. Confirm the order with the physician

A. Hyperoxygenate the client

Suctioning interrupts the patient’s breathing, so hyperoxygenation prevents hypoxia.

I picked B, but giving a snack is not a necessary action before suctioning.

You are working with a patient who suffers from obsessive-compulsive disorder (OCD). They are obsessed with the dangers of germs and compulsively wash their hands hundreds of times per day. Their skin has become red and raw. Which of the following should be included in the treatment plan for this patient?

Select all that apply.

A. Create a schedule for the hand washing ritual.

B. Teach them about the dangers of over washing their hands.

C. Add time for meditation to their daily schedule.

D. Remove the sink from their room so they are unable to wash their hands.

Answer: A, C

Creating a schedule may gradually decrease the amount of time they are allowed to practice the ritual.
Meditation is an excellent coping mechanism to replace handwashing.

I picked A and B.
B: Teaching the client about the dangers of over washing their hands will not be practical or therapeutic. This client is using the ritual of handwashing unconsciously to relieve their anxiety. They are not able to stop and will not be any more inclined to stop if they know it is terrible for them.

The nurse is caring for a client in the emergency department (ED) experiencing delirium tremens. The nurse should take which initial action?

A. Assess the client’s pain level.

B. Implement seizure precautions.

C. Obtain a prescription for chlordiazepoxide.

D. Administer the Glasgow Coma Scale (GCS).

B. Implement seizure precautions.

Delirium Tremens (DTs) is a medical emergency that may result in seizure activity. The nurse should always put the client’s safety at the forefront and provide seizure precautions.

I picked D, but the GCS is not a relevant assessment for DT. A withdrawal Assessment Alcohol Scale is used to determine the severity of withdrawal.

A common prerenal cause of acute kidney injury is:

A. Nephrotoxicity

B. Bladder cancer

C. Contrast media

D. Hypovolemia

D. Hypovolemia

Prerenal reasons are those factors that are external to the kidney. Hypovolemia causes a decrease in blood flow to the organs. Hypovolemia can lead to intrarenal kidney disease.

A and C - Intrarenal causes of AKI are those that cause direct damage to the kidneys, such as medications (nephrotoxicity) and contrast media injection.

B - Bladder cancer is a postrenal cause of AKI, as well as prostate hyperplasia.

Which of the following medications may be prescribed to control hypertension associated with a nephroblastoma?

A. Propranolol

B. Enalapril

C. Nitroprusside

D. Digoxin

B. Enalapril

Think about the RAAS system. ACE inhibitors disrupts the RAAS system. A pt with nephroblastoma may have increased renin in their system promoting HTN. So ACE inhibitors is a great choice for treating HTN caused by nephroblastoma.

The nurse is caring for a patient who had abdominal surgery three days before their assessment. Which sign is a normal part of wound healing and would not need to be reported to the nurse?

A. Serous drainage from the site

B. Warm and tender skin

C. Hardened and erythematic skin

D. Foul-smelling drainage from the site

A. Serous drainage from the site

Moderate amounts of serous drainage from the surgical site is an expected finding after abdominal surgery.

B, C, D are all indications of infection

The nurse is teaching a group of nursing students infectious diseases that are reportable to the local health department. Which of the following conditions should be reported?

Select all that apply.

A. Bacterial vaginosis

B. Herpes simplex virus (HSV)

C. Human immunodeficiency virus (HIV)

D. Hepatitis A

E. Syphilis

F. Human Papilloma Virus infection (HPV)

Answer: C, D, E

Infectious conditions are reportable to the local health department including Human immunodeficiency virus (Choice C), Hepatitis-A (Choice D) and Syphilis (Choice E).

Other reportable conditions include chlamydia, pulmonary tuberculosis, rabies, chickenpox, influenza, and gonorrhea. Healthcare providers have the responsibility to report these to the state/local health departments.

A 7-month-old infant on antibiotic therapy for seven days develops oral thrush. Nystatin oral drops 1 mL PO four times a day are prescribed. Which nursing consideration should be implemented when administering this medication?

A. Give the medication along with water

B. Give the medication through a nipple

C. Give the medication with food

D. Give 0.5 mL in each side of the mouth

D. Give 0.5 mL in each side of the mouth

Oral thrush is a fungal infection by the fungus, candida. For nystatin to be effective, it should come in contact with the infected area. Giving half of the dose on each side ensures that all sides of the mouth are covered in order to reach the infected area.

