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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.
-The “NCLEX Cracker” Team
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.
-The “NCLEX Cracker” Team
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!
-The “NCLEX Cracker” Team
A client is taking a medication that is a cholinergic drug. What receptors should the nurse suspect will be affected? Select all that apply.
Rationale: Cholinergic drugs stimulate smooth muscle and gland secretion and decrease heart rate and force of contraction. Side effects the nurse should be aware of include tachycardia, hypertension, and increased motility in the digestive tract. Anti-cholinergic will have many opposite effects.
Category: Pharmacological and Parenteral Therapies/Adverse Effects/Contraindications/Side Effects/Interactions
Rationale: Cholinergic drugs stimulate smooth muscle and gland secretion and decrease heart rate and force of contraction. Side effects the nurse should be aware of include tachycardia, hypertension, and increased motility in the digestive tract. Anti-cholinergic will have many opposite effects.
Category: Pharmacological and Parenteral Therapies/Adverse Effects/Contraindications/Side Effects/Interactions
A client complains about anxiety, restlessness, and tremor. The nurse looks at the medications the client took this morning to determine what is causing these side effects. What medication should the nurse suspect?
Rationale: Phenylephrine is an adrenergic agent which affects the nervous system. Side effects are anxiety, restlessness, and tremor, as well as increased blood pressure and tachycardia. Nurses should be aware of these side effects and monitor the client prior to and after administration.
Category: Pharmacological and Parenteral Therapies/Adverse Effects/Contraindications/Side Effects/Interactions
Rationale: Phenylephrine is an adrenergic agent which affects the nervous system. Side effects are anxiety, restlessness, and tremor, as well as increased blood pressure and tachycardia. Nurses should be aware of these side effects and monitor the client prior to and after administration.
Category: Pharmacological and Parenteral Therapies/Adverse Effects/Contraindications/Side Effects/Interactions
A client is prescribed bethanechol for urinary retention. Cathy, RN notices the client has a disorder which is contraindicated for this medication. What disorder would the nurse be concerned about?
Rationale: Bethanechol, or urecholine, is a medication that acts on the muscarinic receptors. That means the drug affects smooth muscle and muscular contractions. As asthma is a contraction of the muscles in the airways, the nurse needs to be alert to the fact that this medication could exacerbate asthma and should not be given to those clients.
Category: Pharmacological and Parenteral Therapies/Adverse Effects/Contraindications/Side Effects/Interactions
Rationale: Bethanechol, or urecholine, is a medication that acts on the muscarinic receptors. That means the drug affects smooth muscle and muscular contractions. As asthma is a contraction of the muscles in the airways, the nurse needs to be alert to the fact that this medication could exacerbate asthma and should not be given to those clients.
Category: Pharmacological and Parenteral Therapies/Adverse Effects/Contraindications/Side Effects/Interactions
When would a nurse question an order for atropine?
Rationale: Atropine induces the fight or flight response. It is a drug that constricts many of the blood vessels, including those of the eyes. It would not affect asthma clients, because it does not act on the muscle. In fact, atropine causes bronchial dilation.
Category: Pharmacological and Parenteral Therapies/Adverse Effects/Contraindications/Side Effects/Interactions
Rationale: Atropine induces the fight or flight response. It is a drug that constricts many of the blood vessels, including those of the eyes. It would not affect asthma clients, because it does not act on the muscle. In fact, atropine causes bronchial dilation.
Category: Pharmacological and Parenteral Therapies/Adverse Effects/Contraindications/Side Effects/Interactions
A 56 year old client is being prescribed escitalopram. What side effects will the nurse teach the client to watch for?
Rationale: Lexapro is an SSRI drug and is given for depression. Many of these drugs cause dizziness, and this one can cause insomnia and nausea. The nurse should be sure to teach the client about dizziness and how to prevent falls. Students must be sure to learn generic and brand names of medications for the NCLEX exam.
Category: Pharmacological and Parenteral Therapies/Adverse Effects/Contraindications/Side Effects/Interactions
Rationale: Lexapro is an SSRI drug and is given for depression. Many of these drugs cause dizziness, and this one can cause insomnia and nausea. The nurse should be sure to teach the client about dizziness and how to prevent falls. Students must be sure to learn generic and brand names of medications for the NCLEX exam.
Category: Pharmacological and Parenteral Therapies/Adverse Effects/Contraindications/Side Effects/Interactions
Mr. Smith is taking Ativan for his anxiety. What drug interactions should the nurse teach him to avoid?
Rationale: The client should not mix any drug that has system depressant effects with another drug that also has the same effect, such as alcohol or narcotics. Respiratory system depression and death can occur. In cases where the client must be prescribed narcotic medication with this medication, they will need to be carefully monitored for sedation and respiratory depression.
Category: Pharmacological and Parenteral Therapies/Adverse Effects/Contraindications/Side Effects/Interactions
Rationale: The client should not mix any drug that has system depressant effects with another drug that also has the same effect, such as alcohol or narcotics. Respiratory system depression and death can occur. In cases where the client must be prescribed narcotic medication with this medication, they will need to be carefully monitored for sedation and respiratory depression.
Category: Pharmacological and Parenteral Therapies/Adverse Effects/Contraindications/Side Effects/Interactions
Phenobarbital is prescribed to a client for seizures. What side effect should the nurse teach the client about?
Rationale: Phenobarbital is a barbiturate. The nurse should teach the client about drowsiness, as they may need to avoid operating machinery. They also could become a fall risk due to the drowsiness and disorientation.
Category: Pharmacological and Parenteral Therapies/Adverse Effects/Contraindications/Side Effects/Interactions
Rationale: Phenobarbital is a barbiturate. The nurse should teach the client about drowsiness, as they may need to avoid operating machinery. They also could become a fall risk due to the drowsiness and disorientation.
Category: Pharmacological and Parenteral Therapies/Adverse Effects/Contraindications/Side Effects/Interactions
Phenytoin is prescribed for a client with seizures. The nurse is preparing medications for the morning med pass. What medication should the nurse question?
Rationale: Phenytoin, or Dilantin, interacts with anti-coagulants such as Coumadin. The nurse call the physician to discuss drug interactions before administration. The nurse should also be careful about giving this medication with digitoxin and furosemide as the effects may be reduced.
Category: Pharmacological and Parenteral Therapies/Adverse Effects/Contraindications/Side Effects/Interactions
Rationale: Phenytoin, or Dilantin, interacts with anti-coagulants such as Coumadin. The nurse call the physician to discuss drug interactions before administration. The nurse should also be careful about giving this medication with digitoxin and furosemide as the effects may be reduced.
Category: Pharmacological and Parenteral Therapies/Adverse Effects/Contraindications/Side Effects/Interactions
Valproic acid is ordered for a client with seizures. What is a contraindication to giving this medication? Select all that apply.
Rationale: Valproic acid/Depakene should not be given to clients with liver disorders or those who are taking aspirin or anticoagulants such as Coumadin because of the increased risk of bleeding and the liver’s role in metabolism of medication. Valproic acid is also a GI irritant and should not be mixed with carbonated beverages because they exacerbate the GI irritation. The nurse must carefully assess the client’s medication use and history.
Category: Pharmacological and Parenteral Therapies/Adverse Effects/Contraindications/Side Effects/Interactions
Rationale: Valproic acid/Depakene should not be given to clients with liver disorders or those who are taking aspirin or anticoagulants such as Coumadin because of the increased risk of bleeding and the liver’s role in metabolism of medication. Valproic acid is also a GI irritant and should not be mixed with carbonated beverages because they exacerbate the GI irritation. The nurse must carefully assess the client’s medication use and history.
Category: Pharmacological and Parenteral Therapies/Adverse Effects/Contraindications/Side Effects/Interactions
Mr. Shaker is taking imipramine for depression. What adverse effects should the nurse teach him about?
Rationale: Tofranil blocks the re-uptake of serotonin and norepinephrine. This medication causes many adverse effects to the heart, such as dysrhythmias and hypertension. This drug may also effect glucose levels. It should be used cautiously in clients with cardiac problems.
Category: Pharmacological and Parenteral Therapies/Adverse Effects/Contraindications/Side Effects/Interactions
Rationale: Tofranil blocks the re-uptake of serotonin and norepinephrine. This medication causes many adverse effects to the heart, such as dysrhythmias and hypertension. This drug may also effect glucose levels. It should be used cautiously in clients with cardiac problems.
Category: Pharmacological and Parenteral Therapies/Adverse Effects/Contraindications/Side Effects/Interactions
Phenelzine has the potential to create a hypertensive crisis when given with what other drugs? Select all that apply.
Rationale: Nardil can create a hypertensive crisis when taken with certain medications. A hypertensive crisis is characterized by cardiac dysrhythmias and hypertension. This reaction is serious because it can lead to death. The nurse should teach the client about all medications that interact with this medication and the client must be oriented to ensure they do not take anything else with this drug.
Category: Pharmacological and Parenteral Therapies/Adverse Effects/Contraindications/Side Effects/Interactions
Rationale: Nardil can create a hypertensive crisis when taken with certain medications. A hypertensive crisis is characterized by cardiac dysrhythmias and hypertension. This reaction is serious because it can lead to death. The nurse should teach the client about all medications that interact with this medication and the client must be oriented to ensure they do not take anything else with this drug.
Category: Pharmacological and Parenteral Therapies/Adverse Effects/Contraindications/Side Effects/Interactions
What is the therapeutic blood level for lithium?
Rationale: Lithium has a narrow toxicity window and must be monitored closely to avoid adverse events. The client must be taught to eat the same amount of sodium and drink the same amounts of water each day to avoid a fluctuation in their lithium levels.
Category: Pharmacological and Parenteral Therapies/Adverse Effects/Contraindications/Side Effects/Interactions
Rationale: Lithium has a narrow toxicity window and must be monitored closely to avoid adverse events. The client must be taught to eat the same amount of sodium and drink the same amounts of water each day to avoid a fluctuation in their lithium levels.
Category: Pharmacological and Parenteral Therapies/Adverse Effects/Contraindications/Side Effects/Interactions
Haloperidol is prescribed for an elderly client with aggression issues. The nurse is teaching the family about precautions with this medication. What should she teach?
Rationale: Haloperidol is used to stabilize aggressive behavior, usually in clients with dementia. It should not be stopped abruptly, and if the medication will be stopped, the physician should be notified. Haldol comes in oral and injectable forms.
Category: Pharmacological and Parenteral Therapies/Adverse Effects/Contraindications/Side Effects/Interactions
Rationale: Haloperidol is used to stabilize aggressive behavior, usually in clients with dementia. It should not be stopped abruptly, and if the medication will be stopped, the physician should be notified. Haldol comes in oral and injectable forms.
Category: Pharmacological and Parenteral Therapies/Adverse Effects/Contraindications/Side Effects/Interactions
Mrs. Phillips is prescribed alendronate for her osteoporosis. When would the nurse question this order? Select all that apply.
Rationale: Fosamax should not be given to clients who have trouble swallowing or who have an ulcer because the medication is very irritating. Clients must also be able to sit up in the chair or ambulate after receiving the medication, for 30 minutes, to ensure the medication does not travel back up the esophagus and cause erosions. Physical activity will help prevent bone breakdown in the body. Clients who have dementia should not be precluded from taking this medication as long as they are able to sit up for 30 minutes after taking the medication, and are able to swallow.
Category: Pharmacological and Parenteral Therapies/Adverse Effects/Contraindications/Side Effects/Interactions
Rationale: Fosamax should not be given to clients who have trouble swallowing or who have an ulcer because the medication is very irritating. Clients must also be able to sit up in the chair or ambulate after receiving the medication, for 30 minutes, to ensure the medication does not travel back up the esophagus and cause erosions. Physical activity will help prevent bone breakdown in the body. Clients who have dementia should not be precluded from taking this medication as long as they are able to sit up for 30 minutes after taking the medication, and are able to swallow.
Category: Pharmacological and Parenteral Therapies/Adverse Effects/Contraindications/Side Effects/Interactions
Mrs. Phillips has an order for alendronate 10 mg P.O. daily for osteoporosis. The nurse has tablets that are 5 mg each. How many tablets will be administered? _____ Tablets
Rationale: The tablets are 5 mg each so 2 tablets will be given. Using the dose over hand method, the equation will be set up: 10/x = 5/1. 10=5x. 10 divided by 5 = 2 tablets. Students should use the method of calculation they feel comfortable with.
Category: Pharmacological and Parenteral Therapies/Dosage Calculation
Rationale: The tablets are 5 mg each so 2 tablets will be given. Using the dose over hand method, the equation will be set up: 10/x = 5/1. 10=5x. 10 divided by 5 = 2 tablets. Students should use the method of calculation they feel comfortable with.
Category: Pharmacological and Parenteral Therapies/Dosage Calculation
Kelly is a 65 year old client who has been prescribed Humira for her rheumatoid arthritis. The nurse will teach Kelly about side effects of the drug. What side effect should the nurse teach Kelly to report? Select all that apply.
Rationale: Known side effects of this drug include infections, including opportunistic infections, such as TB, Autoantibodies, and liver failure or elevated liver enzymes. The nurse should teach the client to report all of these events as they can lead to serious fatal conditions. This drug caries a warning for serious infections and malignancy, so it should only be used when the benefits outweigh the risk.
Category: Pharmacological and Parenteral Therapies/Adverse Effects/Contraindications/Side Effects/Interactions
Rationale: Known side effects of this drug include infections, including opportunistic infections, such as TB, Autoantibodies, and liver failure or elevated liver enzymes. The nurse should teach the client to report all of these events as they can lead to serious fatal conditions. This drug caries a warning for serious infections and malignancy, so it should only be used when the benefits outweigh the risk.
Category: Pharmacological and Parenteral Therapies/Adverse Effects/Contraindications/Side Effects/Interactions
The ordered dose of Humira for pediatric clients ≥30 kg (66 lbs.) is 40 mg every other week. The nurse has a vial with 15 mg of Humira per ml. How many ml will be administered? Round to the nearest 10th. ____ml.
Rationale: Humira is a weight based drug, with different doses for different weights, and also different doses in adults based on the condition that is being treated. Using the ratio and proportion method, the nurse would set up the equation 15mg/1ml=40mg/x. 15x=40mg. 40 divided by 15 = 2.66667 ml. Rounded, the answer will be 2.7ml. To double check the answer, students should know that the answer will need to be greater than 1 ml, since 1 ml only contains 15 mg.
Category: Pharmacological and Parenteral Therapies/Dosage Calculation
Rationale: Humira is a weight based drug, with different doses for different weights, and also different doses in adults based on the condition that is being treated. Using the ratio and proportion method, the nurse would set up the equation 15mg/1ml=40mg/x. 15x=40mg. 40 divided by 15 = 2.66667 ml. Rounded, the answer will be 2.7ml. To double check the answer, students should know that the answer will need to be greater than 1 ml, since 1 ml only contains 15 mg.
Category: Pharmacological and Parenteral Therapies/Dosage Calculation
What is the proper indication for administration of Cardizem?
Rationale: Cardizem is labeled for use in clients with angina. It is sometimes used for clients with atrial fibrillation or tachycardia as well. This is a drug that should be given on a step-down unit, or in the ICU as it needs to be titrated according to the client’s response and vital signs. Cardizem can cause bradycardia so it needs to be given with care.
Category: Pharmacological and Parenteral Therapies/Expected Actions/Outcomes
Rationale: Cardizem is labeled for use in clients with angina. It is sometimes used for clients with atrial fibrillation or tachycardia as well. This is a drug that should be given on a step-down unit, or in the ICU as it needs to be titrated according to the client’s response and vital signs. Cardizem can cause bradycardia so it needs to be given with care.
Category: Pharmacological and Parenteral Therapies/Expected Actions/Outcomes
Molly, the nurse is preparing to give Cardizem to a client. What side effects should she warn the client to watch for? Select all that apply.
Rationale: The most serious side effects that are frequently monitored for Cardizem are cardiac side effects as the drug has a major effect on the heart. These are the side effects students should mainly focus on. Other side effects are Amblyopia, CPK elevation, dry mouth, dyspnea, epistaxis, eye irritation, hyperglycemia, hyperuricemia, impotence, muscle cramps, nasal congestion, nocturia, osteoarticular pain, polyuria, sexual difficulties, tinnitus.
Category: Pharmacological and Parenteral Therapies/Adverse Effects/Contraindications/Side Effects/Interactions
Rationale: The most serious side effects that are frequently monitored for Cardizem are cardiac side effects as the drug has a major effect on the heart. These are the side effects students should mainly focus on. Other side effects are Amblyopia, CPK elevation, dry mouth, dyspnea, epistaxis, eye irritation, hyperglycemia, hyperuricemia, impotence, muscle cramps, nasal congestion, nocturia, osteoarticular pain, polyuria, sexual difficulties, tinnitus.
Category: Pharmacological and Parenteral Therapies/Adverse Effects/Contraindications/Side Effects/Interactions
A client with atrial fibrillation is receiving Diltiazem IV. The physician order calls for 5 mg per hour and titrate to keep the client’s hear rate under 100 BPM. The heart rate is currently 95 BPM. The nurse has a bag of Diltiazem labeled 125 mg in 125 ml. At what rate should the nurse set the rate? _____ ml/hr.
Rationale: Using the ratio and proportion method: 125mg/125ml=5mg/x. (125×5) =125x. 625 = 125 x. 625 divided by 125= 5 ml. The nurse may also recognize that a bag of 125 mg in 125 ml is a 1 to 1 solution and may calculate accordingly.
Category: Pharmacological and Parenteral Therapies/Dosage Calculation
Rationale: Using the ratio and proportion method: 125mg/125ml=5mg/x. (125×5) =125x. 625 = 125 x. 625 divided by 125= 5 ml. The nurse may also recognize that a bag of 125 mg in 125 ml is a 1 to 1 solution and may calculate accordingly.
Category: Pharmacological and Parenteral Therapies/Dosage Calculation
Mrs. Jones is prescribed azathioprine. Her nurse should question the order if the client has which disorders? Select all that apply.
Rationale: Imuran is used to reduce the incidence of organ transplant rejection. It weakens the immune system so it should not be given to clients who are receiving other immune system altering drugs or are pregnant. It should also not be given to those with liver disease due to metabolism by the liver.
Category: Pharmacological and Parenteral Therapies/Adverse Effects/Contraindications/Side Effects/Interactions
Rationale: Imuran is used to reduce the incidence of organ transplant rejection. It weakens the immune system so it should not be given to clients who are receiving other immune system altering drugs or are pregnant. It should also not be given to those with liver disease due to metabolism by the liver.
Category: Pharmacological and Parenteral Therapies/Adverse Effects/Contraindications/Side Effects/Interactions
A client taking azathioprine asks what side effects to watch for. What side effects should the nurse include in her teaching? Select all that apply.
Rationale: Common side effects of this drug are listed. Imran can cause tachycardia, but not bradycardia as normal side effect. This drug affects the liver, so bleeding may occur throughout the body. Students should rule out bradycardia if angina is selected as the two usually don’t go hand in hand as side effects of most drugs.
Category: Pharmacological and Parenteral Therapies/Adverse Effects/Contraindications/Side Effects/Interactions
Rationale: Common side effects of this drug are listed. Imran can cause tachycardia, but not bradycardia as normal side effect. This drug affects the liver, so bleeding may occur throughout the body. Students should rule out bradycardia if angina is selected as the two usually don’t go hand in hand as side effects of most drugs.
Category: Pharmacological and Parenteral Therapies/Adverse Effects/Contraindications/Side Effects/Interactions
Mrs. Jones is receiving 2.5 mg/kg/ day of Imuran. She is 125 pounds. What dose will she receive per day? ______ mg
Rationale: 125 pounds divided by 2.2 is 56.82 kg. 56.82 multiplied by 2.5 is 142.05 mg. The client will receive 142. 05 mg per day. This medication is given once daily so it will not need to be divided into doses.
Category: Pharmacological and Parenteral Therapies/Dosage Calculation
Rationale: 125 pounds divided by 2.2 is 56.82 kg. 56.82 multiplied by 2.5 is 142.05 mg. The client will receive 142. 05 mg per day. This medication is given once daily so it will not need to be divided into doses.
Category: Pharmacological and Parenteral Therapies/Dosage Calculation
According to her weight, Mrs. Jones should receive 142.05 mg of Imuran per day. It is available in 50 mg scored tablets. How many tablets will she receive? ____ tabs
Rationale: 142.05 mg/x= 50/1. 142.05=50x. 142.05 divided by 50 = 2.841 tablets. The nurse can only give the tablets in 1/2 tablet increments and the decimal is .841 so it should be rounded up. The client will receive 3 tablets.
Category: Pharmacological and Parenteral Therapies/Dosage Calculation
Rationale: 142.05 mg/x= 50/1. 142.05=50x. 142.05 divided by 50 = 2.841 tablets. The nurse can only give the tablets in 1/2 tablet increments and the decimal is .841 so it should be rounded up. The client will receive 3 tablets.
Category: Pharmacological and Parenteral Therapies/Dosage Calculation
Kim is taking aspirin after having an MI. Which side effects should the nurse teach her that would require stopping the medication? Select all that apply.
Rationale: It is important to stop the medication and call the care provider if the client experiences any symptoms that could indicate bleeding. These side effects could be potentially fatal if left untreated. The nurse should also teach the client to stop the aspirin before a surgical procedure. This should be discussed with the care provider.
Category: Pharmacological and Parenteral Therapies/Adverse Effects/Contraindications/Side Effects/Interactions
Rationale: It is important to stop the medication and call the care provider if the client experiences any symptoms that could indicate bleeding. These side effects could be potentially fatal if left untreated. The nurse should also teach the client to stop the aspirin before a surgical procedure. This should be discussed with the care provider.
Category: Pharmacological and Parenteral Therapies/Adverse Effects/Contraindications/Side Effects/Interactions
The care provider has ordered Aspirin for Kim. What condition would cause the nurse to question this order?
Rationale: Reye’s syndrome is a serious condition that causes swelling in the liver and brain. Reye’s syndrome most often affects children and teenagers recovering from a viral infection, most commonly the flu or chickenpox. Care providers should be cautious in giving aspirin to children and teenagers, but they also should not give it to persons with known Reye’s syndrome.
Category: Pharmacological and Parenteral Therapies/Adverse Effects/Contraindications/Side Effects/Interactions
Rationale: Reye’s syndrome is a serious condition that causes swelling in the liver and brain. Reye’s syndrome most often affects children and teenagers recovering from a viral infection, most commonly the flu or chickenpox. Care providers should be cautious in giving aspirin to children and teenagers, but they also should not give it to persons with known Reye’s syndrome.
Category: Pharmacological and Parenteral Therapies/Adverse Effects/Contraindications/Side Effects/Interactions
Aspirin 325 mg daily P.O. has been ordered for a client with chronic pain. There are 81 mg tablets available. How many should be administered? ______ tabs
Rationale: Using the ration and proportion method: 325/x= 81/1. 81x=325. 325 divided by 81= 4.01 tablets, which is rounded down to 4 tablets.
Category: Pharmacological and Parenteral Therapies/Dosage Calculation
Rationale: Using the ration and proportion method: 325/x= 81/1. 81x=325. 325 divided by 81= 4.01 tablets, which is rounded down to 4 tablets.
Category: Pharmacological and Parenteral Therapies/Dosage Calculation
A client has an order for Morphine. When should the medication be held?
Rationale: Morphine causes a serious complication of respiratory depression. It should not be given to client whose respirations are under 10 per minute. It should not be given even when if clients are asking for more pain medication. Other methods of pain control will need to be investigated if the medication is not controlling the pain with decreased respirations.
Category: Pharmacological and Parenteral Therapies/Adverse Effects/Contraindications/Side Effects/Interactions
Rationale: Morphine causes a serious complication of respiratory depression. It should not be given to client whose respirations are under 10 per minute. It should not be given even when if clients are asking for more pain medication. Other methods of pain control will need to be investigated if the medication is not controlling the pain with decreased respirations.
Category: Pharmacological and Parenteral Therapies/Adverse Effects/Contraindications/Side Effects/Interactions
Morphine 8 mg IV every 4 hours is ordered. The nurse has a concentration of 10 mg in 10 ml. How many ml should be given? ______ ml.
Rationale: Set up the problem using the ratio and proportion method. 8 mg/x=10mg/10ml. 80=10x. 80 divided by 10 is 8 ml. 10 mg could also be divided by 10 ml to see that the concentration is 1 mg per ml.
Category: Pharmacological and Parenteral Therapies/Dosage Calculation
Rationale: Set up the problem using the ratio and proportion method. 8 mg/x=10mg/10ml. 80=10x. 80 divided by 10 is 8 ml. 10 mg could also be divided by 10 ml to see that the concentration is 1 mg per ml.
Category: Pharmacological and Parenteral Therapies/Dosage Calculation
Mrs. Salyers is taking phenytoin for seizures. What side effects should the nurse teach her to report? Select all that apply.
