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0% 11 Please note after timer finished countdowning, quiz will be submitted automatically. Thanks for attempting the quiz Nclex Content Review Class Two Week Two Assessment The number of attempts remaining is 1 User Information 1 / 77 The nurse helps the health care provider perform a Pap smear on a client. When should the nurse instruct the client to carry out follow-up testing? A. Every 6 months B. Every year C. Every 3 years D. Every 5 years Answer- 3RATIONALE: The American Cancer Society (ACS) states that every woman should begin cervical cancer screening about 3 years after they begin having vaginal intercourse but no later than 21 years of age. Screening test should be performed every year if the regular Pap test is being used or every 2 years if the newer liquid-based Pap test is used. Beginning at age 30, women who have had three normal Pap results in a row may be screened every 2 to 3 years while women older than 30 may also be screened every 3 years with the use of either the conventional or the liquid-based Pap test, plus the human papillomavirus (HPV) test. Women 70 years or older who have had three or more normal Pap tests in a row and no abnormal Pap results in the preceding 10 years may choose to stop having Pap tests. Answer- 3RATIONALE: The American Cancer Society (ACS) states that every woman should begin cervical cancer screening about 3 years after they begin having vaginal intercourse but no later than 21 years of age. Screening test should be performed every year if the regular Pap test is being used or every 2 years if the newer liquid-based Pap test is used. Beginning at age 30, women who have had three normal Pap results in a row may be screened every 2 to 3 years while women older than 30 may also be screened every 3 years with the use of either the conventional or the liquid-based Pap test, plus the human papillomavirus (HPV) test. Women 70 years or older who have had three or more normal Pap tests in a row and no abnormal Pap results in the preceding 10 years may choose to stop having Pap tests. 2 / 77 Mr. Brown arrives in the Emergency Room with shortness of breath and edema. The physician prescribes a bolus of furosemide (Lasix) 80 mg IV push to be given STAT. The available vials are labeled “Furosemide 40 mg/2 mL.” How many ml of Lasix will the nurse give? A. 2 mL. B. 3 mL. C. 4 mL. D. 10 mL. Answer; 340mg = 2ml80mg = ?80 * 2/40 =160/40 =4ml Answer; 340mg = 2ml80mg = ?80 * 2/40 =160/40 =4ml 3 / 77 Order is for Heparin 8,000 units subcutaneously every 8 hours. Heparin is available in 10,000 units/mL. How many total mL would you administer in a day (24 hours)? Check Answer; 2.4mlComputations;First, we calculate the ml per dose8,000 units x 1ml/10,000 units = 0.8 ml administered with each dose.0.8ml/8 hrs x 24 hours = 2.4 ml administered in a 24 hour period. Answer; 2.4mlComputations;First, we calculate the ml per dose8,000 units x 1ml/10,000 units = 0.8 ml administered with each dose.0.8ml/8 hrs x 24 hours = 2.4 ml administered in a 24 hour period. 4 / 77 A client is referred to the hospital for complaints of back chronic back pain. A nurse performing a musculoskeletal assessment is inspecting the posterior aspect of the client’s posture as the client stands. After noting an exaggeration of the lateral curvature of the client’s thoracic spine, how does the nurse document this finding? A. Lordosis B. Scoliosis C. Kyphosis D. Osteoporosis Answer- 2RATIONALE: A lateral spinal curvature is called scoliosis. Kyphosis, or hunchback, is an exaggeration of the posterior curvature of the thoracic spine. Lordosis, or swayback, is an increased curvature of the spine at the cervical and lumbar regions. Scoliosis, kyphosis and lordosis can cause pain and discomfort that are a s a result of Loss of height is frequently an early sign of osteoporosis. Answer- 2RATIONALE: A lateral spinal curvature is called scoliosis. Kyphosis, or hunchback, is an exaggeration of the posterior curvature of the thoracic spine. Lordosis, or swayback, is an increased curvature of the spine at the cervical and lumbar regions. Scoliosis, kyphosis and lordosis can cause pain and discomfort that are a s a result of Loss of height is frequently an early sign of osteoporosis. 5 / 77 The charge nurse is supervising a newly transferred nurse employee who is performing an abdominal assessment of a client and preparing to auscultate for bowel sounds. The charge nurse determines that the nurse employee is using correct technique if which part of the abdomen is auscultated first? A. Left upper quadrant B. Left lower quadrant C. Right upper quadrant D. Right lower quadrant Answer- 4RATIONALE: Auscultation involves listening of the abdomen with a stethoscope. The correct order for abdominal assessment is inspection, auscultation, oercussion and then palpation. To auscultate for bowel sounds, the nurse places the diaphragm endpiece of the stethoscope lightly against the skin, then begins to auscultate in the right lower abdominal quadrant, in the area of the ileocecal valve, because bowel sounds are always present there normally. After auscultating the right lower quadrant, the nurse proceeds with the examination by auscultating the right upper quadrant next, followed by left upper quadrant and finally left lower quadrant. Answer- 4RATIONALE: Auscultation involves listening of the abdomen with a stethoscope. The correct order for abdominal assessment is inspection, auscultation, oercussion and then palpation. To auscultate for bowel sounds, the nurse places the diaphragm endpiece of the stethoscope lightly against the skin, then begins to auscultate in the right lower abdominal quadrant, in the area of the ileocecal valve, because bowel sounds are always present there normally. After auscultating the right lower quadrant, the nurse proceeds with the examination by auscultating the right upper quadrant next, followed by left upper quadrant and finally left lower quadrant. 6 / 77 A client who came for appointment to observe healing from previous lump removal is being seen by a health provider and a nurse. The nurse performing a breast examination is preparing to palpate the client’s breasts. In what position should the nurse assist the client to perform palpation? A. A supine position, with the arm on the side being examined positioned behind the head and a small pillow placed under the shoulder on the same side B. A standing position, with the client holding her hands firmly on her hips, with legs spread apart and head in midline position C. A supine position, with the arm on the side being examined positioned across the chest and a pillow placed under the head to avoid strain D. A standing position, with the client holding both arms above her head and looking right at what the nurse is doing to learn Answer- 1RATIONALE: To palpate the breasts, the nurse assists the client into a supine position and positions the client’s arm on the side being examined behind the head. A small pillow is placed under the shoulder on the same side. The nurse uses the pads of the first three fingers to gently compress the breast tissue against the chest wall and notes tissue consistency. Palpation is performed systematically, with care taken to ensure that the entire breast and tail are palpated. The other options are not positions that would allow effective palpation of the breast tissue Answer- 1RATIONALE: To palpate the breasts, the nurse assists the client into a supine position and positions the client’s arm on the side being examined behind the head. A small pillow is placed under the shoulder on the same side. The nurse uses the pads of the first three fingers to gently compress the breast tissue against the chest wall and notes tissue consistency. Palpation is performed systematically, with care taken to ensure that the entire breast and tail are palpated. The other options are not positions that would allow effective palpation of the breast tissue 7 / 77 A client presented to the hospital with complaints of being out of breath and is being seen by the HCP. The nurse sees that the health care provider noted resonance on percussion of the client’s posterior chest. How will the nurse interpret this finding? A. The client has normal, healthy lungs. B. The client has as heamothorax from an accident few years ago. C. Complication from too much smoking. D. the client has air trapped in the lungs. Answer- 1RATIONALE: Resonance on percussion is associated with healthy adult lung tissue. Hyperresonance is noted when too much air is present such as in the case of emphysema where it is trapped in the alveoli and pneumothorax where it is trapped in the pleural space leading to lung collapse. A dull note on percussion or hyporesonance indicates an abnormal density in the lungs, such as that noted in pneumonia, pleural effusion, or atelectasis or heamothorax or in the presence of a tumor. Answer- 1RATIONALE: Resonance on percussion is associated with healthy adult lung tissue. Hyperresonance is noted when too much air is present such as in the case of emphysema where it is trapped in the alveoli and pneumothorax where it is trapped in the pleural space leading to lung collapse. A dull note on percussion or hyporesonance indicates an abnormal density in the lungs, such as that noted in pneumonia, pleural effusion, or atelectasis or heamothorax or in the presence of a tumor. 8 / 77 Your patient weighs 140 lb. Order is for 0.9 mL/kg of body weight. How many mL should the patient get? Round to the nearest tenth. Check Answer; 57.2mlComputations;1kg = 2.2 pounds140/2.2 = 63.6 kg63.6 x 0.9 ml/kg = 57.2 ml Answer; 57.2mlComputations;1kg = 2.2 pounds140/2.2 = 63.6 kg63.6 x 0.9 ml/kg = 57.2 ml 9 / 77 The physician orders an IV with heparin at 500 units/hour. You have a bag with 100 units/mL of solution. How many milliliters per hour will you set on the IV infusion controller?. A. 7ml B. 6ml C. 5ml D. 8ml Answer: 5 ml/hourComputation:100 units = 1ml500 /100 * 1 = 5ml Answer: 5 ml/hourComputation:100 units = 1ml500 /100 * 1 = 5ml 10 / 77 The physician orders an IV with heparin at 500 units/hour. You have a bag with 100 units/mL of solution. How many milliliters per hour will you set on the IV infusion controller?. A. 7ml B. 6ml C. 5ml D. 8ml Answer: 5 ml/hourComputation:100 units = 1ml500 /100 * 1 = 5ml Answer: 5 ml/hourComputation:100 units = 1ml500 /100 * 1 = 5ml 11 / 77 The nurse is caring for a client with end stage live disease who was admitted for bleeding esophageal varices. The bleeding varices were banded successfully but the client declined having a transjugular intrahepatic portal systemic shunt(TIPS) procedure and opted for a do-not-resuscitate (DNR) status. Which topic is most important for the nurse to discuss with the client and family at discharge? A. The importance of calling the healthcare provider immediately if bleeding recurs B. The purpose and use of the DNR bracelet C. Complete abstinence from alcohol D. Proper use of medications including lactulose Ans: 2RATIONALE: A client who opted for DNR in the hospital should be discharged with a DNR bracelet or an active Physician Orders for Life Sustaining Treatment (POLST) form in the community setting.This should be done to ensure that the client’s wishes for emergency care will be carried out by first responders.In other words, DNR bracelet and POLST forms are community based systems that provide emergency responders with legal documentation needed to withhold resuscitation.This client had end stage liver disease and is at high risk for life threatening events such as bleeding esophageal varices and hepatic encephalopathy. This client continues to be at risk for bleeding varices due to the declined TIPS procedure which could have prevented further esophageal varices by treating the portal hypertension. Hence, discharge home teaching must include proper use of DNR bracelet at all times in the community. Ans: 2RATIONALE: A client who opted for DNR in the hospital should be discharged with a DNR bracelet or an active Physician Orders for Life Sustaining Treatment (POLST) form in the community setting.This should be done to ensure that the client’s wishes for emergency care will be carried out by first responders.In other words, DNR bracelet and POLST forms are community based systems that provide emergency responders with legal documentation needed to withhold resuscitation.This client had end stage liver disease and is at high risk for life threatening events such as bleeding esophageal varices and hepatic encephalopathy. This client continues to be at risk for bleeding varices due to the declined TIPS procedure which could have prevented further esophageal varices by treating the portal hypertension. Hence, discharge home teaching must include proper use of DNR bracelet at all times in the community. 12 / 77 For the patient with no healthcare coverage who is seeking medical care, the emergency department staff members decide whether to provide care or transport to a public facility based on which law, enacted by Congress in 1986 and updated in 2003? A. Health Insurance Portability and Accountability Act (HIPAA) B. Emergency Medical Treatment and Active Labor Act (EMTALA) C. Patient Self-Determination Act (PSDA) D. Newborns' and Mothers' Health Protection Act (NMHPA) Answer: 2RATIONALE: The intent of the Emergency Medical Treatment and Active Labor Act (EMTALA) is to ensure public access to emergency services regardless of ability to pay. The EMTALA prohibits “patient dumping,” which is transferring indigent or uninsured patients from a private hospital to a public hospital without appropriate screening and stabilization. An exception is made if a hospital does not have the capability to stabilize a patient or if the patient requests a transfer. However, the hospital has to ensure that the patient is released to or transported with proper medical personnel. Answer: 2RATIONALE: The intent of the Emergency Medical Treatment and Active Labor Act (EMTALA) is to ensure public access to emergency services regardless of ability to pay. The EMTALA prohibits “patient dumping,” which is transferring indigent or uninsured patients from a private hospital to a public hospital without appropriate screening and stabilization. An exception is made if a hospital does not have the capability to stabilize a patient or if the patient requests a transfer. However, the hospital has to ensure that the patient is released to or transported with proper medical personnel. 13 / 77 A nurse performing a physical assessment of a client is checking the client’s mouth and throat. As part of the assessment, the nurse plans to assess the function of cranial nerve X. Which of the following best indicates adequate functioning of this nerve? A. The client is asked to laugh. B. The client is asked to brush and check for gag reflex. C. The client is asked to move the tongue inside their mouth. D. The client is asked to say “ah” as the tongue is depressed with a tongue blade. Answer- 4RATIONALE: To assess the function of cranial nerve XII (the hypoglossal nerve), the nurse asks the client to stick out the tongue. The nurse then notes the forward thrust in the midline as the client protrudes the tongue. The nurse also asks the client to verbalize certain words and then listen for clear, distinct speech. The motor function of cranial nerves IX (the glossopharyngeal nerve) and X (the vagus nerve) is tested by depressing the client’s tongue with a tongue blade and noting pharyngeal movement as the client says “ah.” To test cranial nerve VII (the facial nerve), the nurse asks the client to frown or show his teeth. You don’t ask a client to laugh to observe any of the cranial nerve. Answer- 4RATIONALE: To assess the function of cranial nerve XII (the hypoglossal nerve), the nurse asks the client to stick out the tongue. The nurse then notes the forward thrust in the midline as the client protrudes the tongue. The nurse also asks the client to verbalize certain words and then listen for clear, distinct speech. The motor function of cranial nerves IX (the glossopharyngeal nerve) and X (the vagus nerve) is tested by depressing the client’s tongue with a tongue blade and noting pharyngeal movement as the client says “ah.” To test cranial nerve VII (the facial nerve), the nurse asks the client to frown or show his teeth. You don’t ask a client to laugh to observe any of the cranial nerve. 14 / 77 nurse is preparing to perform the Rinne’s test in a client who reports loss of hearing in one ear. In which anatomic area should the nurse place the stem of the vibrating tuning fork to perform the test? A. beside the ear lobe in front of the ear B. In the midline of the forehead C. On the mastoid process D. At the side with hearing loss on the upper jaw Answer- 3RATIONALE: In Rinne test, the stem of a vibrating tuning fork is placed on the client’s mastoid process. When the client no longer hears the sound, the tuning fork is quickly inverted and placed near the ear canal; the client should again hear the sound. Normally the sound is heard twice as long by way of air conduction (near the ear canal) than by way of bone conduction (at the mastoid process). In the Weber test, the stem of the vibrating tuning fork is placed in the midline of the client’s skull. Normally the client should hear the tone, by way of bone conduction through the skull, equally in the two ears. In Placing the tuning fork at the temporal lobe on the side with hearing loss is not a component of a tuning fork test. Answer- 3RATIONALE: In Rinne test, the stem of a vibrating tuning fork is placed on the client’s mastoid process. When the client no longer hears the sound, the tuning fork is quickly inverted and placed near the ear canal; the client should again hear the sound. Normally the sound is heard twice as long by way of air conduction (near the ear canal) than by way of bone conduction (at the mastoid process). In the Weber test, the stem of the vibrating tuning fork is placed in the midline of the client’s skull. Normally the client should hear the tone, by way of bone conduction through the skull, equally in the two ears. In Placing the tuning fork at the temporal lobe on the side with hearing loss is not a component of a tuning fork test. 15 / 77 A nurse performing a neck assessment of a client is testing the status of cranial nerve XII. Which of the following best indicates that the client has adequate function of this nerve? A. The client can wink and smile. B. The client can lift the eyebrows effectively. C. The client can open their mouth and stick out the tongue. D. The client can shrug the shoulders against resistance. Answer- 3RATIONALE: There are 12 cranial nerves and they are cranial nerve 1- olfactory nerve, 2- optic nerve, 3- oculomotor nerve, 4- trochlear nerve, 5- trigeminal nerve, 6- abducens nerve, 7- facial nerve, 8- vestibulocochlear nerve, 9- glossopharengeal nerve, 10- vagus nerve, 11- spinal accessory nerve, 12- hypoglossal nerve. Cranial nerve XI (spinal accessory nerve) is tested by asking the client to shrug the shoulders against the resistance of the nurse’s hand and to turn the head to each side as the nurse tries to resist the client’s movement. Cranial nerve VII (the facial nerve) is tested by asking the client to smile, frown, close the eyes tightly against the resistance of the nurse, lift the eyebrows, show the teeth, and puff the cheeks. Cranial nerve XII (the hypoglossal nerve) is tested by inspecting the tongue as the client sticks out the tongue. Answer- 3RATIONALE: There are 12 cranial nerves and they are cranial nerve 1- olfactory nerve, 2- optic nerve, 3- oculomotor nerve, 4- trochlear nerve, 5- trigeminal nerve, 6- abducens nerve, 7- facial nerve, 8- vestibulocochlear nerve, 9- glossopharengeal nerve, 10- vagus nerve, 11- spinal accessory nerve, 12- hypoglossal nerve. Cranial nerve XI (spinal accessory nerve) is tested by asking the client to shrug the shoulders against the resistance of the nurse’s hand and to turn the head to each side as the nurse tries to resist the client’s movement. Cranial nerve VII (the facial nerve) is tested by asking the client to smile, frown, close the eyes tightly against the resistance of the nurse, lift the eyebrows, show the teeth, and puff the cheeks. Cranial nerve XII (the hypoglossal nerve) is tested by inspecting the tongue as the client sticks out the tongue. 