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Based on your performance on this “NCLEX Cracker” Practice Test, you’re not yet ready for the NCLEX.
Keep your head up! Also, don’t focus on your estimated score, they mean essentially nothing at the start. Rarely does anyone start these exams and score well immediately, if that was the case then they wouldn’t even need to practice! These are ‘practice’ tests, meaning you’re practicing to improve your skills. If you continue to work hard and study, read and understand the solutions, practice with “NCLEX Cracker” daily and give it your best effort, we promise your score will improve. Review and learn for now, and the scores will come.
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Based on your performance on this “NCLEX Cracker” Practice Test, you barely missed the “passing” mark.
Keep your head up! Also, don’t focus on your estimated score, they mean essentially nothing at the start. Rarely does anyone start these exams and score well immediately, if that was the case then they wouldn’t even need to practice! These are ‘practice’ tests, meaning you’re practicing to improve your skills. If you continue to work hard and study, read and understand the solutions, practice with “NCLEX Cracker” daily and give it your best effort, we promise your score will improve. Review and learn for now, and the scores will come.
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Congratulations! Based on your performance on this “NCLEX Cracker” Practice Test, you’re predicted to pass your NCLEX! Keep hammering away at our NCLEX questions so that you can keep up the great work!
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When teaching a client to go down the stairs using crutches what action by the client demonstrates the need for further teaching?
Rationale – The weight should not be placed on the injured leg. The client should use the crutches to bear weight with moving the injured leg, not the on injured leg. Assuming the tripod position at the top of the stairs is correct. Supporting the injured leg with crutches is correct. Supporting the body weight with crutches when moving the unaffected leg to the stair is correct.
Subcategory- Assistive Devices
Rationale – The weight should not be placed on the injured leg. The client should use the crutches to bear weight with moving the injured leg, not the on injured leg. Assuming the tripod position at the top of the stairs is correct. Supporting the injured leg with crutches is correct. Supporting the body weight with crutches when moving the unaffected leg to the stair is correct.
Subcategory- Assistive Devices
The nurse is teaching a client with postoperative urinary incontinence about the risks involved when using an indwelling urinary catheter. What is the most accurate statement made by the nurse?
Rationale- Urinary tract infections are a leading cause of sepsis in clients with an indwelling urinary catheters and can lead to increased hospital stay and even death. Mobility and future voiding patterns should not be affected by the presence of a catheter. Output should be recorded, through constant monitoring is not required.
Subcategory-Elimination
Rationale- Urinary tract infections are a leading cause of sepsis in clients with an indwelling urinary catheters and can lead to increased hospital stay and even death. Mobility and future voiding patterns should not be affected by the presence of a catheter. Output should be recorded, through constant monitoring is not required.
Subcategory-Elimination
It is observed that a client’s urine is cloudy, amber, and has an unpleasant odor. An inference could be made that the client is experiencing which of the following?
Rationale- Though a urine culture is a definitive diagnostic test to identify a urinary tract infection an inference can be made from the above assessment findings. Urine retention, decreased specific gravity, and the presence of ketones are not symptoms of a urinary tract infection.
Subcategory-Elimination
Rationale- Though a urine culture is a definitive diagnostic test to identify a urinary tract infection an inference can be made from the above assessment findings. Urine retention, decreased specific gravity, and the presence of ketones are not symptoms of a urinary tract infection.
Subcategory-Elimination
What finding is considered a normal change related to aging?
Rationale – A decreased glomerular filtration rate is a normal finding an aging clients. Urethral size changes are not related to aging. The water capacity decreases not increases. The blood flow to the kidneys decreases it does not increase.
Subcategory-Elimination
Rationale – A decreased glomerular filtration rate is a normal finding an aging clients. Urethral size changes are not related to aging. The water capacity decreases not increases. The blood flow to the kidneys decreases it does not increase.
Subcategory-Elimination
What findings are consistent with stressed induced gastrointestinal findings? Select all that apply.
Rationale – Constipation diarrhea and colitis are all common findings in clients’ gastrointestinal complications of stress. Crohn’s disease and incontinence and not findings consistent with gastrointestinal stress-induced symptoms.
Subcategory-Elimination
Rationale – Constipation diarrhea and colitis are all common findings in clients’ gastrointestinal complications of stress. Crohn’s disease and incontinence and not findings consistent with gastrointestinal stress-induced symptoms.
Subcategory-Elimination
A client has progressed from full to partial support with cane when walking. What action by the client demonstrates a clear understanding of cane use?
Rationale – Once a client is able to tolerate some weight bearing, the cane and affected leg can be moved at the same time. Moving the cane before the legs is indicated with maximum support. The unaffected side advances first in maximum support, not in partial weight bearing. The cane should always move ahead, not stay at the side.
Subcategory-Mobility/Immobility
Rationale – Once a client is able to tolerate some weight bearing, the cane and affected leg can be moved at the same time. Moving the cane before the legs is indicated with maximum support. The unaffected side advances first in maximum support, not in partial weight bearing. The cane should always move ahead, not stay at the side.
Subcategory-Mobility/Immobility
What findings demonstrate proper use of crutches? Select all that apply.
Rationale- The client should support their weight on the hand rests. They should maintain their elbows at a 30 degree flexion. The crutches should be measured when the client is supine to ensure that the crutches are one inch longer than the axilla to the heel. The client should be encouraged to stand erect. The shoulder rest should be 1-2 inches below the axilla, 5 inches is too much.
Subcategory-Mobility/Immobility
Rationale- The client should support their weight on the hand rests. They should maintain their elbows at a 30 degree flexion. The crutches should be measured when the client is supine to ensure that the crutches are one inch longer than the axilla to the heel. The client should be encouraged to stand erect. The shoulder rest should be 1-2 inches below the axilla, 5 inches is too much.
Subcategory-Mobility/Immobility
The nurse is planning to provide massage to several of her clients. What client is massage contraindicated in?
Rationale- A client with a deep vein thrombosis should not receive massage because they are at increased risk of clotting. Client diagnosed with arthritis, metastatic cancer or suicidal ideation may benefit from massage.
Subcategory-Non-Pharmacological Comfort Interventions
Rationale- A client with a deep vein thrombosis should not receive massage because they are at increased risk of clotting. Client diagnosed with arthritis, metastatic cancer or suicidal ideation may benefit from massage.
Subcategory-Non-Pharmacological Comfort Interventions
What non-pharmacological pain relief can be used for a joint strain? Select all that apply.
Rationale- Rest, ice and stabilization are undictated for a new acute joint injury. Ibuprofen is indicated, but is the pharmacologic treatment. A nerve block would not be part of an initial treatment of a joint injury.
Subcategory-Non-Pharmacological Comfort Interventions
Rationale- Rest, ice and stabilization are undictated for a new acute joint injury. Ibuprofen is indicated, but is the pharmacologic treatment. A nerve block would not be part of an initial treatment of a joint injury.
Subcategory-Non-Pharmacological Comfort Interventions
The nurse is caring for a Mexican- American client diagnosed with acute abdominal pain. The client is refusing pain medication, blaming the pain on “castigo”. What action by the nurse is priority?
Rationale- It is important to have a clergyman talk to the client about their feelings about the pain being religious punishment (castigo). It is not ethical to administer the medication against the client’s will. An interpreter is not indicated. Documentation should be done, but exploring the client’s feelings is priority.
Subcategory-Non-Pharmacological Comfort Interventions
Rationale- It is important to have a clergyman talk to the client about their feelings about the pain being religious punishment (castigo). It is not ethical to administer the medication against the client’s will. An interpreter is not indicated. Documentation should be done, but exploring the client’s feelings is priority.
Subcategory-Non-Pharmacological Comfort Interventions
What cardiovascular disorders may require the initiation of dietary sodium restriction? Select all that apply.
Rationale- Increased sodium intake may result in fluid retention that may increase blood pressure and further complicate congestive heart failure. Hyperlipidemia and leukemia are not affected by sodium intake. Chronic renal failure is not a cardiovascular disorder.
Subcategory-Nutrition and Oral Hydration
Rationale- Increased sodium intake may result in fluid retention that may increase blood pressure and further complicate congestive heart failure. Hyperlipidemia and leukemia are not affected by sodium intake. Chronic renal failure is not a cardiovascular disorder.
Subcategory-Nutrition and Oral Hydration
What statement regarding nutrition in pregnant women is accurate?
Rationale- Pregnant women need to increase caloric intake by 10% more than non-pregnant women. They need 25-50% more vitamins and minerals than non-pregnant women. Women need to increase folic acid, not decrease. Women need increased protein intake to help with the formation of the placenta and fetal brain development.
Subcategory-Nutrition and Oral Hydration
Rationale- Pregnant women need to increase caloric intake by 10% more than non-pregnant women. They need 25-50% more vitamins and minerals than non-pregnant women. Women need to increase folic acid, not decrease. Women need increased protein intake to help with the formation of the placenta and fetal brain development.
Subcategory-Nutrition and Oral Hydration
What key nutrient should be assessed in a school aged child? Select all that apply.
Rationale- School aged children should be assessed for adequate intake of calcium, vitamin D and Iron. Potassium and sodium intake are not as important at this age.
Subcategory-Nutrition and Oral Hydration
Rationale- School aged children should be assessed for adequate intake of calcium, vitamin D and Iron. Potassium and sodium intake are not as important at this age.
Subcategory-Nutrition and Oral Hydration
A client that has been following an extremely low fat diet should be evaluated for what deficiency?
Rationale- Vitamin A is a fat soluble vitamin that is often depleted when clients are on extremely low fat diets or have issues with metabolizing fats. Vitamin C, Folic Acid and Biotin are all water soluble vitamins.
Subcategory-Nutrition and Oral Hydration
Rationale- Vitamin A is a fat soluble vitamin that is often depleted when clients are on extremely low fat diets or have issues with metabolizing fats. Vitamin C, Folic Acid and Biotin are all water soluble vitamins.
Subcategory-Nutrition and Oral Hydration
What action by the nurse will help decrease embarrassment for a client that needs a bed bath?
Rationale – Even if a client requires full care for a bed bath they can often clean their own peroneal area. Talking to the client while cleansing the peroneal area, asking the client who they prefer to do the cleansing or encouraging a family member to clean them will not decrease embarrassment for the client.
Subcategory-Personal Hygiene
Rationale – Even if a client requires full care for a bed bath they can often clean their own peroneal area. Talking to the client while cleansing the peroneal area, asking the client who they prefer to do the cleansing or encouraging a family member to clean them will not decrease embarrassment for the client.
Subcategory-Personal Hygiene
The nurse is providing foot care for a client admitted with type 1 diabetes. What action by the nurse demonstrates a need for further teaching?
Rationale – Cutting toenails could cause injury and is contraindicated. It is acceptable for the nurse to use lotion, foot powder and clean between the client’s toes.
Subcategory-Personal Hygiene
Rationale – Cutting toenails could cause injury and is contraindicated. It is acceptable for the nurse to use lotion, foot powder and clean between the client’s toes.
Subcategory-Personal Hygiene
During a 3-day hospital stay, what is most likely to have a negative impact on a client’s sleep pattern?
Rationale- A very common psychologic response to pain is restlessness and sleeplessness. Fatigue, familiar stimuli, and relieving anxiety generally promote sleep and rest.
Subcategory-Rest and Sleep
Rationale- A very common psychologic response to pain is restlessness and sleeplessness. Fatigue, familiar stimuli, and relieving anxiety generally promote sleep and rest.
Subcategory-Rest and Sleep
A client admitted to the hospital is being assessed by the nurse. The client informs the nurse that they sleep “well”. What statement by the nurse is most appropriate?
Rationale – When obtaining an assessment of a client’s sleep pattern it is important to determine what the client means by “well”. The nurse should quantify and clarify the client’s statement. Asking if the client normally sleeps well does not clarify the client’s statement. Letting them know their sleep may be interrupted while at the hospital is not appropriate for the assessment on the client’s sleep. Stating that the client will heal faster because they sleep well does not assist in the assessment or clarify “well”.
Subcategory-Rest and Sleep
Rationale – When obtaining an assessment of a client’s sleep pattern it is important to determine what the client means by “well”. The nurse should quantify and clarify the client’s statement. Asking if the client normally sleeps well does not clarify the client’s statement. Letting them know their sleep may be interrupted while at the hospital is not appropriate for the assessment on the client’s sleep. Stating that the client will heal faster because they sleep well does not assist in the assessment or clarify “well”.
Subcategory-Rest and Sleep
The nurse is providing nutritional counseling for a client with a BMI of 32.5. What foods should be encouraged frequently in the nutritional plan?
Rationale- Fresh vegetables and fresh fruits and whole grains are high in vitamins and minerals and offer more fiber which aids in increased bowel elimination and decreased fat absorption.
Subcategory: Nutrition and Oral Hydration
Rationale- Fresh vegetables and fresh fruits and whole grains are high in vitamins and minerals and offer more fiber which aids in increased bowel elimination and decreased fat absorption.
Subcategory: Nutrition and Oral Hydration
What cardiovascular disorders may require the initiation of dietary sodium restriction? Select all that apply.
Rationale- Increased sodium intake may result in fluid retention thus increasing blood pressure that may increase blood pressure and further complicate congestive heart failure. Chronic renal failure is not a cardiovascular disorder. Hyperlipidemia and leukemia are not affected by sodium intake.
Subcategory: Nutrition and Oral Hydration
Rationale- Increased sodium intake may result in fluid retention thus increasing blood pressure that may increase blood pressure and further complicate congestive heart failure. Chronic renal failure is not a cardiovascular disorder. Hyperlipidemia and leukemia are not affected by sodium intake.
Subcategory: Nutrition and Oral Hydration
The nurse is teaching a client who is taking furosemide about the importance of increasing potassium intake. The nurse evaluates that the teaching has been effective when the client identifies what foods as being a good source of potassium?
Rationale- The nurse is teaching a group of client’s about a heart healthy diet. The nurse knows that the teaching has been effective when the client identifies that what dietary modifications can help reduce the risk for heart disease.
Subcategory: Nutrition and Oral Hydration
Rationale- The nurse is teaching a group of client’s about a heart healthy diet. The nurse knows that the teaching has been effective when the client identifies that what dietary modifications can help reduce the risk for heart disease.
Subcategory: Nutrition and Oral Hydration
The nurse is discussing health habits and health practices with a group of teenagers. What action by the nurse is priority?
Rationale- One of the most important aspects of health habits and health practices for teens is making the information fun and interesting. Providing recipes for healthy meals is not priority for this age group. Including the parents will not promote adherence. Consequences will not deter and likely keep the adolescents from listening.
Subcategory- Aging Process
Rationale- One of the most important aspects of health habits and health practices for teens is making the information fun and interesting. Providing recipes for healthy meals is not priority for this age group. Including the parents will not promote adherence. Consequences will not deter and likely keep the adolescents from listening.
Subcategory- Aging Process
A newborn has just been delivered via spontaneous vaginal delivery. The mother is HIV positive. Which intervention is most important for the nurse to do at this time?
Rationale- Bathing the newborn is the priority intervention. By bathing the newborn it ensures that all blood and fluid from mom has been removed from the newborn’s skin. This is priority to do prior to do before administering the Vitamin K injection. It would be contraindicated to place the newborn skin to skin with mom immediately after birth. It is contraindicated for mothers that are HIV positive to breastfeed their newborn due to the virus possibly being transmitted in the breastmilk. Weighing the baby is important after bathing the newborn.
Subcategory- Ante/Intra/Postpartum and Newborn Care
Rationale- Bathing the newborn is the priority intervention. By bathing the newborn it ensures that all blood and fluid from mom has been removed from the newborn’s skin. This is priority to do prior to do before administering the Vitamin K injection. It would be contraindicated to place the newborn skin to skin with mom immediately after birth. It is contraindicated for mothers that are HIV positive to breastfeed their newborn due to the virus possibly being transmitted in the breastmilk. Weighing the baby is important after bathing the newborn.
Subcategory- Ante/Intra/Postpartum and Newborn Care
A nurse is providing education to a mom about breastfeeding. Which statement indicates a need for further teaching?
Rationale- It is important for the mom to initiate skin to skin if the newborn is sleeping on the breast. When breastfeeding a newborn it is not necessary to burp the newborn as they don’t ingest air while nursing on the breast. It is important for the mom to offer both breast when breastfeeding so that the breast can empty evenly. It is important for the nurse to stress that it is important to wake the newborn every 2-3 hrs to nurse. Newborns tend to go through periods of sleep cycles and need to be woken up to nurse so that feedings are not missed.
Subcategory- Ante/Intra/Postpartum and Newborn Care
Rationale- It is important for the mom to initiate skin to skin if the newborn is sleeping on the breast. When breastfeeding a newborn it is not necessary to burp the newborn as they don’t ingest air while nursing on the breast. It is important for the mom to offer both breast when breastfeeding so that the breast can empty evenly. It is important for the nurse to stress that it is important to wake the newborn every 2-3 hrs to nurse. Newborns tend to go through periods of sleep cycles and need to be woken up to nurse so that feedings are not missed.
Subcategory- Ante/Intra/Postpartum and Newborn Care
A woman presents to the prenatal clinic for a routine 28-week visit. Her obstetric history includes a miscarriage at 8 weeks, a live birth of a son at 40 weeks and a live birth of a daughter at 35 weeks. Which of the following best represents the woman’s gravity and parity?
Rationale – It is the woman’s 4th pregnancy. She has had one term, one preterm, one AB, and 2 living children.
Subcategory- Ante/Intra/Postpartum and Newborn Care
Rationale – It is the woman’s 4th pregnancy. She has had one term, one preterm, one AB, and 2 living children.
Subcategory- Ante/Intra/Postpartum and Newborn Care
A client presents to the prenatal clinic with the following findings. Which are considered positive signs of pregnancy? Select all that apply.
Rationale- Fetal heart tones and palpation of fetal parts by the provider are objective findings not attributable to any other condition. Fatigue, amenorrhea and report of fetal movement are subjective findings and may be caused by something other than pregnancy; considered presumptive signs of pregnancy.
Subcategory- Ante/Intra/Postpartum and Newborn Care
Rationale- Fetal heart tones and palpation of fetal parts by the provider are objective findings not attributable to any other condition. Fatigue, amenorrhea and report of fetal movement are subjective findings and may be caused by something other than pregnancy; considered presumptive signs of pregnancy.
Subcategory- Ante/Intra/Postpartum and Newborn Care
A client presents to the prenatal clinic with report of a positive home pregnancy test. She reports a last menstrual period (LMP) of January 14th, 2015. Using Nagels rule, which of the following represents the client’s estimated date of delivery (EDD)?
Rationale- Using Nagels Rule, subtract 3 months and add 7 days to determine the estimated date of delivery. January minus three months, October. 14th plus 7 days would be the 21st. The year would be the same.
Subcategory- Ante/Intra/Postpartum and Newborn Care
Rationale- Using Nagels Rule, subtract 3 months and add 7 days to determine the estimated date of delivery. January minus three months, October. 14th plus 7 days would be the 21st. The year would be the same.
Subcategory- Ante/Intra/Postpartum and Newborn Care
According to Freud’s stages of development. What findings are expected in a 4-year-old child?
Rationale- During the phallic stage, ages 4-6 years old, the child explores their genitalia and is often attracted to the parent of the opposite sex. Toilet training occurs during the anal phase, 1 ½ to 3 years of age. Relationships focused on the same sex parent occur during the latency stage, age 6 to puberty. During puberty activities are focused on gaining independence.
Subcategory-Developmental Stages and Transitions
Rationale- During the phallic stage, ages 4-6 years old, the child explores their genitalia and is often attracted to the parent of the opposite sex. Toilet training occurs during the anal phase, 1 ½ to 3 years of age. Relationships focused on the same sex parent occur during the latency stage, age 6 to puberty. During puberty activities are focused on gaining independence.
Subcategory-Developmental Stages and Transitions
When assessing vision of a baby, what finding should be reported?
Rationale- By 5 months old a child should be able to reach for objects. Newborns cannot focus on objects close the them. A one month old will not recognize parents’ smiles and reactions until about 2-4 months. Babies do not recognize depth changes until 12 months.
Subcategory-Developmental Stages and Transitions
Rationale- By 5 months old a child should be able to reach for objects. Newborns cannot focus on objects close the them. A one month old will not recognize parents’ smiles and reactions until about 2-4 months. Babies do not recognize depth changes until 12 months.
Subcategory-Developmental Stages and Transitions
The nurse is caring for a client that has just been diagnosed with hypertension. The client informs the nurse that they are not going to be able to afford the prescribed medication. What action by the nurse is priority?
Rationale- Case management may be able to help the client find programs or assistance to pay for medications. The health care provider will not be able to reduce cost. It is not indicated to discuss the client’s personal finances. Teaching about lifestyle modifications are important but will not aid in paying for his medications.
Subcategory- Health Promotion/Disease Prevention
Rationale- Case management may be able to help the client find programs or assistance to pay for medications. The health care provider will not be able to reduce cost. It is not indicated to discuss the client’s personal finances. Teaching about lifestyle modifications are important but will not aid in paying for his medications.
Subcategory- Health Promotion/Disease Prevention
What are the roles of a school nurse? Select all that apply.
Rationale- The school nurse is responsible for counseling, health education and health screening. They do not prescribe or diagnose.
Subcategory- Health Screening
Rationale- The school nurse is responsible for counseling, health education and health screening. They do not prescribe or diagnose.
Subcategory- Health Screening
The occupational health nurse recognizes what advantages to maintaining a safe working environment? Select all that apply.
Rationale- Maintaining a safe work environment will lead to reduction in cost and absenteeism. Safety is not going to reduce illness. Hospitalization will be decreased. Disabilities will not be eliminated, but will be decreased.
Subcategory- Health Screening
Rationale- Maintaining a safe work environment will lead to reduction in cost and absenteeism. Safety is not going to reduce illness. Hospitalization will be decreased. Disabilities will not be eliminated, but will be decreased.
Subcategory- Health Screening
The nurse is providing teaching for a group of postmenopausal women. What statement by the women indicates a need for further teaching?
Rationale- Clinical breast exams should be done once a year along with the gynecological exam. Mammograms should be scheduled every other year and women should be informed to check their breasts once a month, at the same time.
Subcategory- Health Screening
Rationale- Clinical breast exams should be done once a year along with the gynecological exam. Mammograms should be scheduled every other year and women should be informed to check their breasts once a month, at the same time.
Subcategory- Health Screening
The nurse should provide teaching regarding risks of high-risk sexual behaviors to a group of teenagers. What statement by a student indicates the teaching was effective?
Rationale- Condoms are not 100% effective in protecting people from STD’s. People can still catch diseases and should be careful. HIV can be caught by kissing or oral sex. STD’s can be transmitted orally as well as through sex. Many people with STD’s are not symptomatic.
Subcategory- High Risk Behaviors
Rationale- Condoms are not 100% effective in protecting people from STD’s. People can still catch diseases and should be careful. HIV can be caught by kissing or oral sex. STD’s can be transmitted orally as well as through sex. Many people with STD’s are not symptomatic.
Subcategory- High Risk Behaviors
What statement about health findings in homeless populations is accurate?