Rationale: Since Dilantin works on the brain to decrease seizures, it can produce negative side effects on the brain. The client should report any side effects that represent a change in mental status. The client should also watch for signs of tardive dyskinesia as they can be serious and permanent if not caught.
Category: Pharmacological and Parenteral Therapies/Adverse Effects/Contraindications/Side Effects/Interactions
Rationale: Since Dilantin works on the brain to decrease seizures, it can produce negative side effects on the brain. The client should report any side effects that represent a change in mental status. The client should also watch for signs of tardive dyskinesia as they can be serious and permanent if not caught.
Category: Pharmacological and Parenteral Therapies/Adverse Effects/Contraindications/Side Effects/Interactions
Mrs. Salyers is taking phenytoin for seizures. What medication should the nurse question if ordered with this medication?
Rationale: Dilantin (Phenytoin) interacts with numerous drugs.
Warfarin (Coumadin) and trimethoprim increase serum phenytoin levels and prolong the serum half-life of phenytoin by inhibiting its metabolism. Consider using other options if possible.
It should also not be administered with drugs that alter the level of consciousness due to the desired action of Dilantin. It can be given with pain medications that do not contain narcotics. The nurse should always check drug interactions before giving new medications with this drug.
Common side effects of Phenytoin includes nausea, stomach pain, loss of appetite, poor coordination, increased hair growth, and enlargement of the gums. Potentially serious side effects include sleepiness, self harm, liver problems, bone marrow suppression, low blood pressure, and toxic epidermal necrolysis. Phenytoin may increase risk of suicidal thoughts or behavior. People on phenytoin should be monitored for any changes in mood, the development or worsening depression, and/or any thoughts or behavior of suicide.
Category: Pharmacological and Parenteral Therapies/Adverse Effects/Contraindications/Side Effects/Interactions
Rationale: Dilantin (Phenytoin) interacts with numerous drugs.
Warfarin (Coumadin) and trimethoprim increase serum phenytoin levels and prolong the serum half-life of phenytoin by inhibiting its metabolism. Consider using other options if possible.
It should also not be administered with drugs that alter the level of consciousness due to the desired action of Dilantin. It can be given with pain medications that do not contain narcotics. The nurse should always check drug interactions before giving new medications with this drug.
Common side effects of Phenytoin includes nausea, stomach pain, loss of appetite, poor coordination, increased hair growth, and enlargement of the gums. Potentially serious side effects include sleepiness, self harm, liver problems, bone marrow suppression, low blood pressure, and toxic epidermal necrolysis. Phenytoin may increase risk of suicidal thoughts or behavior. People on phenytoin should be monitored for any changes in mood, the development or worsening depression, and/or any thoughts or behavior of suicide.
Category: Pharmacological and Parenteral Therapies/Adverse Effects/Contraindications/Side Effects/Interactions
100 mg Dilantin (extended phenytoin sodium capsule, USP) TID P.O. is written as an order. There are 50 mg capsules available. How many capsules will be needed for a 7 day supply? ______capsules.
Rationale: 100/x=50/1. 50x=100. 100 divided by 50 = 2. 2 capsules will be given with each dose. There are 3 doses per day so 2*3=6 capsules per day. The nurse needs to calculate the number of capsules for 7 days so 6 capsules per day will be multiplied by 7 days = 42.
Category: Pharmacological and Parenteral Therapies/Dosage Calculation
Rationale: 100/x=50/1. 50x=100. 100 divided by 50 = 2. 2 capsules will be given with each dose. There are 3 doses per day so 2*3=6 capsules per day. The nurse needs to calculate the number of capsules for 7 days so 6 capsules per day will be multiplied by 7 days = 42.
Category: Pharmacological and Parenteral Therapies/Dosage Calculation
Mrs. Clark is admitted for an asthma exacerbation and is prescribed prednisone. What nursing action should the nurse plan?
Rationale: Prednisone increases glucose in clients. If they are diabetic, the glucose may be difficult to control. If they are not diabetic, the client may need to receive insulin while taking the prednisone, depending on their glucose levels. Choice number 1 is not a nursing action. Students should be careful to choose the answer that most closely answers the question.
Category: Pharmacological and Parenteral Therapies/Adverse Effects/Contraindications/Side Effects/Interactions
Rationale: Prednisone increases glucose in clients. If they are diabetic, the glucose may be difficult to control. If they are not diabetic, the client may need to receive insulin while taking the prednisone, depending on their glucose levels. Choice number 1 is not a nursing action. Students should be careful to choose the answer that most closely answers the question.
Category: Pharmacological and Parenteral Therapies/Adverse Effects/Contraindications/Side Effects/Interactions
Mrs. Clark is taking prednisone for an asthma exacerbation. What priority teaching should the nurse provide?
Rationale: Stopping prednisone slowly is an important piece of information for clients. The adrenal glands become accustomed to the prednisone and it should be tapered to give them time to adjust cortisol production. Stopping prednisone abruptly can lead to fatigue, nausea and vomiting.
Category: Pharmacological and Parenteral Therapies/Adverse Effects/Contraindications/Side Effects/Interactions
Rationale: Stopping prednisone slowly is an important piece of information for clients. The adrenal glands become accustomed to the prednisone and it should be tapered to give them time to adjust cortisol production. Stopping prednisone abruptly can lead to fatigue, nausea and vomiting.
Category: Pharmacological and Parenteral Therapies/Adverse Effects/Contraindications/Side Effects/Interactions
A client has an order for 20 mg of prednisone P.O. today. The nurse has tablets of 2.5 mg. How many tablets will be given? __________tablets
Rationale: Using the ratio and proportion method: 20 mg/x=2.5 mg/1 tablet. 20=2.5x. 20 divided by 2.5 = 8 tablets. Students should double check the answer to make sure the number of tablets calculated was greater than 1, since the tablets on hand are 2.5 mg and 20 mg is needed.
Category: Pharmacological and Parenteral Therapies/Dosage Calculation
Rationale: Using the ratio and proportion method: 20 mg/x=2.5 mg/1 tablet. 20=2.5x. 20 divided by 2.5 = 8 tablets. Students should double check the answer to make sure the number of tablets calculated was greater than 1, since the tablets on hand are 2.5 mg and 20 mg is needed.
Category: Pharmacological and Parenteral Therapies/Dosage Calculation
Mr. Saylor is receiving heparin IV for a pulmonary embolism. What lab should the nurse use to titrate his dose?
Rationale: The PTT, or partial thromboplastin time, is used to evaluate the effect of heparin on the blood. The nurse will titrate the heparin dose until the PTT is within the specified parameters. PT and INR are used for Coumadin levels. A CBC is not used to determine the anticoagulation properties of the blood.
Category: Pharmacological and Parenteral Therapies/Adverse Effects/Contraindications/Side Effects/Interactions
Rationale: The PTT, or partial thromboplastin time, is used to evaluate the effect of heparin on the blood. The nurse will titrate the heparin dose until the PTT is within the specified parameters. PT and INR are used for Coumadin levels. A CBC is not used to determine the anticoagulation properties of the blood.
Category: Pharmacological and Parenteral Therapies/Adverse Effects/Contraindications/Side Effects/Interactions
Mr. Saylor is receiving heparin IV for a pulmonary embolism. His nurse draws his PTT and realizes it is triple what it should be. What should the nurse plan to administer?
Rationale: Protamine sulfate is the antidote for heparin and should be administered, upon consultation with the doctor, when the PTT levels are abnormally high. Clients who are too anti-coagulated are at a high risk of hemorrhage. Vitamin K is used for Coumadin. The other choices would increase the susceptibility of bleeding in the client.
Category: Pharmacological and Parenteral Therapies/Adverse Effects/Contraindications/Side Effects/Interactions
Rationale: Protamine sulfate is the antidote for heparin and should be administered, upon consultation with the doctor, when the PTT levels are abnormally high. Clients who are too anti-coagulated are at a high risk of hemorrhage. Vitamin K is used for Coumadin. The other choices would increase the susceptibility of bleeding in the client.
Category: Pharmacological and Parenteral Therapies/Adverse Effects/Contraindications/Side Effects/Interactions
Mr. Saylor has a new order for heparin that reads Heparin 60 units/kilogram = ________ units (5,000 units maximum) IV push. He weighs 200 pounds. How many units will be given?
Rationale: First convert the client’s weight to kilograms: 200 divided by 2.2= 90.91 kg. Then determine how much medication the client will receive based on their weight: 90.91 kg x 60 units= 5454.6 units. The maximum dose is 5000 units, so the nurse will administer 5000 units even though the client’s weight based dose is 5454.6 units.
Category: Pharmacological and Parenteral Therapies/Dosage Calculation
Rationale: First convert the client’s weight to kilograms: 200 divided by 2.2= 90.91 kg. Then determine how much medication the client will receive based on their weight: 90.91 kg x 60 units= 5454.6 units. The maximum dose is 5000 units, so the nurse will administer 5000 units even though the client’s weight based dose is 5454.6 units.
Category: Pharmacological and Parenteral Therapies/Dosage Calculation
Mr. Saylor has a continuous order for Heparin IV infusion (Heparin 25,000 units /Dextrose 5% 500 ml) at 12 units/kg/hour (1000 units an hour maximum). He weighs 200 pounds. How many units will be given per hour? ________units
Rationale: First, determine the client’s weight in kilograms: 200 divided by 2.2= 90.91 kg. Then, calculate his weight based dose: 90.91 kg x 12 units= 1090.92 units per hour. Note that the maximum dose allowed is 1000 units per hour, and this dose is greater than that. The nurse will administer 1000 units per hour.
Category: Pharmacological and Parenteral Therapies/Dosage Calculation
Rationale: First, determine the client’s weight in kilograms: 200 divided by 2.2= 90.91 kg. Then, calculate his weight based dose: 90.91 kg x 12 units= 1090.92 units per hour. Note that the maximum dose allowed is 1000 units per hour, and this dose is greater than that. The nurse will administer 1000 units per hour.
Category: Pharmacological and Parenteral Therapies/Dosage Calculation
Mr. Saylor has a continuous order for Heparin IV infusion (Heparin 25,000 units /Dextrose 5% 500 ml) at 12 units/kg/hour (1000 units an hour maximum). He is to receive 1000 units per hour. How many ml per hour should the nurse program on the IV pump? _______ml
Rationale: Using the ratio and proportion method: 25000 units/ 500 ml = 1000 units/x. 25000x= 500000. 500000 divided by 25000= 20 ml per hour. Students can break down the units per ml in the bag to get a better idea of the dose contained in 1ml. 25000/500ml= 50 units per ml.
Category: Pharmacological and Parenteral Therapies/Dosage Calculation
Rationale: Using the ratio and proportion method: 25000 units/ 500 ml = 1000 units/x. 25000x= 500000. 500000 divided by 25000= 20 ml per hour. Students can break down the units per ml in the bag to get a better idea of the dose contained in 1ml. 25000/500ml= 50 units per ml.
Category: Pharmacological and Parenteral Therapies/Dosage Calculation
Benztropine is ordered for a newly admitted client. What diagnosis should the nurse expect to find?
Rationale: Cogentin is used to control tremors and stiffness of the muscles due to certain antipsychotic medicines. It also treats the movement disorders caused by Parkinson’s disease. This drug is an anticholinergic.
Category: Pharmacological and Parenteral Therapies/Adverse Effects/Contraindications/Side Effects/Interactions
Rationale: Cogentin is used to control tremors and stiffness of the muscles due to certain antipsychotic medicines. It also treats the movement disorders caused by Parkinson’s disease. This drug is an anticholinergic.
Category: Pharmacological and Parenteral Therapies/Adverse Effects/Contraindications/Side Effects/Interactions
Benztropine is ordered for a newly admitted client. What side effects should the nurse teach the client about? Select all that apply.
Rationale: Cogentin is an anticholinergic. It will produce symptoms that relate to dehydration as it reduces secretions and will dry the client out. Side effects are related to a decrease in fluids, such as the side effects listed above. This drug would be more likely to cause difficult urination than an increase in urinary output.
Category: Pharmacological and Parenteral Therapies/Adverse Effects/Contraindications/Side Effects/Interactions
Rationale: Cogentin is an anticholinergic. It will produce symptoms that relate to dehydration as it reduces secretions and will dry the client out. Side effects are related to a decrease in fluids, such as the side effects listed above. This drug would be more likely to cause difficult urination than an increase in urinary output.
Category: Pharmacological and Parenteral Therapies/Adverse Effects/Contraindications/Side Effects/Interactions
Benztropine is ordered for a newly admitted client. What symptoms would lead the nurse to suspect overdose of this medication? Select all that apply.
Rationale: Cogentin overdose is serious and could lead to death. The nurse should be alert for signs of overdose in clients taking this medication. The signs are those of distress and are related to, but more severe than the side effects.
Category: Pharmacological and Parenteral Therapies/Adverse Effects/Contraindications/Side Effects/Interactions
Rationale: Cogentin overdose is serious and could lead to death. The nurse should be alert for signs of overdose in clients taking this medication. The signs are those of distress and are related to, but more severe than the side effects.
Category: Pharmacological and Parenteral Therapies/Adverse Effects/Contraindications/Side Effects/Interactions
The nurse received report on a client who is receiving magnesium sulfate IV. What problem should the nurse expect to find when assessing this client?
Rationale: The nurse should expect to find a condition for which magnesium sulfate is given. In eclampsia, it is given to prevent seizures or tetany. In other conditions, it may be given to prevent contractions or arrhythmia.
Category: Pharmacological and Parenteral Therapies/Adverse Effects/Contraindications/Side Effects/Interactions
Rationale: The nurse should expect to find a condition for which magnesium sulfate is given. In eclampsia, it is given to prevent seizures or tetany. In other conditions, it may be given to prevent contractions or arrhythmia.
Category: Pharmacological and Parenteral Therapies/Adverse Effects/Contraindications/Side Effects/Interactions
The nurse prepares to draw insulin and mix it before giving it to the client. How should the nurse proceed?
Rationale: The nurse should inject air into the insulin vials in the amount of insulin to given to reduce the resistance from the pressure in the glass vials. The nurse should then draw up the clear or regular insulin to be sure the cloudy insulin does not contaminate the regular insulin vial. Students should remember clear to cloudy.
Category: Pharmacological and Parenteral Therapies/Medication Administration
Rationale: The nurse should inject air into the insulin vials in the amount of insulin to given to reduce the resistance from the pressure in the glass vials. The nurse should then draw up the clear or regular insulin to be sure the cloudy insulin does not contaminate the regular insulin vial. Students should remember clear to cloudy.
Category: Pharmacological and Parenteral Therapies/Medication Administration
Carla, RN is preparing to administer blood to a client and needs to start IV access. Which IV would be most appropriate?
Rationale: When blood components will be given, it is important to ensure the client has an 18 gauge or larger IV. Smaller IV’s can lyse the blood and destroy the cells before they enter the circulation. IV’s should only be placed in the upper arm as a last resort because the veins are smaller and weaker on the surface.
Category: Pharmacological and Parenteral Therapies/Blood and Blood Products
Rationale: When blood components will be given, it is important to ensure the client has an 18 gauge or larger IV. Smaller IV’s can lyse the blood and destroy the cells before they enter the circulation. IV’s should only be placed in the upper arm as a last resort because the veins are smaller and weaker on the surface.
Category: Pharmacological and Parenteral Therapies/Blood and Blood Products
A client in a nursing home stops breathing. The nurse rushes to the client and notices they have a DNRCC for cardiac arrest. What action should the nurse perform first?
Rationale: When a client has a DNR order, the nurse must be aware of the type the client has. The client with a DNRCC-Cardiac Arrest does not wish to receive cardiac measures, such as chest compressions, cardiac medications, or defibrillation, but the nurse can still implement other measures such as providing comfort and oxygen. As in CPR, the nurse should determine responsiveness and immediately call for assistance before proceeding with resuscitation measures.
Category: Management of Care/Advance Directives
Rationale: When a client has a DNR order, the nurse must be aware of the type the client has. The client with a DNRCC-Cardiac Arrest does not wish to receive cardiac measures, such as chest compressions, cardiac medications, or defibrillation, but the nurse can still implement other measures such as providing comfort and oxygen. As in CPR, the nurse should determine responsiveness and immediately call for assistance before proceeding with resuscitation measures.
Category: Management of Care/Advance Directives
A client, who is a full-code, was found unresponsive and CPR was implemented. The client is to receive Adenosine 6mg rapid push. The nurse has a vial marked 10mg per ml. The nurse will administer ____ml.
Rationale: Since there are 10mg/ml and the nurse wants 6mg, the dose can be calculated by setting up the equation 10mg/1ml = 6mg/xml. The equation should be cross-multiplied so 10 *x =1*6. 6 is then divided by 10 to get an answer of 0.6ml. Other mathematical methods may be used, but it is important to remain consistent with the chosen method to avoid errors.
Category: Management of Care/Advance Directives
Rationale: Since there are 10mg/ml and the nurse wants 6mg, the dose can be calculated by setting up the equation 10mg/1ml = 6mg/xml. The equation should be cross-multiplied so 10 *x =1*6. 6 is then divided by 10 to get an answer of 0.6ml. Other mathematical methods may be used, but it is important to remain consistent with the chosen method to avoid errors.
Category: Management of Care/Advance Directives
A client has an Advance Directive. What items might be covered under the Advance Directive? Select All that Apply.
Rationale: A health-care Advance Directive is an instrument that lets family members or health-care providers know what the client’s wishes are in the event they can no longer speak for themselves. The document can cover broad topics such as DNR wishes, and withdrawal of support, in the event that the client is no longer able to speak and they are in a declining state. The health-care Advance Directive does not cover financial issues, and a power of attorney for financial issues should be drawn up separately.
Category: Management of Care/Advance Directives
Rationale: A health-care Advance Directive is an instrument that lets family members or health-care providers know what the client’s wishes are in the event they can no longer speak for themselves. The document can cover broad topics such as DNR wishes, and withdrawal of support, in the event that the client is no longer able to speak and they are in a declining state. The health-care Advance Directive does not cover financial issues, and a power of attorney for financial issues should be drawn up separately.
Category: Management of Care/Advance Directives
The nurse just started their shift and has not yet received report. They are sitting at the nurse’s station. The UAP calls because a client has been found unresponsive. Place the steps the nurse should take in order.
1. Call 911
2. Call for Assistance
3. Check the client’s chart for an Advance Directive
4. Check for responsiveness
5. Begin CPR
Rationale: The nurse is sitting at the nurse’s station, so the first thing they should do is pick up the client’s chart and verify that they do not have a DNR order. If the client has a DNR order, the nurse is legally prevented from completing CPR. In this case, the client does not have a DNR order, so the nurse would continue the steps in the CPR sequence. As the nurse is beginning CPR, someone can be appointed to call for 911 to transport the client to the hospital. If the client were in the hospital, a code blue would be called instead of transporting the client by ambulance.
Category: Management of Care/Advance Directives
Rationale: The nurse is sitting at the nurse’s station, so the first thing they should do is pick up the client’s chart and verify that they do not have a DNR order. If the client has a DNR order, the nurse is legally prevented from completing CPR. In this case, the client does not have a DNR order, so the nurse would continue the steps in the CPR sequence. As the nurse is beginning CPR, someone can be appointed to call for 911 to transport the client to the hospital. If the client were in the hospital, a code blue would be called instead of transporting the client by ambulance.
Category: Management of Care/Advance Directives
The client is scheduled for surgery. While preparing the client, he mentions that he does not understand the procedure. He has already signed the informed consent. What is the best action by the nurse?
Rationale: Signing an informed consent means that the client understands the procedure, along with the risks and benefits. If the client does not understand the procedure and has questions, those need to be answered before the client is prepped for surgery. The nurse is not able to discuss the procedure and risks or benefit with the client, so the surgery must be held until the physician can speak with the client.
Category: Management of Care/Advocacy
Rationale: Signing an informed consent means that the client understands the procedure, along with the risks and benefits. If the client does not understand the procedure and has questions, those need to be answered before the client is prepped for surgery. The nurse is not able to discuss the procedure and risks or benefit with the client, so the surgery must be held until the physician can speak with the client.
Category: Management of Care/Advocacy
The nurse is caring for a client who is scheduled to receive chemotherapy. The client states she can no longer continue to receive chemotherapy because her quality of life is poor. What is the best initial action by the nurse?
Rationale: Since the nurse is currently with the client, it is an ideal time to show advocacy and support for the client by listening to them and discussing their situation. There may be other possibilities for treatment the client has not thought of, or the client may just need someone to listen. The second best option would be to help the client call their spouse and the last intervention would be to call the Dr, after the client has discussed ideas and made up their mind.
Category: Management of Care/Advocacy
Rationale: Since the nurse is currently with the client, it is an ideal time to show advocacy and support for the client by listening to them and discussing their situation. There may be other possibilities for treatment the client has not thought of, or the client may just need someone to listen. The second best option would be to help the client call their spouse and the last intervention would be to call the Dr, after the client has discussed ideas and made up their mind.
Category: Management of Care/Advocacy
A client is admitted who is originally from Mexico. They have been in the United States for 20 years. As the nurse is gathering data, they suspect the client is having trouble understanding questions. What is the best action by the nurse?
Rationale: It is important that a client understands what the nurse is asking them and is able to answer appropriately, as they may have a history or may be taking a medication that could affect their care. Family members are not appropriate interpreters as they may not accurately relay sensitive information. Acute care facilities should have face to face or telephone interpreters that can be utilized. Many clients who do not understand questions or teaching will verbalize that they understand to avoid appearing inadequate.
Category: Management of Care/Advocacy
Rationale: It is important that a client understands what the nurse is asking them and is able to answer appropriately, as they may have a history or may be taking a medication that could affect their care. Family members are not appropriate interpreters as they may not accurately relay sensitive information. Acute care facilities should have face to face or telephone interpreters that can be utilized. Many clients who do not understand questions or teaching will verbalize that they understand to avoid appearing inadequate.
Category: Management of Care/Advocacy
The nurse has several clients during his shift. What task is most appropriate to delegate to a UAP?
Rationale: UAPs can take vital signs, but they cannot do that in a situation that requires assessment by a nurse, such as a client returning from surgery. UAPs cannot change dressings and in most cases cannot remove Foley catheters. The most appropriate task to delegate is the one requiring the least skill and one that does not require assessment. The nurse should immediately follow up with the UAP to ensure the temperature was within normal limits.
Category: Management of Care/Assignment, Delegation and Supervision
Rationale: UAPs can take vital signs, but they cannot do that in a situation that requires assessment by a nurse, such as a client returning from surgery. UAPs cannot change dressings and in most cases cannot remove Foley catheters. The most appropriate task to delegate is the one requiring the least skill and one that does not require assessment. The nurse should immediately follow up with the UAP to ensure the temperature was within normal limits.
Category: Management of Care/Assignment, Delegation and Supervision
The RN is working with an LPN. What skill can be delegated to the LPN?
Rationale: In general, initial tasks should not be delegated to LPNs as they require an initial assessment by an LPN. When delegating to the LPN, always choose the most stable client with the most basic task. The more acute tasks should be handled by the RN. State laws vary, but generally LPNs cannot hang blood or provide initial assessments and teaching.
Category: Management of Care/Assignment, Delegation and Supervision
Rationale: In general, initial tasks should not be delegated to LPNs as they require an initial assessment by an LPN. When delegating to the LPN, always choose the most stable client with the most basic task. The more acute tasks should be handled by the RN. State laws vary, but generally LPNs cannot hang blood or provide initial assessments and teaching.
Category: Management of Care/Assignment, Delegation and Supervision
The nurse is reviewing her assignment for the day. Which client should she see first?
Rationale: The RN should always see the client first who is most critical. The client who cannot breathe will most likely deteriorate more quickly than the other clients. The clients who are vomiting and complaining of pain may be more demanding of the nurse’s time, but they are not the clients with the most serious conditions at this time. Providing the nurse has co-workers who are able to help, they could delegate the medication administration for those clients to them.
Category: Management of Care/Assignment, Delegation and Supervision
Rationale: The RN should always see the client first who is most critical. The client who cannot breathe will most likely deteriorate more quickly than the other clients. The clients who are vomiting and complaining of pain may be more demanding of the nurse’s time, but they are not the clients with the most serious conditions at this time. Providing the nurse has co-workers who are able to help, they could delegate the medication administration for those clients to them.
Category: Management of Care/Assignment, Delegation and Supervision
The nurse is organizing her day. She has several clients to see. Which one should take priority?
Rationale: The nurse should give priority to the client who is at the greatest risk for injury or death. In this case, that is the suicidal client. The nurse will need to place this client on suicidal precautions and ensure someone stays with them 24/7 until the crisis is resolved. The other situations could become acute, but at this time, they are not. The nurse could delegate her UAP to complete vital signs and glucose checks while she attends to client in option #4.