You are taking care of a 79-year-old African American woman on the general medical-surgical floor. While performing your assessment, you notice that she has a very flat affect, inferior communication skills, and seems to only be capable of concrete thinking. She even uses words you have never heard before. Which of the following illnesses do you suspect this woman may suffer from?

A. Bipolar disorder

B. Paranoid personality disorder

C. Schizophrenia

D. Panic disorder

C. Schizophrenia

These signs and symptoms are highly suggestive of schizophrenia. The nurse should speak with the healthcare team about her concerns and request a psychiatric consultation if not already done. Signs and symptoms of schizophrenia include: an inappropriate, flat, or blunted affect, focus on their inward world instead of reality, looseness of associations, echolalia, neologisms, word salad, delusions, hallucinations, and the inability to use abstract thinking skills.

The nurse is caring for an elderly client. The nurse would recognize which of the following statements as false regarding sensory changes in an older adult?

Select all that apply.

A. Increased acuity for high-pitched tones.

B. Decreased sensitivity to glare.

C. Increased tympanic membrane flexibility.

D. Diminished sound discrimination.

E. Decreased taste reception.

Choices A, B, & C are correct. These choices are incorrect regarding changes in the older adult and therefore the correct responses to the question. Older adults commonly experience a loss of acuity for high-pitched frequencies (presbycusis) due to changes in the inner ear such as sclerosis. As adults age, changes in the eye such as smaller pupils and decreased light accommodation can result in increased sensitivity to glare. Age-related changes in the ear also include a thickening of the tympanic membrane, rather than increased flexibility.

Choice D & E are incorrect. These answers describe correct changes in the older adult and therefore are incorrect responses to the question. Sound discrimination is altered in the aging adult, which makes it difficult to hear voices in areas with background noise, such as a television. A decrease in the number of taste buds often causes older clients to have difficulty distinguishing between sweet, sour, and bitter tastes.

Which of the following are substantial nursing interventions for a patient who is one-hour post-op from a cardiac catheterization?

Select all that apply.

A. Administer their regularly scheduled metformin on time.

B. Assess the pulse of the extremity distal to the puncture site.

C. Position them supine with the head of bed at 45 degrees.

D. Monitor for hematoma formation at the puncture site.

Answer: B, D

After a coronary cath, we want to monitor the site for pulse, cap refill, color of extremity, pain & numbness, movement of the extremity. (Option B)
We also want to monitor for bleeding at the site and notify the HCP if there is. (Option D)

Metformin should not be administered right after the procedure because of its reaction with the contrast dye during the cath procedure –> Lactic acidosis.
Withhold metformin for 48 hours!

Head of the bed after a cath lab should be flat or less than 30 degrees for 4 - 6 hours. This position prevents bleeding at the site until it can heal.

The nurse and the Licensed Practical Nurse (LPN) are assigned to a busy medical unit. Which of the following tasks would be appropriate for an LPN to do?

Select all that apply.

A. Reinforcing newborn care education to a 24-year-old first-time mother.

B. Adjustment of a 68-year-old stable patient’s cervical traction as ordered by the provider.

C. Obtaining a fecal occult blood sample from a 16-year-old patient with ulcerative colitis.

D. An assessment of a 36-year-old man newly admitted for chest pain.

Answer: A, B, C

Choices A, B, and C are correct. Initial teaching does not fall within the scope of practice of an LPN. A registered nurse always performs initial instruction. However, LPNs can “reinforce” education (Choice A) to a client. Generally, the tasks that require “critical thinking” should not be delegated to an LPN. Tasks such as obtaining stool samples for occult blood (Choice B) and following health care provider’s orders to adjust cervical traction (Choice C) are all within the scope of practice for an LPN and do not require a critical thinking process. LPNs can apply and remove the cervical collar on stable spinal patients.

The nurse and the Licensed Practical Nurse (LPN) are assigned to a busy medical unit. Which of the following tasks would be appropriate for an LPN to do?

Select all that apply.

A. Reinforcing newborn care education to a 24-year-old first-time mother.

B. Adjustment of a 68-year-old stable patient’s cervical traction as ordered by the provider.

C. Obtaining a fecal occult blood sample from a 16-year-old patient with ulcerative colitis.

D. An assessment of a 36-year-old man newly admitted for chest pain.

Answer: A, B, C

Choices A, B, and C are correct. Initial teaching does not fall within the scope of practice of an LPN. A registered nurse always performs initial instruction. However, LPNs can “reinforce” education (Choice A) to a client. Generally, the tasks that require “critical thinking” should not be delegated to an LPN. Tasks such as obtaining stool samples for occult blood (Choice B) and following health care provider’s orders to adjust cervical traction (Choice C) are all within the scope of practice for an LPN and do not require a critical thinking process. LPNs can apply and remove the cervical collar on stable spinal patients.