Rationale- Homeless clients tend to have high rates of trauma. They also have high incidence of chronic disease such as diabetes. Tuberculosis tends to occur frequently in shelters because of overcrowding and poor ventilation. Due to health issues and lack of care, homeless clients tend to have lower life expectancy.
Subcategory- Lifestyle choices
Rationale- Homeless clients tend to have high rates of trauma. They also have high incidence of chronic disease such as diabetes. Tuberculosis tends to occur frequently in shelters because of overcrowding and poor ventilation. Due to health issues and lack of care, homeless clients tend to have lower life expectancy.
Subcategory- Lifestyle choices
What sequence should the nurse perform an abdominal assessment?
Rationale- The nurse should first inspect, then auscultate. After listening (auscultating) the nurse should percuss and then palpate.
Subcategory- Techniques for physical assessment
Rationale- The nurse should first inspect, then auscultate. After listening (auscultating) the nurse should percuss and then palpate.
Subcategory- Techniques for physical assessment
When performing an assessment of a client’s abdomen what exam should be performed first?
Rationale- Inspection is the first step when assessing all systems. It is, however, unique to the abdominal assessment to auscultate before palpation or percussion in order to reduce false assessment findings by stimulating bowel sounds.
Subcategory- Techniques for physical assessment
Rationale- Inspection is the first step when assessing all systems. It is, however, unique to the abdominal assessment to auscultate before palpation or percussion in order to reduce false assessment findings by stimulating bowel sounds.
Subcategory- Techniques for physical assessment
What valve is best auscultated at the second intercostal space at the sternal border on the left side of the client’s chest?
Rationale – The pulmonic valve is best heard at the sternal border at the second intercostal space on the left side. The mitral valve is best heard at the fourth and the fifth intercostal space at the midclavicular line on the left side of the client. The tricuspid valve is best heard at the sternal border at the fifth intercostal space. The aortic valve is best heard at the second intercostal space on the sternal border on the right side.
Subcategory- Techniques for physical assessment
Rationale – The pulmonic valve is best heard at the sternal border at the second intercostal space on the left side. The mitral valve is best heard at the fourth and the fifth intercostal space at the midclavicular line on the left side of the client. The tricuspid valve is best heard at the sternal border at the fifth intercostal space. The aortic valve is best heard at the second intercostal space on the sternal border on the right side.
Subcategory- Techniques for physical assessment
What assessment is most appropriate to determine fluid overload in a client diagnosed with heart failure?
Rationale- Excessive lower extremity edema is a sign of fluid overload and should be evaluated immediately. Radial pulses are not a strong assessment for fluid overload. Oxygen saturation will not detect early fluid overload.
Subcategory- Techniques for physical assessment
Rationale- Excessive lower extremity edema is a sign of fluid overload and should be evaluated immediately. Radial pulses are not a strong assessment for fluid overload. Oxygen saturation will not detect early fluid overload.
Subcategory- Techniques for physical assessment
A postpartum nurse is performing an assessment. Which finding would require a further work up?
Rationale- Having cramping during breastfeeding is a normal finding. During breastfeeding the newborn causes the release of oxytocin causing uterine cramping. It would be normal for the patient to be voiding large amounts. During the postpartum period the patient begins to diurese the extra fluid volume. It is not uncommon for a postpartum patient to go a few days without having a bowel movement, especially if they are taking narcotics. If the patient reports lower calf pain and tenderness, this could possibly be a sign that the patient has a deep vein thrombosis.
Subcategory- Techniques for physical assessment
Rationale- Having cramping during breastfeeding is a normal finding. During breastfeeding the newborn causes the release of oxytocin causing uterine cramping. It would be normal for the patient to be voiding large amounts. During the postpartum period the patient begins to diurese the extra fluid volume. It is not uncommon for a postpartum patient to go a few days without having a bowel movement, especially if they are taking narcotics. If the patient reports lower calf pain and tenderness, this could possibly be a sign that the patient has a deep vein thrombosis.
Subcategory- Techniques for physical assessment
The nurse is provided nutritional education to a client with an immunodeficiency. What selection I have a client indicates a need for further teaching?
Rationale – A fresh salad will increase the risk of exposure to pathogens. Canned soups, baked chicken and cottage cheese are all safer selections.
Subcategory- Health Promotion Disease Prevention
Rationale – A fresh salad will increase the risk of exposure to pathogens. Canned soups, baked chicken and cottage cheese are all safer selections.
Subcategory- Health Promotion Disease Prevention
A three-month old baby is brought to the pediatrician’s office for a routine checkup. What finding by a nurse should be reported immediately for further investigation?
Rationale – Bruising on the trunk is an indication of physical abuse. At this age children should not have bruising on the trunk other areas of suspicion should be the ears and neck. Babies at three months tend to begin to decrease crying and use other methods to let people know they need things. Not responding to all sounds may be normal at this age. At this age children start to respond to sounds and him may be more delayed than others. Sleeping two hours during the day as a normal finding.
Subcategory-Abuse/Neglect
Rationale – Bruising on the trunk is an indication of physical abuse. At this age children should not have bruising on the trunk other areas of suspicion should be the ears and neck. Babies at three months tend to begin to decrease crying and use other methods to let people know they need things. Not responding to all sounds may be normal at this age. At this age children start to respond to sounds and him may be more delayed than others. Sleeping two hours during the day as a normal finding.
Subcategory-Abuse/Neglect
The mother of a five-month old infant brings a child to the emergency department for treatment of cold and flu like symptoms. The child is vomiting lethargic and irritable. The child is not tracking the mother or healthcare providers with their eyes and has periods where they are not responding. What assessment by the nurse is priority?
Rationale – The baby is showing signs of neurologic deficit and should be assessed for any neurologic changes immediately. These would include changes to the retina and any chance of shaking or head injury. Psychosocial can be gathered as the other assessments are occurring, but not tracking the parents or healthcare providers is more an indication of neurologic changes. Gastrointestinal is important but not priority. Skeletal is also important but not priority over the neurologic assessment.
Subcategory- Abuse/Neglect
Rationale – The baby is showing signs of neurologic deficit and should be assessed for any neurologic changes immediately. These would include changes to the retina and any chance of shaking or head injury. Psychosocial can be gathered as the other assessments are occurring, but not tracking the parents or healthcare providers is more an indication of neurologic changes. Gastrointestinal is important but not priority. Skeletal is also important but not priority over the neurologic assessment.
Subcategory- Abuse/Neglect
What type of behavioral interventions can be done to decrease anxiety? Select all that apply.
Rationale – Flooding, modeling and systematic desensitization are all behavioral interventions used to help prevent anxiety. Cognitive restructuring is not a behavioral therapy, it is a cognitive therapy that is used to replace negative self-talk. Response prevention is used in clients with episodes of compulsive disorder to prevent the behaviors with excessive thoughts.
Subcategory- Behavioral Interventions
Rationale – Flooding, modeling and systematic desensitization are all behavioral interventions used to help prevent anxiety. Cognitive restructuring is not a behavioral therapy, it is a cognitive therapy that is used to replace negative self-talk. Response prevention is used in clients with episodes of compulsive disorder to prevent the behaviors with excessive thoughts.
Subcategory- Behavioral Interventions
A client diagnosed with severe anxiety is undergoing a therapy that includes exposure to imagery of real life stress provoking situations for extended time. When the client’s anxiety diminishes, the session is complete. What type of behavioral intervention does this demonstrate?
Rationale – Flooding is when a stimulus is brought on to provoke anxiety for a period of time until the anxiety eventually decreases. Modeling is a behavior modification. Cognitive restructuring is not a behavioral intervention. Systemic desensitization is an exposure overtime.
Subcategory- Behavioral Interventions
Rationale – Flooding is when a stimulus is brought on to provoke anxiety for a period of time until the anxiety eventually decreases. Modeling is a behavior modification. Cognitive restructuring is not a behavioral intervention. Systemic desensitization is an exposure overtime.
Subcategory- Behavioral Interventions
A client with a history of significant alcohol use is brought to the emergency department by the family members. The client has a blood pressure of 160 over 100 mmHg, pulse of 108 and is slightly tremulous. What question by the nurse is priority?
Rationale – It is important to know when the client had their last drink to anticipate the signs and worsening of withdrawal. The type of alcohol they drink should be included later but is not a priority question. It is important to know how much they drink, but the priority question is when the last drink was. Asking if they’ve ever had medication for withdrawal is important but not priority.
Subcategory- Chemical and Other Dependencies/Substance Use Disorder
Rationale – It is important to know when the client had their last drink to anticipate the signs and worsening of withdrawal. The type of alcohol they drink should be included later but is not a priority question. It is important to know how much they drink, but the priority question is when the last drink was. Asking if they’ve ever had medication for withdrawal is important but not priority.
Subcategory- Chemical and Other Dependencies/Substance Use Disorder
What statement by a client indicates they are progressing in recovery from substance abuse?
Rationale – It is important that the client takes responsibility for the actions they have committed in the outcomes that have resulted while they have utilized drugs. Knowing that they need to stop using drugs does not take accountability. Having a plan to avoid using drugs important part is not priority. It is important that they have a plan for going to narcotics anonymous but that is not taking responsibility for their actions completely.
Subcategory- Chemical and Other Dependencies/Substance Use Disorder
Rationale – It is important that the client takes responsibility for the actions they have committed in the outcomes that have resulted while they have utilized drugs. Knowing that they need to stop using drugs does not take accountability. Having a plan to avoid using drugs important part is not priority. It is important that they have a plan for going to narcotics anonymous but that is not taking responsibility for their actions completely.
Subcategory- Chemical and Other Dependencies/Substance Use Disorder
The client is agitated anxious and upset after learning that their job has been eliminated. What statements by the nurse are appropriate? Select all that apply.
Rationale – It is important to gather information about the stressor and how it happens. It is also important to determine what strategies the client has used in the past you deal with stressful situations. A support system is important in determining who that support system is for the client will help in dealing with the situation. Telling the client not to think about the stressor will only prolong the stress and anxiety. What work for other people may not work for this client and may cause overload.
Subcategory- Crisis Intervention
Rationale – It is important to gather information about the stressor and how it happens. It is also important to determine what strategies the client has used in the past you deal with stressful situations. A support system is important in determining who that support system is for the client will help in dealing with the situation. Telling the client not to think about the stressor will only prolong the stress and anxiety. What work for other people may not work for this client and may cause overload.
Subcategory- Crisis Intervention
A client brought to the emergency room after she was found in a public park with slits on both wrists. What question by the nurse is priority?
Rationale – It is important for the nurse to assess whether or not the client is still suicidal. Asking what made them cut the wrist is not a priority at this time. Asking a kind of they understand why they’re here is not a priority nor appropriate at this time. Asking about family members to call may be done after determining if the client is still at risk for harming themselves.
Subcategory-Crisis Intervention
Rationale – It is important for the nurse to assess whether or not the client is still suicidal. Asking what made them cut the wrist is not a priority at this time. Asking a kind of they understand why they’re here is not a priority nor appropriate at this time. Asking about family members to call may be done after determining if the client is still at risk for harming themselves.
Subcategory-Crisis Intervention
A Hispanic client admitted to the hospital in labor would most likely request what type of traditional healer?
Rationale – A parteras is a healer that provides assistance for women in childbirth and newborn care. A Mambo is a voodoo practitioner in the African-American culture. A shaman is a healer that provides prayer chanting and herbs and both Chinese Southeast Asian and Native American cultures. They use prayer herbs potions and other things to cure illnesses including witchcraft. They are not used during labor and delivery. An Espiritista is a healer that foretells the future it interprets dreams.
Subcategory- Cultural Awareness/Cultural Influences on Health
Rationale – A parteras is a healer that provides assistance for women in childbirth and newborn care. A Mambo is a voodoo practitioner in the African-American culture. A shaman is a healer that provides prayer chanting and herbs and both Chinese Southeast Asian and Native American cultures. They use prayer herbs potions and other things to cure illnesses including witchcraft. They are not used during labor and delivery. An Espiritista is a healer that foretells the future it interprets dreams.
Subcategory- Cultural Awareness/Cultural Influences on Health
A Chinese woman has just delivered a newborn baby. What food selections are consistent with the yin/yang theory related to childbirth? Select all that apply.
Rationale – Chinese women often use dietary practices such as ingestion of warm foods including soup, eggs and rice. Milk and ice water would be cold and avoided in the postpartum period.
Subcategory- Cultural Awareness/Cultural Influences on Health
Rationale – Chinese women often use dietary practices such as ingestion of warm foods including soup, eggs and rice. Milk and ice water would be cold and avoided in the postpartum period.
Subcategory- Cultural Awareness/Cultural Influences on Health
A client admitted with heart failure informs the nurse that he follows kosher Judaism. What foods should be restricted from the client’s diet?
Rationale – Kosher Jewish clients have dietary restrictions such pork and shellfish. Meat and milk are accepted, but cannot be served at the same time. Caffeine is not restricted.
Subcategory-Cultural Awareness/Cultural Influences on Health
Rationale – Kosher Jewish clients have dietary restrictions such pork and shellfish. Meat and milk are accepted, but cannot be served at the same time. Caffeine is not restricted.
Subcategory-Cultural Awareness/Cultural Influences on Health
The nurse is preparing to perform a cultural assessment a newly admitted client. What questions should the nurse include? Select all that apply.
Rationale – It is important to assess aspects such as where the client, their parents and grandparents are from. It is important to ask who they seek healthcare or illness management from. It is it is also important to ask where the client feels that originates. It is not part of the cultural assessment to ask the ethnicity of their healthcare provider and it is a blocking question to ask if someone is resistant to current healthcare practices.
Subcategory- Cultural Awareness/Cultural Influences on Health
Rationale – It is important to assess aspects such as where the client, their parents and grandparents are from. It is important to ask who they seek healthcare or illness management from. It is it is also important to ask where the client feels that originates. It is not part of the cultural assessment to ask the ethnicity of their healthcare provider and it is a blocking question to ask if someone is resistant to current healthcare practices.
Subcategory- Cultural Awareness/Cultural Influences on Health
The client diagnosed with sepsis has developed multiple organ dysfunction syndrome (MODS). What findings suggest the client’s family should be notified that death is impending? Select all that apply.
Rationale – In the hours to days before death, a client will often have bowel or bladder incontinence, inability to swallow and increased pulmonary secretions. They will have decreased muscle tone not increased. They will have decreased urinary output, not increased.
Subcategory- End of Life Care
Rationale – In the hours to days before death, a client will often have bowel or bladder incontinence, inability to swallow and increased pulmonary secretions. They will have decreased muscle tone not increased. They will have decreased urinary output, not increased.
Subcategory- End of Life Care
A client that has passed had donated all of their organs and tissues. The family member asked the nurse why the client is still on life-support if they’re telling them that they are dead. What statement by the nurse is most appropriate?
Rationale – Prior to transplant a client must remain on life-support to keep the tissues and organs oxygenated. Having the healthcare provider come in to talk to them is not necessary. The person receiving the transplant is not transported the hospital, usually the organs are transported to the other facility. The organ and tissue transplant team does not determine that the person is in fact deceased.
Subcategory- End of Life Care
Rationale – Prior to transplant a client must remain on life-support to keep the tissues and organs oxygenated. Having the healthcare provider come in to talk to them is not necessary. The person receiving the transplant is not transported the hospital, usually the organs are transported to the other facility. The organ and tissue transplant team does not determine that the person is in fact deceased.
Subcategory- End of Life Care
A client is accompanied by her daughter, her primary caregiver to a routine checkup. What findings and the client are consistent with caregiver burden? Select all that apply.
Rationale – Signs of caregiver burden in a client are depression, anxiety and change in level of health. Increased use of respite is used to reduce caregiver burden. Involvement of other family members will also help decrease the risk of caregiver burden.
Subcategory- Family Dynamics
Rationale – Signs of caregiver burden in a client are depression, anxiety and change in level of health. Increased use of respite is used to reduce caregiver burden. Involvement of other family members will also help decrease the risk of caregiver burden.
Subcategory- Family Dynamics
A client sustained a severe lower leg injury during a motor vehicle accident. The client is crying and upset after hearing that the injury requires a below the knee amputation. What type of loss is the client experiencing?
Rationale – Situational loss results from a sudden unpredictable external event that brings about injury or change. A necessary loss is one that is part of life. Maturational loss is a necessary loss that also includes normally expected life changes across the lifespan. This would include a child going off to college. A perceived loss is a unique lost defined by the person that is experiencing the loss.
Subcategory- Grief and Loss
Rationale – Situational loss results from a sudden unpredictable external event that brings about injury or change. A necessary loss is one that is part of life. Maturational loss is a necessary loss that also includes normally expected life changes across the lifespan. This would include a child going off to college. A perceived loss is a unique lost defined by the person that is experiencing the loss.
Subcategory- Grief and Loss
The nurse is caring for a client that is admitted with dysfunctional grieving. The client recently lost her husband and has continued to refuse to admit he has passed. What stage of grieving is the client experiencing?
Rationale – Denial is a period in grieving where a person does not accept the fact that the loss has occurred. Bargaining postpones awareness of the loss by trying to prevent it from happening. Depression is when a person realizes the full impact of the loss. Acceptance is when a person finally recognizes and accepts the loss.
Subcategory- Grief and Loss
Rationale – Denial is a period in grieving where a person does not accept the fact that the loss has occurred. Bargaining postpones awareness of the loss by trying to prevent it from happening. Depression is when a person realizes the full impact of the loss. Acceptance is when a person finally recognizes and accepts the loss.
Subcategory- Grief and Loss
A client is due for a blood pressure medication at 0900. When the nurse attempts to enter the room to administer the medication she notices the client is praying. What action by the nurse is most appropriate?
Rationale – The nurse should come back in a short time to administer the medication to not interrupt the client during a period of prayer. The nurse should never leave medication at a client’s bedside. The nurse should not interrupt the client. They should not wait in the room while the client is praying.
Subcategory- Religious and Spiritual Influences on Health
Rationale – The nurse should come back in a short time to administer the medication to not interrupt the client during a period of prayer. The nurse should never leave medication at a client’s bedside. The nurse should not interrupt the client. They should not wait in the room while the client is praying.
Subcategory- Religious and Spiritual Influences on Health
A catholic client is diagnosed with terminal lung cancer. What action by the nurse is most appropriate to promote coping for the client?
Rationale – Clients of Catholic faith often find coping and peace in prayer. Consulting a member of clergy will help the client begin to cope and deal with their diagnosis. Notifying the client’s family is not appropriate for the nurse to do especially not without the client’s permission. Asking the client if they would like you to pray with them can be appropriate but is not most appropriate. Sitting next to the client and silence will not promote acceptance in a client.
Subcategory- Religious and Spiritual Influences on Health
Rationale – Clients of Catholic faith often find coping and peace in prayer. Consulting a member of clergy will help the client begin to cope and deal with their diagnosis. Notifying the client’s family is not appropriate for the nurse to do especially not without the client’s permission. Asking the client if they would like you to pray with them can be appropriate but is not most appropriate. Sitting next to the client and silence will not promote acceptance in a client.
Subcategory- Religious and Spiritual Influences on Health
The nurse is caring for Chinese client who does not speak English. When selecting an interpreter to assist in the care of the client, what characteristics should the nurse consider when selecting an interpreter? Select all that apply.
Rationale – It is important to determine the dialect and ensure effective communication is possible. It is also important that gender sensitive issues are taken into account. Unless no other interpreters are available a member of the client’s family should not be used to interpret. It is often not possible to have someone from the client’s home town. It is not necessary to have someone older to make decisions, the interpreter should not be making medical decisions for the client.
Subcategory- Cultural Awareness/Cultural Influences on Health
Rationale – It is important to determine the dialect and ensure effective communication is possible. It is also important that gender sensitive issues are taken into account. Unless no other interpreters are available a member of the client’s family should not be used to interpret. It is often not possible to have someone from the client’s home town. It is not necessary to have someone older to make decisions, the interpreter should not be making medical decisions for the client.
Subcategory- Cultural Awareness/Cultural Influences on Health
A Hmong client is admitted to the hospital with a severe headache. What intervention is contraindicated in this culture?
Rationale – Placing an ice pack on the head would be contraindicated in this culture as touching the head should only be down by elders. Essential oils, acetaminophen and IV fluids are not contraindicated with this culture.
Subcategory- Cultural Awareness/Cultural Influences on Health
Rationale – Placing an ice pack on the head would be contraindicated in this culture as touching the head should only be down by elders. Essential oils, acetaminophen and IV fluids are not contraindicated with this culture.
Subcategory- Cultural Awareness/Cultural Influences on Health
What cultures are least likely to accept pain medication during childbirth? Select all that apply.
Rationale – Vietnamese women are often stoic and view birth as a normal part of life and are unlikely to take pain medication during labor. Filipino women often see pain as a form of spiritual atonement for past deeds and will often not take pain medication. Puerto Rican women, Mexican women and Arab American women may often take pain medication.
Subcategory- Cultural Awareness/Cultural Influences on Health
Rationale – Vietnamese women are often stoic and view birth as a normal part of life and are unlikely to take pain medication during labor. Filipino women often see pain as a form of spiritual atonement for past deeds and will often not take pain medication. Puerto Rican women, Mexican women and Arab American women may often take pain medication.
Subcategory- Cultural Awareness/Cultural Influences on Health
A client has been diagnosed with terminal brain cancer. The client is placed on hospice care. The family asks the nurse what hospice is. What statement by the nurse indicates a need for further teaching?
Rationale – Hospice is not only care provided by nurses, nurse’s aides and other healthcare providers are included in the client’s care. It usually is an indication that the client has 6 to 12 months or less to live. It is a service to prioritize pain relief and comfort at the end of life. Family may also be involved in the client’s care. It allows people to grieve at home or in the hospital.
Subcategory- End of Life Care
Rationale – Hospice is not only care provided by nurses, nurse’s aides and other healthcare providers are included in the client’s care. It usually is an indication that the client has 6 to 12 months or less to live. It is a service to prioritize pain relief and comfort at the end of life. Family may also be involved in the client’s care. It allows people to grieve at home or in the hospital.
Subcategory- End of Life Care
A client is experiencing acute alcohol withdrawal. What medications will the nurse anticipate administering to this client? Select all that apply.
Rationale –Lorazepam and Chlordiazepoxide are used in acute withdrawal of alcohol. Disulfiram is used for long-term treatment to avoid using alcohol again. Haloperidol and Fluoxetine are not used for acute alcohol withdrawal.
Subcategory-Chemical and Other Dependencies/Substance Use Disorder
Rationale –Lorazepam and Chlordiazepoxide are used in acute withdrawal of alcohol. Disulfiram is used for long-term treatment to avoid using alcohol again. Haloperidol and Fluoxetine are not used for acute alcohol withdrawal.
Subcategory-Chemical and Other Dependencies/Substance Use Disorder
A client participating in a group therapy session stands up and begins to pace the room. The client has their hands clenched at their sides and is visibly tense. What action by the nurse is priority?
Rationale – It is important to take a client that is escalating out of the environment to assess and speak with the client. Confronting the behavior is not appropriate in a group session. Ignoring the behavior will not prevent others from observing are being distracted from the behavior. Encouraging the client to sit back down may further escalate the client.