16 / 77 A nurse performing a skin assessment of a client with congestive heart failure observes that the client’s ankles are swollen. To assess the severity of the edema, the nurse presses the skin at the ankle. deep pitting is present and the indentation remained for a short while. How should the nurse document this finding? A. 1+ edema B. 2+ edema C. 3+ edema D. 4+ edema Answer- 3RATIONALE: If one has congestive heart failure, one or both of the heart’s chambers lose their ability to pump blood effectively. As a result, blood cam back up in the legs, ankles and feet causing edema. Edema is the accumulation of fluid in the intercellular spaces. To check for edema, the nurse presses the thumbs firmly against the ankle malleolus. If the pressure leaves a dent in the skin, pitting edema is present. Edema is graded on a 4-point scale: 1+ indicates mild pitting with a slight indentation, 2+ is moderate pitting in which the indentation subsides rapidly, 3+ represents deep pitting in which the indentation remains for a short time and the ankle is swollen, and 4+ denotes very deep pitting in which the indentation remains for a long time and the ankle is very swollen. Answer- 3RATIONALE: If one has congestive heart failure, one or both of the heart’s chambers lose their ability to pump blood effectively. As a result, blood cam back up in the legs, ankles and feet causing edema. Edema is the accumulation of fluid in the intercellular spaces. To check for edema, the nurse presses the thumbs firmly against the ankle malleolus. If the pressure leaves a dent in the skin, pitting edema is present. Edema is graded on a 4-point scale: 1+ indicates mild pitting with a slight indentation, 2+ is moderate pitting in which the indentation subsides rapidly, 3+ represents deep pitting in which the indentation remains for a short time and the ankle is swollen, and 4+ denotes very deep pitting in which the indentation remains for a long time and the ankle is very swollen. 17 / 77 A nurse is performing an abdominal assessment of a client who complains of right lower abdomial pain. Which method should the nurse use to palpate the abdomen? A. Palpating tender or painful areas last B. Pressing the client’s skin with short, sharp strokes C. Using the thumbs to unknot the pain in the right lower quadrant and then carry out an ultrasound. D. Starting with deep palpation to check the internal organs, then performing light palpation to check for surface lump. Answer- 1RATIONALE: In palpation of the abdomen, the nurse starts with light palpation to detect surface characteristics and accustom the client to being touched before performing deeper palpation but not too deep. To detect deeper abnormalities, an ultrasound can be prescribed by the HCP. The nurse should ask client to locate tender painful areas first so that these areas may be palpated last. The nurse uses one hand to palpate except when certain organs (e.g., kidneys, uterus, adnexa) are being palpated. The nurse avoids any situation in which deep palpation might cause internal injury or pain. Percussion is the act of tapping the client’s skin with the use of short, sharp strokes to assess underlying structures. Answer- 1RATIONALE: In palpation of the abdomen, the nurse starts with light palpation to detect surface characteristics and accustom the client to being touched before performing deeper palpation but not too deep. To detect deeper abnormalities, an ultrasound can be prescribed by the HCP. The nurse should ask client to locate tender painful areas first so that these areas may be palpated last. The nurse uses one hand to palpate except when certain organs (e.g., kidneys, uterus, adnexa) are being palpated. The nurse avoids any situation in which deep palpation might cause internal injury or pain. Percussion is the act of tapping the client’s skin with the use of short, sharp strokes to assess underlying structures. 18 / 77 A client whose mother has just died from breast cancer 6 months ago comes to the clinic after finding a lump in her right breast during breast self-examination. The client says, “I always knew I will end up like my mother”. What am I going to do?” Which response should the nurse give the client? A. "Tell me how you are feeling?" B. "Most lumps found in the breast aren't cancerous, so relax." C. "Let's talk again after the doctor examines you." D. "You shouldn't talk like that; what happened to your mother was unfortunate but yours wont end like hers." Answer- 1RATIONALE: The nurse should always focus on the client’s feelings and concerns and respond so that the client is provided an opportunity to discuss feelings. “Tell me how you are feeling” is the only option that gives the client this opportunity to express her worries. The other options are nontherapeutic and place the client’s feelings on hold. Telling the client to relax may end up agitating the client more as she may perceive that you are not taking her serious. Telling her she won’t end up like her mother is false reassurance and shouldn’t be used on any patient. Answer- 1RATIONALE: The nurse should always focus on the client’s feelings and concerns and respond so that the client is provided an opportunity to discuss feelings. “Tell me how you are feeling” is the only option that gives the client this opportunity to express her worries. The other options are nontherapeutic and place the client’s feelings on hold. Telling the client to relax may end up agitating the client more as she may perceive that you are not taking her serious. Telling her she won’t end up like her mother is false reassurance and shouldn’t be used on any patient. 19 / 77 A nurse collects subjective and objective data from a client who underwent surgery after sustaining a spinal cord injury and is now on braces. The nurse identifies which findings as objective data? Select all that apply. A. Temperature is 99.9° F (37.2°C). B. The client complains of leg pain. C. Blood pressure is 110/78 mm Hg. D. The client’s friend confides in the nurse that the client is in pain. E. The client tells the nurse that he feels warm. Answer- 1,3RATIONALE:: Objective data are the findings collected by the nurse while inspecting, percussing, palpating, and auscultating or observations made by the nurse during data collection. Subjective data are the things the client says about himself or herself or what a family member or significant other says about the client during history-taking. Objective data also include information from the client’s health record and the results of laboratory, diagnostic studies and facial expression of the clients. The client’s temperature and blood pressure readings are objective data, while the client’s complaint of leg pain, feeling of warmth as well as his friend’s complaint to the nurse are all subjective data. Answer- 1,3RATIONALE:: Objective data are the findings collected by the nurse while inspecting, percussing, palpating, and auscultating or observations made by the nurse during data collection. Subjective data are the things the client says about himself or herself or what a family member or significant other says about the client during history-taking. Objective data also include information from the client’s health record and the results of laboratory, diagnostic studies and facial expression of the clients. The client’s temperature and blood pressure readings are objective data, while the client’s complaint of leg pain, feeling of warmth as well as his friend’s complaint to the nurse are all subjective data. 20 / 77 A nurse monitors a terminally I’ll client for which physical signs of approaching death? Select all that apply. A. Increased appetite B. Loss of consciousness C. Loss of bowel control D. Loss of bladder control E. Decreased blood pressure F. Decreased tactile sensation Ans: 2,3,4,5,6RATIONALE: Physical signs of approaching death include: decreased appetite/thirst, decreased blood pressure, loss of consciousness, loss of bowel and bladder control and decreased tactile sensation. Ans: 2,3,4,5,6RATIONALE: Physical signs of approaching death include: decreased appetite/thirst, decreased blood pressure, loss of consciousness, loss of bowel and bladder control and decreased tactile sensation. 21 / 77 A nurse employed in a hospital is waiting to receive a report from the laboratory via the fax machine. The fax machine activates and the nurse expects the report, but instead receives a sexually-oriented photograph. The appropriate initial nursing action is to: A. Cut up the photograph and throw it away. B. Call the police C. Call the laboratory and ask for the individual's name who sent the photograph. D. Call the nursing supervisor and report the incident. Ans: 3RATIONALE: Sexual harassment in the workplace is prohibited by state and federal laws. Sexually suggestive jokes, touching , pressuring a co-worker for a date, and open displays of or transmitting sexually-oriented photographs or posters are examples of sexual harassment by another worker. If the nurse believes that he or she is being subjected to unwelcome sexual conduct, these concerns should be reported to nursing supervisor with immediate effect. Calling police is unnecessary at things this material time. Cutting the photograph and asking for sender’s name are inappropriate initial actions. Ans: 3RATIONALE: Sexual harassment in the workplace is prohibited by state and federal laws. Sexually suggestive jokes, touching , pressuring a co-worker for a date, and open displays of or transmitting sexually-oriented photographs or posters are examples of sexual harassment by another worker. If the nurse believes that he or she is being subjected to unwelcome sexual conduct, these concerns should be reported to nursing supervisor with immediate effect. Calling police is unnecessary at things this material time. Cutting the photograph and asking for sender’s name are inappropriate initial actions. 22 / 77 Bumetamide (Bumex) 0.5 mg IV bolus bid was prescribed; Reconstitution instructions: Constitute to 1000 micrograms/3.1 mL with 4.8mL of 5% Dextrose Water for Injection. How many mL will you administer? Fill in the blanks. Record your answer using one decimal place. Check Answer: (1.5) mL.Computation:1 mg = 1,000 mcgRequired strength = 0.5mgAvailable strength = 1000mcg = 1mgAvailable volume = 3.1mlRequired volume = ?0.5 * 3.1 / 1 = 1.55 = 1.5 ml Answer: (1.5) mL.Computation:1 mg = 1,000 mcgRequired strength = 0.5mgAvailable strength = 1000mcg = 1mgAvailable volume = 3.1mlRequired volume = ?0.5 * 3.1 / 1 = 1.55 = 1.5 ml 23 / 77 Your patient has had the following intake: 10 oz glasses of iced tea, 5 oz cartons of grape juice, ¾ pt of ice cream, 35 oz of juice, 1 ½ L of D5W IV and 6 oz of cottage cheese. What will you record as the total intake in mL for this patient? Fill in the blanks. Check Answer; 3375 ml 1 oz = 30ml1 pt = 500 ml300 + 150 + 375 + 1050 + 1500 = 3375 mlCottage cheese is not liquid at room temperature, so it is not included when calculating intake. Answer; 3375 ml 1 oz = 30ml1 pt = 500 ml300 + 150 + 375 + 1050 + 1500 = 3375 mlCottage cheese is not liquid at room temperature, so it is not included when calculating intake. 24 / 77 MD writes an order for Lortab Elixir 4mg by mouth as needed for pain every 4 hours. Pharmacy dispenses you with 7.5mg/15ml. How many tablespoons will you administer per dose? A. 1 Tbsp/dose B. 8 Tbsp/dose C. 0.6 Tbsp/dose D. 0.25 Tbsp/dose The answer is 3.Available strength; 7.5mgAvailable volume; 15mlRequired strength; 4mgRequired volume; ?15 * 4 / 7.5 = 8 ml1Tbsp = 14 ml? = 8ml? = 8/14 * 1? = 0.57 Tbs = 0.6 Tbsp /dose The answer is 3.Available strength; 7.5mgAvailable volume; 15mlRequired strength; 4mgRequired volume; ?15 * 4 / 7.5 = 8 ml1Tbsp = 14 ml? = 8ml? = 8/14 * 1? = 0.57 Tbs = 0.6 Tbsp /dose 25 / 77 A nurse is caring for a client with Wernicke-Korsakoff syndrome. The nurse teaches the client to consume thiamine-rich food. The nurse determines that the client understands the dietary instructions if he selects which of the following from his menu? A. Chicken. B. Milk. C. Beef. D. Brocolli. Answer; CFood sources of thiamin include beef, liver, nuts, oats, oranges, pork, eggs, seeds, legumes, peas and yeast.Option A: Poultry contains niacin.Option B: Milk contains vitamins A, D, and B2.Option D: Broccoli contains folic acid, vitamins C, E, and K. Answer; CFood sources of thiamin include beef, liver, nuts, oats, oranges, pork, eggs, seeds, legumes, peas and yeast.Option A: Poultry contains niacin.Option B: Milk contains vitamins A, D, and B2.Option D: Broccoli contains folic acid, vitamins C, E, and K. 26 / 77 Two new graduate nurses in the elevator are discussing the COVID19-positive status of a client. One of the clients’ family members is in the elevator and overhears the conversation between the newly graduated nurses. Which of the following statements is true? A. The state board of nursing can discipline the newly graduated nurses' licenses. B. The students have violated the Health Insurance Portability and Accountability Act. C. The client can sue the student nurses for slander and libel. D. The students have violated the Emergency Medical Treatment and Active Labor Ac Ans: 2 The students have violated the Health Insurance Portability and Accountability Act(HIPAA). The new graduate nurses had released the client’s protected personal information to a third party without the patient’s consent and to those who do not have a medical or business need to know. This is a HIPAA violation. Ans: 2 The students have violated the Health Insurance Portability and Accountability Act(HIPAA). The new graduate nurses had released the client’s protected personal information to a third party without the patient’s consent and to those who do not have a medical or business need to know. This is a HIPAA violation. 27 / 77 A nurse employed in a surgical unit in a hospital arrives at work and is told to report/float to the pediatric unit for the day because the unit is understaffed and the census on the pediatric unit is unusually high. The nurse has never worked in the pediatric unit and does not want to float to pediatrics. Which action by the nurse is appropriate? A. Call the nursing supervisor to discuss the request to report to pediatrics. B. Refuse and reject to float to pediatrics. C. Tell the supervisor that she needs to go home because of illness. D. Convince another nurse to float to the pediatric unit. Ans: 1Floating may be acceptable legal practice used by hospitals to solve their understaffing problems, enhance efficiency and reduce staffing costs. Usually a nurse cannot refuse to float unless a union contract guarantees that nurses can work in a specified area or unless the nurse can prove the lack of knowledge for the performance of assigned tasks. When met with this situation the nurse should set priorities and identify potential areas of harm to the client. Nurses must be aware of state statutes and case law when asked to perform services outside of their usual area of practice. The nurse should never perform tasks or render or perform tasks or render services when he or she lacks the knowledge and skills to act competently. It is not appropriate to attempt to convince another nurse to go to the pediatric unit. As a nurse, never refuse to work in another unit. Floating to other unit as an experienced nurse is better than no nurse in that unit. Ans: 1Floating may be acceptable legal practice used by hospitals to solve their understaffing problems, enhance efficiency and reduce staffing costs. Usually a nurse cannot refuse to float unless a union contract guarantees that nurses can work in a specified area or unless the nurse can prove the lack of knowledge for the performance of assigned tasks. When met with this situation the nurse should set priorities and identify potential areas of harm to the client. Nurses must be aware of state statutes and case law when asked to perform services outside of their usual area of practice. The nurse should never perform tasks or render or perform tasks or render services when he or she lacks the knowledge and skills to act competently. It is not appropriate to attempt to convince another nurse to go to the pediatric unit. As a nurse, never refuse to work in another unit. Floating to other unit as an experienced nurse is better than no nurse in that unit. 28 / 77 A client receives cardiopulmonary resuscitation in the emergency department, but it is unsuccessful. The wife of the client indicates that the client is an organ donor and that they want to donate the client’s eyes. Which should the nurse implement first to promote organ transplantation? A. Ask the wife to produce the legal documents supporting the donation B. Confirm that the client is a valid donor with an organ registry C. Place the client in a supine position with the head on one pillow D. Cover the eyes with wet saline gauze pads and small ice packs Ans: 4 When a corneal donor dies, the eyes are closed, covered with sterile gauze pads wet with saline, and cooled with small ice packs. Within 2 to 4 hours the eyes are harvested, and the cornea is usually transplanted within 24 to 48 hours after harvesting. The head of the bed is elevated 30 to 45 degrees to prevent edema and tissue damage. Calling an organ registry and asking the wife to produce documents does not promote organ transplantation. Ans: 4 When a corneal donor dies, the eyes are closed, covered with sterile gauze pads wet with saline, and cooled with small ice packs. Within 2 to 4 hours the eyes are harvested, and the cornea is usually transplanted within 24 to 48 hours after harvesting. The head of the bed is elevated 30 to 45 degrees to prevent edema and tissue damage. Calling an organ registry and asking the wife to produce documents does not promote organ transplantation. 29 / 77 The nursing instructor provides a lecture to nursing students regarding the issue of client’s rights and asks a nursing student to identify a situation that represents an example of invasion of client privacy. Which of the following, if identified by the student, indicates an understanding of a violation of this client right? A. Performing a procedure without consent B. Threatening to give a client a medication C. Telling the client that he or she cannot leave the hospital D. Observing care provided to the client without the client's permission Ans: 4 Invasion of privacy takes place with unreasonable intrusion into an individual’s private affairs. Performing a procedure without consent is an example of battery. Threatening to give a client a medication constitutes assault. Telling the client that the client cannot leave the hospital constitutes false imprisonment. Ans: 4 Invasion of privacy takes place with unreasonable intrusion into an individual’s private affairs. Performing a procedure without consent is an example of battery. Threatening to give a client a medication constitutes assault. Telling the client that the client cannot leave the hospital constitutes false imprisonment. 