Category: Management of Care/Assignment, Delegation and Supervision
Rationale: The nurse should give priority to the client who is at the greatest risk for injury or death. In this case, that is the suicidal client. The nurse will need to place this client on suicidal precautions and ensure someone stays with them 24/7 until the crisis is resolved. The other situations could become acute, but at this time, they are not. The nurse could delegate her UAP to complete vital signs and glucose checks while she attends to client in option #4.
Category: Management of Care/Assignment, Delegation and Supervision
How can the nurse be sure that the person he delegated a task to is able to perform it?
Rationale: Since the nurse maintains responsibility for a task, even when completed by the UAP, they would want to give specific instructions about what they want. They also need to frequently follow up to ensure it is completed correctly. Even if the UAP has been signed off on a task that is not a guarantee that they are able to complete it correctly. Demonstrating the task for the UAP does not guarantee they understand it.
Category: Management of Care/Assignment, Delegation and Supervision
Rationale: Since the nurse maintains responsibility for a task, even when completed by the UAP, they would want to give specific instructions about what they want. They also need to frequently follow up to ensure it is completed correctly. Even if the UAP has been signed off on a task that is not a guarantee that they are able to complete it correctly. Demonstrating the task for the UAP does not guarantee they understand it.
Category: Management of Care/Assignment, Delegation and Supervision
The charge nurse is looking at the client assignments for the day. Which client should be assigned to the LPN?
Rationale: The least complex client should be assigned to the LPN. In this case, that is the client who is being discharged today. If the client is ready for discharge, their acute issues should be resolved. The other clients listed have acute issues that must be monitored and LPNs cannot administer blood.
Category: Management of Care/Assignment, Delegation and Supervision
Rationale: The least complex client should be assigned to the LPN. In this case, that is the client who is being discharged today. If the client is ready for discharge, their acute issues should be resolved. The other clients listed have acute issues that must be monitored and LPNs cannot administer blood.
Category: Management of Care/Assignment, Delegation and Supervision
A client who was admitted to the hospital with COPD is now being discharged. This is a new diagnosis for the client. What resource should the case manager arrange?
Rationale: The client with COPD will generally need to receive oxygen therapy. Since this is a new diagnosis for this client, they would not have the equipment at home, and the case manager should arrange for this. There are currently no indicators that show the client will need home care assistance or transportation. If there were indicators for these services, then the case manager would assist with those as well.
Category: Management of Care/Case Management
Rationale: The client with COPD will generally need to receive oxygen therapy. Since this is a new diagnosis for this client, they would not have the equipment at home, and the case manager should arrange for this. There are currently no indicators that show the client will need home care assistance or transportation. If there were indicators for these services, then the case manager would assist with those as well.
Category: Management of Care/Case Management
A client who has been admitted multiple times for uncontrolled diabetes is being discharged. What service should the case manager consider ordering?
Rationale: Out of the above choices, the weekly home health nurse visits would be most beneficial for this client, because the nurse can assist the client with their medication and make sure they are checking their glucose and taking their medications. The nurse can also determine if the client is out of supplies and assist them in getting those supplies. All therapies ordered will depend on their insurance coverage.
Category: Management of Care/Case Management
Rationale: Out of the above choices, the weekly home health nurse visits would be most beneficial for this client, because the nurse can assist the client with their medication and make sure they are checking their glucose and taking their medications. The nurse can also determine if the client is out of supplies and assist them in getting those supplies. All therapies ordered will depend on their insurance coverage.
Category: Management of Care/Case Management
The case manager is assisting the client with discharge needs. The client mentions that they cannot afford their medications and they hope this new medication is not expensive. The case manager notes that the medication is a new drug on the market. What can the case manager do to promote compliance in this client?
Rationale: New drugs are drugs that do not have generic equivalents and they are normally very expensive. If the client cannot afford their medications, a month supply will not help them with compliance. The case manager is not legally able to call the pharmacy and have the drug changed, but they can call the physician and work with them to find a drug that is available in generic form. This will make the therapy more affordable for the client.
Category: Management of Care/Case Management
Rationale: New drugs are drugs that do not have generic equivalents and they are normally very expensive. If the client cannot afford their medications, a month supply will not help them with compliance. The case manager is not legally able to call the pharmacy and have the drug changed, but they can call the physician and work with them to find a drug that is available in generic form. This will make the therapy more affordable for the client.
Category: Management of Care/Case Management
An 83 year old client is being discharged after suffering a stroke. He has right sided weakness and newly onset confusion this admission. Where would the case manager most likely plan to send him upon discharge?
Rationale: The best place to send this client is to the rehab facility so he can receive assistance with his right sided weakness and continue to mobilize. After the stroke, the confusion will need to be monitored to see if it improves or will be chronic. He cannot be sent home because his is unable to care for himself and we do not know if he has anyone to assist him. Long term care is not yet appropriate because he needs to receive physical therapy for his deficit to try to regain some use of his limbs. Assisted living does not provide rehabilitation services.
Category: Management of Care/Case Management
Rationale: The best place to send this client is to the rehab facility so he can receive assistance with his right sided weakness and continue to mobilize. After the stroke, the confusion will need to be monitored to see if it improves or will be chronic. He cannot be sent home because his is unable to care for himself and we do not know if he has anyone to assist him. Long term care is not yet appropriate because he needs to receive physical therapy for his deficit to try to regain some use of his limbs. Assisted living does not provide rehabilitation services.
Category: Management of Care/Case Management
The case manager is preparing to send a client home with drug samples. His prescription is for 32 units of regular insulin S.Q. with meals 3x day. The case manager will give the client 1 vial of regular insulin, which contains 1000 units. This vial will last ____ days. (Round down to nearest whole number)
Rationale: The client will take, at most, 32 units of insulin 3 x a day. 3×32=96 units per day. This number should be divided by the total units in the vial which is 1000 units. 1000/96= 10.42. Round this down to equal 10 full days of medication dosing.
Category: Management of Care/Case Management
Rationale: The client will take, at most, 32 units of insulin 3 x a day. 3×32=96 units per day. This number should be divided by the total units in the vial which is 1000 units. 1000/96= 10.42. Round this down to equal 10 full days of medication dosing.
Category: Management of Care/Case Management
The client is scheduled to receive dialysis. When the nurse begins her shift in the morning, the client tells her that she is only getting dialysis because a family member wants her to and that she doesn’t want to do it anymore. What is the best response by the nurse?
Rationale: Discontinuing dialysis is a serious step, as it will lead to death. It is important to discuss the outcomes with the client to ensure they understand the consequences, in a non-judgmental manner. Once the nurse is sure she understands the implications of her decision, then it would be appropriate to encourage her to speak with the family member and her doctor. Choice 3 is not appropriate because it closes communication between the client and the nurse.
Category: Management of Care/Client Rights
Rationale: Discontinuing dialysis is a serious step, as it will lead to death. It is important to discuss the outcomes with the client to ensure they understand the consequences, in a non-judgmental manner. Once the nurse is sure she understands the implications of her decision, then it would be appropriate to encourage her to speak with the family member and her doctor. Choice 3 is not appropriate because it closes communication between the client and the nurse.
Category: Management of Care/Client Rights
An oriented client refuses to let a UAP complete a glucose check, and the nurse overhears the UAP tell the client that they are required to check their glucose. What is the best response by the nurse?
Rationale: Clients have a right to refuse medications and treatments, so they would not have to submit to a glucose check if they do not wish to. In this case, the nurse would ask the UAP to stop attempting to check their glucose. If the client appeared confused, or did not understand the implications of refusing a glucose check, the nurse would want to explain those to them. Insulin should never be given without obtaining glucose levels.
Category: Management of Care/Client Rights
Rationale: Clients have a right to refuse medications and treatments, so they would not have to submit to a glucose check if they do not wish to. In this case, the nurse would ask the UAP to stop attempting to check their glucose. If the client appeared confused, or did not understand the implications of refusing a glucose check, the nurse would want to explain those to them. Insulin should never be given without obtaining glucose levels.
Category: Management of Care/Client Rights
A newly diagnosed diabetic asks the nurse what the treatment options are for diabetes. What should the nurse include as treatment options to help the client make an informed decision? Select all that apply
Rationale: With new onset diabetes, there are several treatment methods that could be tried, such as diet, exercise, weight loss, and medications such as oral hypoglycemics and insulin. Diet and exercise as well as weight loss might be enough to bring the disease under control. The nurse would help the client make an informed decision by discussing these treatment methods. Metoprolol is not used to treat diabetes.
Category: Management of Care/Client Rights
Rationale: With new onset diabetes, there are several treatment methods that could be tried, such as diet, exercise, weight loss, and medications such as oral hypoglycemics and insulin. Diet and exercise as well as weight loss might be enough to bring the disease under control. The nurse would help the client make an informed decision by discussing these treatment methods. Metoprolol is not used to treat diabetes.
Category: Management of Care/Client Rights
The nurse strives to promote collaboration with the interdisciplinary team. What action best displays this collaboration?
Rationale: While all answers are examples of collaboration, the nurse working with physical therapy is the best example of collaboration because the nurse is working with someone who is outside the role of nurse or the nursing team. The physical therapist has a completely different function and perception of client care. The second best answer would be collaboration with the nurse practitioner as they are functioning in the role of the care provider, but they still have nursing knowledge.
Category: Management of Care/Collaboration with Interdisciplinary Team
Rationale: While all answers are examples of collaboration, the nurse working with physical therapy is the best example of collaboration because the nurse is working with someone who is outside the role of nurse or the nursing team. The physical therapist has a completely different function and perception of client care. The second best answer would be collaboration with the nurse practitioner as they are functioning in the role of the care provider, but they still have nursing knowledge.
Category: Management of Care/Collaboration with Interdisciplinary Team
The nurse is collaborating with the social worker to arrange care for a client. What information would be most useful for the social worker?
Rationale: The social worker is concerned with financial and social issues. If the client did not have a place to stay, the social worker would contact facilities and use resources to ensure the client had somewhere to go. They are not concerned with medical issues unless it affects payments or placement in a facility. The case manager should be the one who arranges for equipment after discharge.
Category: Management of Care/Collaboration with Interdisciplinary Team
Rationale: The social worker is concerned with financial and social issues. If the client did not have a place to stay, the social worker would contact facilities and use resources to ensure the client had somewhere to go. They are not concerned with medical issues unless it affects payments or placement in a facility. The case manager should be the one who arranges for equipment after discharge.
Category: Management of Care/Collaboration with Interdisciplinary Team
The nurse is taking care of a client and the client states that they do not want to see the UAP in their room again. How should the nurse proceed?
Rationale: The action that promotes team work is asking the UAP if they would mind switching assignments. Telling the client they cannot have another UAP minimizes the client’s feelings. The nurse also needs to be careful about creating an environment of mistrust between staff members, so options 3 and 4 would not be appropriate to do without discussing the issue with the UAP first.
Category: Management of Care/Concepts of Management
Rationale: The action that promotes team work is asking the UAP if they would mind switching assignments. Telling the client they cannot have another UAP minimizes the client’s feelings. The nurse also needs to be careful about creating an environment of mistrust between staff members, so options 3 and 4 would not be appropriate to do without discussing the issue with the UAP first.
Category: Management of Care/Concepts of Management
The charge nurse is making assignments for the shift. She assigns a nurse and a UAP to work together, but the nurse states she does not want to work with that UAP because they are lazy. What is the best response by the charge nurse?
Rationale: The charge nurse should promote teamwork among the staff, so the best option is to help the staff communicate with each other. 1 and 3 do not promote teamwork, and the charge nurse cannot counsel the UAP unless there is evidence the UAP is not doing their job. Once the charge nurse obtains strong evidence, they can have a discussion with the UAP about their performance.
Category: Management of Care/Concepts of Management
Rationale: The charge nurse should promote teamwork among the staff, so the best option is to help the staff communicate with each other. 1 and 3 do not promote teamwork, and the charge nurse cannot counsel the UAP unless there is evidence the UAP is not doing their job. Once the charge nurse obtains strong evidence, they can have a discussion with the UAP about their performance.
Category: Management of Care/Concepts of Management
A nurse is caring for a client who complains that her money has been stolen from her wallet by one of the housekeepers. What action should the nurse take?
Rationale: The nurse should follow the chain of command with concerns such as these, therefore, the appropriate person to notify would be the nurse’s supervisor. The supervisor would then discuss the issue with security and the manager of housekeeping as necessary. The nurse should not confront the other person involved.
Category: Management of Care/Concepts of Management
Rationale: The nurse should follow the chain of command with concerns such as these, therefore, the appropriate person to notify would be the nurse’s supervisor. The supervisor would then discuss the issue with security and the manager of housekeeping as necessary. The nurse should not confront the other person involved.
Category: Management of Care/Concepts of Management
The nurse begins her shift with a narcotics count. The drawer is 2 pills short of Percocet. The previous nurse already left the building. What should the nurse do?
Rationale: When narcotics are missing, it is best to follow the chain of command. The nurse needs a witness to show that the drugs were missing when she began her shift. The charge nurse can take the required action to follow up with the nurse or the manager. The administration may need to document a pattern of missing drugs to move forward with action against the nurse.
Category: Management of Care/Concepts of Management
Rationale: When narcotics are missing, it is best to follow the chain of command. The nurse needs a witness to show that the drugs were missing when she began her shift. The charge nurse can take the required action to follow up with the nurse or the manager. The administration may need to document a pattern of missing drugs to move forward with action against the nurse.
Category: Management of Care/Concepts of Management
A family member of a client calls on the phone and asks the nurse to tell them how the client is doing. What is the best response by the nurse?
Rationale: HIPAA prevents the disclosure of client information without specific client permission. The nurse should be clear and direct in letting the caller know the guidelines. The second best option would be to ask them to speak with the client, but generally the family member would not call the nurse if they think the client is oriented and understands what is going on. The doctor is also not allowed to give out information without consent.
Category: Management of Care/Confidentiality/Information Security
Rationale: HIPAA prevents the disclosure of client information without specific client permission. The nurse should be clear and direct in letting the caller know the guidelines. The second best option would be to ask them to speak with the client, but generally the family member would not call the nurse if they think the client is oriented and understands what is going on. The doctor is also not allowed to give out information without consent.
Category: Management of Care/Confidentiality/Information Security
The nurse notices that the hospital has placed a cart in the hallway with client names and room numbers on it. How should the nurse intervene?
Rationale: If the nurse moves the cart, it will just be returned to its place by another staff member. The best option is to alert management that the cart constitutes a HIPAA violation so they can remove it and prevent it from being replaced. Nurses should always be on the lookout for potential HIPAA violations to help keep client information secure.
Category: Management of Care/Confidentiality/Information Security
Rationale: If the nurse moves the cart, it will just be returned to its place by another staff member. The best option is to alert management that the cart constitutes a HIPAA violation so they can remove it and prevent it from being replaced. Nurses should always be on the lookout for potential HIPAA violations to help keep client information secure.
Category: Management of Care/Confidentiality/Information Security
What item should be included in a hand-off report to the oncoming nurse?
Rationale: In order to take care of the client, the oncoming nurse needs to be aware of any upcoming tests. Other pertinent information includes current diagnoses, recent labs, and changes in vital signs. The nurse should not bias the oncoming nurse by discussing perceptions about family behaviors, unless they pose a danger to the nurse.
Category: Management of Care/Confidentiality/Information Security
Rationale: In order to take care of the client, the oncoming nurse needs to be aware of any upcoming tests. Other pertinent information includes current diagnoses, recent labs, and changes in vital signs. The nurse should not bias the oncoming nurse by discussing perceptions about family behaviors, unless they pose a danger to the nurse.
Category: Management of Care/Confidentiality/Information Security
The nurse is checking orders for a client. Which of these orders would the nurse question?
Rationale: Only approved abbreviations should be used when charting and writing medication orders. CC’s are no longer used for medication measurement. All orders should include the frequency, dose, medication, and route. Medication orders may also include indication.
Category: Management of Care/Confidentiality/Continuity of Care
Rationale: Only approved abbreviations should be used when charting and writing medication orders. CC’s are no longer used for medication measurement. All orders should include the frequency, dose, medication, and route. Medication orders may also include indication.
Category: Management of Care/Confidentiality/Continuity of Care
The nurse is admitting a new client to the unit from home. What action should the nurse take during the admission process?
Rationale: A medication reconciliation must be completed upon admission of a client. The reconciliation should include the medications, doses, frequency and purpose. If the client is unsure about the doses, they can ask a family member to bring the bottles in. An accurate list is important because the physician will restart these medications while in the hospital and will use this list to discontinue medications when the client is discharged.
Category: Management of Care/Confidentiality/Continuity of Care
Rationale: A medication reconciliation must be completed upon admission of a client. The reconciliation should include the medications, doses, frequency and purpose. If the client is unsure about the doses, they can ask a family member to bring the bottles in. An accurate list is important because the physician will restart these medications while in the hospital and will use this list to discontinue medications when the client is discharged.
Category: Management of Care/Confidentiality/Continuity of Care
The client asks the nurse what her lab results are. What is the best response by the nurse?
Rationale: Since the Client Protection and Affordable Health care act was instituted, information is not provided more freely to clients regarding their care. While the nurse cannot tell the client what the physician will do with the lab results, they can tell the client what their results were and whether they were higher or lower than normal. A client does not need to sign a release to find out what their own lab results are.
Category: Management of Care/Confidentiality/Continuity of Care
Rationale: Since the Client Protection and Affordable Health care act was instituted, information is not provided more freely to clients regarding their care. While the nurse cannot tell the client what the physician will do with the lab results, they can tell the client what their results were and whether they were higher or lower than normal. A client does not need to sign a release to find out what their own lab results are.
Category: Management of Care/Confidentiality/Continuity of Care
The nurse is caring for a client and the client complains of being short of breath. What should the nurse do first?
Rationale: The nurse first needs to know what the client’s vital signs are so they can determine if the client has a low O2 or if there is another problem. The nurse will need to be familiar with the client’s diagnosis. If the client has stable vital signs, the nurse should assist the client into bed with the head slightly elevated to encourage easy breathing. If the client has COPD, the nurse may assist the client to lean on an over the bed table. Oxygen is only required if the O2 sat is low.
Category: Management of Care/Confidentiality/Establishing Priorities
Rationale: The nurse first needs to know what the client’s vital signs are so they can determine if the client has a low O2 or if there is another problem. The nurse will need to be familiar with the client’s diagnosis. If the client has stable vital signs, the nurse should assist the client into bed with the head slightly elevated to encourage easy breathing. If the client has COPD, the nurse may assist the client to lean on an over the bed table. Oxygen is only required if the O2 sat is low.
Category: Management of Care/Confidentiality/Establishing Priorities
The nurse is caring for a client with a DVT and the UAP calls the nurse and tells them the client is anxious and having trouble breathing. What action should the nurse take first?
Rationale: Since the client has a DVT, they have a high likelihood of having a clot dislodge and travel to the lung. The nurse should raise the head of the bed so the client can breathe easier, and check the O2 sat while applying O2. Then the nurse would call the care provider for further orders tom diagnose a pulmonary embolism. They would likely be started on heparin if confirmed.
Category: Management of Care/Confidentiality/Establishing Priorities
Rationale: Since the client has a DVT, they have a high likelihood of having a clot dislodge and travel to the lung. The nurse should raise the head of the bed so the client can breathe easier, and check the O2 sat while applying O2. Then the nurse would call the care provider for further orders tom diagnose a pulmonary embolism. They would likely be started on heparin if confirmed.
Category: Management of Care/Confidentiality/Establishing Priorities
A nurse is caring for a client with atrial fibrillation. All of a sudden, when they are walking in the hall, they become confused and have trouble speaking. What action should the nurse take?
Rationale: At this time, the client does not have a gait deficit, but the nurse needs to get the client to their room and into the bed before they complete the assessment. Once in bed, the nurse needs to complete a stroke assessment to determine what deficit the client has. They will then call the physician and a stroke team, depending on the client’s age and condition. The main concern is safety with a stroke and then quick administration of TPA if indicated, usually within 90 minutes.)
Category: Management of Care/Confidentiality/Establishing Priorities
Rationale: At this time, the client does not have a gait deficit, but the nurse needs to get the client to their room and into the bed before they complete the assessment. Once in bed, the nurse needs to complete a stroke assessment to determine what deficit the client has. They will then call the physician and a stroke team, depending on the client’s age and condition. The main concern is safety with a stroke and then quick administration of TPA if indicated, usually within 90 minutes.)
Category: Management of Care/Confidentiality/Establishing Priorities
The nurse is caring for a client who is found to be clammy, cold, and confused. The nurse has just come on shift and has not received report. What should the nurse do?
Rationale: The listed signs are signs of hypoglycemia, so the nurse should suspect low glucose and check the glucose before administering anything. If the client cannot eat or drink, glucagon IM/SQ or Dextrose IV should be administered once it is determined that the glucose is too low. Placing a warming blanket will not benefit the client and will take valuable time away from ensuring the client is safe.
Category: Management of Care/Confidentiality/Establishing Priorities
Rationale: The listed signs are signs of hypoglycemia, so the nurse should suspect low glucose and check the glucose before administering anything. If the client cannot eat or drink, glucagon IM/SQ or Dextrose IV should be administered once it is determined that the glucose is too low. Placing a warming blanket will not benefit the client and will take valuable time away from ensuring the client is safe.
Category: Management of Care/Confidentiality/Establishing Priorities
The nurse just received report on his clients for the day. Which client should the nurse see first?
Rationale: The nurse should give priority to the client who is most acute. In this case, it is the client with the asthma exacerbation. The airway could quickly close and the client will be unable to breathe. It is important for this client to be assessed and receive medications. The COPD client has a chronic condition and is stable. The DVT client does not currently have symptoms but should be assessed second and the MI client who was admitted yesterday should be stabilized at this point.
Category: Management of Care/Confidentiality/Establishing Priorities
Rationale: The nurse should give priority to the client who is most acute. In this case, it is the client with the asthma exacerbation. The airway could quickly close and the client will be unable to breathe. It is important for this client to be assessed and receive medications. The COPD client has a chronic condition and is stable. The DVT client does not currently have symptoms but should be assessed second and the MI client who was admitted yesterday should be stabilized at this point.
Category: Management of Care/Confidentiality/Establishing Priorities
The nurse is preparing medications for several clients. Which medication should be given first?
Rationale: The Clindamycin is ordered on a more frequent basis so it is very important to ensure it is not given late. It does not stay in the blood stream as long and administering it late will cause the trough to bottom out, therefore not effectively killing the intended organisms. The other medications are only administered once a day or twice a day, so there is more leeway with the administration time. Of course, the nurse should also take into account other issues with the clients, when present that may change the priority.
Category: Management of Care/Confidentiality/Establishing Priorities
Rationale: The Clindamycin is ordered on a more frequent basis so it is very important to ensure it is not given late. It does not stay in the blood stream as long and administering it late will cause the trough to bottom out, therefore not effectively killing the intended organisms. The other medications are only administered once a day or twice a day, so there is more leeway with the administration time. Of course, the nurse should also take into account other issues with the clients, when present that may change the priority.
Category: Management of Care/Confidentiality/Establishing Priorities
The nurse has many orders that she needs to complete for the client. What should be completed first?
Rationale: The blood culture should be obtained first, because it takes time for the lab to obtain a result. The nurse cannot administer antibiotics until the blood culture is drawn or the result may be affected. The dressing change is not priority with the given information. The nurse should not transport the client until they have received their medication, unless in an emergency.
Category: Management of Care/Confidentiality/Establishing Priorities
Rationale: The blood culture should be obtained first, because it takes time for the lab to obtain a result. The nurse cannot administer antibiotics until the blood culture is drawn or the result may be affected. The dressing change is not priority with the given information. The nurse should not transport the client until they have received their medication, unless in an emergency.
Category: Management of Care/Confidentiality/Establishing Priorities
The nurse is caring for a client and the physician orders a morphine dose that is 3 times the maximum dose. The nurse questions the order and the physician states to give the medication anyway. The nurse calls the nursing supervisor and they tell her she will be fired if she doesn’t give the medication to the client. What should the nurse do?
Rationale: The nurse should continue to refuse to give the medication if she feels the dose is unsafe and the client cannot handle it. If the nurse gives the medication and the client dies, she will be held liable in a court of law and could lose her license as well. Walking out on the job is abandonment of clients. The nurse cannot change the dose of medication ordered by the care provider.
Category: Management of Care/Confidentiality/Ethical Practice
Rationale: The nurse should continue to refuse to give the medication if she feels the dose is unsafe and the client cannot handle it. If the nurse gives the medication and the client dies, she will be held liable in a court of law and could lose her license as well. Walking out on the job is abandonment of clients. The nurse cannot change the dose of medication ordered by the care provider.
Category: Management of Care/Confidentiality/Ethical Practice
The nurse is caring for a client who has brain cancer and is in hospice care. The client’s family asks for the nurse to give the client morphine even though there are no signs of pain and the client’s respirations are 10. What should the nurse do?
Rationale: The family may feel that the client is continually in pain or they may want assistance in ending the client’s suffering. The nurse cannot ethically give the client pain medication if the client does not appear to be in pain or they have slowed respirations as it may hasten the client’s death. The nurse should continually re-assess the client for pain as the client may be in pain before the 1 hour mark.