Subcategory-Crisis Intervention
Rationale – It is important to take a client that is escalating out of the environment to assess and speak with the client. Confronting the behavior is not appropriate in a group session. Ignoring the behavior will not prevent others from observing are being distracted from the behavior. Encouraging the client to sit back down may further escalate the client.
Subcategory-Crisis Intervention
A client that is receiving a transfusion of packed red blood cells develops chills, fever in low back pain. What action by the nurse is priority?
Rationale – It is imperative that the blood is stopped in the normal saline is hung immediately. Normal saline should be administered through different tubing. Acetaminophen is not priority the infusion should not be decreased in rate it should be stopped. The primary care provider should be contacted after the normal saline is hung.
Subcategory- Blood and Blood Products
Rationale – It is imperative that the blood is stopped in the normal saline is hung immediately. Normal saline should be administered through different tubing. Acetaminophen is not priority the infusion should not be decreased in rate it should be stopped. The primary care provider should be contacted after the normal saline is hung.
Subcategory- Blood and Blood Products
What action by the nurse caring for a client experiencing a transfusion related acute lung injury should be question?
Rationale – Prednisone is not indicated in clients with transfusion related acute lung injury. The nurse should stop the infusion, hang IV normal saline with new IV tubing and administer oxygen via non-rebreather mask and support the airway.
Subcategory- Blood and Blood Products
Rationale – Prednisone is not indicated in clients with transfusion related acute lung injury. The nurse should stop the infusion, hang IV normal saline with new IV tubing and administer oxygen via non-rebreather mask and support the airway.
Subcategory- Blood and Blood Products
Ordered the sequence of hanging a blood product.
Rationale- A crossmatch should be the first step, then pick up blood from the blood bank, followed by checking blood with another RN. Prime an IV line with normal saline and hang the blood monitoring for 15 minutes.
Subcategory- Blood and Blood Products
Rationale- A crossmatch should be the first step, then pick up blood from the blood bank, followed by checking blood with another RN. Prime an IV line with normal saline and hang the blood monitoring for 15 minutes.
Subcategory- Blood and Blood Products
What treatment is indicated for a client experiencing a transfusion related acute lung injury? Select all that apply.
Rationale – A client experiencing a transfusion related acute lung injury should be supported with endotracheal intubation if needed, oxygen administration and aggressive fluid resuscitation. Diphenhydramine is not indicated. Chest tube placement is not necessary.
Subcategory- Blood and Blood Products
Rationale – A client experiencing a transfusion related acute lung injury should be supported with endotracheal intubation if needed, oxygen administration and aggressive fluid resuscitation. Diphenhydramine is not indicated. Chest tube placement is not necessary.
Subcategory- Blood and Blood Products
The nurse picks up a unit of packed red blood c1ells at 0900. The client’s IV line infiltrates as a nurse is preparing to administer the blood. After inserting a new line 45 minutes have passed. What action by the nurse is appropriate?
Rationale – Blood must be hung within 30 minutes of picking it up from the blood bank. The blood should not be hung. Infusing the packed red blood cells at 600 mL’s should not be done. Another nurse should not be verifying the orders, the blood should not be hung.
Subcategory- Blood and Blood Products
Rationale – Blood must be hung within 30 minutes of picking it up from the blood bank. The blood should not be hung. Infusing the packed red blood cells at 600 mL’s should not be done. Another nurse should not be verifying the orders, the blood should not be hung.
Subcategory- Blood and Blood Products
What type of transfusion reaction as a client who has a history of multiple blood transfusions at increased risk for?
Rationale – A client who has had multiple transfusions is at increased risk for febrile nonhemolytic reactions. It does not place them at increased risk for any other form of reaction.
Subcategory- Blood and Blood Products
Rationale – A client who has had multiple transfusions is at increased risk for febrile nonhemolytic reactions. It does not place them at increased risk for any other form of reaction.
Subcategory- Blood and Blood Products
The client has an order for a blood transfusion. The client informs the nurse that the last time they had a transfusion they got very itchy. What action by the nurse is priority?
Rationale – The client with mild signs and symptoms of an allergic reaction can be given an antihistamine prior to their transfusion starting. Diphenhydramine is an antihistamine that is often administered. Starting the transfusion slowly will not avoid a reaction if the client is going to have one. Documenting the client’s statement is appropriate but not priority. The nurse cannot stay with a client through an entire transfusion as we have other clients to care for.
Subcategory- Blood and Blood Products
Rationale – The client with mild signs and symptoms of an allergic reaction can be given an antihistamine prior to their transfusion starting. Diphenhydramine is an antihistamine that is often administered. Starting the transfusion slowly will not avoid a reaction if the client is going to have one. Documenting the client’s statement is appropriate but not priority. The nurse cannot stay with a client through an entire transfusion as we have other clients to care for.
Subcategory- Blood and Blood Products
Which postpartum patient will have to receive Rhogam prior to discharge?
Rationale- A postpartum patient will receive Rhogam when they have a RH – blood type and the newborn is RH +
Subcategory- Expected Actions/Outcomes
Rationale- A postpartum patient will receive Rhogam when they have a RH – blood type and the newborn is RH +
Subcategory- Expected Actions/Outcomes
A woman at 37 weeks of gestation is being treated with Magnesium Sulfate for severe pre-eclampsia. What is the primary goal of this therapy?
Rationale – Magnesium Sulfate is a CNS depressant used to prevent seizure activity/eclampsia. It is not used for sedation, to increase urinary output or resolve hypertension.
Subcategory- Expected Actions/Outcomes
Rationale – Magnesium Sulfate is a CNS depressant used to prevent seizure activity/eclampsia. It is not used for sedation, to increase urinary output or resolve hypertension.
Subcategory- Expected Actions/Outcomes
A woman who delivered a 10 pound, 9-ounce baby girl 24 hours ago is experiencing a hemorrhage on the post-partum unit. The obstetric provider gives a verbal order to the nurse for methylergonovine. What patient condition would preclude administration of this drug?
Rationale- Methylergonovine (Methergine) is contraindicated in patients with HTN. It is not contraindicated in clients with diabetes, depression or hyperthyroidism.
Subcategory- Adverse Effects/Contraindications/Side Effects/Interactions
Rationale- Methylergonovine (Methergine) is contraindicated in patients with HTN. It is not contraindicated in clients with diabetes, depression or hyperthyroidism.
Subcategory- Adverse Effects/Contraindications/Side Effects/Interactions
The nurse is expecting the arrival of a teenager diagnosed with suspected acetaminophen overdose. Which of the following diagnostic laboratory tests does the nurse anticipate as a priority in the care of this client?
Rationale – Acetaminophen is metabolized extensively in the live which can lead to hepatic necrosis that develops with the accumulation of quinine as a byproduct of this metabolism. Adrenal, respiratory and renal function are not affected in ac overdose.
Subcategory- Adverse side effects/contraindications/side effects/Interactions
Rationale – Acetaminophen is metabolized extensively in the live which can lead to hepatic necrosis that develops with the accumulation of quinine as a byproduct of this metabolism. Adrenal, respiratory and renal function are not affected in ac overdose.
Subcategory- Adverse side effects/contraindications/side effects/Interactions
The nurse is assigned care of a client who is to receive a blood transfusion. Which of the following can be assigned to a UAP in anticipation of care of the client receiving a blood transfusion?
Rationale– The transfusion is complete and end transfusion vital signs can be assigned to the UAP. The nurse should obtain client baseline vital signs and closely monitor the client for the first 15 minutes of transfusion – – this is the highest risk time frame for life-threatening reactions to occur. The nurse, not the UAP, is responsible for monitoring the client for effects of medications and blood products.
Subcategory- Blood and blood products
Rationale– The transfusion is complete and end transfusion vital signs can be assigned to the UAP. The nurse should obtain client baseline vital signs and closely monitor the client for the first 15 minutes of transfusion – – this is the highest risk time frame for life-threatening reactions to occur. The nurse, not the UAP, is responsible for monitoring the client for effects of medications and blood products.
Subcategory- Blood and blood products
A nurse in the Emergency Department is caring for a client with multiple traumas from being struck by a motor vehicle. Which of the following actions does the nurse anticipate?
Rationale– Rapid infusion of intravenous fluids, blood products and IV push medications are anticipated in the care of clients with the multiple traumas. All other options are inappropriate IV access options for this client.
Subcategory- Central venous access devices
Rationale– Rapid infusion of intravenous fluids, blood products and IV push medications are anticipated in the care of clients with the multiple traumas. All other options are inappropriate IV access options for this client.
Subcategory- Central venous access devices
A healthcare provider has prescribed levothyroxine sodium 150 mcg po daily for a client diagnosed with hypothyroidism. The nurse has available levothyroxine sodium 0.3 mg tabs. How many tablets will the nurse administer?
Rationale- (0.15 mg/0.3 mg) X 1 tab = 0.5 tab
Subcategory- Dosage Calculations
Rationale- (0.15 mg/0.3 mg) X 1 tab = 0.5 tab
Subcategory- Dosage Calculations
A healthcare provider has ordered a nitroglycerin IV infusion at a rate of 8mL/hr via an IV infusion device. The nurse notes the nitroglycerin available is labeled 50 mg nitroglycerin in 250 mL D5W. What is the hourly dose (in mg/hr) that will be delivered to the client?
Rationale- 250 mL of fluid contains 50 mg of nitroglycerin, therefore, (50mg/250mL = 0.2 mg/mL of nitroglycerin. 8 mL X 0.2 mg = 1.6 mg of nitroglycerin being delivered to the client hourly.
Subcategory- Dosage Calculations
Rationale- 250 mL of fluid contains 50 mg of nitroglycerin, therefore, (50mg/250mL = 0.2 mg/mL of nitroglycerin. 8 mL X 0.2 mg = 1.6 mg of nitroglycerin being delivered to the client hourly.
Subcategory- Dosage Calculations
A nurse is planning education regarding an antihypertensive medication prescribed by a client’s healthcare provider. Which of the following is the most appropriate long term goal for the teaching plan?
Rationale– The long term outcome of medication education is compliance with the medication ordered. All other options are short term goals that contributes to the client’s compliance with the medication order.
Subcategory- Expected actions/Outcomes
Rationale– The long term outcome of medication education is compliance with the medication ordered. All other options are short term goals that contributes to the client’s compliance with the medication order.
Subcategory- Expected actions/Outcomes
A client is diagnosed as having secondary syphilis. Which of the following does the nurse recognize as the medication most likely to be prescribed for the diagnosis of secondary syphilis?
Rationale– Penicillin G IM is the medication of choice if syphilis is < 1 yr. in duration. It is administered IM only. For longer duration, 3 IM injections separated by 1 week is the course of therapy. Subcategory- Medication Administration
Rationale– Penicillin G IM is the medication of choice if syphilis is < 1 yr. in duration. It is administered IM only. For longer duration, 3 IM injections separated by 1 week is the course of therapy. Subcategory- Medication Administration
The nurse is admitting a client with a diagnosis of pericarditis. Which of the following orders from the healthcare provider would the nurse question?
Rationale– Anticoagulants are avoided with diagnosis of pericarditis related to the risk for tamponade. NSAID’s are prescribed to address pain and inflammation. Antibiotics are indicated for bacterial infections. Constipation prophylaxis is appropriate, anticipating a decrease in client activity
Subcategory- Medication Administration
Rationale– Anticoagulants are avoided with diagnosis of pericarditis related to the risk for tamponade. NSAID’s are prescribed to address pain and inflammation. Antibiotics are indicated for bacterial infections. Constipation prophylaxis is appropriate, anticipating a decrease in client activity
Subcategory- Medication Administration
A client asks the nurse, “I don’t understand why I still have terrible spasms when I urinate. I have been taking the phenazopyridine exactly as ordered and I still have painful spasms every time I urinate.” Which of the following is the best response by the nurse?
Rationale– Phenazopyridine is prescribed for the pain of urinary tract infections but does not act on painful urinary tract spasms. Asking if the provider prescribed and antibiotic does not address the client’s concern. Stating “I’m sure” the nurse can make no assumptions regarding health care provider orders and this response does not address the client’s concern.
Subcategory- Medication Administration
Rationale– Phenazopyridine is prescribed for the pain of urinary tract infections but does not act on painful urinary tract spasms. Asking if the provider prescribed and antibiotic does not address the client’s concern. Stating “I’m sure” the nurse can make no assumptions regarding health care provider orders and this response does not address the client’s concern.
Subcategory- Medication Administration
The nurse notes a new health care provider’s order to initiate IV therapy for a client exhibiting signs and symptoms of dehydration. The client has no IV access. Which of the following will the nurse consider when interpreting the order for this therapy? Select all that apply.
Rationale – The critically thinking nurse in this situation must have knowledge of all of this data. The nurse must ensure the therapy is safe and appropriate for the client. Questions such as, “Is this the correct fluid to treat the client’s illness? Does the client require peripheral (short-term access, or long-term access?) What medications may cause adverse interaction. The complete blood count is not essential prior to initiating therapy. Hand veins are to be avoided as first choice for the IV site because these veins are fragile, cannot accommodate high volumes of fluid and are often uncomfortable for the client
Subcategory- Parenteral/Intravenous Therapies
Rationale – The critically thinking nurse in this situation must have knowledge of all of this data. The nurse must ensure the therapy is safe and appropriate for the client. Questions such as, “Is this the correct fluid to treat the client’s illness? Does the client require peripheral (short-term access, or long-term access?) What medications may cause adverse interaction. The complete blood count is not essential prior to initiating therapy. Hand veins are to be avoided as first choice for the IV site because these veins are fragile, cannot accommodate high volumes of fluid and are often uncomfortable for the client
Subcategory- Parenteral/Intravenous Therapies
A client is scheduled to receive IVIG. What complication is priority for the nurse to assess?
Rationale – Anaphylaxis is a serious complication of IVIG administration and should be assessed for by the nurse. Hypertension weakness and nausea are not priority assessments.
Subcategory- Adverse Effects
Rationale – Anaphylaxis is a serious complication of IVIG administration and should be assessed for by the nurse. Hypertension weakness and nausea are not priority assessments.
Subcategory- Adverse Effects
What action by the nurse is priority when preparing to administer medications through a gastrointestinal tube?
Rationale – All medications should be assessed for possible interactions with the enteral feeding prior to preparing to administer the medications. If there is an interaction the feeling should be held for 30 minutes prior to administration of medications. Once there are no interactions identified the nurse will identify the client flash the tube and crush medications that can be crushed. Not all medications will be crushed.
Subcategory- Medication Administration
Rationale – All medications should be assessed for possible interactions with the enteral feeding prior to preparing to administer the medications. If there is an interaction the feeling should be held for 30 minutes prior to administration of medications. Once there are no interactions identified the nurse will identify the client flash the tube and crush medications that can be crushed. Not all medications will be crushed.
Subcategory- Medication Administration
The nurse is caring for four clients receiving opioid analgesics for pain. Which of the following clients does the nurse recognize as being at greatest risk for respiratory depression?
Rationale– This client has compromised pulmonary function and a skeletal injury resulting in a period of immobilization. The other clients are at lower risk for respiratory depression.
Subcategory- Adverse side effects/contraindications/side effects/Interactions
Rationale– This client has compromised pulmonary function and a skeletal injury resulting in a period of immobilization. The other clients are at lower risk for respiratory depression.
Subcategory- Adverse side effects/contraindications/side effects/Interactions
The nurse is planning to administer an IV antibiotic via an un-accessed central venous catheter lumen. Which of the following actions is not appropriate for the nurse to perform in implementing this procedure?
Rationale– Single use chlorhexidine sterile end caps for central venous access devices eliminate the need for swabbing lumen with alcohol. Flushing, and checking for blood return are accepted practices in care of client with a central venous access device.
Subcategory- Central venous access devices
Rationale– Single use chlorhexidine sterile end caps for central venous access devices eliminate the need for swabbing lumen with alcohol. Flushing, and checking for blood return are accepted practices in care of client with a central venous access device.
Subcategory- Central venous access devices
A client’s healthcare provider has ordered lorazepam 4 mg orally in equally divided doses four times a day. What dose will the nurse administer for one dose?
Rationale– 4 mg divided equally into 4 doses is 1 mg/dose. All other doses are incorrect.
Subcategory- Dosage Calculations
Rationale– 4 mg divided equally into 4 doses is 1 mg/dose. All other doses are incorrect.
Subcategory- Dosage Calculations
A nurse is administering 375 mg of penicillin V potassium to a client. The label reads, “200,000 units (125 mg) per 5 mL.” How much penicillin V potassium will the nurse administer for each dose?
Rationale- [375 mg/ 125 mg] X 5 mL = 15 mL to administer for each dose.
Subcategory- Dosage Calculations
Rationale- [375 mg/ 125 mg] X 5 mL = 15 mL to administer for each dose.
Subcategory- Dosage Calculations
The nurse is caring for a client on the night shift. The client had abdominal surgery 12 hours ago. To effectively manage this client’s pain, which of the following is the most appropriate nursing action?
Rationale- It is essential in a client’s recovery process to achieve adequate pain control as soon as possible after surgery. It is appropriate to wake client to provide analgesia around the clock for the first 24-48 hours as necessary to achieve pain control. Waiting for the client to complain of pain may require a longer amount of time and increasing doses of analgesics if the client waits to ask for pain meds until pain is severe. Therapeutic touch will not manage postoperative pain alone, though this is an accepted pain management technique once analgesic pain control is reached. Since this client’s tolerable level of pain is not reported, an assumption of when analgesics are required cannot be made.
Subcategory- Medication Administration
Rationale- It is essential in a client’s recovery process to achieve adequate pain control as soon as possible after surgery. It is appropriate to wake client to provide analgesia around the clock for the first 24-48 hours as necessary to achieve pain control. Waiting for the client to complain of pain may require a longer amount of time and increasing doses of analgesics if the client waits to ask for pain meds until pain is severe. Therapeutic touch will not manage postoperative pain alone, though this is an accepted pain management technique once analgesic pain control is reached. Since this client’s tolerable level of pain is not reported, an assumption of when analgesics are required cannot be made.
Subcategory- Medication Administration
The nurse is caring for a 3-year-old child experiencing pain after surgery. Which of the following pain assessment tools does the nurse recognize as being most appropriate pain assessment for this client?
Rationale– The most appropriate method for a 3 year-old child. Writing skills and cognitive development of a three year-old have not matured to the point of having the ability to maintain a diary or report pain on a numeric scale. The CRIES scale is implemented for neonatal clients.
Subcategory- Pharmacological Pain Management
Rationale– The most appropriate method for a 3 year-old child. Writing skills and cognitive development of a three year-old have not matured to the point of having the ability to maintain a diary or report pain on a numeric scale. The CRIES scale is implemented for neonatal clients.
Subcategory- Pharmacological Pain Management
The nurse is developing a plan of care to manage a client’s pain. Which of the following does the nurse recognize as the priority outcome?
Rationale – This is the overriding, priority goal of pain management. All other options are inappropriate goals for a client in pain.
Subcategory- Pharmacological Pain Management
Rationale – This is the overriding, priority goal of pain management. All other options are inappropriate goals for a client in pain.
Subcategory- Pharmacological Pain Management
The nurse is caring for a client receiving total Parenteral Nutrition (TPN.) Which of the following client laboratory values are essential for the nurse to review considering the adverse side effects of excess amino acids associated with TPN? Select all that apply.
Rationale– Amino acids are the building blocks of protein. Though electrolyte and serum glucose levels are also monitored during TPN therapy, these are not associated with excess protein.
Subcategory- Total Parenteral Nutrition
Rationale– Amino acids are the building blocks of protein. Though electrolyte and serum glucose levels are also monitored during TPN therapy, these are not associated with excess protein.
Subcategory- Total Parenteral Nutrition
The nurse is caring for a client receiving Total Parenteral Nutrition (TPN.) The nurse assesses the client and discovers the client with shoulder and back pain, BP 92/54, dyspnea and cyanosis. What is the nurse’s priority action?
Rationale – The client is exhibiting signs and symptoms of an air embolism, a life-threatening complication of TPN. The TPN infusion must be stopped immediately. Repositioning the client, alerting the rapid response team and providing supplemental oxygen are actions to take once TPN infusion has been stopped.
Subcategory-Total Parenteral Nutrition
Rationale – The client is exhibiting signs and symptoms of an air embolism, a life-threatening complication of TPN. The TPN infusion must be stopped immediately. Repositioning the client, alerting the rapid response team and providing supplemental oxygen are actions to take once TPN infusion has been stopped.
Subcategory-Total Parenteral Nutrition
The nurse is monitoring cyclic total parenteral therapy (TPN) in place for their client. What does the nurse recognize as the rationale for cycling TPN therapy?
Rationale– Cycling the amount of TPN infused up and down would prevent sudden glucose changes. No other option is an accepted rationale for cycling TPN therapy.
Subcategory-Total Parenteral Nutrition
Rationale– Cycling the amount of TPN infused up and down would prevent sudden glucose changes. No other option is an accepted rationale for cycling TPN therapy.
Subcategory-Total Parenteral Nutrition
A client is receiving Ancef 1G IV for cellulitis of the R arm. The client reports feeling tired, is diaphoretic, and complains of her lower back itching. Which of the following actions should the nurse do first?
Rationale- The nurse should expect a potential allergic reaction to the antibiotic and immediately turn off the infusion. Slowing the infusion would not ensure patient safety. Calling the physician and administering Benadryl is important, but not the appropriate first action.
Subcategory-Adverse Effects/Contraindications/Side Effects/Interactions
Rationale- The nurse should expect a potential allergic reaction to the antibiotic and immediately turn off the infusion. Slowing the infusion would not ensure patient safety. Calling the physician and administering Benadryl is important, but not the appropriate first action.
Subcategory-Adverse Effects/Contraindications/Side Effects/Interactions
A client is brought to the Emergency Department by paramedics and is in cardiac arrest. The client has received 1 dose of Epinephrine pre-hospital and has been defibrillated once. Upon arrival, the client is found to be in ventricular fibrillation. The ED physician immediately requests defibrillation followed by a second dose of Epinephrine. What medication does the nurse anticipate to be ordered next?
Rationale- Amiodarone is the approved medication to follow Epinephrine during cardiac arrest. Atropine is given only for symptomatic bradycardia. Adenosine is given for supraventricular tachycardia. Vasopressin is only approved as a substitute for the first or second dose of Epinephrine which this client has already received.
Subcategory- Expected Actions/Outcomes
Rationale- Amiodarone is the approved medication to follow Epinephrine during cardiac arrest. Atropine is given only for symptomatic bradycardia. Adenosine is given for supraventricular tachycardia. Vasopressin is only approved as a substitute for the first or second dose of Epinephrine which this client has already received.
Subcategory- Expected Actions/Outcomes
A client is admitted to the medical/surgical unit for vascular surgery. Routine lab values show a Na2+ level of 130 mEq/L. Which of the following orders would the nurse question?
Rationale- Spironolactone is a potassium sparing diuretic that will further deplete sodium. NPO status is expected for patients waiting for surgery. Options 2 and 3 are appropriate treatments of hyponatremia.
Subcategory- Adverse Effects/Contraindications/Side Effects/Interactions
Rationale- Spironolactone is a potassium sparing diuretic that will further deplete sodium. NPO status is expected for patients waiting for surgery. Options 2 and 3 are appropriate treatments of hyponatremia.