A client has been placed on a sodium-restricted diet following a myocardial infarction. Which of the following would be the most appropriate meals to suggest?

A. Turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk, and 1 orange.

B. Broiled fish, 1 baked potato, ½ cup canned beets, 1 orange, and milk.

C. Canned salmon, fresh broccoli, 1 biscuit, tea, and 1 apple.

D. A bologna sandwich, fresh eggplant, 2 oz fresh fruit, tea, and apple juice.

A. Turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk, and 1 orange.

Not B or C because canned foods are high in salt.
D - bologna meat is high in salt.

In caring for a client who underwent surgical repair of a detached retina of the right eye, which nursing action should the nurse include in the care plan?

Select all that apply.

A. The client should be placed in the prone position

B. Always approach the client from the left side

C. Instruct client to perform deep breathing and coughing exercises

D. Instruct client to avoid bending down

E. Orient client to his environment

F. Prevent constipation by administering a stool softener

Answer: B, D, E, F

The nurse should always approach the client from the unaffected side—in this case, the left side (Choice B), to avoid startling the client. The client should always be oriented to his environment to prevent unwarranted injury (Choice E). Activities that increase intraocular pressure, such as bending down (Choice D), should be avoided. Constipation and straining during defecation may increase intraocular pressure. Stool softeners (Choice F) are administered to avoid constipation.

The intraocular pressure increases significantly within 10 minutes after the patient is placed in the prone position (Choice A)

Bending down, deep breathing (Choice C), hard coughing, sneezing, and other activities that may increase intraocular pressure are discouraged.

As part of your psychosocial assessment of a 46-year-old female client, you would most likely assess which of the following in the client?

A. Level of development

B. Electrolyte levels

C. Affect

D. Effect

C. Affect

You would most likely assess the client’s affect and mood as part of your psychosocial assessment of a 46-year-old female client. For example, a flat affect indicates the abnormal absence of emotion.

The effect is an indicator of the client’s psychological disposition. The effect is the result of a cause and it is not related to the psychosocial assessment of clients. (D)

A - This assessment is mostly for pediatric
B - Electrolyte is a physical assessment

A client has a pressure ulcer with a shallow, partial skin ­thickness, eroded area but no necrotic areas. The nurse would treat the area with which dressing?

A. Alginate

B. Dry gauze

C. Hydrocolloid

D. No dressing is indicated

C. Hydrocolloid

Hydrocolloid dressings are moisture soaking dressings. These are great for an ulcer to minimize moisture and promote healing. (e.g. Baza creams)

Alginate are like Almagel dressings, these are antibacterial dressings that soak up significant drainage wounds.

The nurse is developing a plan of care for a client who had bariatric surgery. Which of the following should the nurse include?

A. Pneumatic compression devices

B. Insertion of an indwelling urinary catheter

C. Strict bed rest

D. Measure the abdominal girth

A. Pneumatic compression devices

After a bariatric surgery, the patient is at risk for hemorrhage, wound disruption, pneumonia, and infection. Venous thromboembolism is a significant complication and may be mitigated using pneumatic compression devices as well as chemical prophylaxis.

Catheter is not indicated for a client after bariatric surgery
Bed rest is not recommended because increase risk for DVT and pneumonia
Abdominal girth is measured after paracentesis or for pts with acites.

When the nurse notes an irregular radial pulse in a client, further evaluation should include assessing for which of the following?

A. The carotid pulse

B. Diminished peripheral circulation

C. The brachial pulse

D. A pulse deficit

D. A pulse deficit

When a radial pulse is irregular, the nurse should assess for a pulse deficit, which evaluates the heart’s ability to eject blood to the peripheral pulse. This is done by taking the apical pulse (of the heart) with the radial pulse.

Which of the following medications would be appropriate for the treatment of an allergic reaction to a blood transfusion?

Select all that apply.

A. Epinephrine

B. Acetaminophen

C. Diphenhydramine

D. Corticosteroids

Answer: A, C, D

Epinephrine, Diphenhydramine, and Corticosteroid drugs are used to treat allergic reactions resulting from a blood transfusion or any other allergen.

Diphenhydramine is used as premedication and treatment.
Corticosteroid is indicated in moderate to severe allergic reactions.
Epinephrine is indicated for severe allergic reactions (anaphylaxis).