Category: Management of Care/Confidentiality/Ethical Practice
Rationale: The family may feel that the client is continually in pain or they may want assistance in ending the client’s suffering. The nurse cannot ethically give the client pain medication if the client does not appear to be in pain or they have slowed respirations as it may hasten the client’s death. The nurse should continually re-assess the client for pain as the client may be in pain before the 1 hour mark.
Category: Management of Care/Confidentiality/Ethical Practice
The nurse is preparing a client for a PICC line and the client does not speak English very well. What is the best action by the nurse?
Rationale: The client would be able to read and understand a consent form in his own language. Most consent forms for simple procedures list the possible effects. A translator or family interpreter would not ensure the client knows what they are signing. There may be legal issues with having a client sign a consent form in a language they do not understand.
Category: Management of Care/Confidentiality/Informed Consent
Rationale: The client would be able to read and understand a consent form in his own language. Most consent forms for simple procedures list the possible effects. A translator or family interpreter would not ensure the client knows what they are signing. There may be legal issues with having a client sign a consent form in a language they do not understand.
Category: Management of Care/Confidentiality/Informed Consent
The nurse is taking care of an 18 year old girl who always asks her mother to explain procedures and exams to her. The nurse needs to obtain informed consent. Who does she need to obtain the consent from?
Rationale: The client is 18 years old, so provided she has no developmental delays that would cause someone to be appointed to make decisions for her, she would sign her own consent forms. A POA found in an advance directive would only go into effect in the event the client loses her faculties and is not able to make decisions for herself. In the event the client is unconsciousness or critically ill and does not have an advance directive, the mother would be able to sign her consents.
Category: Management of Care/Confidentiality/Informed Consent
Rationale: The client is 18 years old, so provided she has no developmental delays that would cause someone to be appointed to make decisions for her, she would sign her own consent forms. A POA found in an advance directive would only go into effect in the event the client loses her faculties and is not able to make decisions for herself. In the event the client is unconsciousness or critically ill and does not have an advance directive, the mother would be able to sign her consents.
Category: Management of Care/Confidentiality/Informed Consent
The nurse, M. Reichart, is transcribing orders from a paper chart to a computer chart. What is the correct procedure when transcribing the orders?
Rationale: When transcribing an order, the nurse must make it clear when it was completed. This includes the date and time, as well as the nurse’s signature. A line should be drawn under the order to show that was where the transcription ended. That way the next person will not mistakenly believe a later order has already been transcribed.
Category: Management of Care/Confidentiality/Information Technology
Rationale: When transcribing an order, the nurse must make it clear when it was completed. This includes the date and time, as well as the nurse’s signature. A line should be drawn under the order to show that was where the transcription ended. That way the next person will not mistakenly believe a later order has already been transcribed.
Category: Management of Care/Confidentiality/Information Technology
The nurse takes a telephone order from a physician. What is the correct way to document the order?
Rationale: The order which is most specific is the correct way to write the order. The physicians name, date, time, and the nurse taking the order must all be listed. The abbreviation T.O must also be listed. If the order is missing one of those components then it is not correct.
Category: Management of Care/Confidentiality/Information Technology
Rationale: The order which is most specific is the correct way to write the order. The physicians name, date, time, and the nurse taking the order must all be listed. The abbreviation T.O must also be listed. If the order is missing one of those components then it is not correct.
Category: Management of Care/Confidentiality/Information Technology
A client is admitted to the hospital with a gunshot wound. He becomes agitated and wants to leave. What is the response by the nurse?
Rationale: As long as the client is not a danger to himself and others, such as a confused client, he is able to leave whenever he wishes. The nurse needs to inform the client what could happen if they leave and the client should sign the AMA form releasing the hospital from responsibility. If the client does not sign the AMA form, 2 nurses can sign as witnesses.
Category: Management of Care/Confidentiality/Legal Rights and Responsibilities
Rationale: As long as the client is not a danger to himself and others, such as a confused client, he is able to leave whenever he wishes. The nurse needs to inform the client what could happen if they leave and the client should sign the AMA form releasing the hospital from responsibility. If the client does not sign the AMA form, 2 nurses can sign as witnesses.
Category: Management of Care/Confidentiality/Legal Rights and Responsibilities
The client arrives at the hospital with a large amount of cash. What is the best action by the nurse to ensure the money is not misplaced during his stay?
Rationale: The money and other valuables needs to be accounted for upon admission. The client needs to sign a statement of the inventory, and the items need to be stored in security. This prevents the items from being stolen and also prevents the client from making a false claim for missing items. The items should not be accessible by other parties. Since someone is usually present in security, there is a chain of custody.
Category: Management of Care/Confidentiality/Legal Rights and Responsibilities
Rationale: The money and other valuables needs to be accounted for upon admission. The client needs to sign a statement of the inventory, and the items need to be stored in security. This prevents the items from being stolen and also prevents the client from making a false claim for missing items. The items should not be accessible by other parties. Since someone is usually present in security, there is a chain of custody.
Category: Management of Care/Confidentiality/Legal Rights and Responsibilities
Which items should be included on an incident report that is sent to the risk management department? Select all that apply.
Rationale: The risk management department looks at hospital events and determines how often they occur and how to prevent them from happening. The client information should be provided so the department can follow up. The nurse should not state that a client fell unless they witnessed them fall. They also should submit the report right away so results of follow-up testing would not be available.
Category: Management of Care/Confidentiality/Performance Improvement (Quality Improvement)
Rationale: The risk management department looks at hospital events and determines how often they occur and how to prevent them from happening. The client information should be provided so the department can follow up. The nurse should not state that a client fell unless they witnessed them fall. They also should submit the report right away so results of follow-up testing would not be available.
Category: Management of Care/Confidentiality/Performance Improvement (Quality Improvement)
The 54 year old client was admitted for a broken arm, which has been pinned. The client is getting ready for discharge and the nurse learns that he has nowhere to be discharged. What referral should the nurse provide?
Rationale: This client is likely to be able to use his arm without rehabilitation as the injury was only a fracture. A simple broken arm does not require acute care. The nurse should provide a referral to local homeless shelters since the client has nowhere to go after discharge. She may want to consult a social worker to discuss the client’s situation with him.
Category: Management of Care/Confidentiality/Referrals
Rationale: This client is likely to be able to use his arm without rehabilitation as the injury was only a fracture. A simple broken arm does not require acute care. The nurse should provide a referral to local homeless shelters since the client has nowhere to go after discharge. She may want to consult a social worker to discuss the client’s situation with him.
Category: Management of Care/Confidentiality/Referrals
The nurse is providing medication instructions for a post-op hip surgery client. The nurse instructs the client to inject lovenox SQ daily. What is the best way to determine the client’s understanding of the instructions?
Rationale: Watching the client administer the medication is the best way to ensure they understand the instructions. If they do not complete the process correctly, the nurse will be able to determine which part they do not understand. Repeating instructions does not ensure the client understands the instructions. The nurse also needs to assess the client’s learning style and be aware of needed accommodations.
Category: Management of Care/Confidentiality/Informed Consent
Rationale: Watching the client administer the medication is the best way to ensure they understand the instructions. If they do not complete the process correctly, the nurse will be able to determine which part they do not understand. Repeating instructions does not ensure the client understands the instructions. The nurse also needs to assess the client’s learning style and be aware of needed accommodations.
Category: Management of Care/Confidentiality/Informed Consent
The nurse is caring for a client who is a DNR in hospice and is using client controlled analgesia (PCA). The nurse notices the client’s wife pushing the client’s medication button while he is asleep. The client’s respirations decrease to 6. What should the nurse do?
Rationale: Since assisted suicide is not legal in most states, and this scenario does not state that the client is in a state where it is legal, the nurse must administer the Narcan to reverse the effects of the narcotic. The client has not stopped breathing and is a DNR. Calling the physician will delay treatment of the client.
Category: Management of Care/Confidentiality/Informed Consent
Rationale: Since assisted suicide is not legal in most states, and this scenario does not state that the client is in a state where it is legal, the nurse must administer the Narcan to reverse the effects of the narcotic. The client has not stopped breathing and is a DNR. Calling the physician will delay treatment of the client.
Category: Management of Care/Confidentiality/Informed Consent
A client with Alzheimer’s has been admitted to the hospital from a nursing home. How should the nurse best collect the client history?
Rationale: The client may not be a reliable historian due to his Alzheimer’s disease. The nurse cannot call a family member until they know who the POA is, due to HIPAA laws concerning the client’s privacy. The best option is to call the nursing home to gather the data.
Category: Management of Care/Confidentiality/Legal Rights and Responsibilities
Rationale: The client may not be a reliable historian due to his Alzheimer’s disease. The nurse cannot call a family member until they know who the POA is, due to HIPAA laws concerning the client’s privacy. The best option is to call the nursing home to gather the data.
Category: Management of Care/Confidentiality/Legal Rights and Responsibilities
The nurse is caring for an 86 year old male and the client mentions he is depressed about some of the age related changes he has experienced. What age related change fits best with this client’s situation?
Rationale: Many of the body systems decline as clients age. They lose muscle and gain fat in its’ place. Older clients usually have decreased energy, though attention span should not be greatly affected. They usually experience a decrease in smell and taste.
Category: Health Promotion and Maintenance/Aging Process
Rationale: Many of the body systems decline as clients age. They lose muscle and gain fat in its’ place. Older clients usually have decreased energy, though attention span should not be greatly affected. They usually experience a decrease in smell and taste.
Category: Health Promotion and Maintenance/Aging Process
The nurse is caring for a 6 month old client and she wants to teach the mother about what types of foods the client should eat at this stage. What should the nurse teach the parent?
Rationale: At 6 months of age, soft table foods can be introduced 1 at a time to determine if the baby can tolerate them. Milk should be continued regularly until 2 years of age and breastfeeding is still recommended for this period if possible. Foods such as hot dogs and grapes should never be fed to infants due to the risk of choking.
Category: Health Promotion and Maintenance/Aging Process
Rationale: At 6 months of age, soft table foods can be introduced 1 at a time to determine if the baby can tolerate them. Milk should be continued regularly until 2 years of age and breastfeeding is still recommended for this period if possible. Foods such as hot dogs and grapes should never be fed to infants due to the risk of choking.
Category: Health Promotion and Maintenance/Aging Process
The nurse is preparing the administer vaccinations to a child at their 18 month appointment. Which vaccinations will be given? Select all that apply.
Rationale: The 18 month old will be nearing the end of their series of vaccines for Hep B, and Polio. They will also receive the DTAP and can receive the influenza vaccine. The HPV vaccine is recommended closer to age 11.
Category: Health Promotion and Maintenance/Aging Process
Rationale: The 18 month old will be nearing the end of their series of vaccines for Hep B, and Polio. They will also receive the DTAP and can receive the influenza vaccine. The HPV vaccine is recommended closer to age 11.
Category: Health Promotion and Maintenance/Aging Process
The nurse is preparing to administer vaccines to an 11 year old client. What vaccines will the nurse prepare? Select all that apply.
Rationale: A child of 11 years old should have already completed their Hep B and polio series. Any age person will receive the influenza vaccine and a child of 11 years old can receive the HPV and meningococcal vaccines for the first time.
Category: Health Promotion and Maintenance/Aging Process
Rationale: A child of 11 years old should have already completed their Hep B and polio series. Any age person will receive the influenza vaccine and a child of 11 years old can receive the HPV and meningococcal vaccines for the first time.
Category: Health Promotion and Maintenance/Aging Process
The nurse is caring for a client in a women’s health clinic who is 50 years old and nearing menopause. What sign/s should the nurse teach the client to watch for?
Rationale: Some of the first signs of menopause can be irregular periods and night sweats. Other symptoms can be weight gain, moodiness, lack of sleep and dry skin. Hot flashes are also another common sign. The nurse should also provide education on possible treatments to alleviate the symptoms of menopause.
Category: Health Promotion and Maintenance/Aging Process
Rationale: Some of the first signs of menopause can be irregular periods and night sweats. Other symptoms can be weight gain, moodiness, lack of sleep and dry skin. Hot flashes are also another common sign. The nurse should also provide education on possible treatments to alleviate the symptoms of menopause.
Category: Health Promotion and Maintenance/Aging Process
The nurse is teaching a group of junior high and high school students about physical changes during puberty. Which item should be included in the teaching?
Rationale: The brain is still developing until the 20’s, which can lead to poor decision making and impulsivity. An imbalance in chemicals during these changes can also lead to a higher risk of suicide in high school age students. The puberty ages mentioned here are too old and puberty generally occurs much earlier. Anorexia is one of the most common eating disorders, but eating disorders themselves are not a common occurrence in school age adolescents.
Category: Health Promotion and Maintenance/Aging Process
Rationale: The brain is still developing until the 20’s, which can lead to poor decision making and impulsivity. An imbalance in chemicals during these changes can also lead to a higher risk of suicide in high school age students. The puberty ages mentioned here are too old and puberty generally occurs much earlier. Anorexia is one of the most common eating disorders, but eating disorders themselves are not a common occurrence in school age adolescents.
Category: Health Promotion and Maintenance/Aging Process
The nurse is working on the labor and delivery unit and discusses procedures with a mother who is in labor. What treatment should the nurse discuss with the mother that will be provided to her newborn?
Rationale: Vitamin K injections are generally given to newborns because newborns lack the clotting factor necessary to stop bleeding. Unless the parents refuse the injection, it will be provided shortly after birth. The other items listed are not given to newborns. Hepatitis B could be provided to a newborn.
Category: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care
Rationale: Vitamin K injections are generally given to newborns because newborns lack the clotting factor necessary to stop bleeding. Unless the parents refuse the injection, it will be provided shortly after birth. The other items listed are not given to newborns. Hepatitis B could be provided to a newborn.
Category: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care
The mother of a newborn informs the nurse she is worried about the baby contracting gonorrhea from the delivery. The nurse informs the client that a medication is instilled in the baby’s eye after birth to ensure they do not have vision problems from the disease. What medication was given?
Rationale: Silver nitrate used to be the medication of choice for STD prevention in infant eyes, but now Erythromycin is used. Tobramycin is another antibiotic that is used in the eye, but is not used for this purpose. The other antibiotics are generally not given in the eye.
Category: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care
Rationale: Silver nitrate used to be the medication of choice for STD prevention in infant eyes, but now Erythromycin is used. Tobramycin is another antibiotic that is used in the eye, but is not used for this purpose. The other antibiotics are generally not given in the eye.
Category: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care
The nurse is caring for a client that just delivered an infant and she notices that no one has been in to visit. What would be the most appropriate statement to make to the client?
Rationale: Choice 2 is open ended and allows the client to elaborate. The nurse needs to find out if the client has someone to help her at home, to be sure she has the necessary support system in place. If the client does not have a support system, the nurse will need to be sure to carefully discuss with the client who she can contact if she is feeling overwhelmed.
Category: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care
Rationale: Choice 2 is open ended and allows the client to elaborate. The nurse needs to find out if the client has someone to help her at home, to be sure she has the necessary support system in place. If the client does not have a support system, the nurse will need to be sure to carefully discuss with the client who she can contact if she is feeling overwhelmed.
Category: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care
The nurse is calculating an expected delivery date for a client whose last menstrual period was on May 20th. What is the expected due date?
Rationale: Due date is calculated by adding 1 year, subtracting 3 months from the last menstrual period and then adding 7 days. That equals a date of February 27th for this client. The other dates are close but are not the result of using this calculation method.
Category: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care
Rationale: Due date is calculated by adding 1 year, subtracting 3 months from the last menstrual period and then adding 7 days. That equals a date of February 27th for this client. The other dates are close but are not the result of using this calculation method.
Category: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care
The client is in labor and asks the nurse for something to eat. The hospital has a policy that laboring women are to be NPO. What is the nurse’s best response?
Rationale: Answer 2 is the most honest answer and the nurse offers to get the client something as soon as she delivers the baby. For safety reasons, clients should not be provided any food or drink while they are in labor. Answer 1 makes it seem like the nurse is not caring about the client and does not want to help.
Category: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care
Rationale: Answer 2 is the most honest answer and the nurse offers to get the client something as soon as she delivers the baby. For safety reasons, clients should not be provided any food or drink while they are in labor. Answer 1 makes it seem like the nurse is not caring about the client and does not want to help.
Category: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care
The nurse is completing a fetal heart rate on a client who presented to the hospital for signs of labor. Which fetal heart rate could indicate the fetus is in trouble?
Rationale: Fetal heart rate should be above 120 during the delivery time frame. A heart rate of 100 is considered bradycardia and could indicate that the baby is compromised. The nurse should alert the physician right away. The other choices are within normal range.
Category: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care
Rationale: Fetal heart rate should be above 120 during the delivery time frame. A heart rate of 100 is considered bradycardia and could indicate that the baby is compromised. The nurse should alert the physician right away. The other choices are within normal range.
Category: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care
The nurse is caring for a client who has recently delivered a newborn and is attempting to breastfeed. The client is concerned that she is not producing milk at this time. What is the best response by the nurse?
Rationale: It can take several days for the mother’s milk to come in. She should continue to have the baby nurse because the suckling action is thought to stimulate milk production. If the mother plans to breastfeed, the baby should not be given formula in the meantime, although the baby may cry from hunger. The baby will receive enough nutrition when the milk comes in. The nurse will also need to instruct the client to supplement if the baby loses too much weight.
Category: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care
Rationale: It can take several days for the mother’s milk to come in. She should continue to have the baby nurse because the suckling action is thought to stimulate milk production. If the mother plans to breastfeed, the baby should not be given formula in the meantime, although the baby may cry from hunger. The baby will receive enough nutrition when the milk comes in. The nurse will also need to instruct the client to supplement if the baby loses too much weight.
Category: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care
The nurse is preparing a newly expectant mother in the 10th week of pregnancy for an ultrasound. The nurse teaches the mother to expect a normal heart rate for the fetus of what number?
Rationale: The normal heart rate of a 10 week old fetus will be around 160 beats per minute. The heart rate will begin to slow down after this time period and may decrease to as little as 120-130 in late pregnancy.
Category: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care
Rationale: The normal heart rate of a 10 week old fetus will be around 160 beats per minute. The heart rate will begin to slow down after this time period and may decrease to as little as 120-130 in late pregnancy.
Category: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care
A client checks into the hospital for signs of labor. What piece of information demonstrates the client is in true labor?
Rationale: Dilation of the cervix is a sure sign the women is in true labor. Other signs are contractions that are regular and increase in intensity, and rupture of membranes. The other choices here can be symptoms noted in false labor.
Category: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care
Rationale: Dilation of the cervix is a sure sign the women is in true labor. Other signs are contractions that are regular and increase in intensity, and rupture of membranes. The other choices here can be symptoms noted in false labor.
Category: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care
The nurse admits a client who experienced rupture of the membranes more than 24 hours ago and has not dilated. She complains of green discharge. What action should the nurse take?
Rationale: The best action the nurse can take is to prepare the client for cesarean delivery. The nurse should be worried about the increased risk of infection due to labor not beginning as it should and the evidence of meconium in the discharge. Once the nurse prepares the client for cesarean, the physician should be called and the client taken to the OR. Induction methods may be too risky at this point due to the time period that has lapsed.
Category: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care
Rationale: The best action the nurse can take is to prepare the client for cesarean delivery. The nurse should be worried about the increased risk of infection due to labor not beginning as it should and the evidence of meconium in the discharge. Once the nurse prepares the client for cesarean, the physician should be called and the client taken to the OR. Induction methods may be too risky at this point due to the time period that has lapsed.
Category: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care
Mr. James is sitting in his chair and wants to go back to bed. He is generally strong but has residual right sided weakness from a stroke. Which assistive device should the nurse select?
Rationale: The client who is strong enough to maneuver himself will benefit from the extra support of a walker. A crutch or cane will be difficult for this client to use due to weakness of the upper and lower extremities on the right side. A Hoyer lift should not be used unless the client is too weak or unable to help move themselves, as the goal is to rehabilitate clients.
Category: Physiological Adaptation/Assistive Devices
Rationale: The client who is strong enough to maneuver himself will benefit from the extra support of a walker. A crutch or cane will be difficult for this client to use due to weakness of the upper and lower extremities on the right side. A Hoyer lift should not be used unless the client is too weak or unable to help move themselves, as the goal is to rehabilitate clients.
Category: Physiological Adaptation/Assistive Devices
Mrs. Cantor complains of pain in her left leg. She does not have any other mobility problems, but limps when walking. What assistive device should the nurse recommend for the client?
Rationale: A client who only has weakness in one leg and can ambulate with a cane for stability. Crutches are not called for unless the client has an acute injury. A walker is used for clients with more weakness or stability issues than this client. A Hoyer lift is only appropriate for clients who are unable to move themselves.
Category: Physiological Adaptation/Assistive Devices
Rationale: A client who only has weakness in one leg and can ambulate with a cane for stability. Crutches are not called for unless the client has an acute injury. A walker is used for clients with more weakness or stability issues than this client. A Hoyer lift is only appropriate for clients who are unable to move themselves.
Category: Physiological Adaptation/Assistive Devices
Mrs. Cantor will be discharged from the hospital with a cane as an assistive device. The nurse is teaching her how to use the cane. What is the appropriate instruction?
Rationale: The arm should only be slightly bent at around a 10-15 degree angle when holding the cane. The client uses the cane for support when walking and the arm must be at an angle to support the extra pressure. The American Academy of Orthopedic surgeons recommends for the cane to be held on the opposite side of the weakness.
Category: Physiological Adaptation/Assistive Devices
Rationale: The arm should only be slightly bent at around a 10-15 degree angle when holding the cane. The client uses the cane for support when walking and the arm must be at an angle to support the extra pressure. The American Academy of Orthopedic surgeons recommends for the cane to be held on the opposite side of the weakness.
Category: Physiological Adaptation/Assistive Devices
Mrs. Cantor will be discharged from the hospital with a cane as an assistive device. The nurse is teaching her how to use the cane. What is the appropriate instruction?
Rationale: The client should advance the cane and step off with their injured leg. They should advance the good leg second. The cane should be held in the arm opposite the bad leg and the arm should be slightly bent. This provides a little extra stability to the client’s gait.
Category: Physiological Adaptation/Assistive Devices
Rationale: The client should advance the cane and step off with their injured leg. They should advance the good leg second. The cane should be held in the arm opposite the bad leg and the arm should be slightly bent. This provides a little extra stability to the client’s gait.
Category: Physiological Adaptation/Assistive Devices
A client has a prosthetic leg and his nurse is teaching him about ways to avoid contractures. What sleeping positions should the nurse include?
Rationale: The client should lay prone when possible at it stretches the front of the stump so the muscles do not become contracted. These clients often sit in wheelchairs and the stump becomes contracted in the forward position. Laying in the other positions will not stretch the leg.
Category: Physiological Adaptation/Assistive Devices
Rationale: The client should lay prone when possible at it stretches the front of the stump so the muscles do not become contracted. These clients often sit in wheelchairs and the stump becomes contracted in the forward position. Laying in the other positions will not stretch the leg.
Category: Physiological Adaptation/Assistive Devices
Mr. Dan has just arrived to the orthopedic unit after an above the knee operation. The nurse teaches him how to prepare his stump for a prosthetic device. What should be taught?
Rationale: The client should keep his stump wrapped with an elastic bandage to reduce edema and shrink the stump enough to fit into a prosthesis. Elevating the extremity may be helpful for swelling, but it will not prepare the stump for a prosthesis. Ice can also be helpful, but will only reduce swelling, and not prepare the stump.
Category: Physiological Adaptation/Assistive Devices
Rationale: The client should keep his stump wrapped with an elastic bandage to reduce edema and shrink the stump enough to fit into a prosthesis. Elevating the extremity may be helpful for swelling, but it will not prepare the stump for a prosthesis. Ice can also be helpful, but will only reduce swelling, and not prepare the stump.
Category: Physiological Adaptation/Assistive Devices
Carla asks the nurse to help put her hearing aid in. How does the nurse accomplish this?
Rationale: The hearing aid should be turned down prior to insertion. If it is not turned down, it can harm the client’s hearing. The client can adjust the sound as needed once the hearing aid is in place. If the batteries are take out, they will not be able to be replaced once the hearing aid is in.
Category: Physiological Adaptation/Assistive Devices
Rationale: The hearing aid should be turned down prior to insertion. If it is not turned down, it can harm the client’s hearing. The client can adjust the sound as needed once the hearing aid is in place. If the batteries are take out, they will not be able to be replaced once the hearing aid is in.
Category: Physiological Adaptation/Assistive Devices
When bathing a female client and cleaning genitalia, how can the nurse best prevent infection?
Rationale: The nurse should think about sterile technique when cleaning the client. It is best to use a new area of the wash cloth each time and wipe from the front to the back. The nurse should start from the outside in, to prevent the dirt and bacteria from being transferred back to the center of the labia.