Subcategory- Adverse Effects/Contraindications/Side Effects/Interactions
A client status post myocardial infarction is discharged on warfarin has received discharge teaching. Which statement, if made by the client, demonstrates a clear understanding of the discharge instructions?
Rationale- Leafy green vegetables contain Vitamin K which will decrease the efficacy of Warfarin and should be avoided. Clients on Warfarin are not required to stop shaving, will not always be cold, and are required to have blood work much more frequently than once a month at the beginning of their therapy in order to ensure therapeutic dosing.
Subcategory- Expected Actions/Outcomes
Rationale- Leafy green vegetables contain Vitamin K which will decrease the efficacy of Warfarin and should be avoided. Clients on Warfarin are not required to stop shaving, will not always be cold, and are required to have blood work much more frequently than once a month at the beginning of their therapy in order to ensure therapeutic dosing.
Subcategory- Expected Actions/Outcomes
A client presents to the Emergency Department with complaints of paralysis that began in his feet and progressing up his calves. What question by the nurse is most appropriate?
Rationale- The client’s symptoms may be indicative of Guillain Barre Syndrome which most commonly occurs after receiving vaccinations. What the patient had for lunch does not relate to the current symptoms. Options 2 and 4 are important questions to ask clients presenting to the ED but are not most appropriate in this situation.
Subcategory- Adverse Effects/Contraindications/Side Effects/Interactions
Rationale- The client’s symptoms may be indicative of Guillain Barre Syndrome which most commonly occurs after receiving vaccinations. What the patient had for lunch does not relate to the current symptoms. Options 2 and 4 are important questions to ask clients presenting to the ED but are not most appropriate in this situation.
Subcategory- Adverse Effects/Contraindications/Side Effects/Interactions
The nurse correctly identifies what type of insulin with a peak of one hour?
Rationale – Novolog has a peak of one hour. Levemir does not peak. Novolin R peaks in 2-5 hours and Novulin N peaks in 4-14 hours.
Subcategory- Expected Actions/Outcomes
Rationale – Novolog has a peak of one hour. Levemir does not peak. Novolin R peaks in 2-5 hours and Novulin N peaks in 4-14 hours.
Subcategory- Expected Actions/Outcomes
A client receiving long-term steroid therapy has abruptly stops taking the medication what signs and symptoms of adrenal insufficiency should the nurse assessed for? Select all that apply
Rationale – Signs and symptoms of adrenal insufficiency and a client with abrupt cessation of a long term steroids include hyperglycemia vomiting and hyperkalemia. Hypertension not hypotension is often found. Dehydration not fluid retention is a common finding.
Subcategory: Adverse Effects/Contraindications
Rationale – Signs and symptoms of adrenal insufficiency and a client with abrupt cessation of a long term steroids include hyperglycemia vomiting and hyperkalemia. Hypertension not hypotension is often found. Dehydration not fluid retention is a common finding.
Subcategory: Adverse Effects/Contraindications
What medications does the nurse anticipate and ministering to a client diagnosed with a gastroesophageal reflux disease? Select all that apply.
Rationale- Pantoprazole, Ranitidine and Esomeprazole are drugs commonly used to treat gastroesophageal reflux disease. Tramadol is a pain medication that is not used to treat gastroesophageal reflux disease. Prednisone is a steroid that often will increase esophageal acid and is often contra indicated in clients with gastroesophageal reflux disease.
Subcategory- Expected Actions/Outcomes
Rationale- Pantoprazole, Ranitidine and Esomeprazole are drugs commonly used to treat gastroesophageal reflux disease. Tramadol is a pain medication that is not used to treat gastroesophageal reflux disease. Prednisone is a steroid that often will increase esophageal acid and is often contra indicated in clients with gastroesophageal reflux disease.
Subcategory- Expected Actions/Outcomes
A client diagnosed with major depressive disorder is prescribed fluoxetine. What symptoms should the psychiatric nurse report immediately? Select all that apply.
Rationale – Ataxia, confusion and sweating are all signs of serotonin syndrome which is a serious complication of SSRIs such as fluoxetine. Hypertension and elevated temperature are common findings not hypotension or decrease temperature.
Subcategory: Adverse Effects/Contraindications
Rationale – Ataxia, confusion and sweating are all signs of serotonin syndrome which is a serious complication of SSRIs such as fluoxetine. Hypertension and elevated temperature are common findings not hypotension or decrease temperature.
Subcategory: Adverse Effects/Contraindications
A client is admitted to the emergency department with a blood pressure of 210/108 after being at a family barbecue, the client reports having two beers and a hotdog. What medication should be reported to the healthcare provider immediately?
Rationale –Phenelzine is a monoamine oxidase inhibitor her. Client should not have tyramine containing foods such as hotdogs or use products including beer. Fluoxetine, Lithium and Imipramine do not cause hypertensive crisis. A hypertensive crisis may arise when these medications are combined with these foods.
Subcategory: Adverse Effects/Contraindications
Rationale –Phenelzine is a monoamine oxidase inhibitor her. Client should not have tyramine containing foods such as hotdogs or use products including beer. Fluoxetine, Lithium and Imipramine do not cause hypertensive crisis. A hypertensive crisis may arise when these medications are combined with these foods.
Subcategory: Adverse Effects/Contraindications
What statement by a client diagnosed with general anxiety disorder that is prescribed alprazolam indicates a need for further teaching?
Rationale – Alprazolam can lead to dependency. The medication is taken when the client feels anxious. They should not drive on the medication. Orthostatic hypotension is a side effect of alprazolam so client should be instructed to get up slowly.
Subcategory: Expected Actions/Outcomes
Rationale – Alprazolam can lead to dependency. The medication is taken when the client feels anxious. They should not drive on the medication. Orthostatic hypotension is a side effect of alprazolam so client should be instructed to get up slowly.
Subcategory: Expected Actions/Outcomes
A client diagnosed with low back pain has received morphine sulfate. The clients blood pressure is 90/60, respiratory rate is eight and their pulse is 55. What medication should the nurse prepare to administer?
Rationale – Naloxone is the antidote for opiate analgesics. Ibuprofen, atropine and calcium gluconate will not resolve the effects of the morphine sulfate.
Subcategory: Pain Management
Rationale – Naloxone is the antidote for opiate analgesics. Ibuprofen, atropine and calcium gluconate will not resolve the effects of the morphine sulfate.
Subcategory: Pain Management
What finding should be reported immediately and a client diagnosed with gout that is taking allopurinol?
Rationale – A platelet count of 100,000 is indicative of bone marrow suppression and should be reported to the health care provider immediately. An INR level of 2.0 is normal. The blood pressures elevated but not a critical level. An erythrocyte sedimentation rate would be elevated and a client with gout would be taking out here now.
Subcategory: Pharmacological adverse effects
Rationale – A platelet count of 100,000 is indicative of bone marrow suppression and should be reported to the health care provider immediately. An INR level of 2.0 is normal. The blood pressures elevated but not a critical level. An erythrocyte sedimentation rate would be elevated and a client with gout would be taking out here now.
Subcategory: Pharmacological adverse effects
A client receiving vancomycin IV has an order for a vancomycin trough level to be drawn. When should the client’s blood be drawn?
Rationale- A trough level should be drawn just prior to administration of the next dose of the medication. The order does not need to be clarified. Drawing it immediately will not give a tough level. Peak levels of medications are drawn 1-2 hours after medications are administered, not trough levels.
Subcategory- Parenteral/Intravenous Therapies
Rationale- A trough level should be drawn just prior to administration of the next dose of the medication. The order does not need to be clarified. Drawing it immediately will not give a tough level. Peak levels of medications are drawn 1-2 hours after medications are administered, not trough levels.
Subcategory- Parenteral/Intravenous Therapies
Prior to inserting the biopsy needle what instruction should be provided to a client that is undergoing a liver biopsy?
Rationale – It is important for the client to exhale and hold her breath as a primary care provider inserts the biopsy needle. They should not forcefully exhale. The client should not tighten their abdominal muscles. The client should not bear down.
Subcategory- Diagnostic Tests
Rationale – It is important for the client to exhale and hold her breath as a primary care provider inserts the biopsy needle. They should not forcefully exhale. The client should not tighten their abdominal muscles. The client should not bear down.
Subcategory- Diagnostic Tests
After undergoing a liver biopsy, what position should the client instructed to lay?
Rationale – A client that is undergone a liver biopsy should be instructed to lie with the biopsy side down which will apply pressure to the site and prevent further bleeding. The client should not lie biopsy site up, prone or supine.
Subcategory- Diagnostic Tests
Rationale – A client that is undergone a liver biopsy should be instructed to lie with the biopsy side down which will apply pressure to the site and prevent further bleeding. The client should not lie biopsy site up, prone or supine.
Subcategory- Diagnostic Tests
A pregnant woman at 41 weeks gestation presents to the prenatal clinic for a non-stress test (NST). Which of the following instructions given by the nurse will correctly prepare the client for testing?
Rationale – The client will need to record fetal movement as part of the NST. Having the client lie on her back will not provide optimal placental perfusion and will adversely affect the fetal heart rate. Lying on their side drinking juice and having them close their eyes and relax neglect the important role the mother plays in reporting and recording fetal movement during an NST.
Subcategory- Diagnostic Tests
Rationale – The client will need to record fetal movement as part of the NST. Having the client lie on her back will not provide optimal placental perfusion and will adversely affect the fetal heart rate. Lying on their side drinking juice and having them close their eyes and relax neglect the important role the mother plays in reporting and recording fetal movement during an NST.
Subcategory- Diagnostic Tests
A client has been brought to the emergency department to rule out diabetes insipidus. What findings are consistent with this diagnosis? Select all that apply.
Rationale – A low urine specific gravity and a high sodium level are consistent with a diagnosis of diabetes insipidus. The blood glucose is not related to diabetes insipidus. Potassium and calcium elevations are not diagnostic for diabetes insipidus.
Subcategory- Laboratory Values
Rationale – A low urine specific gravity and a high sodium level are consistent with a diagnosis of diabetes insipidus. The blood glucose is not related to diabetes insipidus. Potassium and calcium elevations are not diagnostic for diabetes insipidus.
Subcategory- Laboratory Values
What is the purpose of a creatinine clearance test?
Rationale – The purpose of a creatinine clearance test is to determine the glomerular filtration rate. It does not evaluate specific gravity over 24 hours. It does not determine causes of incontinence. It does not evaluate blood glucose in the urine.
Subcategory- Laboratory Values
Rationale – The purpose of a creatinine clearance test is to determine the glomerular filtration rate. It does not evaluate specific gravity over 24 hours. It does not determine causes of incontinence. It does not evaluate blood glucose in the urine.
Subcategory- Laboratory Values
The infant of a gestational diabetic mother is admitted to the nursery. In addition to maintaining adequate caloric intake, what nursing intervention is priority to help prevent hypoglycemia in the newborn?
Rationale – A cold baby will use brown fat for heat (non-shivering thermogenesis) and cause drops in blood sugar.
Subcategory- Potential for Alterations in Body Systems
Rationale – A cold baby will use brown fat for heat (non-shivering thermogenesis) and cause drops in blood sugar.
Subcategory- Potential for Alterations in Body Systems
A client diagnosed with heart failure has an order for insertion of a urinary catheter to monitor urinary output. What actions by the nurse will help prevent catheter associated urinary tract infections? Select all that apply.
Rationale – Aseptic technique should be used when inserting the catheter in a close system should be maintained. Irrigating the catheter and routine replacement increase the risk for infection. The urine collection bag should never be above the client’s bladder.
Subcategory- Potential for Complications of Diagnostic Tests/Treatments/Procedures
Rationale – Aseptic technique should be used when inserting the catheter in a close system should be maintained. Irrigating the catheter and routine replacement increase the risk for infection. The urine collection bag should never be above the client’s bladder.
Subcategory- Potential for Complications of Diagnostic Tests/Treatments/Procedures
What actions by the nurse reduces the risk of catheter associated urinary tract infections during the insertion of the catheter? Select all that apply.
Rationale – It is important to use one final cotton ball to cleanse over the meatus. Discarding the catheter if it enters the vagina is recommended. All of these things can reduce the risk of infection. Releasing the labia after antiseptic has been used is not recommended as it can cause contamination. Applying a catheter secure device on the leg will prevent movement and secure the catheter in place. A separate cotton ball or cleansing applicator should be used for each side of the labia majora and minora.
Subcategory- Potential for Complications of Diagnostic Tests/Treatments/Procedures
Rationale – It is important to use one final cotton ball to cleanse over the meatus. Discarding the catheter if it enters the vagina is recommended. All of these things can reduce the risk of infection. Releasing the labia after antiseptic has been used is not recommended as it can cause contamination. Applying a catheter secure device on the leg will prevent movement and secure the catheter in place. A separate cotton ball or cleansing applicator should be used for each side of the labia majora and minora.
Subcategory- Potential for Complications of Diagnostic Tests/Treatments/Procedures
A client is suspected of having incomplete emptying of the bladder. What type of diagnostic test does the nurse anticipate to measure bladder urine volume?
Rationale – The least invasive test to determine bladder urine volume is a portable bladder ultrasound. Straight catheterization is invasive and risks infection. Computed tomography involves radiation and is not used to determine bladder volume.
Subcategory- Potential for Complications of Diagnostic Tests/Treatments/Procedures
Rationale – The least invasive test to determine bladder urine volume is a portable bladder ultrasound. Straight catheterization is invasive and risks infection. Computed tomography involves radiation and is not used to determine bladder volume.
Subcategory- Potential for Complications of Diagnostic Tests/Treatments/Procedures
A client with a pulse deficit should be assessed for what diagnosis? Select all that apply.
Rationale – A pulse deficit is an indication that a client may have vascular disease or a cardiac dysrhythmia. Hypothermia COPD and bacterial infections do not cause pulse deficits.
Subcategory- Abnormalities in Vital Signs
Rationale – A pulse deficit is an indication that a client may have vascular disease or a cardiac dysrhythmia. Hypothermia COPD and bacterial infections do not cause pulse deficits.
Subcategory- Abnormalities in Vital Signs
What client is expected to have a low resting heart rate?
Rationale – Athletic clients tend to have lower resting heart rates the normal individuals. A client in pain and an afebrile client would be expected to have elevated heart rate. A newborn baby has the highest heart rate of any age group.
Subcategory- Abnormalities in Vital Signs
Rationale – Athletic clients tend to have lower resting heart rates the normal individuals. A client in pain and an afebrile client would be expected to have elevated heart rate. A newborn baby has the highest heart rate of any age group.
Subcategory- Abnormalities in Vital Signs
The Labor and Delivery nurse is interpreting the fetal heart rate tracing (FHT) on the monitor strip of a laboring woman. The baseline FHR is 140 bpm, accelerations are present, there are no decelerations, and moderate variability is noted. What is the most appropriate interpretation of the FHT?
Rationale- According to NICHD guidelines, FHT is category I when baseline is WNL, there are accelerations, no deceleration, and moderate variability.
Subcategory- System Specific Assessments
Rationale- According to NICHD guidelines, FHT is category I when baseline is WNL, there are accelerations, no deceleration, and moderate variability.
Subcategory- System Specific Assessments
The nurse recognizes which finding as a positive sign of pregnancy?
Rationale- HCG can cause false positives in cases of pituitary tumors. Weight gain is a probable sign of pregnancy. Maternal perception of movement is a probable sign.
Subcategory- System Specific Assessments
Rationale- HCG can cause false positives in cases of pituitary tumors. Weight gain is a probable sign of pregnancy. Maternal perception of movement is a probable sign.
Subcategory- System Specific Assessments
During a newborn assessment, the nurse notes red blotches with tiny bumps on the face and chest. How should the nurse document this finding?
Rationale- Erythema toxicum is red blotches on the face and chest. These findings are not consistent with milia, baby acnes or hemangiomas.
Subcategory- System Specific Assessments
Rationale- Erythema toxicum is red blotches on the face and chest. These findings are not consistent with milia, baby acnes or hemangiomas.
Subcategory- System Specific Assessments
Upon admission to the nursery, which of the following is the priority nursing assessment for an infant weighing 9 pounds, 10 ounces?
Rationale – Airway, breathing and circulation are the priority assessments, respiratory rate would breathing and color would indicate circulation. Reflexes, temperature and blood glucose levels are not priority over breathing and circulation.
Subcategory- System Specific Assessments
Rationale – Airway, breathing and circulation are the priority assessments, respiratory rate would breathing and color would indicate circulation. Reflexes, temperature and blood glucose levels are not priority over breathing and circulation.
Subcategory- System Specific Assessments
What is the most appropriate action when auscultating lung sounds in an adult client?
Rationale – The appropriate way to auscultate lung sounds is to place the diaphragm of the stethoscope over the appropriate thoracic landmarks while the client is taking slow deep breaths. The bell of the stethoscope is used to auscultate low pitched sounds in the cardiac assessment.
Subcategory- System Specific Assessments
Rationale – The appropriate way to auscultate lung sounds is to place the diaphragm of the stethoscope over the appropriate thoracic landmarks while the client is taking slow deep breaths. The bell of the stethoscope is used to auscultate low pitched sounds in the cardiac assessment.
Subcategory- System Specific Assessments
When performing a respiratory assessment what technique is most important when progressing from one auscultatory site to the next?
Rationale – When assessing lung sounds it is important to move side to side to compare findings between the right and left lung. Moving top to bottom is not necessary as long as sides are compared. Lateral to medial is not indicated and posterior to anterior is not priority.
Subcategory- System Specific Assessments
Rationale – When assessing lung sounds it is important to move side to side to compare findings between the right and left lung. Moving top to bottom is not necessary as long as sides are compared. Lateral to medial is not indicated and posterior to anterior is not priority.
Subcategory- System Specific Assessments
A hospitalized client with an acute respiratory illness that are harsh and high pitched on inspiration. What assessment finding does this best describe?
Rationale – Stridor is a harsh, high pitched sounds that can be auscultated on inspiration as a result of a narrowing of the upper airway. Crackles produce a bubbling or popping sound that can be auscultated on inspiration and expiration. Wheezes produce a musical or squeaking sounds. Friction rub produces a rubbing or grating sound.
Subcategory- System Specific Assessments
Rationale – Stridor is a harsh, high pitched sounds that can be auscultated on inspiration as a result of a narrowing of the upper airway. Crackles produce a bubbling or popping sound that can be auscultated on inspiration and expiration. Wheezes produce a musical or squeaking sounds. Friction rub produces a rubbing or grating sound.
Subcategory- System Specific Assessments
What initial assessment of a client takes priority?
Rationale – If the airway is not patent then it will lead to respiratory arrest and ultimately cardiac arrest. While all of the above assessments are highly important to complete early during the initial assessment of a client, airway patency is priority.
Subcategory- System Specific Assessments
Rationale – If the airway is not patent then it will lead to respiratory arrest and ultimately cardiac arrest. While all of the above assessments are highly important to complete early during the initial assessment of a client, airway patency is priority.
Subcategory- System Specific Assessments
The post-partum nurse is performing the discharge assessment on a woman who experienced an uncomplicated vaginal delivery two days ago. Which of the following findings would be considered normal? Select all that apply.
Rationale – Small amounts of rubra lochia, a slight separation of abdominal muscles and a repair of laceration are all expected findings. Pain rating of 9/10 two days after an uncomplicated vaginal delivery may represent narcotic dependence. A fundus that is 1-2 cm above the umbilicus and deviated indicates need for client to empty bladder and RN to reassess fundus.
Subcategory- System Specific Assessments
Rationale – Small amounts of rubra lochia, a slight separation of abdominal muscles and a repair of laceration are all expected findings. Pain rating of 9/10 two days after an uncomplicated vaginal delivery may represent narcotic dependence. A fundus that is 1-2 cm above the umbilicus and deviated indicates need for client to empty bladder and RN to reassess fundus.
Subcategory- System Specific Assessments
The nurse is caring for a laboring woman with a recent vaginal exam documented as 5 cm/80%/0. What is an appropriate interpretation of this exam?
Rationale – The exam shows the client is 5 cm dilated, 80% effaced, 0 station (at level of ischial spines).
Subcategory- System Specific Assessments
Rationale – The exam shows the client is 5 cm dilated, 80% effaced, 0 station (at level of ischial spines).
Subcategory- System Specific Assessments
The nurse is evaluating the fetal heart tracing and notes an absence of noticeable fluctuations in the baseline fetal heart rate. What is the correct term for this finding?
Rationale – Absence of noticeable fluctuations is absence of variability.
Subcategory- Diagnostic Tests
Rationale – Absence of noticeable fluctuations is absence of variability.
Subcategory- Diagnostic Tests
A client is admitted for chest pain to rule out myocardial infarction. What lab and diagnostic tests with the nurse anticipate being ordered to determine if the client has had a myocardial infarction? Select all that apply.
Rationale – Troponin would be elevated in the EKG would show abnormalities of the ST segment or T-wave. Triglycerides may be indicate a client is at risk for a myocardial infarction but is not diagnostic for an MI. Alkaline phosphatase is not diagnostic for a myocardial infarction. An electroencephalogram is not a study for myocardial infarction.
Subcategory- Reduction of Risk
Rationale – Troponin would be elevated in the EKG would show abnormalities of the ST segment or T-wave. Triglycerides may be indicate a client is at risk for a myocardial infarction but is not diagnostic for an MI. Alkaline phosphatase is not diagnostic for a myocardial infarction. An electroencephalogram is not a study for myocardial infarction.
Subcategory- Reduction of Risk
A client that has undergone a renal biopsy has developed Flink bruising, a temperature of 99.8°F, blood pressure 104/52 and a pulse of 102. What complication does the nurse suspect?
Rationale – Hemorrhages are suspected when Flink bruising occurs with a decrease in blood pressure and an elevation on the pulse. The signs and symptoms are not consistent with a hematoma, carcinoma with metastasis or infection.
Subcategory-Reduction of Risk
Rationale – Hemorrhages are suspected when Flink bruising occurs with a decrease in blood pressure and an elevation on the pulse. The signs and symptoms are not consistent with a hematoma, carcinoma with metastasis or infection.
Subcategory-Reduction of Risk
What diagnostic test is ordered to confirm a diagnosis if a client tested positive for HIV using the enzyme immunoassay (EIA) test?
Rationale – Western blot test is diagnostic for HIV. It is used when a client has a positive EIA test. Viral load testing is not used for diagnosis. Chest x-ray will not be diagnostics for HIV. They will not repeat a test if it was already positive.
Subcategory- Laboratory Values
Rationale – Western blot test is diagnostic for HIV. It is used when a client has a positive EIA test. Viral load testing is not used for diagnosis. Chest x-ray will not be diagnostics for HIV. They will not repeat a test if it was already positive.
Subcategory- Laboratory Values
A client is admitted to the emergency department for weakness/general malaise. Blood work is drawn and sent to the lab. The results show a K+ level of 2.8 mEq/dL. What action by the nurse is priority?
Rationale- An alteration in potassium level can directly cause cardiac dysrhythmias, a client should immediately be placed onto a cardiac monitor. The nurse would hold furosemide as this medication would further deplete potassium. Beginning IV fluids is important but not priority. Redrawing blood samples can be helpful but is not priority and is not always requested by the physician.