Acetaminophen is not used to treat allergic reactions.

An RN is in charge of the unit with an LPN. Which situation indicates proper delegation of tasks by the RN?

A. The RN delegates to the LPN to check the circulation of the child with a forearm cast.

B. The LPN is tasked to feed a one-year old that just had a cleft palate repair.

C. The LPN demonstrates urinary catheterization to the mother of a child with neurogenic bladder.

D. The RN checks if the LPN completed all delegated tasks.

D. The RN checks if the LPN completed all delegated tasks.

Not A because its and assessment, completed by the RN
Not B because the one year old just had a cleft palate repair, risk for the child to damage his incision site and aspirate if he/she is fed by untrained personnel. This task is for the RN.
Not C because this is pt education

The nurse is assessing a client who has developed cardiac tamponade. Which of the following findings would the nurse expect to observe?

Select all that apply.

A. Bibasilar crackles

B. A systolic murmur

C. Bradycardia

D. Jugular Venous Distention

E. Hypotension

Choices D and E are correct.

Classic manifestations of cardiac tamponade include tachycardia, tachypnea, pericardial rub, jugular venous distention, and hypotension with a narrowed pulse pressure.

Bibasilar crackles, a systolic murmur, and bradycardia would not be consistent with cardiac tamponade. The client with cardiac tamponade would have tachycardia to increase cardiac output, coupled with a pericardial friction rub.

The occupational health nurse is conducting an in-service on reducing back injuries. It would be correct for the nurse to identify the most common location of the injury is the

A. cervical spine.

B. lumbar spine.

C. thoracic spine.

D. pelvis.

B. lumbar spine.

The most common area injured during lifting is the lumbar spine. This is because it supports the lower back.

A nurse is educating a client who just had a skin test for hypersensitivity reactions. The nurse should teach the client which of the following?

A. To ensure that the skin tested areas are kept moist with a mild lotion.

B. To keep out of direct sunlight until the tests are read.

C. To wash the sites every day with a mild soap.

D. To make sure that he comes back on the correct date for reading.

D. To make sure that he comes back on the correct date for reading.

The provider can analyze immediate hypersensitivity reactions soon after the test; however, delayed hypersensitivity reactions should be measured 48 -72 hours later.

A reading done too early or too late would give inaccurate and unreliable results.

Therefore, the nurse should make sure the client has a return appointment and emphasize the importance of getting the skin test site.

The site should be kept dry, and it is not necessary to wash the areas with soap. Direct sunlight will not affect the results; therefore, it’s inappropriate to educate the client to keep the skin test site out of direct sunlight specifically. (Options A, B, C)

Which of the following is true regarding therapeutic communication with infants (1 month to 12 months)?

Select all that apply.

A. They use crying as a means for communication and you should take their crying seriously.

B. They are able to comprehend 5-10 words at this age.

C. They respond to touch and therefore patting and rubbing are effective calming methods.

D. They respond better to a low-pitched voice.

Answer: A, C

At this age, most communication is still nonverbal. Infants use crying as a means for discussion and therefore you should take their crying seriously (Choice A). Infants are very responsive to touch. Patting, rocking, stroking, cuddling, and rubbing them are effective ways to calm them down. Therapeutic communication with an infant will be less focused on the actual words you say and more focused on how you interact with them to create a therapeutic environment (Choice C).

Infants are not able to comprehend words, they only respond to sound and voice. (Choice B)

Infants respond better to high pitched voices, not low (Choice D)

What ethical principle below is accurately paired with a way that ethical principle is applied to nursing practice?

A. Beneficence: Doing no harm during the course of nursing care.

B. Justice: The obligation to be fair; equally dividing time and other resources among a group of clients.

C. Veracity: Fully answering the client’s questions without any withholding of information.

D. Fidelity: Upholding the American Nurses Association’s Code of Ethics.

C. Veracity: Fully answering the client’s questions without any withholding of information.

Veracity is being completely truthful with patients; nurses must not withhold the true information from clients even when it may lead to patient distress.

Choice A is incorrect. Beneficence is doing good and the right thing for the patient. Nonmaleficence is doing no harm.

Choice B is incorrect. While the terms equity and equality may sound similar, implementing one versus the other results in different outcomes for clients in need. Equal distribution means each client is given the same amount of time and resources. Equitable distribution refers to the allocation of exact resources based on the needs of each client to reach an equal outcome. Justice is fairness. Nurses must be fair when they distribute care and resources equitably, which is not always equally among a group of patients. For example, a critically ill patient may require more resources than a less critical patient. This amounts to a fair decision-making process, leading to positive outcomes for both individuals.