30 / 77 The nurse is providing postmortem care for a client who just died after a protracted illness. The client had a do-not-resuscitate order in place at the time of death. A family member was at the bedside when the client died. What interventions should the nurse include during postmortem care? Select all that apply. A. Remove lines and tubes from the body B. Allow family member to assist with care C. Remove the client's dentures D. Call the medical examiner for an autopsy E. Place a pad under the perineum Ans: 2,4,5.RATIONALE: Before initiating postmortem care, the care nurse must consider the need for autopsy and confirm maybe the client is an organ donor. Postmortem care must be done with respect and dignity. Opportunities to participate in the care must be extended to the family and allow religious and cultural rituals when possible.Procedure to perform postmortem care include: -Maintain standard or isolation precautions in place at the time of death. – Gently close the client’s eyes – Remove tubes and dressings following facility protocols. However, these should be left in place only when an autopsy or organ harvest is pending. – Straighten and wash the body and change the linens – Handle the body carefully as tissue damage and bruising occur easily after circulation has stopped. – Replace dentures so that the face maintains its shape. it is difficult to place dentures once rigor mortis sets in. – A towel folded under the chin may be needed to keep the jaw closed. – Place a pad under the perineum to absorb any stool or urine leaking from relaxed sphincters. -Raise the head of the bed to prevent blood from pooling and discoloring the face. – Remove equipment and soiled linens from the room. -Give client belongings to a family member or send with the body to the morgue. Ans: 2,4,5.RATIONALE: Before initiating postmortem care, the care nurse must consider the need for autopsy and confirm maybe the client is an organ donor. Postmortem care must be done with respect and dignity. Opportunities to participate in the care must be extended to the family and allow religious and cultural rituals when possible.Procedure to perform postmortem care include: -Maintain standard or isolation precautions in place at the time of death. – Gently close the client’s eyes – Remove tubes and dressings following facility protocols. However, these should be left in place only when an autopsy or organ harvest is pending. – Straighten and wash the body and change the linens – Handle the body carefully as tissue damage and bruising occur easily after circulation has stopped. – Replace dentures so that the face maintains its shape. it is difficult to place dentures once rigor mortis sets in. – A towel folded under the chin may be needed to keep the jaw closed. – Place a pad under the perineum to absorb any stool or urine leaking from relaxed sphincters. -Raise the head of the bed to prevent blood from pooling and discoloring the face. – Remove equipment and soiled linens from the room. -Give client belongings to a family member or send with the body to the morgue. 31 / 77 The nurse is instructing a client with iron deficiency anemia on the importance of choosing foods high in iron. The nurse should encourage the client to select which of the following foods? A. Nuts and fish. B. Oranges and dark green leafy vegetables. C. Butter and margarine. D. Sugar and candy. Answer; 2 Oranges and dark green leafy vegetables.Dark green leafy vegetables are rich in iron while oranges are a good source of vitamin C, which enhances iron absorption. Answer; 2 Oranges and dark green leafy vegetables.Dark green leafy vegetables are rich in iron while oranges are a good source of vitamin C, which enhances iron absorption. 32 / 77 A client who is recovering from a surgery has been ordered a clear liquid diet. The nurse would offer which item to the client? A. Custard. B. Carbonated beverages. C. Fudge popsicle. D. Pudding. Answer; 2A clear liquid diet consists of foods that are relatively transparent to light and liquid at room and body temperature. Foods allowed on the clear liquid diet (bouillon, clear popsicles, plain gelatin, ice chips, sweetened tea or coffee (no creamer), carbonated beverages, and water) Answer; 2A clear liquid diet consists of foods that are relatively transparent to light and liquid at room and body temperature. Foods allowed on the clear liquid diet (bouillon, clear popsicles, plain gelatin, ice chips, sweetened tea or coffee (no creamer), carbonated beverages, and water) 33 / 77 A nurse is caring for a patient who has a colostomy. Which food would you advice the patient to avoid? A. Cherries, Radishes, and Watermelon B. Caraway seeds, tomato soup, and eggs C. Chicken, grapes, and raspberries D. Squash, Spinach, and Pickles Answer; 1Cherries, Radishes, and Watermelon are gas-causing foods and should be avoided in a patient with colostomy Answer; 1Cherries, Radishes, and Watermelon are gas-causing foods and should be avoided in a patient with colostomy 34 / 77 A patient has a low magnesium level. Which food of the selection below is high in magnesium? Select all that apply A. Avocado B. Liver C. Broccoli D. Tuna E. Mushrooms F. Rhubarb Answer; A, C, DOut of the selection Avocado, Broccoli and tuna are the items high in magnesium. Answer; A, C, DOut of the selection Avocado, Broccoli and tuna are the items high in magnesium. 35 / 77 A nurse has collected data from an African-American client who is at risk for cardiovascular disease. The client tells the nurse that he is a cigarette smoker, drinks while sitting out with friends, and enjoys eating hamburger with enough macaroni. Which piece of data does the nurse identify as an unmodifiable risk factor? A. The client drinks beer every day. B. The client is a cigarette smoker. C. The client is African-American. D. The client eats hamburger with macroni. Answer- 3RATIONALE: Modifiable risk factors are those that can be modified or eliminated to prevent the development of disease. In the case of cardiovascular disease, these include hypertension, obesity, diabetes mellitus, increased serum lipid concentrations, tobacco use, and physical inactivity, diet. Unmodifiable risk factors, those that cannot be modified or eliminated, include age, sex, and heredity. Therefore while the client can change their lifestyle like eat healthily, stop alcohol and smoking, the client can not change their race or genetics. Answer- 3RATIONALE: Modifiable risk factors are those that can be modified or eliminated to prevent the development of disease. In the case of cardiovascular disease, these include hypertension, obesity, diabetes mellitus, increased serum lipid concentrations, tobacco use, and physical inactivity, diet. Unmodifiable risk factors, those that cannot be modified or eliminated, include age, sex, and heredity. Therefore while the client can change their lifestyle like eat healthily, stop alcohol and smoking, the client can not change their race or genetics. 36 / 77 A nurse is educating a client whose family has history of cardiovascular conditions about measures to prevent cardiovascular disease. Which statement by the client indicates a need for further information? A. "I need to reduce my salt intake." B. "I need to cut down on my smoking and watch my weight." C. "I need to start a regular exercise program." D. "I need to eat healthy and reduce my calorie intake." Answer- 2RATIONALE: Risk factors associated with cardiovascular disease include increasing age, sex, excessive alcohol intake, cigarette smoking, diabetes mellitus, increased serum lipid concentrations, excessive dietary sodium, obesity, sedentary lifestyle, and stress. Reduction of salt intake, reducing calorie intake, exercise, and cutting down on fat intake are appropriate preventive measures. The risk of cardiovascular disease and resultant death is higher in smokers than in nonsmokers. The client needs to stop smoking, not “cut down” on the smoking. Answer- 2RATIONALE: Risk factors associated with cardiovascular disease include increasing age, sex, excessive alcohol intake, cigarette smoking, diabetes mellitus, increased serum lipid concentrations, excessive dietary sodium, obesity, sedentary lifestyle, and stress. Reduction of salt intake, reducing calorie intake, exercise, and cutting down on fat intake are appropriate preventive measures. The risk of cardiovascular disease and resultant death is higher in smokers than in nonsmokers. The client needs to stop smoking, not “cut down” on the smoking. 37 / 77 A nurse is educating a client whose family has history of cardiovascular conditions about measures to prevent cardiovascular disease. Which statement by the client indicates a need for further information? A. "I need to reduce my salt intake." B. "I need to cut down on my smoking and watch my weight." C. "I need to start a regular exercise program." D. "I need to eat healthy and reduce my calorie intake." Answer- 2RATIONALE: Risk factors associated with cardiovascular disease include increasing age, sex, excessive alcohol intake, cigarette smoking, diabetes mellitus, increased serum lipid concentrations, excessive dietary sodium, obesity, sedentary lifestyle, and stress. Reduction of salt intake, reducing calorie intake, exercise, and cutting down on fat intake are appropriate preventive measures. The risk of cardiovascular disease and resultant death is higher in smokers than in nonsmokers. The client needs to stop smoking, not “cut down” on the smoking. Answer- 2RATIONALE: Risk factors associated with cardiovascular disease include increasing age, sex, excessive alcohol intake, cigarette smoking, diabetes mellitus, increased serum lipid concentrations, excessive dietary sodium, obesity, sedentary lifestyle, and stress. Reduction of salt intake, reducing calorie intake, exercise, and cutting down on fat intake are appropriate preventive measures. The risk of cardiovascular disease and resultant death is higher in smokers than in nonsmokers. The client needs to stop smoking, not “cut down” on the smoking. 38 / 77 There is an infestation of West Nile Virus in the community, a nurse provides information to a client about measures to prevent infection with West Nile virus. Which statement by the client indicates a need for further information? A. "I can’t go outside for 1 week as it is too dangerous." B. "I have to spray insect repellent on the clothes I intend to wear out." C. "I should wear clothing that covers all of my skin, and I should wear a hat." D. "I should stay indoors at dusk and dawn, when mosquitoes are most active." Answer- 1RATIONALE: West Nile virus is a single-stranded RNA that causes west nile fever and is associated with mosquito bites. Symptoms include headache, high fever, neck stiffness, stupor, disorientation, tremors, convulsion,, muscle weakness, paralysis and coma. The nurse should instruct the client to wear a hat and clothing that covers as much skin as possible when outdoors and to spray insect repellant containing DEET (N, N-diethyl-m-toluamide) on clothes that cover the skin. Mosquitoes are most prevalent in wooded and swampy areas and are most active at dusk and dawn; however, this does not prevent the client from going out during the day for their daily activities. Answer- 1RATIONALE: West Nile virus is a single-stranded RNA that causes west nile fever and is associated with mosquito bites. Symptoms include headache, high fever, neck stiffness, stupor, disorientation, tremors, convulsion,, muscle weakness, paralysis and coma. The nurse should instruct the client to wear a hat and clothing that covers as much skin as possible when outdoors and to spray insect repellant containing DEET (N, N-diethyl-m-toluamide) on clothes that cover the skin. Mosquitoes are most prevalent in wooded and swampy areas and are most active at dusk and dawn; however, this does not prevent the client from going out during the day for their daily activities. 39 / 77 A nurse is to give the hepatitis B vaccine to a 1 day old baby. Which anatomic site should the nurse select for the injection? A. Gluteus muscle B. Vastus lateralis C. Rectus femoris D. Dorsogluteal Answer- 2RATIONALE: Vaccines administered intramuscularly are given in the vastus lateralis muscle in newborns and in the deltoid for older infants and children. The dorsogluteal area is avoided because the site has been associated with low antibody seroconversion rates, indicating a reduced immune response. Also, it is generally recommended that the dorsogluteal site be avoided until a child has been walking for at least 1 year. The rectus femoris is not an acceptable site for injections in neonates. Answer- 2RATIONALE: Vaccines administered intramuscularly are given in the vastus lateralis muscle in newborns and in the deltoid for older infants and children. The dorsogluteal area is avoided because the site has been associated with low antibody seroconversion rates, indicating a reduced immune response. Also, it is generally recommended that the dorsogluteal site be avoided until a child has been walking for at least 1 year. The rectus femoris is not an acceptable site for injections in neonates. 40 / 77 A nurse wants to administer the diphtheria/tetanus/acellular pertussis vaccine (DTaP) to a 6-month-old infant. Which action should the nurse take to reduce or prevent the risk for a local reaction to the vaccine? A. Positioning the infant in the right lateral position with the leg showing B. Mixing the right amount of water and administering the injection in the deltoid muscle C. Changing the needle on the syringe after drawing up the vaccine D. Using an air bubble to clear the needle after injection Answer- 4RATIONALE: To minimize the risk for a local reaction to a vaccine, the nurse selects a needle of adequate length to deposit the vaccine deep into the muscle mass. The vaccine is injected into the vastus lateralis muscle or ventrogluteal muscle (the deltoid may be used in children 18 months of age or older), and an air bubble is used to clear the needle after injection of the vaccine. Changing the needle on the syringe after drawing up the vaccine and before injecting will not decrease the possibility of a local reaction but should also be carried out by the nurse as glass pieces can be stuck inside the needle used to draw up vaccine, therefore a different needle is needed for injecting into the muscle mass. Answer- 4RATIONALE: To minimize the risk for a local reaction to a vaccine, the nurse selects a needle of adequate length to deposit the vaccine deep into the muscle mass. The vaccine is injected into the vastus lateralis muscle or ventrogluteal muscle (the deltoid may be used in children 18 months of age or older), and an air bubble is used to clear the needle after injection of the vaccine. Changing the needle on the syringe after drawing up the vaccine and before injecting will not decrease the possibility of a local reaction but should also be carried out by the nurse as glass pieces can be stuck inside the needle used to draw up vaccine, therefore a different needle is needed for injecting into the muscle mass. 41 / 77 A nurse is caring for a client with pituitary adenoma. The client tells the nurse that a lawyer will be arriving today to prepare a living will. The client asks the nurse to act as one of the witnesses for the will. The appropriate nursing action is to: A. Inform the client that a nurse caring for a client cannot serve as a witness to a living will. B. Refuse to help the client C. Agree to act as a witness D. Call the physician Ans: 1RATIONALE: A living will address the withdrawal or withholding of life-sustaining interventions that unnaturally prolong life. It identifies the person who will make care decisions if the client is unable to take action. It is witnessed and signed by two people who are unrelated to the client. Nurses or employees of a facility in which the client is receiving care and beneficiaries of the client must not serve as a witness. There is no reason to call the physician. Ans: 1RATIONALE: A living will address the withdrawal or withholding of life-sustaining interventions that unnaturally prolong life. It identifies the person who will make care decisions if the client is unable to take action. It is witnessed and signed by two people who are unrelated to the client. Nurses or employees of a facility in which the client is receiving care and beneficiaries of the client must not serve as a witness. There is no reason to call the physician. 42 / 77 A 16year old adolescent is transferred to the medical-surgical floor from intensive care unit(ICU) after sustaining a closed bread injury that left him comatose. The adolescent’s mother is identified as his only guardian. During the evening shift, a man identifying nas adolescent’s father asks the nurse for information about the adolescent’s condition. How should the nurse respond? A. "The client was just transferred to our floor .The ICU staff can best answer your questions". B. "I'm sorry. I can't give you any information. Privacy laws dictate that information is to be given to the legal guardian. You will need to contact the client's mother for information". C. "What have you been told about your child's condition" D. "Let's go to the conference room where we can discuss your child's condition privately". Ans: 2RATIONALE: Privacy laws prevent the nurse from sharing client information with anyone who isn’t designed by the client or in this case, the legal guardian. Therefore the nurse should not share any information with this man identified himself as the adolescent’s father. Ans: 2RATIONALE: Privacy laws prevent the nurse from sharing client information with anyone who isn’t designed by the client or in this case, the legal guardian. Therefore the nurse should not share any information with this man identified himself as the adolescent’s father. 43 / 77 The nursing staff is sitting in the lounge taking their morning break. A nursing assistant tells the group that she thinks that the unit secretary has acquired immunodeficiency syndrome (AIDS) and proceeds to tell the nursing staff that the secretary probably contracted the disease from her husband, who is supposedly a drug addict. Which legal tort has the nursing assistant violated? A. Assault B. Negligence C. Libel D. Slander Ans: 4RATIONALE: Defamation is a false communication or a careless disregard for the truth that causes damage to someone’s reputation, either in writing (libel) or verbally (slander). An assault occurs when a person puts another person in fear of harmful or offensive contact. Negligence involves the actions of professionals that fall below the standard of care for a specific professional group. Ans: 4RATIONALE: Defamation is a false communication or a careless disregard for the truth that causes damage to someone’s reputation, either in writing (libel) or verbally (slander). An assault occurs when a person puts another person in fear of harmful or offensive contact. Negligence involves the actions of professionals that fall below the standard of care for a specific professional group. 