Subcategory- Laboratory Tests
Rationale- An alteration in potassium level can directly cause cardiac dysrhythmias, a client should immediately be placed onto a cardiac monitor. The nurse would hold furosemide as this medication would further deplete potassium. Beginning IV fluids is important but not priority. Redrawing blood samples can be helpful but is not priority and is not always requested by the physician.
Subcategory- Laboratory Tests
A client is transferred from the Recovery Room (PACU) to the med/surg floor status post R THR. The client is an 81 year old female with a medical history of HTN, GERD, Anxiety, CHF, and Hypothyroidism. The client is on 2L O2 via nasal cannula, receiving LR IV @ 125mL/hr, and has orders for pain medication. What assessment findings would the nurse immediately report to the physician?
Rationale- The nurse would immediately report auscultating crackles in the RLL as this may indicate fluid overload secondary to the IV fluids and the patient’s history of CHF. A temperature of 99.1o F is an expected finding in the immediate post-operative period secondary to the inflammatory response and atelectasis. Pain 8/10 is expected and orders are available for pain management therefore not requiring a phone call to the physician. 2+ edema on the operative leg is an expected assessment finding in the post-operative period.
Subcategory- Potential Alterations in Body Systems
Rationale- The nurse would immediately report auscultating crackles in the RLL as this may indicate fluid overload secondary to the IV fluids and the patient’s history of CHF. A temperature of 99.1o F is an expected finding in the immediate post-operative period secondary to the inflammatory response and atelectasis. Pain 8/10 is expected and orders are available for pain management therefore not requiring a phone call to the physician. 2+ edema on the operative leg is an expected assessment finding in the post-operative period.
Subcategory- Potential Alterations in Body Systems
The client is found unresponsive in his hospital room. The cardiac monitor shows polymorphic ventricular tachycardia. A depletion of which of the following electrolytes would be expected and replenished immediately?
Rationale- Polymorphic Ventricular Tachycardia, or Torsades de Pointes, can be caused by a depletion of Mg and can be corrected by administration of Mg via IV. The other electrolytes are not directly related to this particular dysrhythmia.
Subcategory- Laboratory Tests
Rationale- Polymorphic Ventricular Tachycardia, or Torsades de Pointes, can be caused by a depletion of Mg and can be corrected by administration of Mg via IV. The other electrolytes are not directly related to this particular dysrhythmia.
Subcategory- Laboratory Tests
A client returns to the Emergency Department two days after being treated for a fractured left ulna which resulted in cast placement. The client reports pain 8/10 in left arm. What assessment findings require immediate intervention by the nurse?
Rationale- Delayed capillary refill of this client’s left fingers represents a decrease in peripheral circulation which, on a client with a cast, could be indicative of compartment syndrome which is a medical emergency and requires immediate intervention.
Subcategory-Potential for Complications for complications from surgical procedures and health alterations.
Rationale- Delayed capillary refill of this client’s left fingers represents a decrease in peripheral circulation which, on a client with a cast, could be indicative of compartment syndrome which is a medical emergency and requires immediate intervention.
Subcategory-Potential for Complications for complications from surgical procedures and health alterations.
A client presents to the Emergency Department complaining of black tarry stools for two days. The nurse places a peripheral IV catheter and draws lab work. What finding does the nurse anticipate?
Rationale- Black tarry stools is a symptom of an upper GI bleed which will cause a decrease in hemoglobin. An elevated platelet count, decreased WBCs, and a normal potassium level are not expected findings in a patient with a GI bleed.
Subcategory- Laboratory Values
Rationale- Black tarry stools is a symptom of an upper GI bleed which will cause a decrease in hemoglobin. An elevated platelet count, decreased WBCs, and a normal potassium level are not expected findings in a patient with a GI bleed.
Subcategory- Laboratory Values
A client presents to the Emergency Department complaining of dizziness, nausea, and blurry vision. What is the priority nursing intervention for this client?
Rationale- The client’s symptoms may represent severe hyperglycemia. This can quickly be ruled out or confirmed by a finger stick. Inquiring about advanced directives, obtaining a health history, and checking vision are not priority nursing interventions for this client.
Subcategory- Laboratory Values
Rationale- The client’s symptoms may represent severe hyperglycemia. This can quickly be ruled out or confirmed by a finger stick. Inquiring about advanced directives, obtaining a health history, and checking vision are not priority nursing interventions for this client.
Subcategory- Laboratory Values
The client is admitted to the hospital for treatment of a UTI. On the CMP, the nurse notes the BUN to be 23 mg/dL and the Creatinine 1.2 mg/dL. The nurse would anticipate what order based on these lab values?
Rationale- The lab values show the client to be dehydrated. The nurse would expect the physician to order IV fluids to hydrate the patient. NPO status and a fluid restriction would not be appropriate orders as they would further dehydrate the patient. Levaquin is an appropriate treatment for UTI however does not relate to the patient’s hydration status.
Subcategory- Laboratory Values
Rationale- The lab values show the client to be dehydrated. The nurse would expect the physician to order IV fluids to hydrate the patient. NPO status and a fluid restriction would not be appropriate orders as they would further dehydrate the patient. Levaquin is an appropriate treatment for UTI however does not relate to the patient’s hydration status.
Subcategory- Laboratory Values
A client is diagnosed with adrenal insufficiency. What findings are consistent with diagnosis? Select all that apply.
Rationale- Hyperkalemia and hypoglycemia or common findings in clients that knows with adrenal insufficiency. The sodium level would likely be low. The magnesium level would be elevated not decreased. Calcium is often not affected.
Subcategory- Laboratory Values
Rationale- Hyperkalemia and hypoglycemia or common findings in clients that knows with adrenal insufficiency. The sodium level would likely be low. The magnesium level would be elevated not decreased. Calcium is often not affected.
Subcategory- Laboratory Values
What findings are priority to report in a clients that is scheduled for fibrinolytic therapy following a cerebral vascular accident? Select all that apply.
Rationale – Clients with bleeding disorders should not receive fiber Linick therapy. Clients diagnosed with Peptic ulcer disease are also a higher risk for bleeding and should not receive Thrombolytics. Clients diagnosed with COPD and thrombotic myocardial infarction’s can receive thrombolytics.
Subcategory- Complications of Surgical Procedures and Health Alterations
Rationale – Clients with bleeding disorders should not receive fiber Linick therapy. Clients diagnosed with Peptic ulcer disease are also a higher risk for bleeding and should not receive Thrombolytics. Clients diagnosed with COPD and thrombotic myocardial infarction’s can receive thrombolytics.
Subcategory- Complications of Surgical Procedures and Health Alterations
A client that has just undergone bariatric surgery has a nasogastric tube in place connected to low wall suction. The client informs the nurse that they’re extremely nauseous. What action should the nurse take first?
Rationale – The first thing the nurse to do is assess that the suction is turned on. If the nurse determines that the suction is on and the client is still experiencing nausea and no output then the nurse should contact the surgeon. The nurse should not flush the nasogastric tube if the client is nauseous. The needs of gastric tube should not be removed or repositioned.
Subcategory- Potential for Complications from Surgical Procedures
Rationale – The first thing the nurse to do is assess that the suction is turned on. If the nurse determines that the suction is on and the client is still experiencing nausea and no output then the nurse should contact the surgeon. The nurse should not flush the nasogastric tube if the client is nauseous. The needs of gastric tube should not be removed or repositioned.
Subcategory- Potential for Complications from Surgical Procedures
A client that has just undergone bariatric surgery has a nasogastric tube in place connected to low wall suction. The client informs the nurse that they’re extremely nauseous. What action should the nurse take first?
Rationale – The first thing the nurse to do is assess that the suction is turned on. If the nurse determines that the suction is on and the client is still experiencing nausea and no output then the nurse should contact the surgeon. The nurse should not flush the nasogastric tube if the client is nauseous. The needs of gastric tube should not be removed or repositions.
Subcategory- Potential for Complications for complications from surgical procedures and health alterations.
Rationale – The first thing the nurse to do is assess that the suction is turned on. If the nurse determines that the suction is on and the client is still experiencing nausea and no output then the nurse should contact the surgeon. The nurse should not flush the nasogastric tube if the client is nauseous. The needs of gastric tube should not be removed or repositions.
Subcategory- Potential for Complications for complications from surgical procedures and health alterations.
A high risk pregnant client is receiving teaching regarding infant safety. What statement by the client indicates a need for further teaching?
Rationale – Bruises on my chest or abdomen area and near their ears is an indication of child abuse and should be read ported immediately. Babies have to be in a car seat facing the back of the car. Is important not to introduce foods until it is recommended by the healthcare provider. The baby should not be in a parent’s arms when cooking or near an open flame.
Subcategory- Accident/Injury Prevention
Rationale – Bruises on my chest or abdomen area and near their ears is an indication of child abuse and should be read ported immediately. Babies have to be in a car seat facing the back of the car. Is important not to introduce foods until it is recommended by the healthcare provider. The baby should not be in a parent’s arms when cooking or near an open flame.
Subcategory- Accident/Injury Prevention
What safety intervention is priority for a hospitalized older adult client with a platelet count of 70,000, a hemoglobin level of 14 g/dL and hematocrit level of 40%?
Rationale – A client with a platelet count of 70,000 is at risk for bleeding which can be significantly impacted with a fall. A client with a low platelet count in the fall is at high risk for intracranial bleeding. A blood transfusion of packed red blood cells is not indicated, platelet transfusion may be however, that is not a safety intervention. Padded side rails are not indicated at the client does not have a seizure disorder. Room close to the nurse’s station is a good idea however fall precautions are priority.
Subcategory- Accident/Injury Prevention
Rationale – A client with a platelet count of 70,000 is at risk for bleeding which can be significantly impacted with a fall. A client with a low platelet count in the fall is at high risk for intracranial bleeding. A blood transfusion of packed red blood cells is not indicated, platelet transfusion may be however, that is not a safety intervention. Padded side rails are not indicated at the client does not have a seizure disorder. Room close to the nurse’s station is a good idea however fall precautions are priority.
Subcategory- Accident/Injury Prevention
The nurse is attempting to defuse a client. The client continues to pull and try to climb out of the bed. What action by the nurse is appropriate?
Rationale – The most appropriate action by the nurse is to request assistance beating the client. All four side rails being up is considered a restraint and may injure the back of the nurse. Leaving the bed in low position increases the risk of the nurse injuring themselves. Medicating the client is also a form of restraint.
Subcategory- Ergonomic Principles
Rationale – The most appropriate action by the nurse is to request assistance beating the client. All four side rails being up is considered a restraint and may injure the back of the nurse. Leaving the bed in low position increases the risk of the nurse injuring themselves. Medicating the client is also a form of restraint.
Subcategory- Ergonomic Principles
When providing client care, what action by the nurse demonstrates a need for further teaching?
Rationale – Twisting at the trunk may cause muscle strain to the back and the abdomen. This should be avoided when moving or lifting a client. Bending at the knees is appropriate. The tightening of abdominal muscles should be maintained in a tight position to prevent injury and keep balance. Objects that are going to be moved should be maintained close to the body.
Subcategory- Ergonomic Principles
Rationale – Twisting at the trunk may cause muscle strain to the back and the abdomen. This should be avoided when moving or lifting a client. Bending at the knees is appropriate. The tightening of abdominal muscles should be maintained in a tight position to prevent injury and keep balance. Objects that are going to be moved should be maintained close to the body.
Subcategory- Ergonomic Principles
A client goes into cardiac arrest and a code is called. While attempting to give rescue breaths it is realize that there is no Ambu bag present. Who is liable for the missing equipment?
Rationale – If someone is assigned to check and ensure the equipment is functioning and present they should have recognized that there was not an Ambu bag present. The charge nurse is also not liable. The nurse who gathered the crash cart is not legally liable. The nurse caring for the client is not liable.
Subcategory- Safe Use of Equipment
Rationale – If someone is assigned to check and ensure the equipment is functioning and present they should have recognized that there was not an Ambu bag present. The charge nurse is also not liable. The nurse who gathered the crash cart is not legally liable. The nurse caring for the client is not liable.
Subcategory- Safe Use of Equipment
A client has a chemotherapy infusion running. The nurse enters the room and recognizes that the client has a significant extravasation from the vesicant solution going into the tissue. It is determined that the IV infusion pump has malfunctioned. What action, once the client is cared for and stabilized, is most appropriate?
Rationale – The pump should be somewhere safe to be brought up if the litigation occurs. This will be the safeguard for the nurse an institution that the injury to the patient was an equipment failure. The pump should not be discarded. The pump should not be tested or used again. Having the equipment check by someone an institution should be done once the equipment is isolated so that it does not get used or put somewhere else.
Subcategory- Safe Use of Equipment
Rationale – The pump should be somewhere safe to be brought up if the litigation occurs. This will be the safeguard for the nurse an institution that the injury to the patient was an equipment failure. The pump should not be discarded. The pump should not be tested or used again. Having the equipment check by someone an institution should be done once the equipment is isolated so that it does not get used or put somewhere else.
Subcategory- Safe Use of Equipment
When completing an incident report who should document the facts about the incident that occurred?
Rationale – The nurse involved should be the person who reports the facts an incident. The employer attorney and client do not fill out the incident report.
Subcategory- Reporting of Incident/Event/Irregular Occurrence/Variance
Rationale – The nurse involved should be the person who reports the facts an incident. The employer attorney and client do not fill out the incident report.
Subcategory- Reporting of Incident/Event/Irregular Occurrence/Variance
A nurse is completing an incident report after a client’s fall. What information should not be included in these reports? Select all that apply.
Rationale – The nurse should not include opinions of how the incident occurred or defense about fall in the incident occurrence. Conclusions regarding the incident should not be made. The incident report should simply state who is present and what happened. Fax should be the only thing included.
Subcategory- Reporting of Incident/Event/Irregular Occurrence/Variance
Rationale – The nurse should not include opinions of how the incident occurred or defense about fall in the incident occurrence. Conclusions regarding the incident should not be made. The incident report should simply state who is present and what happened. Fax should be the only thing included.
Subcategory- Reporting of Incident/Event/Irregular Occurrence/Variance
What statement by the nurse regarding incident reports indicate a need for further teaching?
Rationale – The nurse should not get in trouble for information included in an incident report. This would deter nurses from completing instant report to the hospital. There should only state facts about the situation. The nurse should not place blame on anyone else involved. The incident report is never placed in a client’s chart.
Subcategory- Reporting of Incident/Event/Irregular Occurrence/Variance
Rationale – The nurse should not get in trouble for information included in an incident report. This would deter nurses from completing instant report to the hospital. There should only state facts about the situation. The nurse should not place blame on anyone else involved. The incident report is never placed in a client’s chart.
Subcategory- Reporting of Incident/Event/Irregular Occurrence/Variance
A nurse is brought to court after a client fell while in their care. What finding is likely to lead to a negative outcome for the nurse?
Rationale – By not documenting the incident are providing information on the client’s chart it appears as a cover-up. This wouldn’t likely impact the client in a negative manner.
Subcategory- Reporting of Incident/Event/Irregular Occurrence/Variance
Rationale – By not documenting the incident are providing information on the client’s chart it appears as a cover-up. This wouldn’t likely impact the client in a negative manner.
Subcategory- Reporting of Incident/Event/Irregular Occurrence/Variance
4. Documentation of the incident in the client’s chart
A client is admitted to the hospital with a diagnosis of acute lymphocytic leukemia. The clients white blood cell count is 1000. What type of precautions should the client be placed?
Rationale – A client that is placed on reverse precautions is placed on this type of isolation to protect themselves from infections others May transmit. The client should not be placed on contact, droplet or airborne precautions.
Subcategory- Reporting of Incident/Event/Irregular Occurrence/Variance
Rationale – A client that is placed on reverse precautions is placed on this type of isolation to protect themselves from infections others May transmit. The client should not be placed on contact, droplet or airborne precautions.
Subcategory- Reporting of Incident/Event/Irregular Occurrence/Variance
A nurse washes their hands and enters a room to find a client with severe epistaxis. What action should the nurse take first?
Rationale – After placing gloves on the client should use gauze or tissues on the patient’s nose and put pressure on the bridge of the nose. The client should be encouraged to tip their head forward not backwards. A rapid response is not indicated for a nosebleed unless the bleeding will not stop.
Subcategory- Standard Precautions/Transmission-based precautions/Surgical Asepsis
Rationale – After placing gloves on the client should use gauze or tissues on the patient’s nose and put pressure on the bridge of the nose. The client should be encouraged to tip their head forward not backwards. A rapid response is not indicated for a nosebleed unless the bleeding will not stop.
Subcategory- Standard Precautions/Transmission-based precautions/Surgical Asepsis
A client is admitted to the hospital for a urinary tract infection. The client is on standard precautions. What action by the nurse is appropriate? Select all that apply.
Rationale – Standard precautions states that needles should never be recapped and requires hand hygiene when entering a room in between any interventions. Placing all clients in a private room is not necessary. Equipment does not need to be clean after each time it is used. Gloves should be changed between each intervention. After changing addressing they should be removed and new gloves please before emptying a urinary catheter.
Subcategory- Standard Precautions/Transmission-based precautions/Surgical Asepsis
Rationale – Standard precautions states that needles should never be recapped and requires hand hygiene when entering a room in between any interventions. Placing all clients in a private room is not necessary. Equipment does not need to be clean after each time it is used. Gloves should be changed between each intervention. After changing addressing they should be removed and new gloves please before emptying a urinary catheter.
Subcategory- Standard Precautions/Transmission-based precautions/Surgical Asepsis
A client is placed an airborne precautions. What action by the nurse demonstrates a need for further teaching?
Rationale – The door should be closed at all times if not entering the room. The client should be in a private negative air pressure room. The nurse should wear a N95 mask. The client should be wearing a surgical mask when transported from the room.
Subcategory- Standard Precautions/Transmission-based precautions/Surgical Asepsis
Rationale – The door should be closed at all times if not entering the room. The client should be in a private negative air pressure room. The nurse should wear a N95 mask. The client should be wearing a surgical mask when transported from the room.
Subcategory- Standard Precautions/Transmission-based precautions/Surgical Asepsis
What type of precautions does the nurse place a client diagnosed with Varicella?
Rationale – A client diagnosed with Varicella should be placed on airborne precautions. Droplet, contact, and reverse precautions will not protect the staff or other clients from contracting the illness.
Subcategory- Standard Precautions/Transmission-based precautions/Surgical Asepsis
Rationale – A client diagnosed with Varicella should be placed on airborne precautions. Droplet, contact, and reverse precautions will not protect the staff or other clients from contracting the illness.
Subcategory- Standard Precautions/Transmission-based precautions/Surgical Asepsis
A pediatric client is admitted to the hospital with a diagnosis of an adenovirus virus. What type of personal protective equipment should the nurse wear when inserting an IV catheter? Select all that apply.
Rationale – A client diagnosed with adenovirus virus should be placed on droplet precautions. When inserting an IV standard precautions are necessary. This would require gloves and a surgical mask to protect from the virus. An N95 mask is not necessary. Goggles and a face shield are also not necessary.
Subcategory- Standard Precautions/Transmission-based precautions/Surgical Asepsis
Rationale – A client diagnosed with adenovirus virus should be placed on droplet precautions. When inserting an IV standard precautions are necessary. This would require gloves and a surgical mask to protect from the virus. An N95 mask is not necessary. Goggles and a face shield are also not necessary.
Subcategory- Standard Precautions/Transmission-based precautions/Surgical Asepsis
. Visitors are at the nurses’ station requesting to enter the room of a client diagnosed with mumps. What protective equipment should the visitors be given to wear?
Rationale – A client diagnosed with mumps should be placed on droplet precautions and a visitor should be encouraged to wear a mask. They do not need to wear gloves, a gown or goggles.
Subcategory- Standard Precautions/Transmission-based precautions/Surgical Asepsis
Rationale – A client diagnosed with mumps should be placed on droplet precautions and a visitor should be encouraged to wear a mask. They do not need to wear gloves, a gown or goggles.
Subcategory- Standard Precautions/Transmission-based precautions/Surgical Asepsis
A client diagnosed with vancomycin resistant enterococcus in the urine has requested a picture of ice water. What personal protective equipment should the nurse where when entering the room to deliver the ice water?
Rationale – When caring for a client who has a microorganism isolated in a specific area that is placed on contact precautions. The nurse does not have to wear personal protective equipment unless they are coming in contact with the infected bodily fluids. By delivering a water pitcher the nurse is not coming in contact with the urine. The nurse does not need to have on gloves a gown or a mask.
Subcategory- Standard Precautions/Transmission-based precautions/Surgical Asepsis
Rationale – When caring for a client who has a microorganism isolated in a specific area that is placed on contact precautions. The nurse does not have to wear personal protective equipment unless they are coming in contact with the infected bodily fluids. By delivering a water pitcher the nurse is not coming in contact with the urine. The nurse does not need to have on gloves a gown or a mask.
Subcategory- Standard Precautions/Transmission-based precautions/Surgical Asepsis
What requires a nurse to wear gloves? Select all that apply.
What action by the nurse is most appropriate before utilizing restraints on a confused client?
Rationale– The nurse should attempt to re-orient the client prior to obtaining an order. Every attempt possible should be made before utilizing restraints. Measuring to ensure restraints will say it is not priority and most restraints can be adapted to the size of the client. Administering sleeping medication to calm a patient is unethical.
Subcategory- Use of Restraints/Safety Devices
Rationale– The nurse should attempt to re-orient the client prior to obtaining an order. Every attempt possible should be made before utilizing restraints. Measuring to ensure restraints will say it is not priority and most restraints can be adapted to the size of the client. Administering sleeping medication to calm a patient is unethical.
Subcategory- Use of Restraints/Safety Devices
A client who is receiving all medications through their Nasogastric tube has pulled the tube multiple times. The nurse has attempted to reorient the patient several times and continue to attempt to pull out the nasogastric tube. What action by the nurse is priority?
Rationale – Restraints may be indicated if a client repeatedly asked calling out tubes for feeding or breathing. Pharmacy cannot change the route of administration if the client is unable to swallow pills. Asking the healthcare provider for a gastrostomy tube will not allow me to access of medications. The nurse should not removing and re-insert an NG tube every time it needs to be used.
Subcategory- Use of Restraints/Safety Devices
Rationale – Restraints may be indicated if a client repeatedly asked calling out tubes for feeding or breathing. Pharmacy cannot change the route of administration if the client is unable to swallow pills. Asking the healthcare provider for a gastrostomy tube will not allow me to access of medications. The nurse should not removing and re-insert an NG tube every time it needs to be used.
Subcategory- Use of Restraints/Safety Devices
What action by the nurse caring for a client in restraints is correct? Select all that apply.
Rationale – The nurse should be able to set one to two fingers between the client’s body and the restraint. They should be checking circulation every hour. Then there should be sure that the client can reach the call bell while in restraints. Restraint should be removed every two hours and skin should be assessed at that time.
Subcategory- Use of Restraints/Safety Devices
Rationale – The nurse should be able to set one to two fingers between the client’s body and the restraint. They should be checking circulation every hour. Then there should be sure that the client can reach the call bell while in restraints. Restraint should be removed every two hours and skin should be assessed at that time.