Category: Physiological Adaptation/Elimination
Rationale: The nurse should think about sterile technique when cleaning the client. It is best to use a new area of the wash cloth each time and wipe from the front to the back. The nurse should start from the outside in, to prevent the dirt and bacteria from being transferred back to the center of the labia.
Category: Physiological Adaptation/Elimination
Mrs. Carmike is complaining of a red rash underneath the folds of her breasts. The nurse suspects the client has an overgrowth of yeast. What should the nurse apply?
Rationale: Miconazole powder is the treatment for yeast and the powder form helps dry out the area. Barrier cream can help prevent chafing but it will not treat yeast. Baby powder will help keep the area dry but will not treat the yeast. Lotion will make the area more prone to yeast growth.
Category: Physiological Adaptation/Elimination
Rationale: Miconazole powder is the treatment for yeast and the powder form helps dry out the area. Barrier cream can help prevent chafing but it will not treat yeast. Baby powder will help keep the area dry but will not treat the yeast. Lotion will make the area more prone to yeast growth.
Category: Physiological Adaptation/Elimination
Mrs. Enron is incontinent and is unable to get up to change her depends underpants. The nurse wants to prevent her from getting a rash from the urine. What should the nurse select?
Rationale: Barrier cream will prevent the urine from contacting the skin and keep the client’s skin intact. Baby powder will not be enough to soak up the urine and lotion will make the area moister. Miconazole powder will only help if the client has a yeast infection.
Category: Physiological Adaptation/Elimination
Rationale: Barrier cream will prevent the urine from contacting the skin and keep the client’s skin intact. Baby powder will not be enough to soak up the urine and lotion will make the area moister. Miconazole powder will only help if the client has a yeast infection.
Category: Physiological Adaptation/Elimination
A male client is unable to bathe himself and requires assistance to prevent infection. How should the nurse proceed?
Rationale: The nurse should wash the glans of the penis first, in a circular motion, from the inside to the outside. Secondly, the nurse should wash the shaft and base. The anal area should be cleaned last. If the client has a foreskin, it should be retracted to clear the smegma.
Category: Physiological Adaptation/Elimination
Rationale: The nurse should wash the glans of the penis first, in a circular motion, from the inside to the outside. Secondly, the nurse should wash the shaft and base. The anal area should be cleaned last. If the client has a foreskin, it should be retracted to clear the smegma.
Category: Physiological Adaptation/Elimination
Molly, the nurse, is teaching family members how to care for a client who is comatose. Which action is requires further teaching?
Rationale: A comatose client’s teeth should only be brushed with the client laying on their side. Water should never be introduced as the client does not have a gag reflex, and the water can run into their lungs. The client may not need a complete bath every time they soil themselves, but that is less important than the client aspirating.
Category: Physiological Adaptation/Elimination
Rationale: A comatose client’s teeth should only be brushed with the client laying on their side. Water should never be introduced as the client does not have a gag reflex, and the water can run into their lungs. The client may not need a complete bath every time they soil themselves, but that is less important than the client aspirating.
Category: Physiological Adaptation/Elimination
Family members of a comatose client notice the client’s mouth is dry and want to brush the client’s teeth or give ice cubes. What should the nurse instruct the family members?
Rationale: It is best to soak a swab in water and swab the mouth when it appears dry. The nurse should instruct the family to be careful about getting too much water on the swab so the client does not aspirate. Lemon Glycerin subs are not used anymore due to their drying effect on the mucosa.
Category: Physiological Adaptation/Elimination
Rationale: It is best to soak a swab in water and swab the mouth when it appears dry. The nurse should instruct the family to be careful about getting too much water on the swab so the client does not aspirate. Lemon Glycerin subs are not used anymore due to their drying effect on the mucosa.
Category: Physiological Adaptation/Elimination
Kelly, the nurse is inserting a straight catheter into a male client who cannot urinate. What is the correct technique?
Rationale: The nurse must hold the penis in an erect position of about 75-90 degrees for catheter insertion. This straightens the urethral canal so the catheter can be inserted easily. The nurse should clean from the center of the meatus and out in circular motion to remove bacteria.
Category: Physiological Adaptation/Elimination
Rationale: The nurse must hold the penis in an erect position of about 75-90 degrees for catheter insertion. This straightens the urethral canal so the catheter can be inserted easily. The nurse should clean from the center of the meatus and out in circular motion to remove bacteria.
Category: Physiological Adaptation/Elimination
Fred, a client, submits a urine sample. The sample is pale yellow and cloudy. What should the nurse suspect?
Rationale: When a client has an infection in the urinary tract, the urine will often become cloudy as the bacteria float in the urine. Other signs could be pain on urination and a temperature. Dehydration usually results in dark urine. Kidney stones usually present with flank pain.
Category: Physiological Adaptation/Elimination
Rationale: When a client has an infection in the urinary tract, the urine will often become cloudy as the bacteria float in the urine. Other signs could be pain on urination and a temperature. Dehydration usually results in dark urine. Kidney stones usually present with flank pain.
Category: Physiological Adaptation/Elimination
Marla assesses a client who has had a TURP and has an order for continuous bladder irrigation. Which of the following is not part of the correct procedure?
Rationale: The client needs a 3 way catheter to begin continuous bladder irrigation. One way goes into the bladder, one way to the drainage bag, and one way to the irrigation fluid. The irrigation bags should be hung on an IV pole so the fluid is able to flow in, and aseptic technique should be used. The nurse should visualize how the procedure will work when selecting the equipment and steps.
Category: Physiological Adaptation/Elimination
Rationale: The client needs a 3 way catheter to begin continuous bladder irrigation. One way goes into the bladder, one way to the drainage bag, and one way to the irrigation fluid. The irrigation bags should be hung on an IV pole so the fluid is able to flow in, and aseptic technique should be used. The nurse should visualize how the procedure will work when selecting the equipment and steps.
Category: Physiological Adaptation/Elimination
Carrie called the nurse because her colostomy appears to be clogged. What is the correct procedure for irrigating the colostomy?
Rationale: The nurse must apply lubricant before inserting foreign items into and orifice. This includes enemas and catheters. In an ideal situation, ostomy bags should not be re-used. Clean technique is all that is needed for ostomy care
Category: Physiological Adaptation/Elimination
Mark, the nurse, is getting ready to provide colostomy care for a client. Which stoma requires additional assessment?
Rationale: The stoma of a colostomy should always appear pink or red and beefy. It should protrude around 3/4 an inch to an inch. Any stoma that is discolored, such as grey, black, or blue, indicates a blood flow problem and requires additional assessment and follow up.
Category: Physiological Adaptation/Elimination
Rationale: The stoma of a colostomy should always appear pink or red and beefy. It should protrude around 3/4 an inch to an inch. Any stoma that is discolored, such as grey, black, or blue, indicates a blood flow problem and requires additional assessment and follow up.
Category: Physiological Adaptation/Elimination
Kim, the nurse, is calculating fluid balance on a client over the last 8 hour shift. The client is receiving IV fluids at 125ml per hour. She drank 8 oz. of orange juice, and she had an output of 1000ml of urine. What is the client’s fluid balance? ______ml
Rationale: 125 ml per hour x 8 hours= 1000. 8 oz. = 240ml. The client took in 1240 ml and put out 1000 ml. The fluid balance is 240ml. Be sure to recognize whether the question is asking for intake, output, or fluid balance.
Category: Physiological Adaptation/Elimination
Rationale: 125 ml per hour x 8 hours= 1000. 8 oz. = 240ml. The client took in 1240 ml and put out 1000 ml. The fluid balance is 240ml. Be sure to recognize whether the question is asking for intake, output, or fluid balance.
Category: Physiological Adaptation/Elimination
A 2 year old client is brought to the clinic for an injury. The nurse wants to teach the mother about the most common injuries in this age group. What should the teaching be focused around?
Rationale: 2 year olds are able to walk and explore the world around them. They are likely to open cabinets and remove contents and may explore them by putting the contents in their mouth. They are not mature enough to ride a bicycle at this age and are not as prone to choking as infants. SIDS generally happens to children under 18 months who may not be able to roll over when sleeping.
Category: Safety and Infection Control/Accident/Error/Injury Prevention
Rationale: 2 year olds are able to walk and explore the world around them. They are likely to open cabinets and remove contents and may explore them by putting the contents in their mouth. They are not mature enough to ride a bicycle at this age and are not as prone to choking as infants. SIDS generally happens to children under 18 months who may not be able to roll over when sleeping.
Category: Safety and Infection Control/Accident/Error/Injury Prevention
The nurse is getting ready to catheterize a client with a Foley catheter. What must the nurse verify before attempting the procedure? Select all that apply.
Rationale: The nurse must first verify that there is an order to catheterize the client and then ensure the right client is identified. Most catheters are made of latex, so it is important for the nurse to verify that the client does not have a latex allergy. If so, a latex-free version can be obtained.
Category: Safety and Infection Control/Accident/Error/Injury Prevention
Rationale: The nurse must first verify that there is an order to catheterize the client and then ensure the right client is identified. Most catheters are made of latex, so it is important for the nurse to verify that the client does not have a latex allergy. If so, a latex-free version can be obtained.
Category: Safety and Infection Control/Accident/Error/Injury Prevention
The nurse is visiting the home of a 6 year old boy. What should the nurse focus her teaching on?
Rationale: Children in the 6 year old range are active and enjoy activities such as riding a bike. It is important to teach about using a helmet to prevent head injuries. The other choices relate more to adolescents who are going through changes in middle school or high school.
Category: Safety and Infection Control/Accident/Error/Injury Prevention
Rationale: Children in the 6 year old range are active and enjoy activities such as riding a bike. It is important to teach about using a helmet to prevent head injuries. The other choices relate more to adolescents who are going through changes in middle school or high school.
Category: Safety and Infection Control/Accident/Error/Injury Prevention
A nurse is preparing a presentation for the local high school, where he will discuss safety. What is the most important safety issue to teach this age group about?
Rationale: While suicide and alcohol are important safety issues in this age group, suicide prevention is the most serious risk as there is a high suicide rate in teenagers. Pregnancy prevention is also important, but is not a safety risk. Students should be taught the triggers and warning signs of suicide.
Category: Safety and Infection Control/Accident/Error/Injury Prevention
Rationale: While suicide and alcohol are important safety issues in this age group, suicide prevention is the most serious risk as there is a high suicide rate in teenagers. Pregnancy prevention is also important, but is not a safety risk. Students should be taught the triggers and warning signs of suicide.
Category: Safety and Infection Control/Accident/Error/Injury Prevention
The nurse received report on an 86 year old client who is a fall risk. Which one of these deficits creates the greatest fall risk for the client?
Rationale: Vertigo, or dizziness, creates the highest fall risk for this client. The question does not state how much vision loss the client has experienced, but clients who have vertigo will almost always stumble or lose their balance. The symptom that causes the highest probability of injury will take priority.
Category: Safety and Infection Control/Accident/Error/Injury Prevention
Rationale: Vertigo, or dizziness, creates the highest fall risk for this client. The question does not state how much vision loss the client has experienced, but clients who have vertigo will almost always stumble or lose their balance. The symptom that causes the highest probability of injury will take priority.
Category: Safety and Infection Control/Accident/Error/Injury Prevention
A nurse is teaching a new mother about safety risks to watch for with her infant. What item takes priority?
Rationale: Infants have an immature regulation system so they are more likely to have pauses in their breathing. If a parent notices signs of respiratory distress, such as apnea, cyanosis, or trouble breathing, they should call 911. SIDS is thought to be caused by respiratory distress or apnea due to trouble breathing or foreign objects.
Category: Safety and Infection Control/Accident/Error/Injury Prevention
Rationale: Infants have an immature regulation system so they are more likely to have pauses in their breathing. If a parent notices signs of respiratory distress, such as apnea, cyanosis, or trouble breathing, they should call 911. SIDS is thought to be caused by respiratory distress or apnea due to trouble breathing or foreign objects.
Category: Safety and Infection Control/Accident/Error/Injury Prevention
A new mother is getting ready to be discharged with her infant. The nurse is checking her car seat to ensure it is configured correctly. Which configuration shows a need for further teaching?
Rationale: Some type of rolls or bumpers should be placed on each side of the infant’s head to prevent neck injury. The car seat should never be facing forward for infants. The seat should always face backward and be secured through the seat belt grooves that are designed to hold the seat belt.
Category: Safety and Infection Control/Accident/Error/Injury Prevention
Rationale: Some type of rolls or bumpers should be placed on each side of the infant’s head to prevent neck injury. The car seat should never be facing forward for infants. The seat should always face backward and be secured through the seat belt grooves that are designed to hold the seat belt.
Category: Safety and Infection Control/Accident/Error/Injury Prevention
The nurse is surveying a home for hazards that could cause client injury. Which hazardous item should the nurse instruct the client to remove?
Rationale: A frayed extension cord could cause electrocution or fire, which could injure or cause death to the client. All of the other choices are items which the client may use to remain safe. A night light helps them see, and even though it is by the sink, it does not say it is getting wet from the sink. Extension cords should be avoided but taping them to the floor is a safer alternative then allowing them to lay loosely.
Category: Safety and Infection Control/Accident/Error/Injury Prevention
Rationale: A frayed extension cord could cause electrocution or fire, which could injure or cause death to the client. All of the other choices are items which the client may use to remain safe. A night light helps them see, and even though it is by the sink, it does not say it is getting wet from the sink. Extension cords should be avoided but taping them to the floor is a safer alternative then allowing them to lay loosely.
Category: Safety and Infection Control/Accident/Error/Injury Prevention
The nurse is making room assignments for a few newly admitted clients. Where should the client with advanced dementia be placed?
Rationale: The client should be placed in a shared room because there would be another person who may be able to alert staff if the client begins wandering or needs help. The client should be placed as close to the nursing station as possible to allow for better supervision and injury prevention. Rooms at the end of the hall may take too long for staff to get to.
Category: Safety and Infection Control/Accident/Error/Injury Prevention
Rationale: The client should be placed in a shared room because there would be another person who may be able to alert staff if the client begins wandering or needs help. The client should be placed as close to the nursing station as possible to allow for better supervision and injury prevention. Rooms at the end of the hall may take too long for staff to get to.
Category: Safety and Infection Control/Accident/Error/Injury Prevention
The charge nurse is preparing for several clients to be admitted and is making room assignments. Which client should be placed near the nursing station?
Rationale: A client with delirium tremens would be withdrawing from alcohol use and could be confused, as well as violent, and a danger to themselves and others. They would require the most supervision from the list of clients. It is not known whether the Alzheimer’s client is confused or exhibits wandering tendencies, as the stage is not stated.
Category: Safety and Infection Control/Accident/Error/Injury Prevention
Rationale: A client with delirium tremens would be withdrawing from alcohol use and could be confused, as well as violent, and a danger to themselves and others. They would require the most supervision from the list of clients. It is not known whether the Alzheimer’s client is confused or exhibits wandering tendencies, as the stage is not stated.
Category: Safety and Infection Control/Accident/Error/Injury Prevention
The nurse is preparing to administer medications to a client. How can the nurse best identify the client?
Rationale: The medical ID band and medical record number could be misplaced on the wrong client. It is difficult to match a client to a photo, because many clients may look alike. If the client can state their name and date of birth, the nurse will have exact confirmation that he/she is administering medications to the correct client.
Category: Safety and Infection Control/Accident/Error/Injury Prevention
Rationale: The medical ID band and medical record number could be misplaced on the wrong client. It is difficult to match a client to a photo, because many clients may look alike. If the client can state their name and date of birth, the nurse will have exact confirmation that he/she is administering medications to the correct client.
Category: Safety and Infection Control/Accident/Error/Injury Prevention
An earthquake has occurred and an influx of clients has been routed to the hospital. The nurses need to make room for critically injured clients. Which client should they discharge from the hospital?
Rationale: The stroke client who is waiting for rehab is stable enough that he can be discharged to an outside facility for rehab. The second least critical option to transfer out of the hospital would be the cancer client who could receive chemotherapy at an outclient location. The other 2 clients are critical at this time.
Category: Safety and Infection Control/Emergency Response Plan
Rationale: The stroke client who is waiting for rehab is stable enough that he can be discharged to an outside facility for rehab. The second least critical option to transfer out of the hospital would be the cancer client who could receive chemotherapy at an outclient location. The other 2 clients are critical at this time.
Category: Safety and Infection Control/Emergency Response Plan
A terrorist attack has been carried out with mass injuries and casualties. During triage, the nurse determines which clients will be seen first. Place the clients in order of priority.
1. A client who was closest to the bomb impact and lost both legs, has a severe abdominal wound and BP 52/35, HR 50, RR 4
2. A client who has scrapes on her face from flying debris, BP 150/80, HR 115, RR 20
3. A client who has a broken leg and a pain rating of 10/10
4. A client who lost several pints of blood and has a suspected internal bleed with BP 80/45, HR 135, RR 22
Rationale: In an emergency triage situation with mass casualties, clients are seen in an order of most serious, but still savable conditions to the least serious. Clients that are unable to be saved as noted by injuries and vital signs are placed last as to not take the resources from clients who can still be saved. Client 4’s vitals are still near normal ranges and the low BP with the high HR and respirations indicate blood loss, but the body is still compensating for the loss. Client 1’s injuries are so severe that there is no compensation by the body and the recovery chance is very slim.
Category: Safety and Infection Control/Emergency Response Plan
Rationale: In an emergency triage situation with mass casualties, clients are seen in an order of most serious, but still savable conditions to the least serious. Clients that are unable to be saved as noted by injuries and vital signs are placed last as to not take the resources from clients who can still be saved. Client 4’s vitals are still near normal ranges and the low BP with the high HR and respirations indicate blood loss, but the body is still compensating for the loss. Client 1’s injuries are so severe that there is no compensation by the body and the recovery chance is very slim.
Category: Safety and Infection Control/Emergency Response Plan
A nurse receives a call that the emergency plan has been activated and he is needed to report to the hospital. What action should the nurse take?
Rationale: The facility should have an emergency response policy that tells employees where to report in case of an emergency. That location will be the central command center. The nursing supervisor will not have time to take calls in the event of an emergency plan activation and the nurse needs to go to the command center to see where his services are most needed. Staff may be placed in different positions than normal.
Category: Safety and Infection Control/Emergency Response Plan
Rationale: The facility should have an emergency response policy that tells employees where to report in case of an emergency. That location will be the central command center. The nursing supervisor will not have time to take calls in the event of an emergency plan activation and the nurse needs to go to the command center to see where his services are most needed. Staff may be placed in different positions than normal.
Category: Safety and Infection Control/Emergency Response Plan
The nurse is caring for a client in a disaster situation. The physician calls for 4mg of morphine stat IM. The nurse has a vial with 10mg per 10ml. The nurse should administer __ml.
Rationale: Since the vial contains 10mg per 10ml, there is 1mg per 1ml in the vial. The order calls for 4mg so 4ml would be administered. If the nurse wanted to set up a math problem, it could be solved by 10mg/10ml=4mg/x and then solve for x.
Category: Safety and Infection Control/Emergency Response Plan
Rationale: Since the vial contains 10mg per 10ml, there is 1mg per 1ml in the vial. The order calls for 4mg so 4ml would be administered. If the nurse wanted to set up a math problem, it could be solved by 10mg/10ml=4mg/x and then solve for x.
Category: Safety and Infection Control/Emergency Response Plan
The nurse is instructing a client to use a walker. What is the correct procedure for walking with a walker?
Rationale: A walker is used to help stabilize the client’s position while they move their feet. The client should not lift the walker or push the walker at the same time they are moving their feet. If the clients cannot put weight on their foot and needs to hop along, then crutches should be used.
Category: Safety and Infection Control/Ergonomic Principles
Rationale: A walker is used to help stabilize the client’s position while they move their feet. The client should not lift the walker or push the walker at the same time they are moving their feet. If the clients cannot put weight on their foot and needs to hop along, then crutches should be used.
Category: Safety and Infection Control/Ergonomic Principles
The client is being taught about crutch use, after tearing his ACL. What crutch gait should the nurse teach as the most stable?
Rationale: The four point gait is most stable because there are 4 points on the ground at all times. Each crutch and each leg is moved as 1 point. This gait cannot be used for someone with a major injury as they need to be able to bear weight on the leg.
Category: Safety and Infection Control/Ergonomic Principles
Rationale: The four point gait is most stable because there are 4 points on the ground at all times. Each crutch and each leg is moved as 1 point. This gait cannot be used for someone with a major injury as they need to be able to bear weight on the leg.
Category: Safety and Infection Control/Ergonomic Principles
The nurse is caring for a client who has an unsteady, weaving gait. What assistive device should she recommend for the client when speaking to the physician?
Rationale: For clients with stability issues, the cane is most effective because it helps them balance themselves. Crutches should only be used during an injury and a walker is normally used for generalized weakness or shuffling steps. A wheelchair should not be recommended because it causes decline rather than rehabilitation.
Category: Safety and Infection Control/Ergonomic Principles
Rationale: For clients with stability issues, the cane is most effective because it helps them balance themselves. Crutches should only be used during an injury and a walker is normally used for generalized weakness or shuffling steps. A wheelchair should not be recommended because it causes decline rather than rehabilitation.
Category: Safety and Infection Control/Ergonomic Principles
A client on the unit has MRSA and the nurse wants to collect a specimen from their wound. What is the correct way to maintain contact precautions?
Rationale: The nurse needs to avoid contamination of herself and of the outside of the bag. If she obtains an assistant to hold the biohazard bag open, she can slide the sample inside without contaminating herself or the outside of the bag.
Category: Safety and Infection Control/Handling Hazardous and Infectious Materials
Rationale: The nurse needs to avoid contamination of herself and of the outside of the bag. If she obtains an assistant to hold the biohazard bag open, she can slide the sample inside without contaminating herself or the outside of the bag.
Category: Safety and Infection Control/Handling Hazardous and Infectious Materials
The nurse is caring for a client who has prostate cancer and has radiation seeds implanted. What PPE is required to protect the nurse from radiation when emptying the client’s urinal?
Rationale: Due to the risk of splashing, experts recommend wearing a gown, gloves, and a mask when handling bodily fluids from someone with recent radiation exposure. Double gloves should be worn when handling chemotherapy. The other answers do not provide sufficient protection from radiation.
Category: Safety and Infection Control/Handling Hazardous and Infectious Materials
Rationale: Due to the risk of splashing, experts recommend wearing a gown, gloves, and a mask when handling bodily fluids from someone with recent radiation exposure. Double gloves should be worn when handling chemotherapy. The other answers do not provide sufficient protection from radiation.
Category: Safety and Infection Control/Handling Hazardous and Infectious Materials
The nurse is surveying the home of a client who will be receiving a total hip replacement. What recommendation is most important to improve safety upon discharge?
Rationale: The client will have a very difficult time getting into and out of the shower, both due to range of motion, and pain from the hip replacement. Shower bars will be a necessity. Item 2 should never be recommended as it creates a fall risk. Items 3 and 4 are nice to have, but do not have the most impact on this client’s condition.
Category: Safety and Infection Control/Home Safety
Rationale: The client will have a very difficult time getting into and out of the shower, both due to range of motion, and pain from the hip replacement. Shower bars will be a necessity. Item 2 should never be recommended as it creates a fall risk. Items 3 and 4 are nice to have, but do not have the most impact on this client’s condition.
Category: Safety and Infection Control/Home Safety
The nurse is visiting a diabetic client who will begin injecting insulin at meals and at bedtime. What household item would be most appropriate for disposal of the client’s used needles?
Rationale: The soda bottle is most appropriate because it has a hard shell and also has a narrow opening so it would be more difficult for someone to stick themselves by reaching inside. It also has a lid which prevents the used needles from coming out easily. A coffee can has a wide opening and a less secure lid, which can result in spills and needle stick injuries. The other options are not appropriate.
Category: Safety and Infection Control/Home Safety
Rationale: The soda bottle is most appropriate because it has a hard shell and also has a narrow opening so it would be more difficult for someone to stick themselves by reaching inside. It also has a lid which prevents the used needles from coming out easily. A coffee can has a wide opening and a less secure lid, which can result in spills and needle stick injuries. The other options are not appropriate.
Category: Safety and Infection Control/Home Safety
The nurse is caring for a client with diabetes. She prepares and administers 40 units of insulin. After administering the insulin, she notices she gave the insulin to the wrong client. What steps should the nurse take? Place them in order.
1. Complete an incident report
2. Assess the client
3. Call the physician
4. Administer D5W
5. Check blood glucose
Rationale: The first thing the nurse should always do is assess the client. This includes checking the blood glucose, so after the nurse begins assessing the client, she will check the glucose. Next the nurse will call the physician to get orders for medication for that client. She will begin the dextrose infusion to prevent the glucose from dropping to rapidly. After the client is stable, an incident report must be filled out.