44 / 77 A client with end-stage renal disease, oxygen-dependent chronic obstructive pulmonary disease and a Do-Not-Resuscitate (DNR) code status is admitted to the medical floor for COPD exacerbation. The nurse walks into the room and finds the client is not breathing. What should the nurse do first? A. Activate the code system B. Check the apical pulse C. Check the blood pressure D. Call the health care provider stat Ans: 2RATIONALE: The care nurse should assess the client first before calling the health care provider. A Do-Not-Resuscitate(DNR) order requires the nurse to withhold resuscitation in the event of cardiac or respiratory arrest. If an event occurs, the nurse should assess for breathing and check the central or apical pulse. After performing these actions, the nurse should call the health care provider to confirm the death. Activating the code system is not appropriate as the client already had an order to withhold resuscitation. Checking the blood pressure is not appropriate in a client who has stopped breathing. Meanwhile, checking the apical pulse is the most appropriate after noticing the client is not breathing again. Ans: 2RATIONALE: The care nurse should assess the client first before calling the health care provider. A Do-Not-Resuscitate(DNR) order requires the nurse to withhold resuscitation in the event of cardiac or respiratory arrest. If an event occurs, the nurse should assess for breathing and check the central or apical pulse. After performing these actions, the nurse should call the health care provider to confirm the death. Activating the code system is not appropriate as the client already had an order to withhold resuscitation. Checking the blood pressure is not appropriate in a client who has stopped breathing. Meanwhile, checking the apical pulse is the most appropriate after noticing the client is not breathing again. 45 / 77 A newly reassigned nurse enters a hospital room at the beginning of the shift and finds the client unconscious and unresponsive. Resuscitation is initiated and then continued by the rapid response team. The nurse realizes that there is a do-not-resuscitate(DNR) prescription posted in the client’s chart. Which action is correct? A. Continue resuscitation until DNR status is verified with health care provider. B. If client shows any signs of life, follow advanced cardiovascular support protocol until stable C. Stop all resuscitation activity immediately D. Once resuscitation has begun, complete it regardless of the client's code status Ans: 3RATIONALE: Failure to stop an erroneous code on a client with an advance directive in a timely attempt may result in legal action. Many health care professionals react to an emergency situation automatically. However, some States will further penalize health care workers with loss of their professional license if they fail to render cardiopulmonary resuscitation in an emergency situation. Please note, health care professionals will not be penalized for an honest mistake. However, resuscitation must end immediately after they are notified of the error. Continuing treatment until the code status is verified with the health care provider constitutes malpractice. Before DNR prescription can be posted in a client’s medical record chart, the health care provider must provide documentation that the client’s code status has been established through consultation with the client or client’s family. Ans: 3RATIONALE: Failure to stop an erroneous code on a client with an advance directive in a timely attempt may result in legal action. Many health care professionals react to an emergency situation automatically. However, some States will further penalize health care workers with loss of their professional license if they fail to render cardiopulmonary resuscitation in an emergency situation. Please note, health care professionals will not be penalized for an honest mistake. However, resuscitation must end immediately after they are notified of the error. Continuing treatment until the code status is verified with the health care provider constitutes malpractice. Before DNR prescription can be posted in a client’s medical record chart, the health care provider must provide documentation that the client’s code status has been established through consultation with the client or client’s family. 46 / 77 A charge nurse completing a deceased client’s chart ‘s audit notes that the chart contains a copy of the client’s advance directive and the do-not-resuscitate (DNR) order. While reviewing the nurses’ notes, the charge nurse finds documentation of code blue and cardiopulmonary resuscitation with a physician entry to discontinue code blue due to existing advance directives and DNR from client. What does the charge nurse conclude? A. She must have read the chart incorrectly B. The code should have continued C. By calling a code blue, the nurse disregarded the client's advance directives and DNR order D. The nurse was correct to call a code blue E. The physician was correct to stop resuscitation efforts Ans: 3, 5.RATIONALE: The charge nurse conclusion should be: by initiating a code blue, the care nurse didn’t follow the client’s advance directive and DNR order. The physician was correct to follow the client’s wishes and stop resuscitation efforts. The physician had the authority to stop the code. Ans: 3, 5.RATIONALE: The charge nurse conclusion should be: by initiating a code blue, the care nurse didn’t follow the client’s advance directive and DNR order. The physician was correct to follow the client’s wishes and stop resuscitation efforts. The physician had the authority to stop the code. 47 / 77 A health care provider writes an order for Viscous Lidocaine 15 mg by mouth every 4 hours as needed for sore throat. Pharmacy dispenses you 30 mg/3ml. How many ml will you administer per dose? A. 0.5 ml/dose B. 3 ml/dose C. 1.5 ml/dose D. 6 ml/dose The answer is 3.Available strength = 30mgAvailable volume = 3mlRequired strength = 15mgRequired volume = ?15/30 *3/1 = 1.5ml The answer is 3.Available strength = 30mgAvailable volume = 3mlRequired strength = 15mgRequired volume = ?15/30 *3/1 = 1.5ml 48 / 77 A health care provider orders kanamycin (Kantrex) 5 mg/kg IM q 12 hr; Available: kanamycin 0.35 Gm/mL. How many mL will you administer for each dose to a 160 lb patient? Fill in the blanks. Check Computation:1pound=0.45lbs160 lbs = 160 * 0.45= 72 kg5 mg/kg x 72 kg = 360 mg1Gm = 1000mg0.35Gm = 350mgSo 350mg = 1ml360/350 * 1 = 1.03ml Computation:1pound=0.45lbs160 lbs = 160 * 0.45= 72 kg5 mg/kg x 72 kg = 360 mg1Gm = 1000mg0.35Gm = 350mgSo 350mg = 1ml360/350 * 1 = 1.03ml 49 / 77 A hospitalized patient with heart failure is on a 1000 mL fluid restriction every 24 hours. During the 7 a.m. to 7 p.m. shift, he has three meals, consuming 1/2 cup of tea with each. He also has 50 mL of water each time he takes his medications at 7 a.m., noon, and 5 p.m. Mid Afternoon, he drinks 200 mL of soda. How many milliliters may he consume during the 7 p.m. to 7 a.m. shift? Fill in the blanks. Check Computation:1cup=240So 1/2cup= 120mL120 mL + 120 mL + 120 mL + 50 mL + 50 mL + 50 mL + 200 mL = 710 mL1000 mL – 710 mL = 290 mL. He can drink 290 mL during the night shift Computation:1cup=240So 1/2cup= 120mL120 mL + 120 mL + 120 mL + 50 mL + 50 mL + 50 mL + 200 mL = 710 mL1000 mL – 710 mL = 290 mL. He can drink 290 mL during the night shift 50 / 77 A nurse conducting a physical assessment is observing the client’s balance and performing tests to determine the client’s sense of equilibrium. Which cranial nerve is the nurse assessing? A. Cranial nerve II B. Cranial nerve IX C. Cranial nerve VII D. Cranial nerve VIII Correct answer: 4Cranial nerve VIII is the acoustic nerve. Hearing tests are performed to assess the cochlear portion of this nerve. Tests to assess equilibrium, such as observation of the client’s balance when the client is walking or standing, involve the vestibular portion. The function of cranial nerve II (the optic nerve) is tested by assessing the client’s visual acuity. Swallowing ability and taste perception of the posterior portion of the tongue are controlled by cranial nerve IX (the glossopharyngeal nerve). Taste perception on the anterior portion of the tongue and the ability to perform facial and eye movements (e.g., closing the eyes) are controlled by cranial nerve VII (the facial nerve). Correct answer: 4Cranial nerve VIII is the acoustic nerve. Hearing tests are performed to assess the cochlear portion of this nerve. Tests to assess equilibrium, such as observation of the client’s balance when the client is walking or standing, involve the vestibular portion. The function of cranial nerve II (the optic nerve) is tested by assessing the client’s visual acuity. Swallowing ability and taste perception of the posterior portion of the tongue are controlled by cranial nerve IX (the glossopharyngeal nerve). Taste perception on the anterior portion of the tongue and the ability to perform facial and eye movements (e.g., closing the eyes) are controlled by cranial nerve VII (the facial nerve). 51 / 77 A nurse performing a neurological assessment of a client who has sustained a stroke (brain attack) is preparing to check for stereognosis. Which action should the nurse take to perform this assessment? A. Placing an object in the client’s hand and asking the client to identify it B. Tracing a number on the client’s hand and asking the client to identify it C. Moving the client’s finger up and down and asking the client which way it is being moved D. Making two simultaneous pinpricks on the skin and asking the client to distinguish them Correct answer: 1Stereognosis is the client’s ability to recognize objects placed in his or her hand. Graphesthesia is the client’s ability to identify a number traced on the client’s hand. Position sense (kinesthesia) is tested by moving the client’s finger or toe up or down and asking the client which way it is being moved. Two-point discrimination is the client’s ability to discriminate two simultaneous pinpricks on the skin. Correct answer: 1Stereognosis is the client’s ability to recognize objects placed in his or her hand. Graphesthesia is the client’s ability to identify a number traced on the client’s hand. Position sense (kinesthesia) is tested by moving the client’s finger or toe up or down and asking the client which way it is being moved. Two-point discrimination is the client’s ability to discriminate two simultaneous pinpricks on the skin. 52 / 77 The nurse uses a CAGE test screening questionnaire to assess for what condition in a client who is reported to be having a lot of work-related problems? A. Excessive or uncontrollable drinking. B. Depression. C. Unhealthy lifestyle behaviors D. Personal response to stress. Correct answer: 1CAGE is a screening questionnaire to identify excessive or uncontrolled drinking (C = Cut down; A = Annoyed; G = Guilty; E = Eye opener). The health history assesses lifestyle, including factors such as exercise, diet, risk reduction, and health promotion behaviors. Coping and stress management are assessed during the functional assessment of the complete health history. Depression is assessed during the review of systems and during the mental status assessment (mood and affect). The Geriatric Depression Scale, Short Form is an assessment instrument for use with older adults. Correct answer: 1CAGE is a screening questionnaire to identify excessive or uncontrolled drinking (C = Cut down; A = Annoyed; G = Guilty; E = Eye opener). The health history assesses lifestyle, including factors such as exercise, diet, risk reduction, and health promotion behaviors. Coping and stress management are assessed during the functional assessment of the complete health history. Depression is assessed during the review of systems and during the mental status assessment (mood and affect). The Geriatric Depression Scale, Short Form is an assessment instrument for use with older adults. 53 / 77 A nurse performed a respiratory assessment of an adult client. The nurse notes a resonance sound on percussion, what interpretation does the nurse make of this finding? A. The client has normal, healthy lungs. B. The client may have a pneumothorax. C. The client most likely has a lung tumor. D. An excessive amount of air is present in the lungs Correct answer: 1Resonance on percussion predominates in healthy adult lung tissue. Hyperresonance is noted when too much air is present such as in the case of emphysema where it is trapped in the alveoli and pneumothorax where it is trapped in the pleural space leading to lung collapse. A dull note on percussion indicates an abnormal density in the lungs, such as that noted in pneumonia, pleural effusion, or atelectasis or in the presence of a tumor. Correct answer: 1Resonance on percussion predominates in healthy adult lung tissue. Hyperresonance is noted when too much air is present such as in the case of emphysema where it is trapped in the alveoli and pneumothorax where it is trapped in the pleural space leading to lung collapse. A dull note on percussion indicates an abnormal density in the lungs, such as that noted in pneumonia, pleural effusion, or atelectasis or in the presence of a tumor. 54 / 77 A nurse has collected health history information from an African-American client aged 74yrs who is at risk for hypertension. The client tells the nurse that he is a cigarette smoker, drinks “a beer or two” every day, and enjoys sitting around watching sports on television, the client also told the nurse that his parents died as a result of complications from hypertension. Which piece of data does the nurse identify as an unmodifiable risk factor? Select all that apply A. The client is African-American. B. The client is a cigarette smoker. C. The client drinks beer every day. D. The client’s condition is hereditary E. The client is aged 74 years. Answer:1, 4,5Modifiable risk factors are those that can be modified or eliminated to prevent the development of disease. In the case of cardiovascular disease, these include hypertension, obesity, diabetes mellitus, increased serum lipid concentrations, tobacco use, and physical inactivity. Unmodifiable risk factors, those that cannot be modified or eliminated, include age, sex, and heredity. Answer:1, 4,5Modifiable risk factors are those that can be modified or eliminated to prevent the development of disease. In the case of cardiovascular disease, these include hypertension, obesity, diabetes mellitus, increased serum lipid concentrations, tobacco use, and physical inactivity. Unmodifiable risk factors, those that cannot be modified or eliminated, include age, sex, and heredity. 55 / 77 A patient is started on the diuretic Spironolactone. Which foods should the patient be careful to avoid eating too much of? A. Eggs B. Green leafy vegetables C. Kiwi D. Hot Dogs Answer; KiwiSpironolactone is known as a potassium-sparing diuretic medication (meaning it keeps potassium) therefore a patient would need to watch how much potassium they eat. Kiwis are high in potassium. Answer; KiwiSpironolactone is known as a potassium-sparing diuretic medication (meaning it keeps potassium) therefore a patient would need to watch how much potassium they eat. Kiwis are high in potassium. 56 / 77 The patient is on a low protein, low sodium, low potassium, low phosphate diet. What type of patient would you expect to be on this type of diet? A. A patient with heart disease B. A patient with osteoporosis C. A patient with chronic kidney disease D. A patient who recently had a gastric bypass surgery Answer; 3The patient with chronic kidney disease should follow this type of diet because protein breaks down into urea so patient will have increased urea levels, low sodium to prevent fluid excess, low potassium to prevent hyperkalemia because glomerulus isn’t filtering out potassium/phosphate as it should and low phosphate to prevent hyperphosphatemia. Answer; 3The patient with chronic kidney disease should follow this type of diet because protein breaks down into urea so patient will have increased urea levels, low sodium to prevent fluid excess, low potassium to prevent hyperkalemia because glomerulus isn’t filtering out potassium/phosphate as it should and low phosphate to prevent hyperphosphatemia. 57 / 77 A patient with Addison’s disease should follow what type of diet? A. High-sodium diet B. Low carb diet C. Low-purine diet D. Renal Diet Answer; 1Patients with Addison’s disease suffer from low sodium levels. Therefore, they need to eat foods high in sodium. These foods usually include butter, soy sauced, frozen foods, ‘fast’ foods, salad dressing, canned foods, and pickled foods. Answer; 1Patients with Addison’s disease suffer from low sodium levels. Therefore, they need to eat foods high in sodium. These foods usually include butter, soy sauced, frozen foods, ‘fast’ foods, salad dressing, canned foods, and pickled foods. 58 / 77 A patient’s potassium level is 6.0. Which food should the patient avoid? A. 6.0 is a normal potassium level so the patient can eat whatever they want without effect B. Pineapple C. Spinach D. Cranberries Answer; 3Normal potassium levels are 3.5-5.0. Therefore a potassium level of 6.0 is considered high so the patient should avoid foods high in potassium. In this case, spinach is the highest in potassium. Answer; 3Normal potassium levels are 3.5-5.0. Therefore a potassium level of 6.0 is considered high so the patient should avoid foods high in potassium. In this case, spinach is the highest in potassium. 59 / 77 A client with hypertension has been told to maintain a diet low in sodium. The nurse who is teaching this client about foods that are allowed should include which food item in a list provided to the client? A. Tomato soup B. French fries C. Instant oatmeal D. Summer squash Answer; 4Summer squash: Foods that are low in sodium include fruits and vegetables Answer; 4Summer squash: Foods that are low in sodium include fruits and vegetables 60 / 77 When is the most appropriate time a nurse teaches a young adult male client to conduct testicular self-examination? A. Carry out self-examination at least every 2 weeks. B. Use both hands to palpate both testes at the same time. C. Perform testicular self- examination same day monthly, starting during puberty. D. Perform the self-examination just before getting into the shower. Answer: 3Testicular self-examination should be performed monthly, starting during puberty. Because men are at greatest risk for testicular cancer between the ages of 18 and 38 years, teaching should be targeted to this age group. Men should be taught to hold the scrotum in one hand and examine each testicle and spermatic cord separately by gently rolling the testicle between the thumb and fingers of the other hand. The client is taught to perform the examination on the same day of each month. Examination is performed after a warm bath or shower, when the testicles are relaxed, descended, and easier to palpate. Answer: 3Testicular self-examination should be performed monthly, starting during puberty. Because men are at greatest risk for testicular cancer between the ages of 18 and 38 years, teaching should be targeted to this age group. Men should be taught to hold the scrotum in one hand and examine each testicle and spermatic cord separately by gently rolling the testicle between the thumb and fingers of the other hand. The client is taught to perform the examination on the same day of each month. Examination is performed after a warm bath or shower, when the testicles are relaxed, descended, and easier to palpate. 