Choice D is incorrect. Fidelity is the duty to keep promises; faithfulness.

A 80-year-old woman is brought to the clinic by her family with fever and changes in her mental status. When attempting to differentiate between delirium and dementia, you know that delirium is characterized by which of the following?

Select all that apply.

A. Abrupt onset

B. Change in psychom*otor activity

C. Irreversible

D. Lasts for months to years

Answer: A, B

An acute illness (fever, sepsis, infection) typically causes delirium, so delirium often has an abrupt onset (Choice A) with rapid progression. There are significant changes in activity resulting in hyperactivity or hypoactivity (Choice B). Delirium is typically reversible when the underlying illness is resolved. Delirium typically lasts for hours to days, whereas dementia lasts for months to years and is usually irreversible.

C and D are characteristics of Dementia.
Dementia has a variety of causes with gradual changes in mentation. In dementia, psychom*otor changes occur later in the disease; speech is sparse and may progress to mutism as the disease advances.

The nurse is caring for a client with tracing on the electrocardiogram show ventricular fibrillation. The nurse should perform which priority action?

A. Initiate a code blue.

B. Establish intravenous access.

C. Notify the primary healthcare physician (PHCP).

D. Assess the client’s airway, breathing, and circulation.

D. Assess the client’s airway, breathing, and circulation.

The tracing indicated that the client is experiencing ventricular fibrillation (Vfib). This is a fatal rhythm. However, the priority action of the nurse is to immediately establish the validity of this fatal arrhythmia tracing by assessing the client’s airway, breathing, and circulation. Ventricular fibrillation is characterized by a complete lack of coordinated contraction, resulting in chaotic electrical activity on the rhythm strip. Due to rapid ventricular contractions, the ventricular filling decreases markedly, leading to a significant decrease in cardiac output. Consequently, a pulse is absent. Clinically, at the time of the event, the patient should be pulseless, unconscious, and unresponsive.

I picked A, to initiate code blue. Please note that the same question may be presented differently with assessment findings disclosed within the question (e.g. information such as the patient is unresponsive and pulse is absent within the question stem), the answer would then be choice A (proceed with CPR and defibrillation because the assessment has already been completed).

The nurse is planning to assist a respiratory therapist in performing a chest physiotherapy procedure. Which of the following is the initial action by the nurse before the process?

A. Place a gown or fabric between the hands or percussion device and the client’s skin

B. Walk with the patient for a few laps around the unit to aid in percussion

C. Administer a prescribed bronchodilator

D. Call the physician to confirm x-ray results

C. Administer a prescribed bronchodilator

The nurse should make sure that the patient receives a prescribed bronchodilator about 15 minutes before their chest physiotherapy procedure. Chest physiotherapy is used to loosen secretions trapped in the lungs. When administered before this procedure, a bronchodilator helps to dilate the bronchioles and liquify secretions.

Which of the following statements regarding the anatomy of pediatric patients are true?

Select all that apply.

A. Pediatric patients have a smaller body surface area compared to adult patients.

B. Pediatric patients have a larger head in proportion to their body.

C. Pediatric patients have enlarged airway passages.

D. Pediatric patients have an immature blood brain barrier.

Answer: B, D

Pediatric patients have a more massive head in proportion to their bodies than adults do. When babies are born, their head makes up about 25% of their total length. As they grow, this proportion lessens until the head is about 12% of the overall body height around ten years of age.

Pediatric patients have an immature blood-brain barrier. The blood-brain wall is a filtering mechanism built into the blood vessels that carry blood to the brain. They are meant to block out the passage of substances that could be harmful to the brain, but this mechanism is immature in pediatric patients. This means that pediatric patients are more at risk of drugs or toxins entering their circulation, as these could pass into the brain and cerebrospinal column, causing damage.

Pediatric pts have a proportionally smaller body surface area compared to adult patients. Pediatric patients have a proportionally larger body surface area compared to adult patients. The body surface area is merely the total surface area of the human body. The smaller your patient is, the larger the ratio of surface area to the size of their body is. This means that younger children with proportionally large body surface areas will be more susceptible to medications and drugs that affect or are absorbed through their skin. (Option A)

Pediatric patients do not have enlarged airway passages; they have smaller airways than adults. Also, pediatric patients have immature lungs. This is why pediatric patients are at risk for respiratory illnesses such as asthma, RSV, and bronchiolitis. (Option C)