Category: Safety and Infection Control/Reporting of Incident/Event/Irregular Occurrence/Variance
Rationale: The first thing the nurse should always do is assess the client. This includes checking the blood glucose, so after the nurse begins assessing the client, she will check the glucose. Next the nurse will call the physician to get orders for medication for that client. She will begin the dextrose infusion to prevent the glucose from dropping to rapidly. After the client is stable, an incident report must be filled out.
Category: Safety and Infection Control/Reporting of Incident/Event/Irregular Occurrence/Variance
The nurse is completing an incident report on a client she incorrectly administered insulin to. What is the best example of an incident narrative?
Rationale: Answer 1 is correct because it is most specific about what happened and what was done to correct the problem. The investigators need to know whether the nurse followed up with the physician and took steps to ensure the client was not harmed. Another good item to add would be any description of what led to the nurse administering the medication to the wrong client.
Category: Safety and Infection Control/Reporting of Incident/Event/Irregular Occurrence/Variance
Rationale: Answer 1 is correct because it is most specific about what happened and what was done to correct the problem. The investigators need to know whether the nurse followed up with the physician and took steps to ensure the client was not harmed. Another good item to add would be any description of what led to the nurse administering the medication to the wrong client.
Category: Safety and Infection Control/Reporting of Incident/Event/Irregular Occurrence/Variance
The nurse is working in client’s room and notices the electrical cord on the bed is frayed. What is the best action?
Rationale: The nurse should always err on the side of safety so the safest action is to go ahead and remove the bed and call maintenance. The nurse must also tag the piece of equipment so it does not end up back in circulation until it is repaired.
Category: Safety and Infection Control/Reporting of Incident/Safe use of Equipment
Rationale: The nurse should always err on the side of safety so the safest action is to go ahead and remove the bed and call maintenance. The nurse must also tag the piece of equipment so it does not end up back in circulation until it is repaired.
Category: Safety and Infection Control/Reporting of Incident/Safe use of Equipment
The nurse is caring for a baby on the mother-baby unit and notices that the baby is missing from the nursery. The nurse asks the mother if she had the baby and she does not. What should the nurse do?
Rationale: If the parents do not have the baby and the baby is not on the unit, the nurse should call security to lock down the facility and institute a code. This will help alert all staff members in the building that a newborn is missing. Staff should pay close attention to stairwells and anyone carrying what looks like it could be a newborn.
Category: Safety and Infection Control/Reporting of Incident/Security plan
Rationale: If the parents do not have the baby and the baby is not on the unit, the nurse should call security to lock down the facility and institute a code. This will help alert all staff members in the building that a newborn is missing. Staff should pay close attention to stairwells and anyone carrying what looks like it could be a newborn.
Category: Safety and Infection Control/Reporting of Incident/Security plan
The nurse receives a call from someone who mentions they placed a bomb in the building. What is the best action by the nurse?
Rationale: All answers contain important information, but the priority action by the nurse should be alerting police so the building can be evacuated and clients can be kept safe. It may be helpful for the nurse to stall the caller so a trained expert from the police department can talk to them or trace their location.
Category: Safety and Infection Control/Reporting of Incident/Security plan
Rationale: All answers contain important information, but the priority action by the nurse should be alerting police so the building can be evacuated and clients can be kept safe. It may be helpful for the nurse to stall the caller so a trained expert from the police department can talk to them or trace their location.
Category: Safety and Infection Control/Reporting of Incident/Security plan
A client is on isolation for measles. What PPE should the nurse wear when caring for the client?
Rationale: A client with measles is on airborne precautions per the CDC. The nurse and all visitors need to wear an N-95 respirator at the minimum. If blood or other bodily fluids will be plashed, the nurse will don additional PPE as needed.
Category: Safety and Infection Control/Standard Precautions/Transmission-Based Precautions/Surgical Asepsis
Rationale: A client with measles is on airborne precautions per the CDC. The nurse and all visitors need to wear an N-95 respirator at the minimum. If blood or other bodily fluids will be plashed, the nurse will don additional PPE as needed.
Category: Safety and Infection Control/Standard Precautions/Transmission-Based Precautions/Surgical Asepsis
The nurse is caring for a client with influenza and wishes to ask them a question. What PPE is appropriate?
Rationale: As long as the nurse is not coming into contact with bodily fluids, a mask is all that is required for clients under droplet precautions. If the nurse will be exposed to body fluids, they may wish to wear additional PPE such as gown, gloves, and mask.
Category: Safety and Infection Control/Standard Precautions/Transmission-Based Precautions/Surgical Asepsis
Rationale: As long as the nurse is not coming into contact with bodily fluids, a mask is all that is required for clients under droplet precautions. If the nurse will be exposed to body fluids, they may wish to wear additional PPE such as gown, gloves, and mask.
Category: Safety and Infection Control/Standard Precautions/Transmission-Based Precautions/Surgical Asepsis
The nurse is caring for a client with clostridium difficile and needs to change the client and clean up stool that is on the bed. What PPE is appropriate?
Rationale: The nurse should never touch and surfaces in the room of a client with C. diff without wearing gloves, and since the nurse will be cleaning up stool, a gown is required to prevent the nurse from getting stool on their uniform. The nurse should also follow up with hand washing as hand sanitizer does not kill C.diff.
Category: Safety and Infection Control/Standard Precautions/Transmission-Based Precautions/Surgical Asepsis
Rationale: The nurse should never touch and surfaces in the room of a client with C. diff without wearing gloves, and since the nurse will be cleaning up stool, a gown is required to prevent the nurse from getting stool on their uniform. The nurse should also follow up with hand washing as hand sanitizer does not kill C.diff.
Category: Safety and Infection Control/Standard Precautions/Transmission-Based Precautions/Surgical Asepsis
The nurse is caring for a client who is having a procedure and notes that surgical asepsis should be used. What is the best explanation of surgical asepsis?
Rationale: The best statement for surgical asepsis is that surfaces are 99% free of pathogens. It is rare that a surface would be completely free of pathogens. When cleaning for surgical asepsis, the goal is 99% free of germs. Medical asepsis would strive for a reduction in pathogens.
Category: Safety and Infection Control/Standard Precautions/Transmission-Based Precautions/Surgical Asepsis
Rationale: The best statement for surgical asepsis is that surfaces are 99% free of pathogens. It is rare that a surface would be completely free of pathogens. When cleaning for surgical asepsis, the goal is 99% free of germs. Medical asepsis would strive for a reduction in pathogens.
Category: Safety and Infection Control/Standard Precautions/Transmission-Based Precautions/Surgical Asepsis
Mark, RN assesses vital signs on a client in the AM who complains of 10/10 pain. Vitals are BP 145/75, RR 22, HR 120 and T 98.6. He administers 2mg of dilauded IV and comes back in 30 minutes to assess the client again. Which vital signs should the nurse expect if the medication was effective?
Rationale: Vital signs such as heart rate, respirations and blood pressure tend to rise when a client is in extreme pain. If the pain is controlled, the nurse should expect the vital signs to return to a baseline level for the client. The nurse should compare current vital signs to previously charted vital signs.
Category: Reduction of Risk Potential/Changes/Abnormalities in Vital Signs
Rationale: Vital signs such as heart rate, respirations and blood pressure tend to rise when a client is in extreme pain. If the pain is controlled, the nurse should expect the vital signs to return to a baseline level for the client. The nurse should compare current vital signs to previously charted vital signs.
Category: Reduction of Risk Potential/Changes/Abnormalities in Vital Signs
A client is in the hospital and the nurse notices an increased blood pressure. At what level should the nurse become concerned with the blood pressure and call for medication orders?
Rationale: The first blood pressure reading that should cause the nurse to become concerned is 150/75 as anything greater than 150 is considered hypertensive. At 155 systolic, the nurse would have already had opportunity to call the physician. The number students should look for for Blood pressure and blood glucose is generally 150.
Category: Reduction of Risk Potential/Changes/Abnormalities in Vital Signs
Rationale: The first blood pressure reading that should cause the nurse to become concerned is 150/75 as anything greater than 150 is considered hypertensive. At 155 systolic, the nurse would have already had opportunity to call the physician. The number students should look for for Blood pressure and blood glucose is generally 150.
Category: Reduction of Risk Potential/Changes/Abnormalities in Vital Signs
Kim, a client admitted to the hospital for GI bleeding, had a hemoglobin of 5 and a hematocrit of 26. She received 2 units of blood and her hemoglobin is now 6 and hematocrit is 28. What is the best initial action by the nurse?
Rationale: The best initial action is to assess the client. The nurse may be able to determine other causes of bleeding, such as blood in the urine, vomit, or can assess the abdomen to determine if there may be internal bleeding. After this initial step, the nurse may need to prepare the client for surgery, or call the physician.
Category: Reduction of Risk Potential/Diagnostic Tests
Rationale: The best initial action is to assess the client. The nurse may be able to determine other causes of bleeding, such as blood in the urine, vomit, or can assess the abdomen to determine if there may be internal bleeding. After this initial step, the nurse may need to prepare the client for surgery, or call the physician.
Category: Reduction of Risk Potential/Diagnostic Tests
Kim, a client admitted to the hospital for GI bleeding, had a hemoglobin of 5 and a hematocrit of 26. The nurse has an order to draw blood from her PICC line for a CBC sample. How should the nurse proceed?
Category: Reduction of Risk Potential/Diagnostic Tests
Category: Reduction of Risk Potential/Diagnostic Tests
Jay is diabetic and the nurse will check his blood glucose. What procedure should the nurse follow?
Rationale: The nurse should be sure to identify the client and then follow clean technique to check the client’s blood sugar. The first drop should be wiped as the alcohol on the finger can lead to a higher than normal glucose reading.
Category: Reduction of Risk Potential/Diagnostic Tests
Rationale: The nurse should be sure to identify the client and then follow clean technique to check the client’s blood sugar. The first drop should be wiped as the alcohol on the finger can lead to a higher than normal glucose reading.
Category: Reduction of Risk Potential/Diagnostic Tests
A mother on the labor and delivery unit asks the nurse what the fetal heart rate monitor should say. The nurse teaches the mother about normal heart rates in the fetus. When would the fetal heart rate be considered bradycardic?
Rationale: Anything under 110 as a baseline would be considered bradycardia in a fetus and would be cause for concern. The nurse should look at the baseline rate and not at the variable heart rate. The baseline heart rate is determined in a 10- minute window.
Category: Reduction of Risk Potential/Diagnostic Tests
Rationale: Anything under 110 as a baseline would be considered bradycardia in a fetus and would be cause for concern. The nurse should look at the baseline rate and not at the variable heart rate. The baseline heart rate is determined in a 10- minute window.
Category: Reduction of Risk Potential/Diagnostic Tests
A mother on the labor and delivery unit asks the nurse what the fetal heart rate monitor should say. The nurse teaches the mother about normal heart rates in the fetus. When should the nurse teach her that a heart rate would be tachycardic?
Rationale: The nurse should look at the baseline rate and not at the variable heart rate. The baseline heart rate is determined in a 10- minute window. Remember that the heart rate of the fetus should be higher than that of an adult.
Category: Reduction of Risk Potential/Diagnostic Tests
Rationale: The nurse should look at the baseline rate and not at the variable heart rate. The baseline heart rate is determined in a 10- minute window. Remember that the heart rate of the fetus should be higher than that of an adult.
Category: Reduction of Risk Potential/Diagnostic Tests
Janet RN teaches her client about types of decelerations. What should she tell the client is a deceleration where the nadir of the deceleration occurs after the peak of the contraction?
Rationale: Visually apparent, usually symmetrical gradual decrease and return of the FHR associated with a uterine contraction with gradual FHR decrease is defined as from the onset to the FHR nadir of >30 seconds. The decrease in FHR is calculated from the onset to the nadir of the deceleration. The deceleration is delayed in timing, with the nadir of the deceleration occurring after the peak of the contraction. In most cases, the onset, nadir, and recovery of the deceleration occur after the beginning, peak, and ending of the contraction respectively. It is usually caused by uteroplacental insufficiency.
Category: Reduction of Risk Potential/Diagnostic Tests
Rationale: Visually apparent, usually symmetrical gradual decrease and return of the FHR associated with a uterine contraction with gradual FHR decrease is defined as from the onset to the FHR nadir of >30 seconds. The decrease in FHR is calculated from the onset to the nadir of the deceleration. The deceleration is delayed in timing, with the nadir of the deceleration occurring after the peak of the contraction. In most cases, the onset, nadir, and recovery of the deceleration occur after the beginning, peak, and ending of the contraction respectively. It is usually caused by uteroplacental insufficiency.
Category: Reduction of Risk Potential/Diagnostic Tests
A client comes to the clinic for an amniocentesis. What symptoms should the nurse teach her to report after the procedure? Select all that apply.
Rationale: Amniocentesis is an invasive procedure. The nurse should teach the client to report these symptoms because they could represent infection or miscarriage. If the client experiences dizziness, the nurse should teach the client to lay on her left side to increase blood flow.
Category: Reduction of Risk Potential/Diagnostic Tests
Rationale: Amniocentesis is an invasive procedure. The nurse should teach the client to report these symptoms because they could represent infection or miscarriage. If the client experiences dizziness, the nurse should teach the client to lay on her left side to increase blood flow.
Category: Reduction of Risk Potential/Diagnostic Tests
Mr. Call is diabetic and he is having this hemoglobin A1C checked. What result requires further teaching about diabetes?
Rationale: A hemoglobin A1C of 12 represents an average blood sugar of 298 mg/dL (16.5 mmol/L). A hemoglobin A1C of 6 represents an average blood sugar of 126 mg/dL (7 mmol/L). The nurse should teach the client to keep their glucose under 150 at all times.
Category: Reduction of Risk Potential/Diagnostic Tests
Rationale: A hemoglobin A1C of 12 represents an average blood sugar of 298 mg/dL (16.5 mmol/L). A hemoglobin A1C of 6 represents an average blood sugar of 126 mg/dL (7 mmol/L). The nurse should teach the client to keep their glucose under 150 at all times.
Category: Reduction of Risk Potential/Diagnostic Tests
The nurse prepares to take a wound culture on a client with a stage 4 ulcer. How should she proceed?
Rationale: In order to obtain an accurate specimen, the nurse should swab the center of the wound and swab outward toward the edges. Swabbing outside the wound or on the perimeter will not give an accurate indication of what is growing inside the wound. The nurse would not want to cleanse before culturing, as cleansing will remove some of the organisms in the wound.
Category: Reduction of Risk Potential/Diagnostic Tests
Rationale: In order to obtain an accurate specimen, the nurse should swab the center of the wound and swab outward toward the edges. Swabbing outside the wound or on the perimeter will not give an accurate indication of what is growing inside the wound. The nurse would not want to cleanse before culturing, as cleansing will remove some of the organisms in the wound.
Category: Reduction of Risk Potential/Diagnostic Tests
Kevin, a client in a hospital, has a blood glucose of 265. The nurse gives his lunch dose of insulin, but an hour later he complains of feeling dizzy and sweaty. The nurse checks his glucose again and it is 350. The client didn’t eat lunch. What is the best action by the nurse?
Rationale: The nurse should obtain an order for an extra dose of insulin as the client has not even eaten lunch and his glucose continues to rise. The rising glucose may be an effect from the client’s breakfast or from a medication, such as a steroid. The nurse should not give his evening dose of insulin as the client will need that with dinner.
Category: Reduction of Risk Potential/Diagnostic Tests
Rationale: The nurse should obtain an order for an extra dose of insulin as the client has not even eaten lunch and his glucose continues to rise. The rising glucose may be an effect from the client’s breakfast or from a medication, such as a steroid. The nurse should not give his evening dose of insulin as the client will need that with dinner.
Category: Reduction of Risk Potential/Diagnostic Tests
The nurse needs to send a guaiac sample to the lab. What is the best way for the nurse to collect it?
Rationale: The client should defecate in a hat and the nurse should collect a stool sample by smearing stool on a guaiac card with a spatula or wooden stick. The nurse should ensure that the sample does not have urine in it. Only a minimal amount is needed. If reading the results on the unit, the nurse will apply developer to the sample and read the result. Otherwise, it will be send to the lab.
Category: Reduction of Risk Potential/Diagnostic Tests
Rationale: The client should defecate in a hat and the nurse should collect a stool sample by smearing stool on a guaiac card with a spatula or wooden stick. The nurse should ensure that the sample does not have urine in it. Only a minimal amount is needed. If reading the results on the unit, the nurse will apply developer to the sample and read the result. Otherwise, it will be send to the lab.
Category: Reduction of Risk Potential/Diagnostic Tests
A client is admitted to the ICU with the following ABG’s pH 7.37, PaO2 59, PaCO2 50, HCO3 30. How should the nurse interpret this?
Rationale: This is compensated respiratory acidosis because the pH is within normal limits. You can see that the O2 is too low and the CO2 is too high. The bicarb is too high. Normals are pH 7.35-7.45, PaO2: 80-100 mmHg, SaO2: 95-100%, PaCO2: 35-45 mmHg, HCO3: 22-26 mEq/L. The values would be uncompensated when the pH does not return to normal. Since the O2 is low, the CO2 is low, and the bicarb is high, the bicarb is attempting to compensate for the O2 levels.
Category: Reduction of Risk Potential/Laboratory Values
Rationale: This is compensated respiratory acidosis because the pH is within normal limits. You can see that the O2 is too low and the CO2 is too high. The bicarb is too high. Normals are pH 7.35-7.45, PaO2: 80-100 mmHg, SaO2: 95-100%, PaCO2: 35-45 mmHg, HCO3: 22-26 mEq/L. The values would be uncompensated when the pH does not return to normal. Since the O2 is low, the CO2 is low, and the bicarb is high, the bicarb is attempting to compensate for the O2 levels.
Category: Reduction of Risk Potential/Laboratory Values
A client is admitted to the ICU with the following ABG’s pH 7.25, PaO2 59, PaCO2 50, HCO3 30. How should the nurse interpret this?
Rationale: You can see that the O2 is too low and the CO2 is too high. The bicarb is too high. The pH is low. Normals are pH 7.35-7.45, PaO2: 80-100 mmHg, SaO2: 95-100%, PaCO2: 35-45 mmHg, HCO3: 22-26 mEq/L. The bicarb is attempting to compensate for the respiratory decline, but it has not been effective because the pH has not returned to normal. This is partially compensated.
Category: Reduction of Risk Potential/Laboratory Values
Rationale: You can see that the O2 is too low and the CO2 is too high. The bicarb is too high. The pH is low. Normals are pH 7.35-7.45, PaO2: 80-100 mmHg, SaO2: 95-100%, PaCO2: 35-45 mmHg, HCO3: 22-26 mEq/L. The bicarb is attempting to compensate for the respiratory decline, but it has not been effective because the pH has not returned to normal. This is partially compensated.
Category: Reduction of Risk Potential/Laboratory Values
A client is admitted to the step-down unit with the following ABG’s pH 7.40, PaO2 74, PaCO2 28, HCO3 19. How should the nurse interpret this?
Rationale: Normals are pH 7.35-7.45, PaO2: 80-100 mmHg, SaO2: 95-100%, PaCO2: 35-45 mmHg, HCO3: 22-26 mEq/L This is compensated respiratory alkalosis because the pH is normal and the 02 levels are low. When the numbers are low, it should lead you to believe alkalosis.
Category: Reduction of Risk Potential/Laboratory Values
Rationale: Normals are pH 7.35-7.45, PaO2: 80-100 mmHg, SaO2: 95-100%, PaCO2: 35-45 mmHg, HCO3: 22-26 mEq/L This is compensated respiratory alkalosis because the pH is normal and the 02 levels are low. When the numbers are low, it should lead you to believe alkalosis.
Category: Reduction of Risk Potential/Laboratory Values
Molly, RN is caring for a client with the following ABG values: pH 7.25, PaO2 55, PaCO2 30, HCO3 19. The client is cyanotic and confused. How should the nurse proceed?
Rationale: This client has respiratory alkalosis that is not compensated. Their O2 values have deteriorated to the point that the client may need to be intubated to save their life. The oxygen devices will not regulate the breathing enough to correct the deficit.
Category: Reduction of Risk Potential/Laboratory Values
Rationale: This client has respiratory alkalosis that is not compensated. Their O2 values have deteriorated to the point that the client may need to be intubated to save their life. The oxygen devices will not regulate the breathing enough to correct the deficit.
Category: Reduction of Risk Potential/Laboratory Values
When feeding a client, the client coughs uncontrollably after each bite. The UAP reports the information to the nurse. What is the best initial action by the nurse?
Rationale: The best initial action is to raise the head of the bed to 90 degrees when feeding the client. The client may have been laying down too low and could have been aspirating their food due to swallowing difficulties. If the client continues to cough or has a history of pneumonia, it would be best to obtain a barium swallow exam. This exam watches food as it is chewed and swallowed, and will be able to detect aspirations.
Category: Reduction of Risk Potential/Laboratory Values
Rationale: The best initial action is to raise the head of the bed to 90 degrees when feeding the client. The client may have been laying down too low and could have been aspirating their food due to swallowing difficulties. If the client continues to cough or has a history of pneumonia, it would be best to obtain a barium swallow exam. This exam watches food as it is chewed and swallowed, and will be able to detect aspirations.
Category: Reduction of Risk Potential/Laboratory Values
Brian RN, is assigned to a client with a diagnosis of decreased vascular perfusion. What condition should Brian expect when assessing this client?
Rationale: Any client who has undergone surgery is at risk for decreased vascular perfusion. This happens both from trauma to the tissues during surgery, and as a result of immobility. Diabetes will also affect vascular perfusion, but not until the client has been diabetic for a long period.
Category: Reduction of Risk Potential/Potential for Alterations in Body Systems
Rationale: Any client who has undergone surgery is at risk for decreased vascular perfusion. This happens both from trauma to the tissues during surgery, and as a result of immobility. Diabetes will also affect vascular perfusion, but not until the client has been diabetic for a long period.
Category: Reduction of Risk Potential/Potential for Alterations in Body Systems
Which client would be at the highest risk for skin breakdown?
Rationale: A client who is chronically bed-ridden would have decreased muscle mass as well as continued shear forces on their skin from being moved in bed. The carnation shakes don’t provide very much protein, so they are at risk for skin break-down due to nutrition. The other clients are temporarily affected.
Category: Reduction of Risk Potential/Potential for Alterations in Body Systems
Rationale: A client who is chronically bed-ridden would have decreased muscle mass as well as continued shear forces on their skin from being moved in bed. The carnation shakes don’t provide very much protein, so they are at risk for skin break-down due to nutrition. The other clients are temporarily affected.
Category: Reduction of Risk Potential/Potential for Alterations in Body Systems
The NG tube of a client who is in observation for a partial bowel obstruction has now started putting out dark brown coffee ground drainage. The client is complaining of abdominal pain 10/10 and has a distended abdomen. What is the best action by the nurse?
Rationale: Usually a client with a partial bowel obstruction can be placed on NPO status and watched. Sometimes these cases resolve on their own. If the client is progressing and returning stool through the NG tube, surgery will be likely. The nurse should leave the NG tube to suction to continue to decompress the stomach.
Category: Reduction of Risk Potential/Potential for Alterations in Body Systems
Rationale: Usually a client with a partial bowel obstruction can be placed on NPO status and watched. Sometimes these cases resolve on their own. If the client is progressing and returning stool through the NG tube, surgery will be likely. The nurse should leave the NG tube to suction to continue to decompress the stomach.
Category: Reduction of Risk Potential/Potential for Alterations in Body Systems
A client just returned to the unit after a cardiac catheterization. What side effects or complications should the nurse watch for? Select all that apply.
Rationale: Cardiac catheterization involves the insertion of a probe into the right femoral artery. The probe is used to examine the heart, from the right side. These clients receive anticoagulation and are at a high risk of bleeding. Clots can also develop after the procedure and can cut off circulation in the right leg. The nurse should assess pulses below the femoral site.
Category: Reduction of Risk Potential/Potential for Alterations in Body Systems
Rationale: Cardiac catheterization involves the insertion of a probe into the right femoral artery. The probe is used to examine the heart, from the right side. These clients receive anticoagulation and are at a high risk of bleeding. Clots can also develop after the procedure and can cut off circulation in the right leg. The nurse should assess pulses below the femoral site.
Category: Reduction of Risk Potential/Potential for Alterations in Body Systems
The nurse is removing a Foley catheter. What instructions should she give to the client?
Rationale: Sometimes after the catheter is removed, the bladder may spasm or may not recognize the need to void. The nurse should carefully watch the client after the catheter is removed and ask them to report if they are unable to void within 8 hours. If unable to void, the catheter may need to be re-inserted and bladder training should be started.
Category: Reduction of Risk Potential/Potential for Complications of Diagnostic Tests/Treatments/Procedures
Rationale: Sometimes after the catheter is removed, the bladder may spasm or may not recognize the need to void. The nurse should carefully watch the client after the catheter is removed and ask them to report if they are unable to void within 8 hours. If unable to void, the catheter may need to be re-inserted and bladder training should be started.
Category: Reduction of Risk Potential/Potential for Complications of Diagnostic Tests/Treatments/Procedures
Debra, RN prepares to administer a bolus feeding through a gastric tube. What is the best action to verify placement and patency?