61 / 77 A nurse at a health fair is conducting teaching sessions on dietary measures to help prevent cancer. Which foods should the nurse encourage clients attending the teaching sessions to eat as a means of preventing cancer? Select all that apply. A. Fruits B. Red meats C. Vegetables D. Foods low in fiber E. High-nitrate foods Answer: 1,3Dietary factors related to the development of cancer include foods that are high in fat and low in fiber, foods that are high in animal fat, high-nitrate foods, and those that contain preservatives, contaminants, and additives. Therefore, of the options provided, fruits and vegetables are the food items whose consumption should be encouraged as a means of preventing cancer. Answer: 1,3Dietary factors related to the development of cancer include foods that are high in fat and low in fiber, foods that are high in animal fat, high-nitrate foods, and those that contain preservatives, contaminants, and additives. Therefore, of the options provided, fruits and vegetables are the food items whose consumption should be encouraged as a means of preventing cancer. 62 / 77 The nurse plans primary prevention activities for a client. Which measures are primary prevention activities? Select all that apply. A. Immunizations B. Pollution control C. An exercise regimen D. Cardiac rehabilitation E. Self-examination practices F. Diabetes mellitus management Answer: 123Primary prevention activities are those that prevent disease or dysfunction, including health-education programs and wellness activities that maintain or improve health. Examples of primary prevention include immunizations, pollution control, nutrition, and exercise. Secondary prevention activities are focused on clients who are experiencing health problems, on activities such as screening techniques (self-examination practices, mammography, blood pressure screening), and on treatment of disease at an early stage to limit disability. Tertiary prevention is focused on rehabilitation to minimize the effects of a long-term disease and to assist clients in achieving the highest possible level of function. Examples include cardiac rehabilitation and diabetes mellitus management. Answer: 123Primary prevention activities are those that prevent disease or dysfunction, including health-education programs and wellness activities that maintain or improve health. Examples of primary prevention include immunizations, pollution control, nutrition, and exercise. Secondary prevention activities are focused on clients who are experiencing health problems, on activities such as screening techniques (self-examination practices, mammography, blood pressure screening), and on treatment of disease at an early stage to limit disability. Tertiary prevention is focused on rehabilitation to minimize the effects of a long-term disease and to assist clients in achieving the highest possible level of function. Examples include cardiac rehabilitation and diabetes mellitus management. 63 / 77 The mother of a two-month-old baby calls the nurse at a well-baby clinic two days after the first DTaP immunization. She reports that the baby feels very warm, has cried inconsolably for as long as three hours, and has had several shaking spells. The response of the nurse should be to A. Instruct the mother to call 911 for an ambulance to transport the infant B. Suggest that these are expected reactions and to begin every 4 hour antipyretics C. Tell the mother to take the infant immediately to the nearest emergency room D. Give instructions to bring the infant to the clinic now Correct answer is: 1Instruct the mother to call 911 for an ambulance to transport the infant. The exhibited findings of the infant indicate a severe reaction to the immunizations. Immediate attention is needed & an ambulance with trained staff needs to transport because of the risk of grand mal seizures from potential encephalopathy which is a critical reaction. The mother would need to be instructed after this acute reaction to inform the provider of this reaction to the first dose of DTaP. Based on the need and risk involved to the infant, the health care provider may decide that further DTaP immunizations are contraindicated for life. The clinic nurse would need to document in the notes for this infant: the instructions given, findings reported by the mother, and specific follow-up needs for the next clinic visit in relation to teaching and evaluation of the outcome of this event. Correct answer is: 1Instruct the mother to call 911 for an ambulance to transport the infant. The exhibited findings of the infant indicate a severe reaction to the immunizations. Immediate attention is needed & an ambulance with trained staff needs to transport because of the risk of grand mal seizures from potential encephalopathy which is a critical reaction. The mother would need to be instructed after this acute reaction to inform the provider of this reaction to the first dose of DTaP. Based on the need and risk involved to the infant, the health care provider may decide that further DTaP immunizations are contraindicated for life. The clinic nurse would need to document in the notes for this infant: the instructions given, findings reported by the mother, and specific follow-up needs for the next clinic visit in relation to teaching and evaluation of the outcome of this event. 64 / 77 After a physical examination the nurse documents which records as subjective data? Select all that apply A. The client is allergic to strawberries. B. The last menstrual period was 30 days ago. C. The client takes acetaminophen (Tylenol) for headaches. D. A 1 × 2-inch (5 cm) scar is present on the lower right portion of the abdomen E. Client’s blood pressure was 120/80mmhg Correct answer: 1,2,3Subjective data, collected during the health history, consist of information that the client gives about him or herself. Objective data are obtained through physical examination and vital signs measurements, what the nurse observes, and laboratory study and diagnostic test results. Allergies, the date of the client’s last menstrual period, and the reported use of medication for headaches are all subjective data. Correct answer: 1,2,3Subjective data, collected during the health history, consist of information that the client gives about him or herself. Objective data are obtained through physical examination and vital signs measurements, what the nurse observes, and laboratory study and diagnostic test results. Allergies, the date of the client’s last menstrual period, and the reported use of medication for headaches are all subjective data. 65 / 77 A client is brought to the emergency department after a motor vehicle accident. The client is alert and cooperative but has sustained multiple fractures of the legs. What are the steps required by a nurse in data collection? A. Perform initial examination. B. Ask health history questions. C. Collect all required health history including family history. D. Initiate emergency measures. E. Document and prepare client for surgery Correct answer: 2,1,4,3,5If the client is alert and cooperative and if the situation is not life-threatening, the nurse should attempt to obtain as much subjective and objective data as possible to address data collection while caring for the client. Correct answer: 2,1,4,3,5If the client is alert and cooperative and if the situation is not life-threatening, the nurse should attempt to obtain as much subjective and objective data as possible to address data collection while caring for the client. 66 / 77 which action is most appropriate for a nurse to minimise potential for a local reaction to vaccine during routine immunization of a 6 months old infant? A. Using an air bubble to clear the needle after injection B. Changing the needle on the syringe after drawing up the vaccine C. Using a 1.5-inch (3.8 cm) needle for injection D. Administering the injection in the deltoid muscle Correct Answer: 1To minimize the potential for a local reaction to a vaccine, the nurse selects a needle of adequate length to deposit the vaccine deep into the muscle mass. The vaccine is injected into the vastuslateralis muscle or ventrogluteal muscle (the deltoid may be used in children 18 months of age or older), and an air bubble is used to clear the needle after injection of the vaccine. Changing the needle on the syringe after drawing up the vaccine and before injecting will not decrease the possibility of a local reaction. Correct Answer: 1To minimize the potential for a local reaction to a vaccine, the nurse selects a needle of adequate length to deposit the vaccine deep into the muscle mass. The vaccine is injected into the vastuslateralis muscle or ventrogluteal muscle (the deltoid may be used in children 18 months of age or older), and an air bubble is used to clear the needle after injection of the vaccine. Changing the needle on the syringe after drawing up the vaccine and before injecting will not decrease the possibility of a local reaction. 67 / 77 A nurse has provided information to a client about measures to prevent diabetes mellitus Which statement by the client indicates a need for further information? A. "I need to avoid intake of all sugary foods and drinks." B. "I am to consume diets rich in vegetables, fibres, Fruits and whole grains as recommended." C. "I need to start a regular exercise program." D. "I need to watch my weight and cut down on my saturated fat." Correct answer: 1Risk factors associated with diabetes mellitus is majorly obesity. Measures to control excessive weight gain incude; regular exercise at least three times a week, consumption of calorie-controlled diets, client should consume vegetables, fruits, whole grains and fibres. Option 1 is a negative statement because it’s not specific and a little bit of glucose is still required for normal cell function. Correct answer: 1Risk factors associated with diabetes mellitus is majorly obesity. Measures to control excessive weight gain incude; regular exercise at least three times a week, consumption of calorie-controlled diets, client should consume vegetables, fruits, whole grains and fibres. Option 1 is a negative statement because it’s not specific and a little bit of glucose is still required for normal cell function. 68 / 77 A nurse provides information to a client about measures to prevent infection with West Nile virus. Which statement by the client indicates a good understanding of the information given? A. "I need to go to the woods as longs as I don’t spend more that two hours there." B. "I don't need to use insect repellent if my clothes are covering my skin." C. "I should wear clothing that covers all of my skin, and I should wear a hat." D. "I must not stay indoors at dusk and dawn, when mosquitoes are most active." Correct answer: 3West Nile virus is associated with mosquito bites. The nurse should instruct the client to wear a hat and clothing that covers as much skin as possible when outdoors and to spray insect repellant containing DEET (N, N-diethyl-m-toluamide) on clothes that cover the skin. Mosquitoes are most prevalent in wooded and swampy areas and are most active at dusk and dawn. Other options are negative statements on the information passed to the patient hence, showing no good understanding. Correct answer: 3West Nile virus is associated with mosquito bites. The nurse should instruct the client to wear a hat and clothing that covers as much skin as possible when outdoors and to spray insect repellant containing DEET (N, N-diethyl-m-toluamide) on clothes that cover the skin. Mosquitoes are most prevalent in wooded and swampy areas and are most active at dusk and dawn. Other options are negative statements on the information passed to the patient hence, showing no good understanding. 69 / 77 A nurse collects subjective and objective data from a client who was just admitted on account of frequent stooling and vomiting. The nurse identifies which findings as objective data? Select all that apply. A. Pulse rate is 50 b/min B. The client complains general body weakness C. Blood pressure is 80/40 mm Hg. D. Patient's complain of abdominal pain. E. The nurse observes the skin to be cold and clammy. Correct answer 135Subjective data are the things the client says about himself or herself or what a family member or significant other says about the client during history-taking. Objective data are the findings collected by the nurse while inspecting, percussing, palpating, and auscultating. Objective data also includes information from the client’s health record and the results of laboratory and diagnostic studies. The client’s pulse rate and blood pressure readings are objective data, as is the nurse’s observation of the skin. The other options constitute subjective data. Correct answer 135Subjective data are the things the client says about himself or herself or what a family member or significant other says about the client during history-taking. Objective data are the findings collected by the nurse while inspecting, percussing, palpating, and auscultating. Objective data also includes information from the client’s health record and the results of laboratory and diagnostic studies. The client’s pulse rate and blood pressure readings are objective data, as is the nurse’s observation of the skin. The other options constitute subjective data. 70 / 77 A nurse is supervising the postmortem care of a client. Which action by the nursing assistants who are performing the care is appropriate? A. Keep the client's body in a flat , supine position. B. Elevate the head of the bed 30° as soon as possible after death. C. Remove the client's dentures and place them in a denture cup with the client's name on the lid. D. Close the client's eyes by taping the eyelids shut. Ans: 2RATIONALE: The nurse may delegate postmortem care to nursing assistants, but the nurse must be knowledgeable about correct postmortem care. The care given must protect the client’s body from damage or disfigurement. Elevating the head of bed immediately after the client’s death can help reduce facial discoloring from Rigor mortis. Using tape may damage the delicate eyelid tissues, dentures should be placed inside the client’s mouth during postmortem care to maintain facial structure. Ans: 2RATIONALE: The nurse may delegate postmortem care to nursing assistants, but the nurse must be knowledgeable about correct postmortem care. The care given must protect the client’s body from damage or disfigurement. Elevating the head of bed immediately after the client’s death can help reduce facial discoloring from Rigor mortis. Using tape may damage the delicate eyelid tissues, dentures should be placed inside the client’s mouth during postmortem care to maintain facial structure. 71 / 77 A patient who is admitted to the hospital gives the nurse an advance directive. The nurse should understand that an advance directive is: A. A written statement that defines acceptable care if the patient becomes incapacitated. B. The name of the person designated by the patient to make health – related decisions should the patient become incapacitated. C. A statement identifying the patient as an organ donor. D. A written statement authorizing a particular surgical procedure. RATIONALE: An advance directive is a written document that contains directives of a person’s choices regarding end of life care. A person must have the cognitive and communicative abilities to execute decisions regarding their desires. It includes wishes for treatment options should the person become unable to do so.A durable power of attorney for healthcare designates an individual to make medical decisions in case the patient is unable to do so.A statement identifying the person as an organ donor may be included in an advance directive, but it is not the only information an advance directive. This information would typically included on an organ donor card.A written statement authorizing a particular surgical procedure is a consent form. RATIONALE: An advance directive is a written document that contains directives of a person’s choices regarding end of life care. A person must have the cognitive and communicative abilities to execute decisions regarding their desires. It includes wishes for treatment options should the person become unable to do so.A durable power of attorney for healthcare designates an individual to make medical decisions in case the patient is unable to do so.A statement identifying the person as an organ donor may be included in an advance directive, but it is not the only information an advance directive. This information would typically included on an organ donor card.A written statement authorizing a particular surgical procedure is a consent form. 72 / 77 The nurse notes that an advance directive is in the client’s medical record. Which of the following statements represents the best description of guidelines a nurse would follow in this case? A. A durable power of attorney for health care is invoked only when the client has a terminal condition or is in persistent vegetative state. B. A living will is invoked only when the client has a terminal condition or is in a persistent vegetative state. C. A living will allows an appointed person to make healthcare decisions when the client is in an incapacitated state. D. The client cannot make changes in the advance directive once the client is admitted into the hospital. Ans: 2RATIONALE: A living will directs the client’s healthcare in the event of a terminal illness or condition. A durable power of attorney is invoked when the client is no longer able to make decisions on his or her own behalf . The client may change advance directive at any time. Ans: 2RATIONALE: A living will directs the client’s healthcare in the event of a terminal illness or condition. A durable power of attorney is invoked when the client is no longer able to make decisions on his or her own behalf . The client may change advance directive at any time. 73 / 77 A client has suffered an extensive brain injury and can’t make his own treatment choices. Which written document is recognized by state law and provides directions for provision of care at a time when the client can’t make his own choices? A. Patient self determination. B. Living will C. Durable power of attorney D. Advance directive Ans: 4RATIONALE: An advanced directive is a document written or completed by the client and used by a facility to provide care at a time when the client can’t make his own choices. The living Will and Durable Power Of Attorney(DPOA) are both examples of advanced directives. A living will is a document that is prepared by a competent adult and provides direction regarding medical care if the client becomes incapacitated. Durable power of attorney is an authorization enabling any competent individual to name someone else to exercise decision making authority on the individual’s behalf under specific circumstances. The patient self-determination Act of 1990 allows client to write instructions for their care and treatment for a time when they become unable to make their own decisions. Ans: 4RATIONALE: An advanced directive is a document written or completed by the client and used by a facility to provide care at a time when the client can’t make his own choices. The living Will and Durable Power Of Attorney(DPOA) are both examples of advanced directives. A living will is a document that is prepared by a competent adult and provides direction regarding medical care if the client becomes incapacitated. Durable power of attorney is an authorization enabling any competent individual to name someone else to exercise decision making authority on the individual’s behalf under specific circumstances. The patient self-determination Act of 1990 allows client to write instructions for their care and treatment for a time when they become unable to make their own decisions. 