Subcategory- Use of Restraints/Safety Devices
A client has an order for a bed enclosure that has a top and zippered sites. What action by the nurse is most appropriate?
Rationale – A bed that is enclosed that has the top and zippered sides is a form of restraint that requires an order. There is no indication of the client would need a private room. The nurse should make sure they receive an order from the physician. Checking the zippers work properly once a shift is not a priority. The client should be allowed time out of bed more than once if shift if they are able to be out of bed.
Subcategory- Use of Restraints/Safety Devices
Rationale – A bed that is enclosed that has the top and zippered sides is a form of restraint that requires an order. There is no indication of the client would need a private room. The nurse should make sure they receive an order from the physician. Checking the zippers work properly once a shift is not a priority. The client should be allowed time out of bed more than once if shift if they are able to be out of bed.
Subcategory- Use of Restraints/Safety Devices
A client is confused and climbing out of bed. The physician has ordered a chest restraint. What action by the nurse demonstrates a need for further education?
Rationale- The restraint should be placed over the top of the client’s gown, not under it. The strap should be tightened not movable parts of the bed. It is important to explain the procedure to the family and the client. The client’s breathing should be assessed after placing the chest restraint and moved if necessary.
Subcategory- Use of Restraints/Safety Devices
Rationale- The restraint should be placed over the top of the client’s gown, not under it. The strap should be tightened not movable parts of the bed. It is important to explain the procedure to the family and the client. The client’s breathing should be assessed after placing the chest restraint and moved if necessary.
Subcategory- Use of Restraints/Safety Devices
A client is confused and anxious and attempting to climb out of bed. The nurse has tried to reorient the client, place them on fall precautions and the client continues to climb out of bed. What action by the nurse is appropriate?
Rationale- If a confused client continues to try to climb out of bed is in danger of injuring themselves. The nurse should request a restraints to protect the client. Putting the client in the hallway in a chair will not guarantee their safety. The mattress should not be placed on the floor. It is not appropriate to tell the family they have to stay with the patient.
Subcategory- Use of Restraints/Safety Devices
Rationale- If a confused client continues to try to climb out of bed is in danger of injuring themselves. The nurse should request a restraints to protect the client. Putting the client in the hallway in a chair will not guarantee their safety. The mattress should not be placed on the floor. It is not appropriate to tell the family they have to stay with the patient.
Subcategory- Use of Restraints/Safety Devices
The oncoming nurse received report from another nurse about a client who currently has soft wrist restraints on after they tried to remove their endotracheal tube. What action by the Nurse is priority?
Rationale – It is important to check for the order if a client has restringing us. The restraints should not be removed unless the client is no longer only at the endotracheal tube or the order is no longer valid. Performing in all vascular assessment is not priority. The client will need an indwelling urinary catheter.
Subcategory- Use of Restraints/Safety Devices
Rationale – It is important to check for the order if a client has restringing us. The restraints should not be removed unless the client is no longer only at the endotracheal tube or the order is no longer valid. Performing in all vascular assessment is not priority. The client will need an indwelling urinary catheter.
Subcategory- Use of Restraints/Safety Devices
The nurse answers a call bell of a client in restraints. The nurse notices the restraint is tied to the bed’s side rail. What action by the nurse is priority?
Rationale- It is important that the nurse moves the restraint to a non-moveable part of the bed. An incident report does not need to be filed. Notifying the assigned nurse should be done after moving the restraint. Lowering the bedrail should not be done until the restraint is moved.
Subcategory- Use of Restraints/Safety Devices
Rationale- It is important that the nurse moves the restraint to a non-moveable part of the bed. An incident report does not need to be filed. Notifying the assigned nurse should be done after moving the restraint. Lowering the bedrail should not be done until the restraint is moved.
Subcategory- Use of Restraints/Safety Devices
A high risk pregnant client is receiving teaching regarding infant safety. What statement by the client indicates a need for further teaching?
Rationale – Bruises on my chest or abdomen area and near their ears is an indication of child abuse and should be read ported immediately. Babies have to be in a car seat facing the back of the car. Is important not to introduce foods until it is recommended by the healthcare provider. The baby should not be an apparent arms when you’re cooking are near a fire.
Subcategory- Accident Preventio
Rationale – Bruises on my chest or abdomen area and near their ears is an indication of child abuse and should be read ported immediately. Babies have to be in a car seat facing the back of the car. Is important not to introduce foods until it is recommended by the healthcare provider. The baby should not be an apparent arms when you’re cooking are near a fire.
Subcategory- Accident Preventio
What safety intervention is priority for a hospitalized older adult client with a platelet count of 70,000, a hemoglobin level of 14 g/dL and hematocrit level of 40%?
Rationale – A client with a platelet count of 70,000 is at risk for bleeding which can be significantly impacted with a fall. A client with a low platelet count in the fall is at high risk for intracranial bleeding. A blood transfusion of packed red blood cells is not indicated, platelet transfusion May be however that is not a safety intervention. How did side rails are not indicated at the client does not have a seizure disorder. Room close to the nurse’s station is a good idea however fall precautions are priority.
Subcategory- Accident Prevention
Rationale – A client with a platelet count of 70,000 is at risk for bleeding which can be significantly impacted with a fall. A client with a low platelet count in the fall is at high risk for intracranial bleeding. A blood transfusion of packed red blood cells is not indicated, platelet transfusion May be however that is not a safety intervention. How did side rails are not indicated at the client does not have a seizure disorder. Room close to the nurse’s station is a good idea however fall precautions are priority.
Subcategory- Accident Prevention
A nurse caring for a client with Tuberculosis and MRSA in their sputum is exiting the client’s room. Put the following actions in the order that they should be performed.
Rationale – Gloves are most contaminated, hand hygiene is always performed after removing gloves – hands may have become contaminated in the process of glove removal, clean hands then can be used in removing protective eye wear. The gown is removed next and the mask is last.
Subcategory- Standards Precautions/Transmission-based Precautions/Surgical Asepsis
Rationale – Gloves are most contaminated, hand hygiene is always performed after removing gloves – hands may have become contaminated in the process of glove removal, clean hands then can be used in removing protective eye wear. The gown is removed next and the mask is last.
Subcategory- Standards Precautions/Transmission-based Precautions/Surgical Asepsis
What finding is consistent with a client diagnosed with metabolic alkalosis?
Rationale – Normal pH is 7.35-7.45. A client with metabolic alkalosis, the pH is elevated above 7.43 and they’re bicarbonate, HCO3 would be elevated above 26. The PaCO2 is not used to diagnose metabolic alkalosis. And an anion gap of 14 as normal.
Subcategory- Fluid and Electrolyte Imbalances
Rationale – Normal pH is 7.35-7.45. A client with metabolic alkalosis, the pH is elevated above 7.43 and they’re bicarbonate, HCO3 would be elevated above 26. The PaCO2 is not used to diagnose metabolic alkalosis. And an anion gap of 14 as normal.
Subcategory- Fluid and Electrolyte Imbalances
What finding is consistent with a client diagnosed with respiratory acidosis? Select all that apply.
Rationale – A client with respiratory acidosis would have a low pH and a high PaCO2. The anion gap is normal. The Pa02 is within normal range. The HCO3 is not used to diagnose respiratory acidosis.
Subcategory- Fluid and Electrolyte Imbalances
Rationale – A client with respiratory acidosis would have a low pH and a high PaCO2. The anion gap is normal. The Pa02 is within normal range. The HCO3 is not used to diagnose respiratory acidosis.
Subcategory- Fluid and Electrolyte Imbalances
What components of an arterial blood gas results should be evaluated by a nurse in determining an acid base balance? Select all that apply.
Rationale- The components of an arterial blood gas are the pH, PCO2 and HCO3. Potassium chloride and sodium are important electrolytes, however they are not part of an arterial blood gas.
Subcategory- Fluid and Electrolyte Imbalances
Rationale- The components of an arterial blood gas are the pH, PCO2 and HCO3. Potassium chloride and sodium are important electrolytes, however they are not part of an arterial blood gas.
Subcategory- Fluid and Electrolyte Imbalances
The nurse is reviewing arterial blood gas values for a client admitted with chronic obstructive disease (COPD). The client has a pH of 7.29, a PaCO2 of 51 and then HCO3 of 26. What type of acid base and balance does the nurse suspect?
Rationale – A pH of 7.29 indicate acidosis and a PaCO2 indicate that it is respiratory and nature. The findings are not consistent with metabolic acidosis, metabolic alkalosis or respiratory alkalosis.
Subcategory- Fluid and Electrolyte Imbalances
Rationale – A pH of 7.29 indicate acidosis and a PaCO2 indicate that it is respiratory and nature. The findings are not consistent with metabolic acidosis, metabolic alkalosis or respiratory alkalosis.
Subcategory- Fluid and Electrolyte Imbalances
A client diagnosed with diabetic ketoacidosis has the following labs: PH 7.29, PCO2 45, HCO3 19, potassium 5.8 mEq/L, sodium of 138 mEq/L. What imbalances does the nurse identify? Select all that apply.
Rationale- Both the pH and bicarbonate indicate metabolic acidosis. The elevated potassium signifies hyperkalemia. The sodium level is within normal limits. The PaCO2 as normal there’s no indication of hypoxia.
Subcategory- Fluid and Electrolyte Imbalances
Rationale- Both the pH and bicarbonate indicate metabolic acidosis. The elevated potassium signifies hyperkalemia. The sodium level is within normal limits. The PaCO2 as normal there’s no indication of hypoxia.
Subcategory- Fluid and Electrolyte Imbalances
When evaluating a client diagnosed with respiratory alkalosis which findings does the nurse anticipate?
Rationale – Respiratory alkalosis the pH is elevated and the PaCO2 is decreased. Normal pH is 7.35 to 7.45, normal HCO3 is 22 to 26. Normal PaCO2 was 35 to 45.
Subcategory- Fluid and Electrolyte Imbalances
Rationale – Respiratory alkalosis the pH is elevated and the PaCO2 is decreased. Normal pH is 7.35 to 7.45, normal HCO3 is 22 to 26. Normal PaCO2 was 35 to 45.
Subcategory- Fluid and Electrolyte Imbalances
A client that has had a myocardial infarction has decreased cardiac output. What findings are consistent with decreased cardiac output? Select all that apply.
Rationale – A client with decreased cardiac output will have hypotension, cool clammy skin and weak pulse is. A pulse of 62 is normal. Oxygen saturation will be lower than normal.
Subcategory- Hemodynamics
Rationale – A client with decreased cardiac output will have hypotension, cool clammy skin and weak pulse is. A pulse of 62 is normal. Oxygen saturation will be lower than normal.
Subcategory- Hemodynamics
Which of the following is the degree of stretch of the cardiac muscle fibers at the end of diastole?
Rationale – Preload is the degree of stretch of the cardiac muscle fibers at the end of diastole. Afterload is the amount of resistance to ejection of blood from the ventricle. The stroke volume is the amount of blood ejected from one of the ventricles during the heartbeat. The ejection fraction as a percentage of a diastolic blood volume is ejected from the ventricle each time a heartbeat.
Subcategory- Hemodynamics
Rationale – Preload is the degree of stretch of the cardiac muscle fibers at the end of diastole. Afterload is the amount of resistance to ejection of blood from the ventricle. The stroke volume is the amount of blood ejected from one of the ventricles during the heartbeat. The ejection fraction as a percentage of a diastolic blood volume is ejected from the ventricle each time a heartbeat.
Subcategory- Hemodynamics
What does the Frank Starling Law explain?
Rationale – The Frank Starling Law explains that the greater the initial length or stretch of a cardiac muscle the greater the shortening that occurs. It does not explain the resistance of systemic blood pressure to the left ventricular ejection that is systemic vascular resistance. It does not describe the force that is generated by the contraction of the myocardium that is contractility. It does not explain the resistance of pulmonary blood pressure to the right ventricular ejection that is pulmonary vascular resistance.
Subcategory- Hemodynamis
Rationale – The Frank Starling Law explains that the greater the initial length or stretch of a cardiac muscle the greater the shortening that occurs. It does not explain the resistance of systemic blood pressure to the left ventricular ejection that is systemic vascular resistance. It does not describe the force that is generated by the contraction of the myocardium that is contractility. It does not explain the resistance of pulmonary blood pressure to the right ventricular ejection that is pulmonary vascular resistance.
Subcategory- Hemodynamis
What are components of the pathophysiology of chronic obstructive pulmonary disease COPD? Select all that apply.
Rationale – Bronchospasm, inflammation of the large and small airways and increased resistance to airflow are all findings and COPD. Vasodilation not vasoconstriction occurs and a thickening not fitting of the bronchial walls occurs.
Subcategory- Pathophysiology
Rationale – Bronchospasm, inflammation of the large and small airways and increased resistance to airflow are all findings and COPD. Vasodilation not vasoconstriction occurs and a thickening not fitting of the bronchial walls occurs.
Subcategory- Pathophysiology
A client with crackles bilaterally in the bases of the lungs has an oxygen saturation of 88%. Where are oxygen and carbon dioxide exchanged in the blood that may have resulted in the low oxygen saturation for this client?
Rationale – The alveoli are the small air sacs in the lungs with a thin layer of squamous epithelium that exchange gasses with the blood via the small capillaries that cover them. Crackles in the lung indicate that there is fluid present and may inhibit the exchange of gasses resulting in a low oxygen saturation.
Subcategory- Pathophysiology
Rationale – The alveoli are the small air sacs in the lungs with a thin layer of squamous epithelium that exchange gasses with the blood via the small capillaries that cover them. Crackles in the lung indicate that there is fluid present and may inhibit the exchange of gasses resulting in a low oxygen saturation.
Subcategory- Pathophysiology
Analyze the following data and use it to answer the question below.
pH 7.48
PaCO2 37 mmHg
HCO3 27 mEq/L
When assessing the above arterial blood gasses ,what acid-base disturbance is the client experiencing?
Rationale – Metabolic alkalosis is an elevated pH and elevated HCO3. Acidosis would have a decreased pH. Respiratory alkalosis would have a decreased PaC02.
Subcategory- Fluid and Electrolyte Imbalances
Rationale – Metabolic alkalosis is an elevated pH and elevated HCO3. Acidosis would have a decreased pH. Respiratory alkalosis would have a decreased PaC02.
Subcategory- Fluid and Electrolyte Imbalances
When assessing the above arterial blood gasses what acid base disturbance is the client experiencing?
Rationale – Metabolic alkalosis is an elevated pH and elevated HCO3. Acidosis would have a decreased pH. Respiratory alkalosis would have a decreased PaC02.
Subcategory- Fluid and Electrolyte Imbalances
Rationale – Metabolic alkalosis is an elevated pH and elevated HCO3. Acidosis would have a decreased pH. Respiratory alkalosis would have a decreased PaC02.
Subcategory- Fluid and Electrolyte Imbalances
Analyze the following data and use it to answer the question below.
pH 7.25
PaCO2 55 mmHg
HCO3 24 mEq/L
When assessing the above arterial blood gases above, what acid base disturbance is the client experiencing?
Rationale – The client with a low pH and elevated PaCO2 is experiencing respiratory acidosis. Metabolic acidosis would have a low HCO3 and a low pH. Alkalosis would have an elevated pH.
Subcategory- Fluid and Electrolyte Imbalances
Rationale – The client with a low pH and elevated PaCO2 is experiencing respiratory acidosis. Metabolic acidosis would have a low HCO3 and a low pH. Alkalosis would have an elevated pH.
Subcategory- Fluid and Electrolyte Imbalances
A pregnant client at 32 weeks of gestation arrives via ambulance the emergency department complaining of painless. Bright red vaginal bleeding. The triage nurse suspects which of the following pregnancy complications?
Rationale – Painless, bright red vaginal bleeding is the hallmark sign of placenta Previa. The symptoms are not consistent with Pre-eclampsia, preterm labor or abruptio placentae.
Subcategory- Medical Emergencies
Rationale – Painless, bright red vaginal bleeding is the hallmark sign of placenta Previa. The symptoms are not consistent with Pre-eclampsia, preterm labor or abruptio placentae.
Subcategory- Medical Emergencies
An infant born at 35 weeks of gestation is admitted to the nursery. What finding is not consistent with this gestational age?
Rationale – Dry peeling skin is hallmark of a post-term baby Milia, Lanugo and vernix caseosa are seen in preterm babies.
Subcategory- Alterations in Body Systems
Rationale – Dry peeling skin is hallmark of a post-term baby Milia, Lanugo and vernix caseosa are seen in preterm babies.
Subcategory- Alterations in Body Systems
The nurse is assessing a newborn born to a mother who is a heroin user. What findings does the nurse anticipate?
Rationale – Infants born to drug addicted mothers are irritable and difficult to soothe. Lethargy, normal bowel movements and organized suck/swallow reflex are not consistent with children born to heroin addicted mothers.
Subcategory- Alterations in Body Systems
Rationale – Infants born to drug addicted mothers are irritable and difficult to soothe. Lethargy, normal bowel movements and organized suck/swallow reflex are not consistent with children born to heroin addicted mothers.
Subcategory- Alterations in Body Systems
The nurse is caring for a client with congestive heart failure and is monitoring the effect of hydralazine therapy. Which hemodynamic parameter will the nurse monitor?
Rationale- SVR reflects the resistance to ventricular ejection or afterload. Hydralazine relaxes vascular smooth muscle, decreasing peripheral resistance1, 2, & 3 – These parameters will be monitored, but do not reflect afterload as directly
Subcategory-Hemodynamic Monitoring
Rationale- SVR reflects the resistance to ventricular ejection or afterload. Hydralazine relaxes vascular smooth muscle, decreasing peripheral resistance1, 2, & 3 – These parameters will be monitored, but do not reflect afterload as directly
Subcategory-Hemodynamic Monitoring
The nurse is caring for a client with telemetry monitoring. Which of the following would the nurse note regarding the cardiac rhythm strip that indicates ventricular tachycardia?
Rationale– Widened QRS complex is a characteristic of ventricular tachycardia as well as absent P-wave. Elevated T-wave is typically seen in hyperkalemia. Prolonged PR interval is a characteristic of first and second degree heart block. Atrial rate >350 beats/min is indicative of atrial fibrillation.
Subcategory-Hemodynamic Monitoring
Rationale– Widened QRS complex is a characteristic of ventricular tachycardia as well as absent P-wave. Elevated T-wave is typically seen in hyperkalemia. Prolonged PR interval is a characteristic of first and second degree heart block. Atrial rate >350 beats/min is indicative of atrial fibrillation.
Subcategory-Hemodynamic Monitoring
Which of the following would the nurse include in teaching a client about Cushing’s syndrome?
Rationale– Client’s with hyperthyroidism do not tolerate heat well. Client’s with Cushing’s should eat a high-protein diet, Addison’s disease requires increased sodium and fluid intake.
Subcategory- Illness Management
Rationale– Client’s with hyperthyroidism do not tolerate heat well. Client’s with Cushing’s should eat a high-protein diet, Addison’s disease requires increased sodium and fluid intake.
Subcategory- Illness Management
The healthcare provider has completed pre-procedure teaching with a client prior to the surgical removal of varicose veins. The nurse is evaluating the success of the healthcare provider’s teaching. Which of the following statements by the client indicates that the teaching was successful?
Rationale – Ligation and removal is the procedure. Laser will not prevent further occurrence. Cold therapy is not used for varicosities. Pieces of veins can be used for a bypass procedure but that is not a treatment for varicose veins.
Subcategory- Illness Management
Rationale – Ligation and removal is the procedure. Laser will not prevent further occurrence. Cold therapy is not used for varicosities. Pieces of veins can be used for a bypass procedure but that is not a treatment for varicose veins.
Subcategory- Illness Management
The nurse is reviewing a client’s laboratory findings. Which of the following findings will the nurse immediately report to the healthcare provider?
Rationale- Normal level is 8.-10.5 mg/dL, higher values are associated with dysrhythmias and heart block. Sodium, Chloride, and Magnesium levels are all within normal limits.
Subcategory- Illness Management
Rationale- Normal level is 8.-10.5 mg/dL, higher values are associated with dysrhythmias and heart block. Sodium, Chloride, and Magnesium levels are all within normal limits.
Subcategory- Illness Management
The nurse is caring for an adult with an arteriovenous fistula with hemodialysis treatments. Which of the following is the best action by the nurse to prevent complications associated with arteriovenous fistulas?
Rationale– This best protects patency of fistula. No IVs should be placed in an arm with a fistula. Assessing fistula will not prevent complications, only detect them.
Subcategory- Illness Management
Rationale– This best protects patency of fistula. No IVs should be placed in an arm with a fistula. Assessing fistula will not prevent complications, only detect them.
Subcategory- Illness Management
Which of the following is a common priority short-term outcome when the nurse is caring for clients recently admitted to the hospital for alcohol detoxification?
Rationale – Recognition of the health consequences of alcohol on the body is the first action to help the client comply with the treatment plan. The plan for treatment will have already been discussed with the client prior to admission. Glucose levels are not needed for all clients.
Subcategory- Illness Management
Rationale – Recognition of the health consequences of alcohol on the body is the first action to help the client comply with the treatment plan. The plan for treatment will have already been discussed with the client prior to admission. Glucose levels are not needed for all clients.
Subcategory- Illness Management
The nurse is assigned care of a neonate experiencing drug withdrawal. Which of the following actions by the nurse is most beneficial?
Rationale- Sleep disturbance is common among neonates experiencing drug withdrawal. Medications are commonly given to combat withdrawal symptoms. Less stimulation of neonate will help neonate sleep. Swaddling is preferred to keep neonate from flailing and stimulating self.
Subcategory- Illness Management
Rationale- Sleep disturbance is common among neonates experiencing drug withdrawal. Medications are commonly given to combat withdrawal symptoms. Less stimulation of neonate will help neonate sleep. Swaddling is preferred to keep neonate from flailing and stimulating self.
Subcategory- Illness Management
The nurse is planning education with a primigravida client that has a positive hepatitis B surface antigen lab result. Which of the following will the nurse include in the teaching plan? Select all that apply
Rationale– All are appropriate management. An infant at birth will receive hepatitis prophylaxis. Isolation of infant is not necessary. Infection is not transmitted through a breast-feeding mother’s breast milk.
Subcategory- Illness Management
Rationale– All are appropriate management. An infant at birth will receive hepatitis prophylaxis. Isolation of infant is not necessary. Infection is not transmitted through a breast-feeding mother’s breast milk.
Subcategory- Illness Management
A client diagnosed with chronic obstructive pulmonary disease (COPD) is being discharged from the hospital after homecare instructions by the nurse. Which of the following statements by the client indicates they require further teaching?
Rationale– The worst time of the day for clients with COPD is the morning. All other choices indicate successful teaching.
Subcategory- Illness Management
Rationale– The worst time of the day for clients with COPD is the morning. All other choices indicate successful teaching.
Subcategory- Illness Management
A 50 year-old hospitalized client with a diagnosis of cancer has been receiving 10 mg of morphine sulfate. Which of the following doses of oral morphine does the nurse anticipate the healthcare provider will order?