Rationale: The most accurate way to determine if a gastric tube is in the stomach and functioning correctly, is to aspirate for contents and check the pH with a pH strip. Inserting air into the tube will cause gurgling no matter where the tube is sitting. A chest x-ray is not in the appropriate place to view the stomach. Placement should be checked before each use, to avoid peritonitis, as these tubes are frequently dislodged from the stomach.
Category: Reduction of Risk Potential/Potential for Complications of Diagnostic Tests/Treatments/Procedures
Rationale: The most accurate way to determine if a gastric tube is in the stomach and functioning correctly, is to aspirate for contents and check the pH with a pH strip. Inserting air into the tube will cause gurgling no matter where the tube is sitting. A chest x-ray is not in the appropriate place to view the stomach. Placement should be checked before each use, to avoid peritonitis, as these tubes are frequently dislodged from the stomach.
Category: Reduction of Risk Potential/Potential for Complications of Diagnostic Tests/Treatments/Procedures
The nurse is assessing a client for partner abuse. What question would be most appropriate?
Rationale: When assessing a client for abuse or violence, the nurse should be as specific as possible when asking questions. The nurse should elicit information about behaviors that are common in abusers, such as becoming angry when their partner brings up certain topics. In this case questions 2 and 3 could elicit non-specific information or information that applies to every couple, regardless of an abusive pattern.
Category: Psychosocial Integrity/Abuse/Neglect
Rationale: When assessing a client for abuse or violence, the nurse should be as specific as possible when asking questions. The nurse should elicit information about behaviors that are common in abusers, such as becoming angry when their partner brings up certain topics. In this case questions 2 and 3 could elicit non-specific information or information that applies to every couple, regardless of an abusive pattern.
Category: Psychosocial Integrity/Abuse/Neglect
The nurse is assessing an elderly client for abuse. What behavior by the client could indicate to the nurse that the client is being abused?
Rationale: Often in elderly client abuse, family members may exert control over the client. Signs of this could be that the client is afraid to speak and answer questions, or that they only speak if the abuser allows them to speak. They may also use the client’s income to buy themselves things, rather than to take care of the client. In this case, the client will appear unclean or in need of clothing or toiletries. The nurse must assess the situation carefully and report the suspicion to a supervisor or social worker for evaluation and follow up by elder abuse services in that county.
Category: Psychosocial Integrity/Abuse/Neglect
Rationale: Often in elderly client abuse, family members may exert control over the client. Signs of this could be that the client is afraid to speak and answer questions, or that they only speak if the abuser allows them to speak. They may also use the client’s income to buy themselves things, rather than to take care of the client. In this case, the client will appear unclean or in need of clothing or toiletries. The nurse must assess the situation carefully and report the suspicion to a supervisor or social worker for evaluation and follow up by elder abuse services in that county.
Category: Psychosocial Integrity/Abuse/Neglect
A mother brings her child to the clinic and says she is worried that the child is being abused by someone. The nurse discusses signs of abuse in children with the mother. Which item will be included?
Rationale: Avoidance of certain situations can be a sign of abuse or bullying. The nurse should help the mother think about times when this may be the case with the child. Other signs can be inappropriate emotional behavior or sexual behavior. The nurse must recognize which behaviors are normal for children, such as tantrums, refusing to take baths, or explainable accidents.
Category: Psychosocial Integrity/Abuse/Neglect
Rationale: Avoidance of certain situations can be a sign of abuse or bullying. The nurse should help the mother think about times when this may be the case with the child. Other signs can be inappropriate emotional behavior or sexual behavior. The nurse must recognize which behaviors are normal for children, such as tantrums, refusing to take baths, or explainable accidents.
Category: Psychosocial Integrity/Abuse/Neglect
The nurse is working with a client who has been abused to move past the abuse. What suggestion can the nurse give for adaptive coping strategies?
Rationale: Adaptive coping strategies are those that can help the client move on and rebuild their life. Maladaptive strategies are those that do not deal with the problem. Often, maladaptive strategies can cause problems in the client’s life because they affect the client’s behavior and how they interact with others. The nurse should aim for adaptive strategies.
Category: Psychosocial Integrity/Abuse/Neglect
Rationale: Adaptive coping strategies are those that can help the client move on and rebuild their life. Maladaptive strategies are those that do not deal with the problem. Often, maladaptive strategies can cause problems in the client’s life because they affect the client’s behavior and how they interact with others. The nurse should aim for adaptive strategies.
Category: Psychosocial Integrity/Abuse/Neglect
The nurse is working with a client who is overcoming abuse to identify maladaptive coping techniques that may be hindering his recovery. What should the nurse point out as a maladaptive technique?
Rationale: Clients should not isolate themselves from others when dealing with abuse, because it can lead to loneliness and isolation. They should focus on positive or adaptive coping techniques that will help them collaborate with others in society. The nurse should work with the client to identify adaptive coping techniques.
Category: Psychosocial Integrity/Abuse/Neglect
Rationale: Clients should not isolate themselves from others when dealing with abuse, because it can lead to loneliness and isolation. They should focus on positive or adaptive coping techniques that will help them collaborate with others in society. The nurse should work with the client to identify adaptive coping techniques.
Category: Psychosocial Integrity/Abuse/Neglect
A manic client comes up to the nurse’s computer and interrupts her while she is talking on the phone, talking about her family coming to visit today. What is the best response by the nurse?
Rationale: Manic clients often lack self-control because they develop a high amount of energy. They need to be active physically or verbally. They may also not recognize boundaries. It is important for the nurse to recognize this behavior and set boundaries for the client. The nurse will need to be clear and consistent in boundary setting.
Category: Psychosocial Integrity/Behavioral Interventions
Rationale: Manic clients often lack self-control because they develop a high amount of energy. They need to be active physically or verbally. They may also not recognize boundaries. It is important for the nurse to recognize this behavior and set boundaries for the client. The nurse will need to be clear and consistent in boundary setting.
Category: Psychosocial Integrity/Behavioral Interventions
The nurse is working with a client on the behavioral health unit. She suspects the client might be depressed. What signs or symptoms would most alert the nurse to this?
Rationale: The signs that most point toward depression are that the client is unkempt and will not look at the nurse when speaking. The other behaviors could be explained in other ways such as the client is tired. Depressed clients may not interact with others or want to leave their room. They may also display a flat affect and experience motor retardation.
Category: Psychosocial Integrity/Behavioral Interventions
Rationale: The signs that most point toward depression are that the client is unkempt and will not look at the nurse when speaking. The other behaviors could be explained in other ways such as the client is tired. Depressed clients may not interact with others or want to leave their room. They may also display a flat affect and experience motor retardation.
Category: Psychosocial Integrity/Behavioral Interventions
A client with attention-deficit hyperactivity disorder is displaying disruptive behaviors at home. How should the nurse advise the parents to intervene?
Rationale: The parents need to be sure the child is focused and listening before giving instructions. If the client is focused and is still displaying disruptive behaviors, the parents will need to consider disciplinary actions. These could include punishments and rewards. The parents may need to re-direct the client frequently, but be careful not to seem irritated.
Category: Psychosocial Integrity/Behavioral Interventions
Rationale: The parents need to be sure the child is focused and listening before giving instructions. If the client is focused and is still displaying disruptive behaviors, the parents will need to consider disciplinary actions. These could include punishments and rewards. The parents may need to re-direct the client frequently, but be careful not to seem irritated.
Category: Psychosocial Integrity/Behavioral Interventions
The nurse is instructing a mental health client about coping skills. What is the best way to determine the coping skills have worked?
Rationale: Having the client keep the journal is the most effective way to determine in the coping skills are working, because the client is being asked to describe situation and skills used as well as whether they worked or not. The nurse needs to consider which item will best demonstrate that the client is coping effectively.
Category: Psychosocial Integrity/Behavioral Interventions
Rationale: Having the client keep the journal is the most effective way to determine in the coping skills are working, because the client is being asked to describe situation and skills used as well as whether they worked or not. The nurse needs to consider which item will best demonstrate that the client is coping effectively.
Category: Psychosocial Integrity/Behavioral Interventions
The nurse is working with a client with obsessive compulsive disorder. How can the nurse best assist the client in reducing their anxiety?
Rationale: If they client is prevented from completing rituals, they will become more anxious. The nurse should always let the client complete their obsessive compulsive rituals. It is more important for the client to verbalize and act out coping mechanisms than it is for the nurse to identify them. The nurse may want to describe several methods that are helpful and allow the client to choose the methods they feel will be beneficial to them.
Category: Psychosocial Integrity/Behavioral Interventions
Rationale: If they client is prevented from completing rituals, they will become more anxious. The nurse should always let the client complete their obsessive compulsive rituals. It is more important for the client to verbalize and act out coping mechanisms than it is for the nurse to identify them. The nurse may want to describe several methods that are helpful and allow the client to choose the methods they feel will be beneficial to them.
Category: Psychosocial Integrity/Behavioral Interventions
The nurse is caring for a client who has a history of drinking a case of beer per day. What action by the nurse is most important for client safety?
Rationale: Clients who are alcoholic have a risk of withdrawal symptoms. These symptoms include hypertension, hallucinations, agitation and tremors. Ativan is usually given to reduce these symptoms once the client scores high enough on the scale. The scale should be implemented upon admission.
Category: Psychosocial Integrity/Chemical and other dependencies/Substance use disorder
Rationale: Clients who are alcoholic have a risk of withdrawal symptoms. These symptoms include hypertension, hallucinations, agitation and tremors. Ativan is usually given to reduce these symptoms once the client scores high enough on the scale. The scale should be implemented upon admission.
Category: Psychosocial Integrity/Chemical and other dependencies/Substance use disorder
The nurse is caring for an alcoholic client and is worried about the client withdrawing and is also worried about the client’s nutritional status. What medications or treatments would the nurse expect to implement? Select all that apply.
Rationale: The standard precautions for alcohol withdrawal include Librium and/ or Ativan to reduce symptoms. Alcoholic clients are often nutritionally deprived, so they are in need of vitamin replacement. A specific vitamin they are deficient in is thiamine. Other multivitamins are given through a yellow bag of IV fluid with added vitamins, called a rally pack or a banana bag.
Category: Psychosocial Integrity/Chemical and other dependencies/Substance use disorder
Rationale: The standard precautions for alcohol withdrawal include Librium and/ or Ativan to reduce symptoms. Alcoholic clients are often nutritionally deprived, so they are in need of vitamin replacement. A specific vitamin they are deficient in is thiamine. Other multivitamins are given through a yellow bag of IV fluid with added vitamins, called a rally pack or a banana bag.
Category: Psychosocial Integrity/Chemical and other dependencies/Substance use disorder
The client admits to the emergency room with lethargy, slurred speech, and RR of 6 after taking some pills at a party. Which medication should the nurse anticipate giving the client?
Rationale: With slowed sensation and decreased respirations, the nurse could anticipate the client had taken a narcotic such as Demerol or morphine. The only medication that can be given for opiate overdose is narcan. The nurse should attempt to confirm what the client has taken by family member or friend, or obtain a urine specimen to test for substances, if time allows, before giving the narcan.
Category: Psychosocial Integrity/Chemical and other dependencies/Substance use disorder
Rationale: With slowed sensation and decreased respirations, the nurse could anticipate the client had taken a narcotic such as Demerol or morphine. The only medication that can be given for opiate overdose is narcan. The nurse should attempt to confirm what the client has taken by family member or friend, or obtain a urine specimen to test for substances, if time allows, before giving the narcan.
Category: Psychosocial Integrity/Chemical and other dependencies/Substance use disorder
What risk is increased in clients who are schizophrenic and also drug users?
Rationale: Drug use can often make the symptoms of schizophrenia worse. The nurse should assess the client for drug use and also counsel them on the effects of drug use, such as increased hallucinations and injury to themselves and others. The drugs will not help with their symptoms.
Category: Psychosocial Integrity/Chemical and other dependencies/Substance use disorder
Rationale: Drug use can often make the symptoms of schizophrenia worse. The nurse should assess the client for drug use and also counsel them on the effects of drug use, such as increased hallucinations and injury to themselves and others. The drugs will not help with their symptoms.
Category: Psychosocial Integrity/Chemical and other dependencies/Substance use disorder
A client who is getting divorced is complaining that they feel like they are a failure and no one wants them. What is the best response or action by the nurse?
Rationale: The nurse should complete the action that most helps the client feel like they are in control of their life and have some hope. The nurse should not minimize the client’s feelings. The nurse should never tell the client that everything will get better, or make promises that they cannot fulfill. It may be helpful for the nurse to sit with the client, but it is better for them to open a line of communication.
Category: Psychosocial Integrity/Coping Mechanisms
Rationale: The nurse should complete the action that most helps the client feel like they are in control of their life and have some hope. The nurse should not minimize the client’s feelings. The nurse should never tell the client that everything will get better, or make promises that they cannot fulfill. It may be helpful for the nurse to sit with the client, but it is better for them to open a line of communication.
Category: Psychosocial Integrity/Coping Mechanisms
Mr. Smith is admitted to the medical- surgical unit for chemotherapy after his cancer has returned for the third time. He stares at the floor and is reluctant to speak when the nurse speaks to him. What is the nurse’s best response?
Rationale: When a nurse notices a client is depressed, they should first assess for suicidal ideation. The priority action is to keep the client safe. If the nurse finds that the client is suicidal, they should stay with the client and remove any objects that could be used in a suicide. The nurse should not ask closed ended questions, or try to minimize the client’s feelings. The nurse should also be careful about asking the client questions that they mind find patronizing.
Category: Psychosocial Integrity/Crisis Intervention
Rationale: When a nurse notices a client is depressed, they should first assess for suicidal ideation. The priority action is to keep the client safe. If the nurse finds that the client is suicidal, they should stay with the client and remove any objects that could be used in a suicide. The nurse should not ask closed ended questions, or try to minimize the client’s feelings. The nurse should also be careful about asking the client questions that they mind find patronizing.
Category: Psychosocial Integrity/Crisis Intervention
Mr. Smith has just been re-admitted with his 3rd episode of cancer. He confides to the nurse that he has had thoughts of suicide. What actions should the nurse take? Place in order.
1. Remove all dangerous objects from room
2. Contact the physician to notify them that the client is suicidal
3. Stay with the client
4. Call the charge nurse and ask for a sitter to stay with the client
5. Complete a no suicide contract with the client
Rationale: Safety is the highest priority, so the nurse should stay with the client until help is found. The nurse can ask the charge nurse to find someone to stay with the client. Before the nurse leaves the room, a no – suicide contract should be completed. Upon leaving the room, the nurse can take all dangerous objects with them and then can call the physician to discuss the client’s condition.
Category: Psychosocial Integrity/Crisis Intervention
Rationale: Safety is the highest priority, so the nurse should stay with the client until help is found. The nurse can ask the charge nurse to find someone to stay with the client. Before the nurse leaves the room, a no – suicide contract should be completed. Upon leaving the room, the nurse can take all dangerous objects with them and then can call the physician to discuss the client’s condition.
Category: Psychosocial Integrity/Crisis Intervention
Mrs. Alawi is admitted to the orthopedic unit for knee-replacement surgery. She is visiting from Saudi Arabia. How should the nurse plan to best communicate with her?
Rationale: The best and most helpful way to communicate with clients who do not speak English as a first language is to obtain an interpreter to ensure the information is relayed correctly. Forms in Arabic would be helpful as can acting out scenarios, but they do not replace the need for an interpreter. The nurse should never rely on a family member to relay information correctly.
Category: Psychosocial Integrity/Cultural Awareness/Cultural Influences on Health
Rationale: The best and most helpful way to communicate with clients who do not speak English as a first language is to obtain an interpreter to ensure the information is relayed correctly. Forms in Arabic would be helpful as can acting out scenarios, but they do not replace the need for an interpreter. The nurse should never rely on a family member to relay information correctly.
Category: Psychosocial Integrity/Cultural Awareness/Cultural Influences on Health
Ragu, a 21 year old foreign college student from India, has just been diagnosed with schizophrenia. His roommates noticed he was hallucinating when he was talking to someone who was not there. The nurse needs to determine who his support system will be when he is discharged. How should the nurse proceed?
Rationale: As long as the client is lucid, it is best to ask him who he feels he can trust to support him and help him through this difficult time. The nurse should not contact anyone else about the client unless the client consents to provide information to those people. If consent is given, the nurse might want to contact the family and notify them of the illness. The nurse needs to keep in mind HIPAA regulations as well as the wishes and capabilities of the client, when making decisions.
Category: Psychosocial Integrity/Cultural Awareness/Cultural Influences on Health
Rationale: As long as the client is lucid, it is best to ask him who he feels he can trust to support him and help him through this difficult time. The nurse should not contact anyone else about the client unless the client consents to provide information to those people. If consent is given, the nurse might want to contact the family and notify them of the illness. The nurse needs to keep in mind HIPAA regulations as well as the wishes and capabilities of the client, when making decisions.
Category: Psychosocial Integrity/Cultural Awareness/Cultural Influences on Health
An elderly hospice client is in the final stages of life and is receiving palliative care. What should the nurse teach the family about palliative care?
Rationale: Palliative care is used to make sure the terminal client is comfortable, and can include pain medications and radiation to prevent tumors from increasing in size. Palliative care is not aimed at treating a terminal condition. Clients can receive palliative care when there is no benefit to treatment, or if they refuse treatment.
Category: Psychosocial Integrity/End of Life Care
Rationale: Palliative care is used to make sure the terminal client is comfortable, and can include pain medications and radiation to prevent tumors from increasing in size. Palliative care is not aimed at treating a terminal condition. Clients can receive palliative care when there is no benefit to treatment, or if they refuse treatment.
Category: Psychosocial Integrity/End of Life Care
Why should the nurse be aware of family dynamics?
Rationale: The nurse should include the family in family centered care when the client allows, because it will help the client improve more quickly. If the family understands the interventions, they can assist the client to complete them. The family dynamics should not override the client’s ability to make decisions for themselves when the client is competent.
Category: Psychosocial Integrity/Family Dynamics
Rationale: The nurse should include the family in family centered care when the client allows, because it will help the client improve more quickly. If the family understands the interventions, they can assist the client to complete them. The family dynamics should not override the client’s ability to make decisions for themselves when the client is competent.
Category: Psychosocial Integrity/Family Dynamics
Mary’s spouse died 6 months ago and she asks the nurse why she is still grieving the loss. What is the best response by the nurse?
Rationale: The grieving process can last for years and the client may not ever fully get over their loss, but they need to be able to care for themselves. This includes working, and maintaining their home and relationships. If the client is not able to care for themselves, counseling or support groups can be helpful. The nurse should gather more information about how the client is doing.
Category: Psychosocial Integrity/Grief and Loss
Rationale: The grieving process can last for years and the client may not ever fully get over their loss, but they need to be able to care for themselves. This includes working, and maintaining their home and relationships. If the client is not able to care for themselves, counseling or support groups can be helpful. The nurse should gather more information about how the client is doing.
Category: Psychosocial Integrity/Grief and Loss
Mrs. Smith has periods of feeling low and unable to get out of bed, followed by periods of feeling on top of the world and spending impulsively. What disorder should the nurse expect?
Rationale: Bipolar disorder clients are characterized by periods of depression and periods of mania, where they might speak actively, or spend too much money. Schizophrenia is generally characterized by hallucinations or delusions and thought disturbances. Anxiety is often described as a feeling of doom or tightness in the chest.
Category: Psychosocial Integrity/Mental Health Concepts
Rationale: Bipolar disorder clients are characterized by periods of depression and periods of mania, where they might speak actively, or spend too much money. Schizophrenia is generally characterized by hallucinations or delusions and thought disturbances. Anxiety is often described as a feeling of doom or tightness in the chest.
Category: Psychosocial Integrity/Mental Health Concepts
The hospital has a policy that noise must be kept to a minimum level at all times. What is the reasoning for this?
Rationale: High noise levels have been shown to increase stress in patents and therefore increase healing times. Hospitals want to decrease noise levels as a way to help clients rest. Some of the other reasons listed may also be true but are not the actual reason noise levels are monitored on a unit.
Category: Psychosocial Integrity/Stress Management
Rationale: High noise levels have been shown to increase stress in patents and therefore increase healing times. Hospitals want to decrease noise levels as a way to help clients rest. Some of the other reasons listed may also be true but are not the actual reason noise levels are monitored on a unit.
Category: Psychosocial Integrity/Stress Management
Mary complains of being stressed out too often and unable to rest. What could be contributing to Mary’s stress level?
Rationale: Leaving the television on all night decreases the quality of sleep, and therefore leads to higher levels of stress. The brain still tries to process noises and lights. It is advised to turn off all electronics at least 1 hour prior to bedtime. The other items listed are likely to reduce stress levels in the client.
Category: Psychosocial Integrity/Stress Management
Rationale: Leaving the television on all night decreases the quality of sleep, and therefore leads to higher levels of stress. The brain still tries to process noises and lights. It is advised to turn off all electronics at least 1 hour prior to bedtime. The other items listed are likely to reduce stress levels in the client.
Category: Psychosocial Integrity/Stress Management
In which state of the therapeutic relationship is the client most likely to regress?
Rationale: During the termination stage, the client thinks about all of the progress they have made and also about how they will survive outside of the therapeutic environment. The client may become anxious and can even regress during this period. It is important for the nurse to prepare the client for this stage and remind them of all of the work they have done. They should be able to apply their learned coping strategies on the outside.
Category: Psychosocial Integrity/Therapeutic Environment
Rationale: During the termination stage, the client thinks about all of the progress they have made and also about how they will survive outside of the therapeutic environment. The client may become anxious and can even regress during this period. It is important for the nurse to prepare the client for this stage and remind them of all of the work they have done. They should be able to apply their learned coping strategies on the outside.
Category: Psychosocial Integrity/Therapeutic Environment
Mr. Charles has been diagnosed with congestive heart failure. What statement by the client requires further teaching by the nurse?
Rationale: If the client states he is unable to take a bath at home, the nurse should teach the client ways to make this more feasible for him. He can use a shower chair so he will not have to exert so much energy in the shower. He can also use adaptive tools such as a loofah on a stick to help him take a bath more easily. The other options demonstrate that the client is doing well and understands his diagnosis.
Category: Physiological Adaptation/Alterations in Body Systems
Rationale: If the client states he is unable to take a bath at home, the nurse should teach the client ways to make this more feasible for him. He can use a shower chair so he will not have to exert so much energy in the shower. He can also use adaptive tools such as a loofah on a stick to help him take a bath more easily. The other options demonstrate that the client is doing well and understands his diagnosis.
Category: Physiological Adaptation/Alterations in Body Systems
A client is preparing for radiation therapy and ask the nurse about the side effects. What should the nurse include? Select all that apply.
Rationale: Side effects vary based on the site that is being treated, but generally include fatigue and hair loss for any site. Dry mouth and nausea are side effects of radiation in the neck and abdominal area. Arthralgia is not a side effect of radiation.
Category: Physiological Adaptation/Alterations in Body Systems
Rationale: Side effects vary based on the site that is being treated, but generally include fatigue and hair loss for any site. Dry mouth and nausea are side effects of radiation in the neck and abdominal area. Arthralgia is not a side effect of radiation.
Category: Physiological Adaptation/Alterations in Body Systems
A client thinks she may be pregnant, but it has not been confirmed by ultrasound. What sign, if reported, could indicate a complication? Select all that apply.
Rationale: The nurse should be alert for signs of a pregnancy complication that could indicate miscarriage, ectopic pregnancy, or other complications such as pre-eclampsia. Fatigue is a normal complication. Swelling of the extremities could indicate pre-eclampsia. Dimness or blurred vision could indicate diabetes or eclampsia, but it could also be normal, so the client should be evaluated.
Category: Physiological Adaptation/Alterations in Body Systems
Rationale: The nurse should be alert for signs of a pregnancy complication that could indicate miscarriage, ectopic pregnancy, or other complications such as pre-eclampsia. Fatigue is a normal complication. Swelling of the extremities could indicate pre-eclampsia. Dimness or blurred vision could indicate diabetes or eclampsia, but it could also be normal, so the client should be evaluated.
Category: Physiological Adaptation/Alterations in Body Systems
How should the RN position a client who will be having a thoracentesis?
Rationale: Clients who will be having a thoracentesis should be placed leaning over an over-the-bed table so the physician will have good access to insert the needle, between the ribs. The arms should be raised away from the body. If the client is unable to learn over a table, they may be placed on their side for the procedure.
Category: Physiological Adaptation/Alterations in Body Systems
Rationale: Clients who will be having a thoracentesis should be placed leaning over an over-the-bed table so the physician will have good access to insert the needle, between the ribs. The arms should be raised away from the body. If the client is unable to learn over a table, they may be placed on their side for the procedure.
Category: Physiological Adaptation/Alterations in Body Systems
What would be an appropriate task to assign to the UAP when a client is having a bronchoscopy?