74 / 77 A 62-year-old woman has been admitted to the hospital for a surgical procedure. During the admission process, the nurse asks whether she has a living will or a durable power of attorney. The patient asks, “What is a living will?” The best response by the nurse would be which of the following? A. "A living will and a durable power of attorney are both advance directives." B. "A living will identifies a person who will make healthcare decisions in the event you are unable to do so." C. "A living will states your wishes regarding future healthcare if you become unable to give instructions." D. "I will tell a case manager that you would like additional information." Ans: 3 RATIONALE: A living will state your wishes regarding future healthcare if you become unable to give instructions. Generally, there are two types of advance directives: a living will and a durable power of attorney. A living will is a directive that declares the patient’s wishes should the patient become unable to give instruction. A durable power of attorney identifies a person who will make healthcare decisions in the event the patient is unable to do so. Simply saying a living will and durable power of attorney are both advance directives is broadly stated and does not give as much information to the patient. Ans: 3 RATIONALE: A living will state your wishes regarding future healthcare if you become unable to give instructions. Generally, there are two types of advance directives: a living will and a durable power of attorney. A living will is a directive that declares the patient’s wishes should the patient become unable to give instruction. A durable power of attorney identifies a person who will make healthcare decisions in the event the patient is unable to do so. Simply saying a living will and durable power of attorney are both advance directives is broadly stated and does not give as much information to the patient. 75 / 77 To assist a client who is on admission with personal hygiene, which intervention by the nurse would be best in this situation? A. Asking the client’s relative to bathe the client and call the nurse to dress client up. B. Encouraging the client to perform as much of the bath as possible while being there for them. C. Completely bathing and grooming the client to help the client feel good and comfortable. D. Asking a unlicensed assistive personnel (UAP) to completely bathe the client and attend to all their needs. Answers- 2RATIONALE: Although it may be appropriate for the client’s relative to contribute to client’s care, asking thr relative to bath the client is not the best way to help the client. During the bath, the nurse can integrate other nursing activities, including client assessment and interventions such as range-of-motion exercises, application of dressings, skin inspection, and care for intravenous sites, so asking a UAP to completely bathe the client is not the appropriate choice. While providing hygiene, the nurse must preserve as much of the client’s independence as possible. Therefore, encouraging the client to perform as much of the bath as possible is the best option of those provided. Answers- 2RATIONALE: Although it may be appropriate for the client’s relative to contribute to client’s care, asking thr relative to bath the client is not the best way to help the client. During the bath, the nurse can integrate other nursing activities, including client assessment and interventions such as range-of-motion exercises, application of dressings, skin inspection, and care for intravenous sites, so asking a UAP to completely bathe the client is not the appropriate choice. While providing hygiene, the nurse must preserve as much of the client’s independence as possible. Therefore, encouraging the client to perform as much of the bath as possible is the best option of those provided. 76 / 77 A home care nurse is teaching a client who is having difficulty sleeping about ways to promote sleep. What teachings should the nurse provide to the client? Select all that apply. A. put on your television when going to bed. B. Consume light food when hungry at night C. Keep your room warm and humid. D. Exercise your limbs adequately just before going to sleep. E. Try not to sleep during the day. Answer- 2,5RATIONALE: Eating light food at night when hungry helps promote comfort because there is a low chance that the patient will suffer indigestion and may put the client in the right mode to sleep. The room atmosphere should be comfortable, neither very cold nor very warm or humid. Exercising everyday is good but should be done earlier in the day like morning and afternoon time. Exercising 3 hours before bedtime should be avoided. Also distracting activities or sounds like watching television or listening to the radio should be avoided at bedtime.However heavy meals at night should be avoided as it may lead to some discomfort which can disturb one’s sleep pattern. Answer- 2,5RATIONALE: Eating light food at night when hungry helps promote comfort because there is a low chance that the patient will suffer indigestion and may put the client in the right mode to sleep. The room atmosphere should be comfortable, neither very cold nor very warm or humid. Exercising everyday is good but should be done earlier in the day like morning and afternoon time. Exercising 3 hours before bedtime should be avoided. Also distracting activities or sounds like watching television or listening to the radio should be avoided at bedtime.However heavy meals at night should be avoided as it may lead to some discomfort which can disturb one’s sleep pattern. 77 / 77 A registered nurse is collecting subjective data from a client about the client’s daily meal consumption. Which question should the nurse ask the client first? A. "Can you tell me what you ate and drank over the last 24 hours?" B. "Do you cook your own meal?" C. "Do you have adequate income to buy what you want?" D. "Do you eat adequate diet?" Answer- ARATIONALE: The first question the nurse should ask the client would provide data about the client’s typical daily intake. Once this has been determined, the nurse would collect data regarding who cooks and prepares the food and whether the client has adequate income to buy adequate meal. The nurse might ask the client about adequate diet before teaching the client about healthy eating habits. However, the registered nurse would use the client’s answer as a guide for teaching nutrition and adequate diet regardless of whether the client has known about it. Answer- ARATIONALE: The first question the nurse should ask the client would provide data about the client’s typical daily intake. Once this has been determined, the nurse would collect data regarding who cooks and prepares the food and whether the client has adequate income to buy adequate meal. The nurse might ask the client about adequate diet before teaching the client about healthy eating habits. However, the registered nurse would use the client’s answer as a guide for teaching nutrition and adequate diet regardless of whether the client has known about it. Your score is Please rate this Quiz Send feedback
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Nclex Content Review Class Two
Week Two Assessment
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1 / 77
The nurse helps the health care provider perform a Pap smear on a client. When should the nurse instruct the client to carry out follow-up testing?
Answer- 3
RATIONALE: The American Cancer Society (ACS) states that every woman should begin cervical cancer screening about 3 years after they begin having vaginal intercourse but no later than 21 years of age. Screening test should be performed every year if the regular Pap test is being used or every 2 years if the newer liquid-based Pap test is used. Beginning at age 30, women who have had three normal Pap results in a row may be screened every 2 to 3 years while women older than 30 may also be screened every 3 years with the use of either the conventional or the liquid-based Pap test, plus the human papillomavirus (HPV) test. Women 70 years or older who have had three or more normal Pap tests in a row and no abnormal Pap results in the preceding 10 years may choose to stop having Pap tests.
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Mr. Brown arrives in the Emergency Room with shortness of breath and edema. The physician prescribes a bolus of furosemide (Lasix) 80 mg IV push to be given STAT. The available vials are labeled “Furosemide 40 mg/2 mL.” How many ml of Lasix will the nurse give?
Answer; 3
40mg = 2ml
80mg = ?
80 * 2/40 =160/40 =4ml
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Order is for Heparin 8,000 units subcutaneously every 8 hours. Heparin is available in 10,000 units/mL. How many total mL would you administer in a day (24 hours)?
Answer; 2.4ml
Computations;
First, we calculate the ml per dose
8,000 units x 1ml/10,000 units = 0.8 ml administered with each dose.
0.8ml/8 hrs x 24 hours = 2.4 ml administered in a 24 hour period.
4 / 77
A client is referred to the hospital for complaints of back chronic back pain. A nurse performing a musculoskeletal assessment is inspecting the posterior aspect of the client’s posture as the client stands. After noting an exaggeration of the lateral curvature of the client’s thoracic spine, how does the nurse document this finding?
Answer- 2
RATIONALE: A lateral spinal curvature is called scoliosis. Kyphosis, or hunchback, is an exaggeration of the posterior curvature of the thoracic spine. Lordosis, or swayback, is an increased curvature of the spine at the cervical and lumbar regions. Scoliosis, kyphosis and lordosis can cause pain and discomfort that are a s a result of Loss of height is frequently an early sign of osteoporosis.
5 / 77
The charge nurse is supervising a newly transferred nurse employee who is performing an abdominal assessment of a client and preparing to auscultate for bowel sounds. The charge nurse determines that the nurse employee is using correct technique if which part of the abdomen is auscultated first?
Answer- 4
RATIONALE: Auscultation involves listening of the abdomen with a stethoscope. The correct order for abdominal assessment is inspection, auscultation, oercussion and then palpation. To auscultate for bowel sounds, the nurse places the diaphragm endpiece of the stethoscope lightly against the skin, then begins to auscultate in the right lower abdominal quadrant, in the area of the ileocecal valve, because bowel sounds are always present there normally. After auscultating the right lower quadrant, the nurse proceeds with the examination by auscultating the right upper quadrant next, followed by left upper quadrant and finally left lower quadrant.
6 / 77
A client who came for appointment to observe healing from previous lump removal is being seen by a health provider and a nurse. The nurse performing a breast examination is preparing to palpate the client’s breasts. In what position should the nurse assist the client to perform palpation?
Answer- 1
RATIONALE: To palpate the breasts, the nurse assists the client into a supine position and positions the client’s arm on the side being examined behind the head. A small pillow is placed under the shoulder on the same side. The nurse uses the pads of the first three fingers to gently compress the breast tissue against the chest wall and notes tissue consistency. Palpation is performed systematically, with care taken to ensure that the entire breast and tail are palpated. The other options are not positions that would allow effective palpation of the breast tissue
7 / 77
A client presented to the hospital with complaints of being out of breath and is being seen by the HCP. The nurse sees that the health care provider noted resonance on percussion of the client’s posterior chest. How will the nurse interpret this finding?
RATIONALE: Resonance on percussion is associated with healthy adult lung tissue. Hyperresonance is noted when too much air is present such as in the case of emphysema where it is trapped in the alveoli and pneumothorax where it is trapped in the pleural space leading to lung collapse. A dull note on percussion or hyporesonance indicates an abnormal density in the lungs, such as that noted in pneumonia, pleural effusion, or atelectasis or heamothorax or in the presence of a tumor.
8 / 77
Your patient weighs 140 lb. Order is for 0.9 mL/kg of body weight. How many mL should the patient get? Round to the nearest tenth.
Answer; 57.2ml
1kg = 2.2 pounds
140/2.2 = 63.6 kg
63.6 x 0.9 ml/kg = 57.2 ml
9 / 77
The physician orders an IV with heparin at 500 units/hour. You have a bag with 100 units/mL of solution. How many milliliters per hour will you set on the IV infusion controller?.
Answer: 5 ml/hour
Computation:
100 units = 1ml
500 /100 * 1 = 5ml
10 / 77
11 / 77
The nurse is caring for a client with end stage live disease who was admitted for bleeding esophageal varices. The bleeding varices were banded successfully but the client declined having a transjugular intrahepatic portal systemic shunt(TIPS) procedure and opted for a do-not-resuscitate (DNR) status. Which topic is most important for the nurse to discuss with the client and family at discharge?
Ans: 2
RATIONALE: A client who opted for DNR in the hospital should be discharged with a DNR bracelet or an active Physician Orders for Life Sustaining Treatment (POLST) form in the community setting.This should be done to ensure that the client’s wishes for emergency care will be carried out by first responders.In other words, DNR bracelet and POLST forms are community based systems that provide emergency responders with legal documentation needed to withhold resuscitation.
This client had end stage liver disease and is at high risk for life threatening events such as bleeding esophageal varices and hepatic encephalopathy. This client continues to be at risk for bleeding varices due to the declined TIPS procedure which could have prevented further esophageal varices by treating the portal hypertension. Hence, discharge home teaching must include proper use of DNR bracelet at all times in the community.
12 / 77
For the patient with no healthcare coverage who is seeking medical care, the emergency department staff members decide whether to provide care or transport to a public facility based on which law, enacted by Congress in 1986 and updated in 2003?
Answer: 2
RATIONALE: The intent of the Emergency Medical Treatment and Active Labor Act (EMTALA) is to ensure public access to emergency services regardless of ability to pay. The EMTALA prohibits “patient dumping,” which is transferring indigent or uninsured patients from a private hospital to a public hospital without appropriate screening and stabilization. An exception is made if a hospital does not have the capability to stabilize a patient or if the patient requests a transfer. However, the hospital has to ensure that the patient is released to or transported with proper medical personnel.
13 / 77
A nurse performing a physical assessment of a client is checking the client’s mouth and throat. As part of the assessment, the nurse plans to assess the function of cranial nerve X. Which of the following best indicates adequate functioning of this nerve?
RATIONALE: To assess the function of cranial nerve XII (the hypoglossal nerve), the nurse asks the client to stick out the tongue. The nurse then notes the forward thrust in the midline as the client protrudes the tongue. The nurse also asks the client to verbalize certain words and then listen for clear, distinct speech. The motor function of cranial nerves IX (the glossopharyngeal nerve) and X (the vagus nerve) is tested by depressing the client’s tongue with a tongue blade and noting pharyngeal movement as the client says “ah.” To test cranial nerve VII (the facial nerve), the nurse asks the client to frown or show his teeth. You don’t ask a client to laugh to observe any of the cranial nerve.
14 / 77
nurse is preparing to perform the Rinne’s test in a client who reports loss of hearing in one ear. In which anatomic area should the nurse place the stem of the vibrating tuning fork to perform the test?
RATIONALE: In Rinne test, the stem of a vibrating tuning fork is placed on the client’s mastoid process. When the client no longer hears the sound, the tuning fork is quickly inverted and placed near the ear canal; the client should again hear the sound. Normally the sound is heard twice as long by way of air conduction (near the ear canal) than by way of bone conduction (at the mastoid process). In the Weber test, the stem of the vibrating tuning fork is placed in the midline of the client’s skull. Normally the client should hear the tone, by way of bone conduction through the skull, equally in the two ears. In Placing the tuning fork at the temporal lobe on the side with hearing loss is not a component of a tuning fork test.
15 / 77
A nurse performing a neck assessment of a client is testing the status of cranial nerve XII. Which of the following best indicates that the client has adequate function of this nerve?
RATIONALE: There are 12 cranial nerves and they are cranial nerve 1- olfactory nerve, 2- optic nerve, 3- oculomotor nerve, 4- trochlear nerve, 5- trigeminal nerve, 6- abducens nerve, 7- facial nerve, 8- vestibulocochlear nerve, 9- glossopharengeal nerve, 10- vagus nerve, 11- spinal accessory nerve, 12- hypoglossal nerve. Cranial nerve XI (spinal accessory nerve) is tested by asking the client to shrug the shoulders against the resistance of the nurse’s hand and to turn the head to each side as the nurse tries to resist the client’s movement. Cranial nerve VII (the facial nerve) is tested by asking the client to smile, frown, close the eyes tightly against the resistance of the nurse, lift the eyebrows, show the teeth, and puff the cheeks. Cranial nerve XII (the hypoglossal nerve) is tested by inspecting the tongue as the client sticks out the tongue.
16 / 77
A nurse performing a skin assessment of a client with congestive heart failure observes that the client’s ankles are swollen. To assess the severity of the edema, the nurse presses the skin at the ankle. deep pitting is present and the indentation remained for a short while. How should the nurse document this finding?
RATIONALE: If one has congestive heart failure, one or both of the heart’s chambers lose their ability to pump blood effectively. As a result, blood cam back up in the legs, ankles and feet causing edema. Edema is the accumulation of fluid in the intercellular spaces. To check for edema, the nurse presses the thumbs firmly against the ankle malleolus. If the pressure leaves a dent in the skin, pitting edema is present. Edema is graded on a 4-point scale: 1+ indicates mild pitting with a slight indentation, 2+ is moderate pitting in which the indentation subsides rapidly, 3+ represents deep pitting in which the indentation remains for a short time and the ankle is swollen, and 4+ denotes very deep pitting in which the indentation remains for a long time and the ankle is very swollen.
17 / 77
A nurse is performing an abdominal assessment of a client who complains of right lower abdomial pain. Which method should the nurse use to palpate the abdomen?
RATIONALE: In palpation of the abdomen, the nurse starts with light palpation to detect surface characteristics and accustom the client to being touched before performing deeper palpation but not too deep. To detect deeper abnormalities, an ultrasound can be prescribed by the HCP. The nurse should ask client to locate tender painful areas first so that these areas may be palpated last. The nurse uses one hand to palpate except when certain organs (e.g., kidneys, uterus, adnexa) are being palpated. The nurse avoids any situation in which deep palpation might cause internal injury or pain. Percussion is the act of tapping the client’s skin with the use of short, sharp strokes to assess underlying structures.