Rationale – There is a 3:1 ratio for equianalgesic dosing of IV to oral morphine, so three times the IV dose should be ordered. 10 mg – 25 mg or is too low for adequate equianalgesic effect. 40 mg is too much for equianalgesic effect.
Subcategory- Illness Management
Rationale – There is a 3:1 ratio for equianalgesic dosing of IV to oral morphine, so three times the IV dose should be ordered. 10 mg – 25 mg or is too low for adequate equianalgesic effect. 40 mg is too much for equianalgesic effect.
Subcategory- Illness Management
Which of the following arterial blood gas findings for a client with acute renal failure should be reported to the health care provider immediately?
Rationale– In the case of acute renal failure, accumulation of uric acid in the blood results in metabolic acidosis with low bicarbonate (HCO3-) in attempt to neutralize the acid. This is a dangerously low pH indicating a life-threatening acidotic state. While 7.47 and 7.46 are both alkalotic, they are not significantly elevated. 7.35 is slightly acidotic but the bicarbonate level is normal, indicating the body has no need to buffer this slight acid variation in serum pH.
Subcategory- Medical Emergencies
Rationale– In the case of acute renal failure, accumulation of uric acid in the blood results in metabolic acidosis with low bicarbonate (HCO3-) in attempt to neutralize the acid. This is a dangerously low pH indicating a life-threatening acidotic state. While 7.47 and 7.46 are both alkalotic, they are not significantly elevated. 7.35 is slightly acidotic but the bicarbonate level is normal, indicating the body has no need to buffer this slight acid variation in serum pH.
Subcategory- Medical Emergencies
The nurse enters a client room to find them laying bed, pale, diaphoretic, and weak, stating “my heart’s beating so fast!” What is the priority action for the nurse?
Rationale– These are signs and symptoms of acute coronary syndrome and rapid intervention is essential for rescue of the client. All other interventions follow alerting the rapid response team.
Subcategory- Medical Emergencies
Rationale– These are signs and symptoms of acute coronary syndrome and rapid intervention is essential for rescue of the client. All other interventions follow alerting the rapid response team.
Subcategory- Medical Emergencies
An Emergency Department nurse is assessing a client who was the driver involved in a motor vehicle accident. Assessment finding include dyspnea, chest pain, and paradoxical chest wall movement. What is the priority sequence for the actions listed below?
Rationale – The client was the driver in the motor vehicle, with potential for chest injury due to impact with steering wheel. The client is exhibiting the signs and symptoms of flail chest that can lead to respiratory failure. Flail chest is a medical emergency requiring rapid assessment and intervention. With the potential for severe hypoxia the client requires supplemental oxygenation. With the potential for rapidly deteriorating status, a means of rapidly administering medications and IV fluids is essential. Drawing arterial blood gas is high risk for pulmonary tissue damage with rapid assessment required to anticipate further interventions. Flail chest may require endotracheal intubation. Administering is essential to avoid hypoventilation due to chest pain. Obtain a chest x-ray to assess extent of multiple rib fractures. Obtain ECG is the lowest priority since signs and symptoms do not indicate altered cardiac function.
Subcategory- Medical Emergencies
Rationale – The client was the driver in the motor vehicle, with potential for chest injury due to impact with steering wheel. The client is exhibiting the signs and symptoms of flail chest that can lead to respiratory failure. Flail chest is a medical emergency requiring rapid assessment and intervention. With the potential for severe hypoxia the client requires supplemental oxygenation. With the potential for rapidly deteriorating status, a means of rapidly administering medications and IV fluids is essential. Drawing arterial blood gas is high risk for pulmonary tissue damage with rapid assessment required to anticipate further interventions. Flail chest may require endotracheal intubation. Administering is essential to avoid hypoventilation due to chest pain. Obtain a chest x-ray to assess extent of multiple rib fractures. Obtain ECG is the lowest priority since signs and symptoms do not indicate altered cardiac function.
Subcategory- Medical Emergencies
A client’s CAT scan reveals a large epidural hematoma, and spine X-rays are negative. The family asks the Emergency Department nurse what are the implications of these findings for their family member. Which of the following is the nurse’s best response?
Rationale– Epidural hematoma is a surgical emergency. Because of the side effects of narcotic analgesics, morphine sulfate would not be administered – they may cause further depression of level of consciousness interfering with the accuracy of neurological assessment findings. Admission to the hospital will occur but the next priority action based on the assessment findings is immediate surgery. There is no need for a neck brace because the client had negative X-ray findings.
Subcategory- Medical Emergencies
Rationale– Epidural hematoma is a surgical emergency. Because of the side effects of narcotic analgesics, morphine sulfate would not be administered – they may cause further depression of level of consciousness interfering with the accuracy of neurological assessment findings. Admission to the hospital will occur but the next priority action based on the assessment findings is immediate surgery. There is no need for a neck brace because the client had negative X-ray findings.
Subcategory- Medical Emergencies
A client presents to the Emergency Department with a gunshot wound to the chest, hypotension, tachycardia, tachypnea, and decreased CO2, cool/clammy skin, and decreased capillary refill. Which of the following is the interpretation of the assessment findings?
Rationale– All signs and symptoms of progressive shock. Late stage shock is characterized by organ failure, acute respiratory distress syndrome, bleeding and coagulation abnormalities and coma. Early shock findings include normal blood pressure, tachycardia restlessness, anxiety, and normal or slightly decreased urine output. With increased intracranial pressure early symptoms are visual changes: as this progresses, headache, papilledema, and vomiting. Late stage increased intracranial pressure is manifested by widening pulse pressure and deterioration of level of consciousness.
Subcategory- Pathophysiology
Rationale– All signs and symptoms of progressive shock. Late stage shock is characterized by organ failure, acute respiratory distress syndrome, bleeding and coagulation abnormalities and coma. Early shock findings include normal blood pressure, tachycardia restlessness, anxiety, and normal or slightly decreased urine output. With increased intracranial pressure early symptoms are visual changes: as this progresses, headache, papilledema, and vomiting. Late stage increased intracranial pressure is manifested by widening pulse pressure and deterioration of level of consciousness.
Subcategory- Pathophysiology
The nurse has completed teaching a client about treatment options for managing polycystic kidney disease (PKD.) Which of the following statements by the client indicates they understand the information taught?
Rationale– With PKD 2,000 -2,500 mL of fluids daily is required to help prevent UTI and calculi. Restricting fluid intake is too little fluid for a client with PKD. ACE inhibitors are prescribed to control hypertension in PKD. PKD is a hereditary disease so immediate family could be impacted by this disease.
Subcategory- Pathophysiology
Rationale– With PKD 2,000 -2,500 mL of fluids daily is required to help prevent UTI and calculi. Restricting fluid intake is too little fluid for a client with PKD. ACE inhibitors are prescribed to control hypertension in PKD. PKD is a hereditary disease so immediate family could be impacted by this disease.
Subcategory- Pathophysiology
A client has been admitted to the Intensive Care Unit following the occurrence of bleeding esophageal varices. The ICU nurse client must administer several transfusions of fresh frozen plasma (FFP) over the course of several hours. During infusion of the third unit of FFP the client complains of back pain, headache. What will the nurse’s next action be?
Rationale– Hemolytic transfusion reaction is suspected, therefore immediate termination of the FFP with rapid assessment for severity of transfusion reaction is essential. Stopping the transfusion and flushing the blood administration tubing with normal saline or flushing the blood tubing and notifying the blood bank involve administering an amount of blood causing transfusion reaction. An unnecessary amount of blood will be administered to the client since the normal saline flush bag and FFP are connected at the “Y” above the drip chamber of blood administration tubing.
Subcategory- Unexpected Response to Therapies
Rationale– Hemolytic transfusion reaction is suspected, therefore immediate termination of the FFP with rapid assessment for severity of transfusion reaction is essential. Stopping the transfusion and flushing the blood administration tubing with normal saline or flushing the blood tubing and notifying the blood bank involve administering an amount of blood causing transfusion reaction. An unnecessary amount of blood will be administered to the client since the normal saline flush bag and FFP are connected at the “Y” above the drip chamber of blood administration tubing.
Subcategory- Unexpected Response to Therapies
A nurse is caring for a 9 year-old client who has a cast applied for a fractured radius. The child is complaining of pain unrelieved by a narcotic analgesic dose that has been effective four hours earlier. Which of the following assessment findings by the nurse is indicative of an unexpected response to ordered therapies?
Rationale– Weakness and tingling of the affected limb (arm) are abnormal neurovascular assessment findings that could indicate compartment syndrome. Mild cyanosis and coolness of toes, as well as weak pedal pulse compared to unaffected limb are not related to the diagnosis of radius fracture, the arm is affected, not the foot. The tachycardia could be an effect of unrelieved pain.
Subcategory- Unexpected Response to Therapies
Rationale– Weakness and tingling of the affected limb (arm) are abnormal neurovascular assessment findings that could indicate compartment syndrome. Mild cyanosis and coolness of toes, as well as weak pedal pulse compared to unaffected limb are not related to the diagnosis of radius fracture, the arm is affected, not the foot. The tachycardia could be an effect of unrelieved pain.
Subcategory- Unexpected Response to Therapies
The nurse is caring for an adult client weighing 92 kg in the Intensive Care Unit. The client has been diagnosed with acute kidney failure and is undergoing hemodialysis daily. What assessments by the nurse indicate an unexpected response to hemodialysis?
Rationale– A sign of increasing fluid volume indicating ineffective treatment. This is a sign of worsening renal function. Daily downward weight trend indicates resolving fluid volume excess or dehydration. Central Venous Pressure of 3 mmHg is normal. Oliguria in adults is defined as urine output <0.5mL/kg/hr). For this client weighing 92 kg, the cutoff for determining their decreased output is <46 mL/kg/hr) This client is putting out an acceptable hourly amount of urine.
Subcategory- Unexpected Response to Therapies
Rationale– A sign of increasing fluid volume indicating ineffective treatment. This is a sign of worsening renal function. Daily downward weight trend indicates resolving fluid volume excess or dehydration. Central Venous Pressure of 3 mmHg is normal. Oliguria in adults is defined as urine output <0.5mL/kg/hr). For this client weighing 92 kg, the cutoff for determining their decreased output is <46 mL/kg/hr) This client is putting out an acceptable hourly amount of urine.
Subcategory- Unexpected Response to Therapies
Analyze the following data and use it to answer the question below.
pH 7.25
PaCO2 55 mmHg
HCO3 24 mEq/L
When assessing the above arterial blood gases, what acid base disturbance does the nurse identify the client is experiencing?
Rationale- The client with a low pH and elevated PaCO2 is experiencing respiratory acidosis. Metabolic acidosis would have a low HCO3 and a low pH. Alkalosis would have an elevated pH.
Subcategory- Fluid and Electrolytes
Rationale- The client with a low pH and elevated PaCO2 is experiencing respiratory acidosis. Metabolic acidosis would have a low HCO3 and a low pH. Alkalosis would have an elevated pH.
Subcategory- Fluid and Electrolytes
A client is admitted to the hospital with chest pain. The client reports their heart is beating very fast. What action by the nurse is priority?
Rationale – If the client reports their heart is beating very fast, the nurse must determine the rate of the heartbeat. A report of a rapid heart rate alone is not an indication for a rapid response. If the clients rate is very rapid the nurse should then contact the healthcare provider. A complete cardiac assessment should not be done until the rate is determined in the provider has been contacted.
Subcategory- Medical Emergencies
Rationale – If the client reports their heart is beating very fast, the nurse must determine the rate of the heartbeat. A report of a rapid heart rate alone is not an indication for a rapid response. If the clients rate is very rapid the nurse should then contact the healthcare provider. A complete cardiac assessment should not be done until the rate is determined in the provider has been contacted.
Subcategory- Medical Emergencies
A client presents to the Emergency Department with chest pain 7/10 radiating to the middle back. What order should the interventions be performed?
Rationale-The immediate administration of oxygen is important in order to decrease the demand on the heart. Nitroglycerin is next as it will also decrease demand secondary to vasodilation and hopefully decrease the client’s pain. Aspirin is next in order to decrease the potential for an existing thrombus to increase in size. Finally, Morphine can be administered for pain relief as well as a decrease in demand on the heart secondary to vasodilation.
Subcategory-Medical Emergencies
Rationale-The immediate administration of oxygen is important in order to decrease the demand on the heart. Nitroglycerin is next as it will also decrease demand secondary to vasodilation and hopefully decrease the client’s pain. Aspirin is next in order to decrease the potential for an existing thrombus to increase in size. Finally, Morphine can be administered for pain relief as well as a decrease in demand on the heart secondary to vasodilation.
Subcategory-Medical Emergencies
A client presents to the Emergency Department with chest pain. An EKG reveals a prolonged PR interval and suspects 1st degree A-V block. What describes the physiology that is occurring in 1st degree A-V block?
Rationale- 1st degree A-V block is a delay in the conduction of the signal from the SA node to the AV node within the heart and is represented on an EKG by a prolonged PR interval. The other answers do not represent 1st degree A-V block.
Subcategory-Pathophysiology
Rationale- 1st degree A-V block is a delay in the conduction of the signal from the SA node to the AV node within the heart and is represented on an EKG by a prolonged PR interval. The other answers do not represent 1st degree A-V block.
Subcategory-Pathophysiology
A client is brought to the Emergency Department via ambulance after an MVA. The nurse knows that which assessment finding requires immediate intervention?
Rationale- Tracheal deviation is indicative of a tension pneumothorax and is a medical emergency requiring immediate intervention. Open femur fractures require quick intervention but are not immediately life-threatening. The left arm laceration has been stabilized by a pressure dressing and does not require immediate intervention. A client reporting a headache of 3/10 is important to note and monitor, however does not require immediate intervention.
Subcategory- Medical Emergencies
Rationale- Tracheal deviation is indicative of a tension pneumothorax and is a medical emergency requiring immediate intervention. Open femur fractures require quick intervention but are not immediately life-threatening. The left arm laceration has been stabilized by a pressure dressing and does not require immediate intervention. A client reporting a headache of 3/10 is important to note and monitor, however does not require immediate intervention.
Subcategory- Medical Emergencies
A client is newly diagnosed with right-sided congestive heart failure. What assessment findings would be expected for this particular client?
Rationale- Right-sided heart failure manifests as extremity edema. Crackles in the lungs can be indicative of left-sided heart failure. Decreased pedal pulses typically result from a dysfunction in peripheral circulation. Irregular heart sounds indicate a dysrhythmia such as atrial fibrillation.
Subcategory- Alterations in Body Systems
Rationale- Right-sided heart failure manifests as extremity edema. Crackles in the lungs can be indicative of left-sided heart failure. Decreased pedal pulses typically result from a dysfunction in peripheral circulation. Irregular heart sounds indicate a dysrhythmia such as atrial fibrillation.
Subcategory- Alterations in Body Systems
A client on the oncology floor is experiencing hypotension secondary to a narcotic drip for pain management. The client asks the nurse “why is my heart beating so fast? What is wrong with me?” Which reply by the nurse is appropriate?
Rationale- Tachycardia is a part of the compensatory mechanism of the cardiovascular system when hypotension is present. The heart beating faster will provide more adequate cardiac output. Other options are not appropriate responses to this client’s question.
Subcategory- Hemodynamics
Rationale- Tachycardia is a part of the compensatory mechanism of the cardiovascular system when hypotension is present. The heart beating faster will provide more adequate cardiac output. Other options are not appropriate responses to this client’s question.
Subcategory- Hemodynamics
What term refers to a central repository of information related to client care across distributed locations that is used in healthcare?
Rationale- Clinical information systems are repositories of information related to client care across locations. This does not represent an EMR, OIS or DPS.
Subcategory- Information Technology
Rationale- Clinical information systems are repositories of information related to client care across locations. This does not represent an EMR, OIS or DPS.
Subcategory- Information Technology
The nurse is caring for a client who was recently diagnosed with advanced pancreatic cancer. The client tells the nurse they are ready to give up, however, the family and the physician continue encouraging the client to try new treatments. The client informs the nurse that they were afraid to let down their loved ones but they really feel they are ready for hospice. What action by the nurse demonstrates advocacy?
Rationale- Informing the family members of the client’s wishes is against HIPAA. Consulting case management may be indicated but is not advocating for the client in this situation. Asking the physician to have a group meeting with the client and their family members will not allow the client to make their own decision as they have already stated they feel pressure from family to continue on seeking alternative treatment(s).
Subcategory- Advocacy
Rationale- Informing the family members of the client’s wishes is against HIPAA. Consulting case management may be indicated but is not advocating for the client in this situation. Asking the physician to have a group meeting with the client and their family members will not allow the client to make their own decision as they have already stated they feel pressure from family to continue on seeking alternative treatment(s).
Subcategory- Advocacy
The nurse is providing teaching to the family of a dying patient regarding a do not resuscitate order. What statement by the family members indicates a need for further teaching?
Rationale – A DNR order does not give permission to end someone’s life, it allows for a natural death to occur. When a DNR order is in place CPR will not be performed. Medications can be ordered to help the client be comfortable. If the client stops breathing they will not be given rescue breaths or intubated and life-saving actions will not be performed.
Subcategory- Advance Directives
Rationale – A DNR order does not give permission to end someone’s life, it allows for a natural death to occur. When a DNR order is in place CPR will not be performed. Medications can be ordered to help the client be comfortable. If the client stops breathing they will not be given rescue breaths or intubated and life-saving actions will not be performed.
Subcategory- Advance Directives
The unlicensed assistive personnel reports to the nurse that the client has repeatedly asked for the results of an electrocardiogram that the UAP performed. What statement by the nurse is most appropriate?
Rationale – An electrocardiogram and other tests should be interpreted by the healthcare provider, not the UAP or the nurse. It is not appropriate for the UAP to give the patient results from a diagnostic test. It is not appropriate to avoid going in the room until the healthcare provider arrives. The nurse can also not give results of a lab or diagnostic test to a client.
Subcategory- Assignment, Delegation, and Supervision
Rationale – An electrocardiogram and other tests should be interpreted by the healthcare provider, not the UAP or the nurse. It is not appropriate for the UAP to give the patient results from a diagnostic test. It is not appropriate to avoid going in the room until the healthcare provider arrives. The nurse can also not give results of a lab or diagnostic test to a client.
Subcategory- Assignment, Delegation, and Supervision
A client that has undergone a nephrectomy is receiving medication through a central venous catheter and has a chest tube in place. What action by the nurse indicates a need for further teaching?
Rationale – The IV pump is hooked up to a central venous catheter and should not be touched by an unlicensed assistive personnel. Keeping the chest tube unclamped while walking the client is not contraindicated. Requesting the licensed practical nurse to administer oral medications is within their scope of practice. Administering pain medication through the central line one hour prior to walking the client will assist in decreasing pain.
Subcategory – Assignment, Delegation, and Supervision
Rationale – The IV pump is hooked up to a central venous catheter and should not be touched by an unlicensed assistive personnel. Keeping the chest tube unclamped while walking the client is not contraindicated. Requesting the licensed practical nurse to administer oral medications is within their scope of practice. Administering pain medication through the central line one hour prior to walking the client will assist in decreasing pain.
Subcategory – Assignment, Delegation, and Supervision
A client is being admitted to the labor and delivery unit. The client informs the nurse that they do not want their spouse to know about a previous abortion. What action by the nurse is most appropriate?
Rationale – If the client does not want a component of their health history disclosed to their spouse the healthcare provider is required to maintain confidentiality. Encouraging them to tell their spouse goes against their wishes. Omitting the information from the client’s record is illegal. Informing them that this information cannot be withheld from their spouse is not correct.
Subcategory- Confidentiality/Information Security
Rationale – If the client does not want a component of their health history disclosed to their spouse the healthcare provider is required to maintain confidentiality. Encouraging them to tell their spouse goes against their wishes. Omitting the information from the client’s record is illegal. Informing them that this information cannot be withheld from their spouse is not correct.
Subcategory- Confidentiality/Information Security
A client diagnosed with pulmonary embolism has the following labs. What lab value should the nurse report immediately?
Rationale – An INR of 0.4 is significantly low and should be reported immediately as this client is at increased risk for clotting. Hemoglobin, platelet count and prothrombin time are all within normal limits.
Subcategory-Establishing Priorities
Rationale – An INR of 0.4 is significantly low and should be reported immediately as this client is at increased risk for clotting. Hemoglobin, platelet count and prothrombin time are all within normal limits.
Subcategory-Establishing Priorities
A client that has been vomiting for two days has the following labs:- Potassium 3.0 mEq/L, sodium level of 145 mEq/L, magnesium of 1.5 mEq/L and calcium level of 9.0 mg/dL. What lab value should be reported to the health care provider immediately?
Rationale – A potassium level of 3.0 is significantly low and can lead to a cardiac dysrhythmia. The sodium, magnesium and calcium levels are all within normal limits.
Subcategory- Establishing Priorities
Rationale – A potassium level of 3.0 is significantly low and can lead to a cardiac dysrhythmia. The sodium, magnesium and calcium levels are all within normal limits.
Subcategory- Establishing Priorities
The family of a client with terminal cancer has requested the health care providers do not share the client’s prognosis with the client. While caring for the client they ask the nurse if they are dying. What ethical principle best describes the situation?
Rationale – The nurse has an obligation to tell the truth (veracity). The situation is difficult in that the client has the right to make decisions. Justice is fair and equal treatment. Autonomy is the right of a client to make decisions in their care. Non-maleficence is to prevent harm to a client.
Subcategory- Ethical Practice
Rationale – The nurse has an obligation to tell the truth (veracity). The situation is difficult in that the client has the right to make decisions. Justice is fair and equal treatment. Autonomy is the right of a client to make decisions in their care. Non-maleficence is to prevent harm to a client.
Subcategory- Ethical Practice
What statement by the nurse is most appropriate when verifying informed consent?
Rationale – The nurse should ask the client to tell them about the surgery. The nurse should encourage the client to talk in their own words. Asking if they understand the risks of surgery does not determine if they know all areas of the surgery including benefits. Asking what the surgeon told them does not ensure they understand it. Asking a client if they really want surgery is not an appropriate question.
Subcategory- Informed Consent
Rationale – The nurse should ask the client to tell them about the surgery. The nurse should encourage the client to talk in their own words. Asking if they understand the risks of surgery does not determine if they know all areas of the surgery including benefits. Asking what the surgeon told them does not ensure they understand it. Asking a client if they really want surgery is not an appropriate question.
Subcategory- Informed Consent
The nurse has received their assignments for the day. One of the clients in the assignment has a do not resuscitate (DNR) order. The nurse does not agree ethically with these types of medical orders. What action by the nurse is most appropriate?
Rationale – It is important that if the nurse does not feel ethically able to care for a client they request to switch assignments. Informing the client of their beliefs is not ethical. Having a UAP provide most of the care is not ethically appropriate. Requesting assistance by another nurse when the client needs care is not providing optimal patient care.
Subcategory- Advance Directives
Rationale – It is important that if the nurse does not feel ethically able to care for a client they request to switch assignments. Informing the client of their beliefs is not ethical. Having a UAP provide most of the care is not ethically appropriate. Requesting assistance by another nurse when the client needs care is not providing optimal patient care.