18 / 77
A client whose mother has just died from breast cancer 6 months ago comes to the clinic after finding a lump in her right breast during breast self-examination. The client says, “I always knew I will end up like my mother”. What am I going to do?” Which response should the nurse give the client?
RATIONALE: The nurse should always focus on the client’s feelings and concerns and respond so that the client is provided an opportunity to discuss feelings. “Tell me how you are feeling” is the only option that gives the client this opportunity to express her worries. The other options are nontherapeutic and place the client’s feelings on hold. Telling the client to relax may end up agitating the client more as she may perceive that you are not taking her serious. Telling her she won’t end up like her mother is false reassurance and shouldn’t be used on any patient.
19 / 77
A nurse collects subjective and objective data from a client who underwent surgery after sustaining a spinal cord injury and is now on braces. The nurse identifies which findings as objective data? Select all that apply.
Answer- 1,3
RATIONALE:: Objective data are the findings collected by the nurse while inspecting, percussing, palpating, and auscultating or observations made by the nurse during data collection. Subjective data are the things the client says about himself or herself or what a family member or significant other says about the client during history-taking. Objective data also include information from the client’s health record and the results of laboratory, diagnostic studies and facial expression of the clients. The client’s temperature and blood pressure readings are objective data, while the client’s complaint of leg pain, feeling of warmth as well as his friend’s complaint to the nurse are all subjective data.
20 / 77
A nurse monitors a terminally I’ll client for which physical signs of approaching death? Select all that apply.
Ans: 2,3,4,5,6
RATIONALE: Physical signs of approaching death include: decreased appetite/thirst, decreased blood pressure, loss of consciousness, loss of bowel and bladder control and decreased tactile sensation.
21 / 77
A nurse employed in a hospital is waiting to receive a report from the laboratory via the fax machine. The fax machine activates and the nurse expects the report, but instead receives a sexually-oriented photograph. The appropriate initial nursing action is to:
Ans: 3
RATIONALE: Sexual harassment in the workplace is prohibited by state and federal laws. Sexually suggestive jokes, touching , pressuring a co-worker for a date, and open displays of or transmitting sexually-oriented photographs or posters are examples of sexual harassment by another worker. If the nurse believes that he or she is being subjected to unwelcome sexual conduct, these concerns should be reported to nursing supervisor with immediate effect. Calling police is unnecessary at things this material time. Cutting the photograph and asking for sender’s name are inappropriate initial actions.
22 / 77
Bumetamide (Bumex) 0.5 mg IV bolus bid was prescribed; Reconstitution instructions: Constitute to 1000 micrograms/3.1 mL with 4.8mL of 5% Dextrose Water for Injection. How many mL will you administer? Fill in the blanks. Record your answer using one decimal place.
Answer: (1.5) mL.Computation:1 mg = 1,000 mcgRequired strength = 0.5mgAvailable strength = 1000mcg = 1mgAvailable volume = 3.1mlRequired volume = ?0.5 * 3.1 / 1 = 1.55 = 1.5 ml
23 / 77
Your patient has had the following intake: 10 oz glasses of iced tea, 5 oz cartons of grape juice, ¾ pt of ice cream, 35 oz of juice, 1 ½ L of D5W IV and 6 oz of cottage cheese. What will you record as the total intake in mL for this patient? Fill in the blanks.
Answer; 3375 ml
1 oz = 30ml
1 pt = 500 ml
300 + 150 + 375 + 1050 + 1500 = 3375 ml
Cottage cheese is not liquid at room temperature, so it is not included when calculating intake.
24 / 77
MD writes an order for Lortab Elixir 4mg by mouth as needed for pain every 4 hours. Pharmacy dispenses you with 7.5mg/15ml. How many tablespoons will you administer per dose?
The answer is 3.
Available strength; 7.5mg
Available volume; 15ml
Required strength; 4mg
Required volume; ?
15 * 4 / 7.5 = 8 ml
1Tbsp = 14 ml
? = 8ml
? = 8/14 * 1
? = 0.57 Tbs = 0.6 Tbsp /dose
25 / 77
A nurse is caring for a client with Wernicke-Korsakoff syndrome. The nurse teaches the client to consume thiamine-rich food. The nurse determines that the client understands the dietary instructions if he selects which of the following from his menu?
Answer; C
Food sources of thiamin include beef, liver, nuts, oats, oranges, pork, eggs, seeds, legumes, peas and yeast.
Option A: Poultry contains niacin.
Option B: Milk contains vitamins A, D, and B2.
Option D: Broccoli contains folic acid, vitamins C, E, and K.
26 / 77
Two new graduate nurses in the elevator are discussing the COVID19-positive status of a client. One of the clients’ family members is in the elevator and overhears the conversation between the newly graduated nurses. Which of the following statements is true?
The students have violated the Health Insurance Portability and Accountability Act(HIPAA). The new graduate nurses had released the client’s protected personal information to a third party without the patient’s consent and to those who do not have a medical or business need to know. This is a HIPAA violation.
27 / 77
A nurse employed in a surgical unit in a hospital arrives at work and is told to report/float to the pediatric unit for the day because the unit is understaffed and the census on the pediatric unit is unusually high. The nurse has never worked in the pediatric unit and does not want to float to pediatrics. Which action by the nurse is appropriate?
Ans: 1
Floating may be acceptable legal practice used by hospitals to solve their understaffing problems, enhance efficiency and reduce staffing costs. Usually a nurse cannot refuse to float unless a union contract guarantees that nurses can work in a specified area or unless the nurse can prove the lack of knowledge for the performance of assigned tasks. When met with this situation the nurse should set priorities and identify potential areas of harm to the client. Nurses must be aware of state statutes and case law when asked to perform services outside of their usual area of practice. The nurse should never perform tasks or render or perform tasks or render services when he or she lacks the knowledge and skills to act competently. It is not appropriate to attempt to convince another nurse to go to the pediatric unit. As a nurse, never refuse to work in another unit. Floating to other unit as an experienced nurse is better than no nurse in that unit.
28 / 77
A client receives cardiopulmonary resuscitation in the emergency department, but it is unsuccessful. The wife of the client indicates that the client is an organ donor and that they want to donate the client’s eyes. Which should the nurse implement first to promote organ transplantation?
Ans: 4
When a corneal donor dies, the eyes are closed, covered with sterile gauze pads wet with saline, and cooled with small ice packs. Within 2 to 4 hours the eyes are harvested, and the cornea is usually transplanted within 24 to 48 hours after harvesting. The head of the bed is elevated 30 to 45 degrees to prevent edema and tissue damage. Calling an organ registry and asking the wife to produce documents does not promote organ transplantation.
29 / 77
The nursing instructor provides a lecture to nursing students regarding the issue of client’s rights and asks a nursing student to identify a situation that represents an example of invasion of client privacy. Which of the following, if identified by the student, indicates an understanding of a violation of this client right?
Invasion of privacy takes place with unreasonable intrusion into an individual’s private affairs. Performing a procedure without consent is an example of battery. Threatening to give a client a medication constitutes assault. Telling the client that the client cannot leave the hospital constitutes false imprisonment.
30 / 77
The nurse is providing postmortem care for a client who just died after a protracted illness. The client had a do-not-resuscitate order in place at the time of death. A family member was at the bedside when the client died. What interventions should the nurse include during postmortem care? Select all that apply.
Ans: 2,4,5.
RATIONALE: Before initiating postmortem care, the care nurse must consider the need for autopsy and confirm maybe the client is an organ donor. Postmortem care must be done with respect and dignity. Opportunities to participate in the care must be extended to the family and allow religious and cultural rituals when possible.
Procedure to perform postmortem care include: -Maintain standard or isolation precautions in place at the time of death. – Gently close the client’s eyes – Remove tubes and dressings following facility protocols. However, these should be left in place only when an autopsy or organ harvest is pending. – Straighten and wash the body and change the linens – Handle the body carefully as tissue damage and bruising occur easily after circulation has stopped. – Replace dentures so that the face maintains its shape. it is difficult to place dentures once rigor mortis sets in. – A towel folded under the chin may be needed to keep the jaw closed. – Place a pad under the perineum to absorb any stool or urine leaking from relaxed sphincters. -Raise the head of the bed to prevent blood from pooling and discoloring the face. – Remove equipment and soiled linens from the room. -Give client belongings to a family member or send with the body to the morgue.
31 / 77
The nurse is instructing a client with iron deficiency anemia on the importance of choosing foods high in iron. The nurse should encourage the client to select which of the following foods?
Answer; 2 Oranges and dark green leafy vegetables.
Dark green leafy vegetables are rich in iron while oranges are a good source of vitamin C, which enhances iron absorption.
32 / 77
A client who is recovering from a surgery has been ordered a clear liquid diet. The nurse would offer which item to the client?
Answer; 2
A clear liquid diet consists of foods that are relatively transparent to light and liquid at room and body temperature. Foods allowed on the clear liquid diet (bouillon, clear popsicles, plain gelatin, ice chips, sweetened tea or coffee (no creamer), carbonated beverages, and water)
33 / 77
A nurse is caring for a patient who has a colostomy. Which food would you advice the patient to avoid?
Answer; 1
Cherries, Radishes, and Watermelon are gas-causing foods and should be avoided in a patient with colostomy
34 / 77
A patient has a low magnesium level. Which food of the selection below is high in magnesium? Select all that apply
Answer; A, C, D
Out of the selection Avocado, Broccoli and tuna are the items high in magnesium.
35 / 77
A nurse has collected data from an African-American client who is at risk for cardiovascular disease. The client tells the nurse that he is a cigarette smoker, drinks while sitting out with friends, and enjoys eating hamburger with enough macaroni. Which piece of data does the nurse identify as an unmodifiable risk factor?
RATIONALE: Modifiable risk factors are those that can be modified or eliminated to prevent the development of disease. In the case of cardiovascular disease, these include hypertension, obesity, diabetes mellitus, increased serum lipid concentrations, tobacco use, and physical inactivity, diet. Unmodifiable risk factors, those that cannot be modified or eliminated, include age, sex, and heredity. Therefore while the client can change their lifestyle like eat healthily, stop alcohol and smoking, the client can not change their race or genetics.
36 / 77
A nurse is educating a client whose family has history of cardiovascular conditions about measures to prevent cardiovascular disease. Which statement by the client indicates a need for further information?
RATIONALE: Risk factors associated with cardiovascular disease include increasing age, sex, excessive alcohol intake, cigarette smoking, diabetes mellitus, increased serum lipid concentrations, excessive dietary sodium, obesity, sedentary lifestyle, and stress. Reduction of salt intake, reducing calorie intake, exercise, and cutting down on fat intake are appropriate preventive measures. The risk of cardiovascular disease and resultant death is higher in smokers than in nonsmokers. The client needs to stop smoking, not “cut down” on the smoking.
37 / 77
38 / 77
There is an infestation of West Nile Virus in the community, a nurse provides information to a client about measures to prevent infection with West Nile virus. Which statement by the client indicates a need for further information?
RATIONALE: West Nile virus is a single-stranded RNA that causes west nile fever and is associated with mosquito bites. Symptoms include headache, high fever, neck stiffness, stupor, disorientation, tremors, convulsion,, muscle weakness, paralysis and coma. The nurse should instruct the client to wear a hat and clothing that covers as much skin as possible when outdoors and to spray insect repellant containing DEET (N, N-diethyl-m-toluamide) on clothes that cover the skin. Mosquitoes are most prevalent in wooded and swampy areas and are most active at dusk and dawn; however, this does not prevent the client from going out during the day for their daily activities.
39 / 77
A nurse is to give the hepatitis B vaccine to a 1 day old baby. Which anatomic site should the nurse select for the injection?
RATIONALE: Vaccines administered intramuscularly are given in the vastus lateralis muscle in newborns and in the deltoid for older infants and children. The dorsogluteal area is avoided because the site has been associated with low antibody seroconversion rates, indicating a reduced immune response. Also, it is generally recommended that the dorsogluteal site be avoided until a child has been walking for at least 1 year. The rectus femoris is not an acceptable site for injections in neonates.
40 / 77
A nurse wants to administer the diphtheria/tetanus/acellular pertussis vaccine (DTaP) to a 6-month-old infant. Which action should the nurse take to reduce or prevent the risk for a local reaction to the vaccine?
RATIONALE: To minimize the risk for a local reaction to a vaccine, the nurse selects a needle of adequate length to deposit the vaccine deep into the muscle mass. The vaccine is injected into the vastus lateralis muscle or ventrogluteal muscle (the deltoid may be used in children 18 months of age or older), and an air bubble is used to clear the needle after injection of the vaccine. Changing the needle on the syringe after drawing up the vaccine and before injecting will not decrease the possibility of a local reaction but should also be carried out by the nurse as glass pieces can be stuck inside the needle used to draw up vaccine, therefore a different needle is needed for injecting into the muscle mass.
41 / 77
A nurse is caring for a client with pituitary adenoma. The client tells the nurse that a lawyer will be arriving today to prepare a living will. The client asks the nurse to act as one of the witnesses for the will. The appropriate nursing action is to:
RATIONALE: A living will address the withdrawal or withholding of life-sustaining interventions that unnaturally prolong life. It identifies the person who will make care decisions if the client is unable to take action. It is witnessed and signed by two people who are unrelated to the client. Nurses or employees of a facility in which the client is receiving care and beneficiaries of the client must not serve as a witness. There is no reason to call the physician.
42 / 77
A 16year old adolescent is transferred to the medical-surgical floor from intensive care unit(ICU) after sustaining a closed bread injury that left him comatose. The adolescent’s mother is identified as his only guardian. During the evening shift, a man identifying nas adolescent’s father asks the nurse for information about the adolescent’s condition. How should the nurse respond?
RATIONALE: Privacy laws prevent the nurse from sharing client information with anyone who isn’t designed by the client or in this case, the legal guardian. Therefore the nurse should not share any information with this man identified himself as the adolescent’s father.
43 / 77
The nursing staff is sitting in the lounge taking their morning break. A nursing assistant tells the group that she thinks that the unit secretary has acquired immunodeficiency syndrome (AIDS) and proceeds to tell the nursing staff that the secretary probably contracted the disease from her husband, who is supposedly a drug addict. Which legal tort has the nursing assistant violated?
RATIONALE: Defamation is a false communication or a careless disregard for the truth that causes damage to someone’s reputation, either in writing (libel) or verbally (slander). An assault occurs when a person puts another person in fear of harmful or offensive contact. Negligence involves the actions of professionals that fall below the standard of care for a specific professional group.
44 / 77
A client with end-stage renal disease, oxygen-dependent chronic obstructive pulmonary disease and a Do-Not-Resuscitate (DNR) code status is admitted to the medical floor for COPD exacerbation. The nurse walks into the room and finds the client is not breathing. What should the nurse do first?
RATIONALE: The care nurse should assess the client first before calling the health care provider. A Do-Not-Resuscitate(DNR) order requires the nurse to withhold resuscitation in the event of cardiac or respiratory arrest. If an event occurs, the nurse should assess for breathing and check the central or apical pulse. After performing these actions, the nurse should call the health care provider to confirm the death. Activating the code system is not appropriate as the client already had an order to withhold resuscitation. Checking the blood pressure is not appropriate in a client who has stopped breathing. Meanwhile, checking the apical pulse is the most appropriate after noticing the client is not breathing again.
45 / 77
A newly reassigned nurse enters a hospital room at the beginning of the shift and finds the client unconscious and unresponsive. Resuscitation is initiated and then continued by the rapid response team. The nurse realizes that there is a do-not-resuscitate(DNR) prescription posted in the client’s chart. Which action is correct?
RATIONALE: Failure to stop an erroneous code on a client with an advance directive in a timely attempt may result in legal action. Many health care professionals react to an emergency situation automatically. However, some States will further penalize health care workers with loss of their professional license if they fail to render cardiopulmonary resuscitation in an emergency situation. Please note, health care professionals will not be penalized for an honest mistake. However, resuscitation must end immediately after they are notified of the error. Continuing treatment until the code status is verified with the health care provider constitutes malpractice. Before DNR prescription can be posted in a client’s medical record chart, the health care provider must provide documentation that the client’s code status has been established through consultation with the client or client’s family.
46 / 77
A charge nurse completing a deceased client’s chart ‘s audit notes that the chart contains a copy of the client’s advance directive and the do-not-resuscitate (DNR) order. While reviewing the nurses’ notes, the charge nurse finds documentation of code blue and cardiopulmonary resuscitation with a physician entry to discontinue code blue due to existing advance directives and DNR from client. What does the charge nurse conclude?
Ans: 3, 5.
RATIONALE: The charge nurse conclusion should be: by initiating a code blue, the care nurse didn’t follow the client’s advance directive and DNR order. The physician was correct to follow the client’s wishes and stop resuscitation efforts. The physician had the authority to stop the code.
47 / 77
A health care provider writes an order for Viscous Lidocaine 15 mg by mouth every 4 hours as needed for sore throat. Pharmacy dispenses you 30 mg/3ml. How many ml will you administer per dose?
Available strength = 30mg
Available volume = 3ml
Required strength = 15mg
Required volume = ?
15/30 *3/1 = 1.5ml
48 / 77
A health care provider orders kanamycin (Kantrex) 5 mg/kg IM q 12 hr; Available: kanamycin 0.35 Gm/mL. How many mL will you administer for each dose to a 160 lb patient? Fill in the blanks.
1pound=0.45lbs
160 lbs = 160 * 0.45= 72 kg
5 mg/kg x 72 kg = 360 mg
1Gm = 1000mg
0.35Gm = 350mg
So 350mg = 1ml
360/350 * 1 = 1.03ml
49 / 77
A hospitalized patient with heart failure is on a 1000 mL fluid restriction every 24 hours. During the 7 a.m. to 7 p.m. shift, he has three meals, consuming 1/2 cup of tea with each. He also has 50 mL of water each time he takes his medications at 7 a.m., noon, and 5 p.m. Mid Afternoon, he drinks 200 mL of soda. How many milliliters may he consume during the 7 p.m. to 7 a.m. shift? Fill in the blanks.
1cup=240
So 1/2cup= 120mL
120 mL + 120 mL + 120 mL + 50 mL + 50 mL + 50 mL + 200 mL = 710 mL
1000 mL – 710 mL = 290 mL. He can drink 290 mL during the night shift
50 / 77
A nurse conducting a physical assessment is observing the client’s balance and performing tests to determine the client’s sense of equilibrium. Which cranial nerve is the nurse assessing?
Correct answer: 4
Cranial nerve VIII is the acoustic nerve. Hearing tests are performed to assess the cochlear portion of this nerve. Tests to assess equilibrium, such as observation of the client’s balance when the client is walking or standing, involve the vestibular portion. The function of cranial nerve II (the optic nerve) is tested by assessing the client’s visual acuity. Swallowing ability and taste perception of the posterior portion of the tongue are controlled by cranial nerve IX (the glossopharyngeal nerve). Taste perception on the anterior portion of the tongue and the ability to perform facial and eye movements (e.g., closing the eyes) are controlled by cranial nerve VII (the facial nerve).
51 / 77
A nurse performing a neurological assessment of a client who has sustained a stroke (brain attack) is preparing to check for stereognosis. Which action should the nurse take to perform this assessment?
Correct answer: 1
Stereognosis is the client’s ability to recognize objects placed in his or her hand. Graphesthesia is the client’s ability to identify a number traced on the client’s hand. Position sense (kinesthesia) is tested by moving the client’s finger or toe up or down and asking the client which way it is being moved. Two-point discrimination is the client’s ability to discriminate two simultaneous pinpricks on the skin.
52 / 77
The nurse uses a CAGE test screening questionnaire to assess for what condition in a client who is reported to be having a lot of work-related problems?
CAGE is a screening questionnaire to identify excessive or uncontrolled drinking (C = Cut down; A = Annoyed; G = Guilty; E = Eye opener). The health history assesses lifestyle, including factors such as exercise, diet, risk reduction, and health promotion behaviors. Coping and stress management are assessed during the functional assessment of the complete health history. Depression is assessed during the review of systems and during the mental status assessment (mood and affect). The Geriatric Depression Scale, Short Form is an assessment instrument for use with older adults.
53 / 77
A nurse performed a respiratory assessment of an adult client. The nurse notes a resonance sound on percussion, what interpretation does the nurse make of this finding?
Resonance on percussion predominates in healthy adult lung tissue. Hyperresonance is noted when too much air is present such as in the case of emphysema where it is trapped in the alveoli and pneumothorax where it is trapped in the pleural space leading to lung collapse. A dull note on percussion indicates an abnormal density in the lungs, such as that noted in pneumonia, pleural effusion, or atelectasis or in the presence of a tumor.
54 / 77
A nurse has collected health history information from an African-American client aged 74yrs who is at risk for hypertension. The client tells the nurse that he is a cigarette smoker, drinks “a beer or two” every day, and enjoys sitting around watching sports on television, the client also told the nurse that his parents died as a result of complications from hypertension. Which piece of data does the nurse identify as an unmodifiable risk factor? Select all that apply
Answer:1, 4,5
Modifiable risk factors are those that can be modified or eliminated to prevent the development of disease. In the case of cardiovascular disease, these include hypertension, obesity, diabetes mellitus, increased serum lipid concentrations, tobacco use, and physical inactivity. Unmodifiable risk factors, those that cannot be modified or eliminated, include age, sex, and heredity.
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A patient is started on the diuretic Spironolactone. Which foods should the patient be careful to avoid eating too much of?
Answer; Kiwi
Spironolactone is known as a potassium-sparing diuretic medication (meaning it keeps potassium) therefore a patient would need to watch how much potassium they eat. Kiwis are high in potassium.
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The patient is on a low protein, low sodium, low potassium, low phosphate diet. What type of patient would you expect to be on this type of diet?
The patient with chronic kidney disease should follow this type of diet because protein breaks down into urea so patient will have increased urea levels, low sodium to prevent fluid excess, low potassium to prevent hyperkalemia because glomerulus isn’t filtering out potassium/phosphate as it should and low phosphate to prevent hyperphosphatemia.
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A patient with Addison’s disease should follow what type of diet?
Patients with Addison’s disease suffer from low sodium levels. Therefore, they need to eat foods high in sodium. These foods usually include butter, soy sauced, frozen foods, ‘fast’ foods, salad dressing, canned foods, and pickled foods.
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A patient’s potassium level is 6.0. Which food should the patient avoid?
Normal potassium levels are 3.5-5.0. Therefore a potassium level of 6.0 is considered high so the patient should avoid foods high in potassium. In this case, spinach is the highest in potassium.
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A client with hypertension has been told to maintain a diet low in sodium. The nurse who is teaching this client about foods that are allowed should include which food item in a list provided to the client?
Answer; 4
Summer squash: Foods that are low in sodium include fruits and vegetables
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When is the most appropriate time a nurse teaches a young adult male client to conduct testicular self-examination?
Answer: 3
Testicular self-examination should be performed monthly, starting during puberty. Because men are at greatest risk for testicular cancer between the ages of 18 and 38 years, teaching should be targeted to this age group. Men should be taught to hold the scrotum in one hand and examine each testicle and spermatic cord separately by gently rolling the testicle between the thumb and fingers of the other hand. The client is taught to perform the examination on the same day of each month. Examination is performed after a warm bath or shower, when the testicles are relaxed, descended, and easier to palpate.
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A nurse at a health fair is conducting teaching sessions on dietary measures to help prevent cancer. Which foods should the nurse encourage clients attending the teaching sessions to eat as a means of preventing cancer? Select all that apply.
Answer: 1,3
Dietary factors related to the development of cancer include foods that are high in fat and low in fiber, foods that are high in animal fat, high-nitrate foods, and those that contain preservatives, contaminants, and additives. Therefore, of the options provided, fruits and vegetables are the food items whose consumption should be encouraged as a means of preventing cancer.
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The nurse plans primary prevention activities for a client. Which measures are primary prevention activities? Select all that apply.
Answer: 123
Primary prevention activities are those that prevent disease or dysfunction, including health-education programs and wellness activities that maintain or improve health. Examples of primary prevention include immunizations, pollution control, nutrition, and exercise. Secondary prevention activities are focused on clients who are experiencing health problems, on activities such as screening techniques (self-examination practices, mammography, blood pressure screening), and on treatment of disease at an early stage to limit disability. Tertiary prevention is focused on rehabilitation to minimize the effects of a long-term disease and to assist clients in achieving the highest possible level of function. Examples include cardiac rehabilitation and diabetes mellitus management.
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The mother of a two-month-old baby calls the nurse at a well-baby clinic two days after the first DTaP immunization. She reports that the baby feels very warm, has cried inconsolably for as long as three hours, and has had several shaking spells. The response of the nurse should be to
Correct answer is: 1
Instruct the mother to call 911 for an ambulance to transport the infant. The exhibited findings of the infant indicate a severe reaction to the immunizations. Immediate attention is needed & an ambulance with trained staff needs to transport because of the risk of grand mal seizures from potential encephalopathy which is a critical reaction. The mother would need to be instructed after this acute reaction to inform the provider of this reaction to the first dose of DTaP. Based on the need and risk involved to the infant, the health care provider may decide that further DTaP immunizations are contraindicated for life. The clinic nurse would need to document in the notes for this infant: the instructions given, findings reported by the mother, and specific follow-up needs for the next clinic visit in relation to teaching and evaluation of the outcome of this event.
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After a physical examination the nurse documents which records as subjective data? Select all that apply
Correct answer: 1,2,3
Subjective data, collected during the health history, consist of information that the client gives about him or herself. Objective data are obtained through physical examination and vital signs measurements, what the nurse observes, and laboratory study and diagnostic test results. Allergies, the date of the client’s last menstrual period, and the reported use of medication for headaches are all subjective data.
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A client is brought to the emergency department after a motor vehicle accident. The client is alert and cooperative but has sustained multiple fractures of the legs. What are the steps required by a nurse in data collection?
Correct answer: 2,1,4,3,5
If the client is alert and cooperative and if the situation is not life-threatening, the nurse should attempt to obtain as much subjective and objective data as possible to address data collection while caring for the client.
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which action is most appropriate for a nurse to minimise potential for a local reaction to vaccine during routine immunization of a 6 months old infant?
Correct Answer: 1
To minimize the potential for a local reaction to a vaccine, the nurse selects a needle of adequate length to deposit the vaccine deep into the muscle mass. The vaccine is injected into the vastuslateralis muscle or ventrogluteal muscle (the deltoid may be used in children 18 months of age or older), and an air bubble is used to clear the needle after injection of the vaccine. Changing the needle on the syringe after drawing up the vaccine and before injecting will not decrease the possibility of a local reaction.
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A nurse has provided information to a client about measures to prevent diabetes mellitus Which statement by the client indicates a need for further information?
Risk factors associated with diabetes mellitus is majorly obesity. Measures to control excessive weight gain incude; regular exercise at least three times a week, consumption of calorie-controlled diets, client should consume vegetables, fruits, whole grains and fibres. Option 1 is a negative statement because it’s not specific and a little bit of glucose is still required for normal cell function.
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A nurse provides information to a client about measures to prevent infection with West Nile virus. Which statement by the client indicates a good understanding of the information given?
Correct answer: 3
West Nile virus is associated with mosquito bites. The nurse should instruct the client to wear a hat and clothing that covers as much skin as possible when outdoors and to spray insect repellant containing DEET (N, N-diethyl-m-toluamide) on clothes that cover the skin. Mosquitoes are most prevalent in wooded and swampy areas and are most active at dusk and dawn. Other options are negative statements on the information passed to the patient hence, showing no good understanding.
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A nurse collects subjective and objective data from a client who was just admitted on account of frequent stooling and vomiting. The nurse identifies which findings as objective data? Select all that apply.
Correct answer 135
Subjective data are the things the client says about himself or herself or what a family member or significant other says about the client during history-taking. Objective data are the findings collected by the nurse while inspecting, percussing, palpating, and auscultating. Objective data also includes information from the client’s health record and the results of laboratory and diagnostic studies. The client’s pulse rate and blood pressure readings are objective data, as is the nurse’s observation of the skin. The other options constitute subjective data.
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A nurse is supervising the postmortem care of a client. Which action by the nursing assistants who are performing the care is appropriate?
RATIONALE: The nurse may delegate postmortem care to nursing assistants, but the nurse must be knowledgeable about correct postmortem care. The care given must protect the client’s body from damage or disfigurement. Elevating the head of bed immediately after the client’s death can help reduce facial discoloring from Rigor mortis. Using tape may damage the delicate eyelid tissues, dentures should be placed inside the client’s mouth during postmortem care to maintain facial structure.
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A patient who is admitted to the hospital gives the nurse an advance directive. The nurse should understand that an advance directive is:
RATIONALE: An advance directive is a written document that contains directives of a person’s choices regarding end of life care. A person must have the cognitive and communicative abilities to execute decisions regarding their desires. It includes wishes for treatment options should the person become unable to do so.
A durable power of attorney for healthcare designates an individual to make medical decisions in case the patient is unable to do so.
A statement identifying the person as an organ donor may be included in an advance directive, but it is not the only information an advance directive. This information would typically included on an organ donor card.
A written statement authorizing a particular surgical procedure is a consent form.
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The nurse notes that an advance directive is in the client’s medical record. Which of the following statements represents the best description of guidelines a nurse would follow in this case?
RATIONALE: A living will directs the client’s healthcare in the event of a terminal illness or condition. A durable power of attorney is invoked when the client is no longer able to make decisions on his or her own behalf . The client may change advance directive at any time.
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A client has suffered an extensive brain injury and can’t make his own treatment choices. Which written document is recognized by state law and provides directions for provision of care at a time when the client can’t make his own choices?
RATIONALE: An advanced directive is a document written or completed by the client and used by a facility to provide care at a time when the client can’t make his own choices. The living Will and Durable Power Of Attorney(DPOA) are both examples of advanced directives. A living will is a document that is prepared by a competent adult and provides direction regarding medical care if the client becomes incapacitated. Durable power of attorney is an authorization enabling any competent individual to name someone else to exercise decision making authority on the individual’s behalf under specific circumstances. The patient self-determination Act of 1990 allows client to write instructions for their care and treatment for a time when they become unable to make their own decisions.
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A 62-year-old woman has been admitted to the hospital for a surgical procedure. During the admission process, the nurse asks whether she has a living will or a durable power of attorney. The patient asks, “What is a living will?” The best response by the nurse would be which of the following?
RATIONALE: A living will state your wishes regarding future healthcare if you become unable to give instructions. Generally, there are two types of advance directives: a living will and a durable power of attorney. A living will is a directive that declares the patient’s wishes should the patient become unable to give instruction. A durable power of attorney identifies a person who will make healthcare decisions in the event the patient is unable to do so. Simply saying a living will and durable power of attorney are both advance directives is broadly stated and does not give as much information to the patient.
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To assist a client who is on admission with personal hygiene, which intervention by the nurse would be best in this situation?
Answers- 2
RATIONALE: Although it may be appropriate for the client’s relative to contribute to client’s care, asking thr relative to bath the client is not the best way to help the client. During the bath, the nurse can integrate other nursing activities, including client assessment and interventions such as range-of-motion exercises, application of dressings, skin inspection, and care for intravenous sites, so asking a UAP to completely bathe the client is not the appropriate choice. While providing hygiene, the nurse must preserve as much of the client’s independence as possible. Therefore, encouraging the client to perform as much of the bath as possible is the best option of those provided.
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A home care nurse is teaching a client who is having difficulty sleeping about ways to promote sleep. What teachings should the nurse provide to the client? Select all that apply.
Answer- 2,5
RATIONALE: Eating light food at night when hungry helps promote comfort because there is a low chance that the patient will suffer indigestion and may put the client in the right mode to sleep. The room atmosphere should be comfortable, neither very cold nor very warm or humid. Exercising everyday is good but should be done earlier in the day like morning and afternoon time. Exercising 3 hours before bedtime should be avoided. Also distracting activities or sounds like watching television or listening to the radio should be avoided at bedtime.
However heavy meals at night should be avoided as it may lead to some discomfort which can disturb one’s sleep pattern.
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A registered nurse is collecting subjective data from a client about the client’s daily meal consumption. Which question should the nurse ask the client first?
Answer- A
RATIONALE: The first question the nurse should ask the client would provide data about the client’s typical daily intake. Once this has been determined, the nurse would collect data regarding who cooks and prepares the food and whether the client has adequate income to buy adequate meal. The nurse might ask the client about adequate diet before teaching the client about healthy eating habits. However, the registered nurse would use the client’s answer as a guide for teaching nutrition and adequate diet regardless of whether the client has known about it.
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