Subcategory- Advance Directives
A home health care nurse is caring for a client who has recently been turned down by their healthcare insurance company for equipment needed in their home. What action may the nurse take in advocating for the client?
Rationale – Contacting the healthcare insurance company may help provide information necessary to get the equipment covered or help the client find out what additional information is needed. Purchasing the equipment for the client is not advocating for the client. Searching for reduced cost equipment will help the client, however it isn’t advocating for the coverage of the equipment. Notifying the healthcare provider is not advocating for the client.
Subcategory- Advocacy
Rationale – Contacting the healthcare insurance company may help provide information necessary to get the equipment covered or help the client find out what additional information is needed. Purchasing the equipment for the client is not advocating for the client. Searching for reduced cost equipment will help the client, however it isn’t advocating for the coverage of the equipment. Notifying the healthcare provider is not advocating for the client.
Subcategory- Advocacy
A client participating in a study of a new chemotherapy drug has informed the nurse they only participated because the healthcare provider informed them their insurance would not likely pay for the other drug being used in this diagnosis. What client right has been violated?
Rationale – The client has a right to self-determination. They should not feel or have undue influence to participate in the study. The right to privacy would be in regards to worrying about embarrassment or being anonymous. The right to full disclosure would involve withholding information about the client’s participation in the study or giving them false or misleading information about what participating would involve. The right to not be harmed would be a delay in treatment or lead to physical, emotional or legal recourse.
Subcategory- Client Rights
Rationale – The client has a right to self-determination. They should not feel or have undue influence to participate in the study. The right to privacy would be in regards to worrying about embarrassment or being anonymous. The right to full disclosure would involve withholding information about the client’s participation in the study or giving them false or misleading information about what participating would involve. The right to not be harmed would be a delay in treatment or lead to physical, emotional or legal recourse.
Subcategory- Client Rights
A nurse is working alongside of a healthcare provider during a very busy time in the emergency department. The healthcare provider asks the nurse their feelings about a client with vague symptoms. What competency of collaboration does this exhibit?
Rationale- Mutual respect and trust are shown by confidence in the other person’s knowledge and abilities. Autonomy is allowing someone to make their own decision, it is not related to collaboration. Communication is simply talking amongst each other. Decision-making would be shared responsibility for an outcome, a decision has not been made or attempted in this situation.
Subcategory- Collaboration with Interdisciplinary Team
Rationale- Mutual respect and trust are shown by confidence in the other person’s knowledge and abilities. Autonomy is allowing someone to make their own decision, it is not related to collaboration. Communication is simply talking amongst each other. Decision-making would be shared responsibility for an outcome, a decision has not been made or attempted in this situation.
Subcategory- Collaboration with Interdisciplinary Team
The nurse is caring for a client when they begin to seize and lose consciousness. The nurse assesses the client for a radial pulse but is not able to palpate one. What action by the nurse is priority?
Rationale- It is important to initiate a code if caring for a hospitalized client that becomes unresponsive with no pulse to begin life-saving measures. Contacting the provider is not appropriate. Checking an apical pulse will delay treatment. Providing two rounds of CPR will delay defibrillation if indicated.
Subcategory- Concepts of Management
Rationale- It is important to initiate a code if caring for a hospitalized client that becomes unresponsive with no pulse to begin life-saving measures. Contacting the provider is not appropriate. Checking an apical pulse will delay treatment. Providing two rounds of CPR will delay defibrillation if indicated.
Subcategory- Concepts of Management
A nursing unit runs well with minimal direction needed from the nurse manager. What type of leadership does this demonstrate?
Rationale – A nursing unit that runs well with minimal direction is an example of a Democratic leadership style. Autocratic would be simply run by the nurse manager. Laissez-faire would not have any direction. Bureaucratic leadership would be fixed duties under hierarchy rules for management.
Subcategory- Concepts of Management
Rationale – A nursing unit that runs well with minimal direction is an example of a Democratic leadership style. Autocratic would be simply run by the nurse manager. Laissez-faire would not have any direction. Bureaucratic leadership would be fixed duties under hierarchy rules for management.
Subcategory- Concepts of Management
After documenting client care, the nurse leaves the computer and forgets to logout. What ethical right does this violate?
Rationale – The client has the right to confidentiality. By leaving the computer on and not logging out the nurse risks a breach in confidentiality. This does not relate to justice veracity or fidelity.
Subcategory- Confidentiality/Information Security
Rationale – The client has the right to confidentiality. By leaving the computer on and not logging out the nurse risks a breach in confidentiality. This does not relate to justice veracity or fidelity.
Subcategory- Confidentiality/Information Security
A nurse wishing to advance their career in nursing should exhibit what type of power?
Rationale- A nurse that exhibits expert power is knowledgeable and experienced in their specialty area of the nursing profession. Reward, coercive and legitimate power will not help advance a nurse in their career.
Subcategory- Concepts of Management
Rationale- A nurse that exhibits expert power is knowledgeable and experienced in their specialty area of the nursing profession. Reward, coercive and legitimate power will not help advance a nurse in their career.
Subcategory- Concepts of Management
What element of problem-solving is essential?
Rationale – It is important to define a problem before you are able to gather data analyze it or consider alternatives. Defining the problem allows an understanding of what the problem truly encompasses.
Subcategory- Concepts of Management
Rationale – It is important to define a problem before you are able to gather data analyze it or consider alternatives. Defining the problem allows an understanding of what the problem truly encompasses.
Subcategory- Concepts of Management
The nurse is caring for the following four clients. Which client should the nurse see first?
Rationale- The client diagnosed with appendicitis may have had a rupture, a rigid board like abdomen is not a normal finding. The client with acute cholecystitis needs to be seen but is not a priority. The client with pancreatitis would be expected to have a serum amylase that is elevated and the client waiting for a paracentesis is not priority over the patient with a board like abdomen.
Subcategory- Establishing Priorities
Rationale- The client diagnosed with appendicitis may have had a rupture, a rigid board like abdomen is not a normal finding. The client with acute cholecystitis needs to be seen but is not a priority. The client with pancreatitis would be expected to have a serum amylase that is elevated and the client waiting for a paracentesis is not priority over the patient with a board like abdomen.
Subcategory- Establishing Priorities
A client that underwent a thyroidectomy three days ago has developed numbness and difficulty moving several fingers. What action by the nurse is priority?
Rationale – If the client is symptomatic for hypocalcemia the client will end up needing to be given IV calcium gluconate. Injury to the parathyroids can lead to hypocalcemia in a client who is undergone a thyroidectomy. An echocardiogram would not be priority at this time. The client’s symptoms are not consistent with hypo or hyperkalemia and do not require the potassium level be checked. An Endotracheal intubation is not indicated.
Subcategory- Establishing Priorities
Rationale – If the client is symptomatic for hypocalcemia the client will end up needing to be given IV calcium gluconate. Injury to the parathyroids can lead to hypocalcemia in a client who is undergone a thyroidectomy. An echocardiogram would not be priority at this time. The client’s symptoms are not consistent with hypo or hyperkalemia and do not require the potassium level be checked. An Endotracheal intubation is not indicated.
Subcategory- Establishing Priorities
A healthy adult client presents to the health care clinic requesting an influenza vaccination. Due to a shortage of the vaccination at this time, the vaccine is only being offered to older adult clients and those with existing medical conditions. What ethical principle does this demonstrate?
Rationale – Justice is fairness and quality. When resources are scarce, medications need to be distributed amongst those in the greatest need first. The situation does not demonstrate promoting good, preventing harm or telling the truth.
Subcategory- Ethical Practice
Rationale – Justice is fairness and quality. When resources are scarce, medications need to be distributed amongst those in the greatest need first. The situation does not demonstrate promoting good, preventing harm or telling the truth.
Subcategory- Ethical Practice
A client requests pain medication when the nurse enters the room. The nurse is extremely busy but promises the client they will return to administer the pain medication. 15 minutes later the nurse returns and administers the pain medication to the client. What ethical principle does this demonstrate?
Rationale – Fidelity refers to integrity, truthfulness and dedication. It is the nurse remaining faithful to the ethical principles and doing what they say they are going to do. Autonomy is the right of the patient to make their own decisions. Beneficence is promoting good and non-maleficence is preventing harm.
Subcategory- Ethical Practice
Rationale – Fidelity refers to integrity, truthfulness and dedication. It is the nurse remaining faithful to the ethical principles and doing what they say they are going to do. Autonomy is the right of the patient to make their own decisions. Beneficence is promoting good and non-maleficence is preventing harm.
Subcategory- Ethical Practice
A client has received alprazolam and is prepared for surgery when the surgeon explains the benefits, risks and alternatives. What activity by the nurse is appropriate?
Rationale – It is important to notify the physician that the client was medicated. The nurse should check to ensure that an informed consent is received prior to medicating a client. The ethics board does not need to be consulted at this point. It is not legal to obtain an informed consent after the client has been medicated. Asking the client if they understand is not appropriate, they are medicated.
Subcategory- Informed Consent
Rationale – It is important to notify the physician that the client was medicated. The nurse should check to ensure that an informed consent is received prior to medicating a client. The ethics board does not need to be consulted at this point. It is not legal to obtain an informed consent after the client has been medicated. Asking the client if they understand is not appropriate, they are medicated.
Subcategory- Informed Consent
What information should be included by the surgeon when obtaining informed consent? Select all that apply.
Rationale – The surgeon must disclose any alternatives, benefits and potential complications of the surgery as part of an informed consent. The surgeon does not need to disclose the number of prior surgeries performed or the negative outcomes of those surgeries as part of an informed consent.
Subcategory- Informed Consent
Rationale – The surgeon must disclose any alternatives, benefits and potential complications of the surgery as part of an informed consent. The surgeon does not need to disclose the number of prior surgeries performed or the negative outcomes of those surgeries as part of an informed consent.
Subcategory- Informed Consent
The nurse correctly identifies an electronic health record (EHR) as what type of record?
Rationale – An electronic health record is a longitudinal record of client health information. The international classification system is just that a classification system. It is not data from multiple applications used by a facility that is an EMR. A central repository is the clinical information system.
Subcategory- Information Technology
Rationale – An electronic health record is a longitudinal record of client health information. The international classification system is just that a classification system. It is not data from multiple applications used by a facility that is an EMR. A central repository is the clinical information system.
Subcategory- Information Technology
A nursing student has asked the nurse what site they should use when writing a professional paper for their class. What statement by the nurse is accurate?
Rationale- CINAHL is a professional site that should be used for scholarly papers. Google and WebMD are websites. Hospital protocol should not be used.
Subcategory- Information Technology
Rationale- CINAHL is a professional site that should be used for scholarly papers. Google and WebMD are websites. Hospital protocol should not be used.
Subcategory- Information Technology
A nurse is struggling with alcohol use. What action by the nurse will best protect their license?
Rationale – The State Board of Nursing will act more favorably if the nurse self identifies issues with alcohol or drugs. Requesting character witnesses will not increase the likelihood of keeping their license if they do not report themselves. Waiting for state agencies to report any incidences that occurred will not protect the nurse’s license. Attempting to avoid use of alcohol while working will not protect the client’s license. Incidences that occurred outside of the hospital may still affect the licensure status.
Subcategory- Legal Rights and Responsibilities
Rationale – The State Board of Nursing will act more favorably if the nurse self identifies issues with alcohol or drugs. Requesting character witnesses will not increase the likelihood of keeping their license if they do not report themselves. Waiting for state agencies to report any incidences that occurred will not protect the nurse’s license. Attempting to avoid use of alcohol while working will not protect the client’s license. Incidences that occurred outside of the hospital may still affect the licensure status.
Subcategory- Legal Rights and Responsibilities
A client at risk for falls is returned to bed. The nurse forgets to place the bed alarm on and the client falls out of bed. What legal action may the nurse face?
Rationale- The nurse places themself at risk for negligence charges by not taking proper precautions to protect a client at risk for falls. This is not an example of malpractice. It is not a HIPAA violation and it is not abandonment.
Subcategory- Legal Rights and Responsibilities
Rationale- The nurse places themself at risk for negligence charges by not taking proper precautions to protect a client at risk for falls. This is not an example of malpractice. It is not a HIPAA violation and it is not abandonment.
Subcategory- Legal Rights and Responsibilities
A client arrives to the emergency department with difficulty breathing. Emergency medical services mention that they believe the client has a DNR. The son is on the way to the hospital. The client codes before the son arrives. What action by the nurse appropriate?
Rationale – CPR should be provided because a DNR is not in hand or ordered. It is not appropriate to contact the son, this will withhold lifesaving measures. Withholding life-saving care should not be done without a DNR in place. Administering medications only is not indicated.
Subcategory- Information security
Rationale – CPR should be provided because a DNR is not in hand or ordered. It is not appropriate to contact the son, this will withhold lifesaving measures. Withholding life-saving care should not be done without a DNR in place. Administering medications only is not indicated.
Subcategory- Information security
A client is admitted for pneumonia and has requested to see the recent report on the computer. What action by the nurse is appropriate?
Rationale – The client reports must be interpreted and reported by the primary care provider. Once they are interpreted a client must follow protocols or access the client portal to get their information.
Subcategory- Information security
Rationale – The client reports must be interpreted and reported by the primary care provider. Once they are interpreted a client must follow protocols or access the client portal to get their information.
Subcategory- Information security
A client is brought in with family and determined to have a life threatening cardiac rhythm. The client informs the nurse and healthcare provider they do not wish to have any life-saving measures and would like to have a Do Not Resuscitate order. The family is upset arguing with the client and nurse. What action should the nurse take first?
Rationale – The nurse should ask the family to step out briefly. It is not indicated at this point to call security or request an ethics consult. The healthcare provider should be informed and brought in when family leaves the roomto allow the provider time to speak privately with the client.
Subcategory-Advanced Directives
Rationale – The nurse should ask the family to step out briefly. It is not indicated at this point to call security or request an ethics consult. The healthcare provider should be informed and brought in when family leaves the roomto allow the provider time to speak privately with the client.
Subcategory-Advanced Directives
The nurse is caring for the following four clients. Which client care is appropriate to delegate to the licensed vocational nurse (LVN)?
Rationale – Measuring the output of a client receiving CBI is the most appropriate care to delegate to an LVN. An LVN can measure output for a client. Teaching is not an appropriate item to delegate to an LVN. They can reinforce teaching, but initial teaching must be assessed. Listening to the lungs of a client is an assessment that is not within the scope of practice for an LVN. Ambulating a client that has undergone a CABG should be done with an RN or by an RN to enable assessment of any complications that may arise.
Subcategory-Information Security
Rationale – Measuring the output of a client receiving CBI is the most appropriate care to delegate to an LVN. An LVN can measure output for a client. Teaching is not an appropriate item to delegate to an LVN. They can reinforce teaching, but initial teaching must be assessed. Listening to the lungs of a client is an assessment that is not within the scope of practice for an LVN. Ambulating a client that has undergone a CABG should be done with an RN or by an RN to enable assessment of any complications that may arise.
Subcategory-Information Security
The nurse is assigned the following four clients. Which client should the nurse see first?
Rationale – A client with bilateral DVT’s with shortness of breath is at risk for an acute pulmonary embolism. The client being short of breath is an indication that the nurse should see them immediately. The client with COPD who has an oxygen saturation of 89% with wheezing is a normal finding with a COPD client and is not a higher priority than a client with a new onset of shortness of breath. The client with abdominal pain and vomiting is not priority. The client with chronic renal failure who has Claudia peritoneal fluid is not priority over a client with shortness of breath and who is diagnosed with DVT’s.
Subcategory- Prioritization
Rationale – A client with bilateral DVT’s with shortness of breath is at risk for an acute pulmonary embolism. The client being short of breath is an indication that the nurse should see them immediately. The client with COPD who has an oxygen saturation of 89% with wheezing is a normal finding with a COPD client and is not a higher priority than a client with a new onset of shortness of breath. The client with abdominal pain and vomiting is not priority. The client with chronic renal failure who has Claudia peritoneal fluid is not priority over a client with shortness of breath and who is diagnosed with DVT’s.
Subcategory- Prioritization
The nurse is caring for the following for clients. Which client should the nurse see it first?
Rationale – A client with a history of falls is at high risk for additional falls. The client also has dementia which is another indication the client should be closely monitored and observed first. The client with a UTI with orange urine is a normal finding as the client is likely taking pyridium. 3+ pitting Edema with heart failure is not an abnormal finding and not priority. The client with tuberculosis on airborne precautions should be seen once the other clients are stable.
Subcategory- Prioritization
Rationale – A client with a history of falls is at high risk for additional falls. The client also has dementia which is another indication the client should be closely monitored and observed first. The client with a UTI with orange urine is a normal finding as the client is likely taking pyridium. 3+ pitting Edema with heart failure is not an abnormal finding and not priority. The client with tuberculosis on airborne precautions should be seen once the other clients are stable.
Subcategory- Prioritization
The pediatric nurse is assigned the following four clients. Which client should the nurse see first?
Rationale – Swelling in the joint space is a sign of acute bleeding that needs to be addressed immediately in a client diagnosed with hemophilia. The client with cystic fibrosis can receive the treatment after this client has been seen. The 12-year-old that is refusing to eat is not priority over a client who may have acute bleeding. The client with tonsillitis that is waiting for surgery in the morning should be assessed but is not priority over a client at risk for bleeding.
Subcategory- Prioritization
Rationale – Swelling in the joint space is a sign of acute bleeding that needs to be addressed immediately in a client diagnosed with hemophilia. The client with cystic fibrosis can receive the treatment after this client has been seen. The 12-year-old that is refusing to eat is not priority over a client who may have acute bleeding. The client with tonsillitis that is waiting for surgery in the morning should be assessed but is not priority over a client at risk for bleeding.
Subcategory- Prioritization
What finding should be reported immediately in a client who has just undergone a cystectomy with ileal conduit?
Rationale –A lack of urine output may be an indication that the client has a leak. Abdominal pain after lifting is important but is not priority. Bleeding around the incision site maybe normal for sure. After surgery. No bowel movement in today should be reported but is not priority.
Subcategory- Prioritization
Rationale –A lack of urine output may be an indication that the client has a leak. Abdominal pain after lifting is important but is not priority. Bleeding around the incision site maybe normal for sure. After surgery. No bowel movement in today should be reported but is not priority.
Subcategory- Prioritization
What finding should be reported to the primary care provider in a client suspected of having gastroesophageal reflux disease? Select all that apply.
Rationale- Symptoms consistent with gastroesophageal reflux disease that should be reported to the healthcare provider include belching, flatulence and water brash. Nausea and anorexia are not common findings of gastroesophageal reflux disease.
Subcategory- Prioritization
Rationale- Symptoms consistent with gastroesophageal reflux disease that should be reported to the healthcare provider include belching, flatulence and water brash. Nausea and anorexia are not common findings of gastroesophageal reflux disease.
Subcategory- Prioritization
The nurse is caring for the following four clients. Which client has the highest risk for infection?
Rationale – The male client that is receiving chemotherapy and neutropenic is at increased risk for infection. A neutropenic client does not have the ability to fight off infection. A client diagnosed with diabetes has a normal BMI so they only have one at risk factor. The female client with the white blood cell count of 3000 has a normal white blood cell count and temperature, although slightly elevated, does not increase the risk of infection. The female with indwelling catheter is already receiving antibiotics.
Subcategory- Prioritization
Rationale – The male client that is receiving chemotherapy and neutropenic is at increased risk for infection. A neutropenic client does not have the ability to fight off infection. A client diagnosed with diabetes has a normal BMI so they only have one at risk factor. The female client with the white blood cell count of 3000 has a normal white blood cell count and temperature, although slightly elevated, does not increase the risk of infection. The female with indwelling catheter is already receiving antibiotics.
Subcategory- Prioritization
A client who has undergone laparoscopic sleeve gastrectomy three days prior is suspected of having dumping syndrome. What findings should be reported to the healthcare provider immediately? Select all that apply.
Rationale – A client who is experiencing dumping syndrome will often have severe abdominal cramping and a feeling of fullness. They will have tachycardia and tachypnea not bradycardia or bradypnea. They tend to have sweating and flushing not dry mucous membranes or skin.
Subcategory- Prioritization
Rationale – A client who is experiencing dumping syndrome will often have severe abdominal cramping and a feeling of fullness. They will have tachycardia and tachypnea not bradycardia or bradypnea. They tend to have sweating and flushing not dry mucous membranes or skin.
Subcategory- Prioritization
A client is hospitalized with a diagnosis of hepatitis A and the nurse identifies five nursing issues for this client. Arrange the following findings identified in priority order.
Rationale – Acute pain is the priority, though pharmacological interventions must be limited to medications without hepatotoxic effects. Nutrition is the next priority and if positive outcomes are seen in this area, fatigue will decrease, which will leading to a greater activity tolerance. Altered skin integrity resulting from pruritis secondary to accumulation of bilirubin pigments in bile salts has not occurred yet, leading this diagnosis to be of lowest priority.
Subcategory: Standards Precautions/Transmission-based Precautions/Surgical Asepsis
Rationale – Acute pain is the priority, though pharmacological interventions must be limited to medications without hepatotoxic effects. Nutrition is the next priority and if positive outcomes are seen in this area, fatigue will decrease, which will leading to a greater activity tolerance. Altered skin integrity resulting from pruritis secondary to accumulation of bilirubin pigments in bile salts has not occurred yet, leading this diagnosis to be of lowest priority.
Subcategory: Standards Precautions/Transmission-based Precautions/Surgical Asepsis
A client diagnosed with Acute Coronary Syndrome has the following orders when they arrive to the cardiac unit. What intervention by the nurse is priority?
Rationale – The electrocardiogram should be done first, then atorvastatin 80mg administered. But notice how the answer choice reads “Repeat electrocardiogram”, indicating that it has already been done; the “repeat” in the answer choice makes this a trap. Read answer choices carefully on the actual NCLEX.
The EKG is used to determine if there is further damage or worsening of the client’s condition. A nutritional consult is not priority when the client is first admitted. Ibuprofen is contraindicated in this client and should not be administered.
Subcategory: Prioritization
Rationale – The electrocardiogram should be done first, then atorvastatin 80mg administered. But notice how the answer choice reads “Repeat electrocardiogram”, indicating that it has already been done; the “repeat” in the answer choice makes this a trap. Read answer choices carefully on the actual NCLEX.
The EKG is used to determine if there is further damage or worsening of the client’s condition. A nutritional consult is not priority when the client is first admitted. Ibuprofen is contraindicated in this client and should not be administered.
Subcategory: Prioritization
The nurse is anticipating admission of a client diagnosed with neutropenia. Which nursing action is a priority?
Rationale – The client is at high risk for infection. Hand washing is the single most important means of preventing the spread of infection. Instructing the client to wear a mask outside of the room, not consume fresh produce, raw or undercooked eggs and placing the client in a private room or with a client without infectious processes are important considerations but not as important as the basics of hand hygiene
Subcategory: Establishing Priorities
Rationale – The client is at high risk for infection. Hand washing is the single most important means of preventing the spread of infection. Instructing the client to wear a mask outside of the room, not consume fresh produce, raw or undercooked eggs and placing the client in a private room or with a client without infectious processes are important considerations but not as important as the basics of hand hygiene
Subcategory: Establishing Priorities