Rationale: The nurse must consider which tasks are appropriate for the UAP and also which tasks are appropriate for the client. The UAP is only able to accept delegation of vital signs and providing the client with ice water, however the client is sedated and should not be given water or ice. The nurse should be careful not to assign tasks to the UAP that require assessment.
Category: Physiological Adaptation/Alterations in Body Systems
Rationale: The nurse must consider which tasks are appropriate for the UAP and also which tasks are appropriate for the client. The UAP is only able to accept delegation of vital signs and providing the client with ice water, however the client is sedated and should not be given water or ice. The nurse should be careful not to assign tasks to the UAP that require assessment.
Category: Physiological Adaptation/Alterations in Body Systems
A client is undergoing radiation therapy and is experiencing nausea and vomiting. What home remedy can the nurse teach the client about?
Rationale: A common home remedy for nausea is peppermint. The nurse can teach the client to suck on peppermint candy. This should relax the stomach contractions. If peppermint is not effective, the client can take medications that dry secretions, such as Benadryl.
Category: Physiological Adaptation/Alterations in Body Systems
Rationale: A common home remedy for nausea is peppermint. The nurse can teach the client to suck on peppermint candy. This should relax the stomach contractions. If peppermint is not effective, the client can take medications that dry secretions, such as Benadryl.
Category: Physiological Adaptation/Alterations in Body Systems
Mr. Sahai has a brain injury and is has a temperature of 95 degrees Fahrenheit. What should the nurse do to best promote optimal temperature in this client?
Rationale: Students should realize that a temperature of 95 degrees Fahrenheit is hypothermic. The client needs to be warmed, so placing a warming blanket is the most effective method, as it allows the nurse to closely regulate the temperature of the client and confine the heat to the client. Turning up the room temperature may not be effective as the temperatures are difficult to regulate and much of the heat can be lost through the door.
Category: Physiological Adaptation/Alterations in Body Systems
Rationale: Students should realize that a temperature of 95 degrees Fahrenheit is hypothermic. The client needs to be warmed, so placing a warming blanket is the most effective method, as it allows the nurse to closely regulate the temperature of the client and confine the heat to the client. Turning up the room temperature may not be effective as the temperatures are difficult to regulate and much of the heat can be lost through the door.
Category: Physiological Adaptation/Alterations in Body Systems
Carrie, RN wants to provide mouth care for a client who is on a ventilator. What is the best positioning for this task?
Rationale: The client should be placed in a side lying position as clients who are on ventilators are generally unable to clear secretions from the oral cavity. A side-lying position will allow the toothpaste and liquid to drain out the side of the mouth. The nurse must be very careful to prevent pneumonia or aspiration in these clients.
Category: Physiological Adaptation/Alterations in Body Systems
Rationale: The client should be placed in a side lying position as clients who are on ventilators are generally unable to clear secretions from the oral cavity. A side-lying position will allow the toothpaste and liquid to drain out the side of the mouth. The nurse must be very careful to prevent pneumonia or aspiration in these clients.
Category: Physiological Adaptation/Alterations in Body Systems
Carrie, RN is assessing a client with a wound. When would she document a stage 4 pressure ulcer?
Rationale: In a stage 4 ulcer, there is full thickness tissue loss with exposed bone, tendon or muscle. Osteomyelitis is likely to occur in clients where the bone is exposed. Clients with stage 4 ulcers require a special mattress to decrease injury as they are usually bed-ridden. They also require frequent repositioning and prevention of positioning on the ulcer.
Category: Physiological Adaptation/Alterations in Body Systems
Rationale: In a stage 4 ulcer, there is full thickness tissue loss with exposed bone, tendon or muscle. Osteomyelitis is likely to occur in clients where the bone is exposed. Clients with stage 4 ulcers require a special mattress to decrease injury as they are usually bed-ridden. They also require frequent repositioning and prevention of positioning on the ulcer.
Category: Physiological Adaptation/Alterations in Body Systems
Carrie, RN is taking care of her client who has a stage 4 pressure ulcer. She wants to prevent infection in this client. What signs should she teach the family to watch for?
Rationale: Signs of infection are warmth at the site, fever, and thick tenacious drainage that is yellow to green in nature. The nurse should teach the family member to report any of these signs immediately. Early treatment can prevent osteomyelitis or systemic infections. The nurse should also teach the family to use sterile technique when applying new dressings, to prevent contamination of the wound.
Category: Physiological Adaptation/Alterations in Body Systems
Rationale: Signs of infection are warmth at the site, fever, and thick tenacious drainage that is yellow to green in nature. The nurse should teach the family member to report any of these signs immediately. Early treatment can prevent osteomyelitis or systemic infections. The nurse should also teach the family to use sterile technique when applying new dressings, to prevent contamination of the wound.
Category: Physiological Adaptation/Alterations in Body Systems
Mr. Craig has a JP drain that he is learning to care for himself, as he will be discharged. The nurse is assessing his knowledge about caring for the drain. When would the nurse need to provide further instruction?
Rationale: JP (Jackson Pratt) drains work by reverse pressure. The client must squeeze all of the air out of the drain, until the sides are touching and then close the lid. The pressure slowly pulls drainage out of the wound. If the drain is not squeezed together before it is closed, it will not be effective.
Category: Physiological Adaptation/Alterations in Body Systems
Rationale: JP (Jackson Pratt) drains work by reverse pressure. The client must squeeze all of the air out of the drain, until the sides are touching and then close the lid. The pressure slowly pulls drainage out of the wound. If the drain is not squeezed together before it is closed, it will not be effective.
Category: Physiological Adaptation/Alterations in Body Systems
Jackie is the nurse caring for a client who is on peritoneal dialysis. When should she suspect an issue with the peritoneal dialysis?
Rationale: Peritonitis is a serious complication that can occur from peritoneal dialysis. The nurse must be careful to avoid introduction of any bacteria into the abdomen when setting up the dialysis. Signs of peritonitis can be a rigid abdomen, abdominal pain, and fever.
Category: Physiological Adaptation/Alterations in Body Systems
Rationale: Peritonitis is a serious complication that can occur from peritoneal dialysis. The nurse must be careful to avoid introduction of any bacteria into the abdomen when setting up the dialysis. Signs of peritonitis can be a rigid abdomen, abdominal pain, and fever.
Category: Physiological Adaptation/Alterations in Body Systems
The manager sees a nurse who is changing the dressing on a wound. The nurse washes her hands and applies sterile gloves to remove the dressing. Then she removes those gloves and applies non-latex gloves to apply the dressing. What is the best action by the manager?
Rationale: To prevent the spread of infection, sterile gloves should be worn when cleansing the wound and applying a new dressing. Sterile gloves are not needed for removing the old dressing, as it is contaminated, however the student needs to recognize the most important issue from a set of options. The nurse should dispose of dressings in a bio-hazard bag.
Category: Physiological Adaptation/Alterations in Body Systems
Rationale: To prevent the spread of infection, sterile gloves should be worn when cleansing the wound and applying a new dressing. Sterile gloves are not needed for removing the old dressing, as it is contaminated, however the student needs to recognize the most important issue from a set of options. The nurse should dispose of dressings in a bio-hazard bag.
Category: Physiological Adaptation/Alterations in Body Systems
What is the most effective means of preventing transmission of diseases?
Rationale: Multiple studies have shown that hand washing is the single most effective means of preventing disease transmission. The scrubbing action of hand washing is specifically the part that removes organisms. Other actions are helpful additions to hand washing.
Category: Physiological Adaptation/Alterations in Body Systems
Rationale: Multiple studies have shown that hand washing is the single most effective means of preventing disease transmission. The scrubbing action of hand washing is specifically the part that removes organisms. Other actions are helpful additions to hand washing.
Category: Physiological Adaptation/Alterations in Body Systems
A nurse prepares to remove a dressing for a dressing change, but when he attempts to remove it, it is stuck to the drainage. What action by the nurse would remove the dressing and prevent injury to the client?
Rationale: When a wound must be debrided, it is common to pull the dry dressing off and remove the tissue with it. In this case, the nurse does not have an order for debridement and wants to remove the dressing without hurting the client. Soaking the dressing prior to removal will loosen it from the wound secretions.
Category: Physiological Adaptation/Alterations in Body Systems
Rationale: When a wound must be debrided, it is common to pull the dry dressing off and remove the tissue with it. In this case, the nurse does not have an order for debridement and wants to remove the dressing without hurting the client. Soaking the dressing prior to removal will loosen it from the wound secretions.
Category: Physiological Adaptation/Alterations in Body Systems
A client with a colostomy presents with redness and soreness around the ostomy site. What is the best action by the nurse?
Rationale: The nurse must prevent skin breakdown which could lead to infection. Pain medication will only mask the symptoms of the redness and soreness around the site. The nurse must clean the site and use preventative measures to prevent skin breakdown.
Category: Physiological Adaptation/Alterations in Body Systems
Rationale: The nurse must prevent skin breakdown which could lead to infection. Pain medication will only mask the symptoms of the redness and soreness around the site. The nurse must clean the site and use preventative measures to prevent skin breakdown.
Category: Physiological Adaptation/Alterations in Body Systems
A client was admitted to the ICU with increased intracranial pressure. As the nurse gives the client a bath, how should she position the client?
Rationale: Clients with increased intracranial pressure should normally be placed in low fowlers, with he head elevated, but less than 30 degrees. This prevents an increase in ICP. Depending on other factors, the physician may order you to specifically place the client in another position.
Category: Physiological Adaptation/Alterations in Body Systems
Rationale: Clients with increased intracranial pressure should normally be placed in low fowlers, with he head elevated, but less than 30 degrees. This prevents an increase in ICP. Depending on other factors, the physician may order you to specifically place the client in another position.
Category: Physiological Adaptation/Alterations in Body Systems
A client with suspected TB is admitted to the progressive care unit. What protective equipment will the nurse select before entering the room?
Rationale: Tuberculosis is an airborne spread disease. An n-95 respirator is required to prevent employees from breathing the particles in, which are suspended in the air. A negative pressure room is also required to prevent the particles from being spread throughout the hospital. A gown and gloves should be worn as part of standard precautions and to prevent contamination of the clothes with the particles.
Category: Physiological Adaptation/Alterations in Body Systems
Rationale: Tuberculosis is an airborne spread disease. An n-95 respirator is required to prevent employees from breathing the particles in, which are suspended in the air. A negative pressure room is also required to prevent the particles from being spread throughout the hospital. A gown and gloves should be worn as part of standard precautions and to prevent contamination of the clothes with the particles.
Category: Physiological Adaptation/Alterations in Body Systems
On the first day post-operatively, a client’s surgical site began to exhibit drainage. What is the best action by the nurse?
Rationale: The nurse should not remove the dressing that was placed by the surgeon, but should mark the drainage so the physician can see the amount when they make rounds. Changing the dressing could lead to an incorrect assessment of the wound by the physician and it may disturb the wound. It should not be necessary to call the physician unless the client is excessively bleeding or is exhibiting wound dehiscence.
Category: Physiological Adaptation/Alterations in Body Systems
Rationale: The nurse should not remove the dressing that was placed by the surgeon, but should mark the drainage so the physician can see the amount when they make rounds. Changing the dressing could lead to an incorrect assessment of the wound by the physician and it may disturb the wound. It should not be necessary to call the physician unless the client is excessively bleeding or is exhibiting wound dehiscence.
Category: Physiological Adaptation/Alterations in Body Systems
Sally, RN is assessing a client after surgery. This client scores a 15 on the Glasgow Coma Scale. What does this score demonstrate?
Rationale: The highest score a client can receive on the Glasgow Coma Scale is a 15. That means the client’s eyes, verbal and motor faculties ae functioning fully. For a high score, students should think about the best possible functioning. For the lowest score, students should visualize the lowest functioning.
Category: Physiological Adaptation/Alterations in Body Systems
Rationale: The highest score a client can receive on the Glasgow Coma Scale is a 15. That means the client’s eyes, verbal and motor faculties ae functioning fully. For a high score, students should think about the best possible functioning. For the lowest score, students should visualize the lowest functioning.
Category: Physiological Adaptation/Alterations in Body Systems
Sally, RN completes a Glasgow Coma Scale on her client. Her client scores a 2 on the verbal component. The family asks what this means. What should Sally teach them?
Rationale: The verbal component of the Glasgow Coma Scale ranges from a score of 1 to a score of 5. The lower the score, the worse condition the client is in. The client can go from making no sounds, to conversing appropriately.
Category: Physiological Adaptation/Alterations in Body Systems
Rationale: The verbal component of the Glasgow Coma Scale ranges from a score of 1 to a score of 5. The lower the score, the worse condition the client is in. The client can go from making no sounds, to conversing appropriately.
Category: Physiological Adaptation/Alterations in Body Systems
A post-op client is exhibiting a decreased in oxygen saturation. He has an order for an incentive spirometer. How should the nurse instruct him to use it?
Rationale: The incentive spirometer works by expanding the lungs and the alveoli during inspiration. Breathing in slowly will produce the best expansion of the lungs. The client should mark his highest volume of inspiration on the scale which is on the incentive spirometer.
Category: Physiological Adaptation/Alterations in Body Systems
Rationale: The incentive spirometer works by expanding the lungs and the alveoli during inspiration. Breathing in slowly will produce the best expansion of the lungs. The client should mark his highest volume of inspiration on the scale which is on the incentive spirometer.
Category: Physiological Adaptation/Alterations in Body Systems
A client presents with complaints of dizziness. The nurse assesses her and finds BP 100/65, HR of 115, RR of 18, and Temp of 96.5. She had voided 160 ml for the 8 hour shift. What action should the nurse take?
Rationale: Dizziness, a low blood pressure, urine output less than 30ml per hour and an elevated heart rate are signs of dehydration. The nurse should start IV fluids at the rate ordered by the care provider. Students should assume that any action listed is already ordered, so there is no need to call the physician.
Category: Physiological Adaptation/Alterations in Body Systems
Rationale: Dizziness, a low blood pressure, urine output less than 30ml per hour and an elevated heart rate are signs of dehydration. The nurse should start IV fluids at the rate ordered by the care provider. Students should assume that any action listed is already ordered, so there is no need to call the physician.
Category: Physiological Adaptation/Alterations in Body Systems
A client presents with complaints of shortness of breath. The nurse assesses her and finds BP 160/80, HR of 90, RR of 20, and Temp of 96.5. Lung sounds findings are crackles bilaterally. She voided 160 ml for the 8 hour shift. What action should the nurse take?
Rationale: An elevated blood pressure, increased respirations, and crackles occur when a client is overloaded with fluid and struggling to breathe. Often, this happens in clients with congestive heart failure, but could happen anytime there is a severe increase in fluid. Other signs might be swelling of the extremities or distended jugular veins. The physician should not be called until current orders are utilized, such as administering Lasix and their effectiveness is evaluated.
Category: Physiological Adaptation/Alterations in Body Systems
Rationale: An elevated blood pressure, increased respirations, and crackles occur when a client is overloaded with fluid and struggling to breathe. Often, this happens in clients with congestive heart failure, but could happen anytime there is a severe increase in fluid. Other signs might be swelling of the extremities or distended jugular veins. The physician should not be called until current orders are utilized, such as administering Lasix and their effectiveness is evaluated.
Category: Physiological Adaptation/Alterations in Body Systems
Lab values on a client are sodium 130, chloride 95, potassium 3.5, bicarbonate 25, magnesium 1.9, and glucose 200. What IV fluid would be best for the nurse to select, based on the lab values?
Rationale: This client’s sodium is decreased. All of the other electrolyte levels are normal, with the exception of glucose. Normal saline is the only fluid listed with a higher concentration of sodium than the normal amount found in the blood. Since the client’s potassium is normal, the nurse would need to select the fluid without the potassium.
Category: Physiological Adaptation/Alterations in Body Systems
Rationale: This client’s sodium is decreased. All of the other electrolyte levels are normal, with the exception of glucose. Normal saline is the only fluid listed with a higher concentration of sodium than the normal amount found in the blood. Since the client’s potassium is normal, the nurse would need to select the fluid without the potassium.
Category: Physiological Adaptation/Alterations in Body Systems
Lab values on a client are sodium 140, chloride 95, potassium 3.5, bicarbonate 25, magnesium 1.9, and glucose 70. What IV fluid would be best for the nurse to select, based on the lab values?
Rationale: This client has normal lab values, with the exception of glucose. Since the student doesn’t have any other information other than what is in the question, they do not know if the client can eat or not. The test-taker should select the fluid that fits with the current problem.
Category: Physiological Adaptation/Alterations in Body Systems
Rationale: This client has normal lab values, with the exception of glucose. Since the student doesn’t have any other information other than what is in the question, they do not know if the client can eat or not. The test-taker should select the fluid that fits with the current problem.
Category: Physiological Adaptation/Alterations in Body Systems
The client had lab values sodium 130, chloride 95, potassium 3.5, bicarbonate 25, magnesium 1.9, and glucose 200. The client was given an infusion of 0.9% NS through his PICC line but this morning, his sodium remains 130. The client is lethargic and confused. What should the nurse administer?
Rationale: 3% normal saline can be given if a client is symptomatic due to low sodium levels, and other treatments haven’t worked. The nurse should be careful to administer the IV fluid slowly. It must be ran through a central line to prevent extravasation of the skin.
Category: Physiological Adaptation/Alterations in Body Systems
Rationale: 3% normal saline can be given if a client is symptomatic due to low sodium levels, and other treatments haven’t worked. The nurse should be careful to administer the IV fluid slowly. It must be ran through a central line to prevent extravasation of the skin.
Category: Physiological Adaptation/Alterations in Body Systems
A client exhibits the following rhythm on a telemetry monitor. What is the best initial action the nurse should take?
Rationale: The number one action the nurse should take in any situation is to assess the client and determine how they are reacting at that point in time. A client who has removed their monitor can exhibit this time pattern on telemetry, and may be sleeping when the nurse enters the room. Asystole is not a shockable rhythm as there is no electrical activity in the heart for the machine to convert.
Category: Physiological Adaptation/Alterations in Body Systems
Rationale: The number one action the nurse should take in any situation is to assess the client and determine how they are reacting at that point in time. A client who has removed their monitor can exhibit this time pattern on telemetry, and may be sleeping when the nurse enters the room. Asystole is not a shockable rhythm as there is no electrical activity in the heart for the machine to convert.
Category: Physiological Adaptation/Alterations in Body Systems
A client exhibits the following rhythm on a telemetry monitor. What is the best initial action the nurse should take?
Rationale: When a client is experiencing supraventricular tachycardia, it often helps to have the client bear down like they are having a bowel movement. This is called the vagal maneuver and stimulates cranial nerve 10. Many times, this will bring the client out of the rhythm and no further action is necessary.
Category: Physiological Adaptation/Alterations in Body Systems
Rationale: When a client is experiencing supraventricular tachycardia, it often helps to have the client bear down like they are having a bowel movement. This is called the vagal maneuver and stimulates cranial nerve 10. Many times, this will bring the client out of the rhythm and no further action is necessary.
Category: Physiological Adaptation/Alterations in Body Systems
The nurse looks at a client’s rhythm on a telemetry monitor. What rhythm does the nurse recognize?
Rationale: This rhythm does not contain atrial contractions (p waves). This indicates it is coming from the ventricles. The ventricular rhythm is irregular, which indicates fibrillation. This is a life threatening emergency and should be defibrillated.
Category: Physiological Adaptation/Alterations in Body Systems
Rationale: This rhythm does not contain atrial contractions (p waves). This indicates it is coming from the ventricles. The ventricular rhythm is irregular, which indicates fibrillation. This is a life threatening emergency and should be defibrillated.
Category: Physiological Adaptation/Alterations in Body Systems
The nurse looks at a client’s rhythm on a telemetry monitor. What rhythm does the nurse recognize?
Rationale: This rhythm does not have a clear p wave, so the nurse should know that the impulses aren’t being conducted correctly from the atria. In atrial fibrillation, the QRS complexes may appear irregular vs in atrial flutter where they appear regular and the p waves look like sawthoothes. Treatment of this can vary, depending on how long the client has it and the symptoms. Usually, if symptomatic, the client will be placed on medication to convert the rhythm or may be cardioverted.
Category: Physiological Adaptation/Alterations in Body Systems
Rationale: This rhythm does not have a clear p wave, so the nurse should know that the impulses aren’t being conducted correctly from the atria. In atrial fibrillation, the QRS complexes may appear irregular vs in atrial flutter where they appear regular and the p waves look like sawthoothes. Treatment of this can vary, depending on how long the client has it and the symptoms. Usually, if symptomatic, the client will be placed on medication to convert the rhythm or may be cardioverted.
Category: Physiological Adaptation/Alterations in Body Systems
A client is able to complete full range of motion activities against full resistance. How would this level of functioning be graded when entering it into the client’s chart?
Rationale: The muscular grading system ranges from 0-5. 0 is no movement or contraction. 5 is full range of motion and full resistance. Think about the numbers on the scale and the increments that take place between each one.
Category: Physiological Adaptation/Mobility/Immobility
Rationale: The muscular grading system ranges from 0-5. 0 is no movement or contraction. 5 is full range of motion and full resistance. Think about the numbers on the scale and the increments that take place between each one.
Category: Physiological Adaptation/Mobility/Immobility
Molly RN is assessing a client who has a cast for the 5 P’s. Which P’s are included in this assessment? Select all that apply.
Rationale: Paroxysmal means a sudden, violent outburst of action. This does not happen when someone experiences compartment syndrome, which is what the nurse is looking for in this case. The nurse tests the nervous system to ensure the compartments are not being compressed by the cast. The 5th element to this assessment is paralysis
Category: Physiological Adaptation/Mobility/Immobility
Rationale: Paroxysmal means a sudden, violent outburst of action. This does not happen when someone experiences compartment syndrome, which is what the nurse is looking for in this case. The nurse tests the nervous system to ensure the compartments are not being compressed by the cast. The 5th element to this assessment is paralysis
Category: Physiological Adaptation/Mobility/Immobility
A physical therapist is working with the nurse to assess the client’s range of motion. What range of motion in the lumbar spine would require a referral to the physical therapist?
Rationale: Lateral flexion should be 35 degrees. Clients who demonstrate flexion or extension less than the normal amount would benefit from a referral to physical therapy. The more mobile the client is, the less chance for injury there will be.
Category: Physiological Adaptation/Mobility/Immobility
Rationale: Lateral flexion should be 35 degrees. Clients who demonstrate flexion or extension less than the normal amount would benefit from a referral to physical therapy. The more mobile the client is, the less chance for injury there will be.
Category: Physiological Adaptation/Mobility/Immobility
A client is having a test to determine if she has carpal tunnel syndrome. The RN asks her to hold her wrists in acute flexion for 60 seconds and does not note any numbness, tingling, or pain. What should the nurse enter in the chart?
Rationale: A phalen’s test is negative if the client does not notice numbness, tingling, or pain during the test. A ballottement test is used to determine if there is increased fluid behind the patella. The nurse should also assess for a history of repetitive movements such as typing, to determine if a client may be at risk for carpal tunnel syndrome.
Category: Physiological Adaptation/Mobility/Immobility
Rationale: A phalen’s test is negative if the client does not notice numbness, tingling, or pain during the test. A ballottement test is used to determine if there is increased fluid behind the patella. The nurse should also assess for a history of repetitive movements such as typing, to determine if a client may be at risk for carpal tunnel syndrome.
Category: Physiological Adaptation/Mobility/Immobility
Mr. Sam states he is experiencing an increased amount of pain from kidney stones. The nurse suspects that he is a drug seeker. He asks for pain medication after receiving morphine 1 hour ago. His order is for morphine every 2 hours. What is the best action by the nurse?
Rationale: The nurse should attempt any non-pharmacologic methods available to receive the pain, whether the nurse thinks the client is in pain or is seeking drug. Massage, guided imagery, and distraction can be used, among other things. The nurse should never give the client medication when it is not due. If non-pharmacologic methods do not work, the nurse could call the physician to discuss the situation.
Category: Physiological Adaptation/Non-Pharmacological Comfort Interventions
Rationale: The nurse should attempt any non-pharmacologic methods available to receive the pain, whether the nurse thinks the client is in pain or is seeking drug. Massage, guided imagery, and distraction can be used, among other things. The nurse should never give the client medication when it is not due. If non-pharmacologic methods do not work, the nurse could call the physician to discuss the situation.
Category: Physiological Adaptation/Non-Pharmacological Comfort Interventions
A stroke client presents to the unit and is asking for dinner. How should the nurse proceed?
Rationale: The standard test for swallowing abilities after a stroke is the fluid test. If the client is successful, the nurse will need to call the physician to obtain an order for a diet. The nurse should be careful to ensure the client’s condition is not labile or deteriorating, before allowing the client to eat. The client must be stable.
Category: Physiological Adaptation/Nutrition and Oral Hydration
Rationale: The standard test for swallowing abilities after a stroke is the fluid test. If the client is successful, the nurse will need to call the physician to obtain an order for a diet. The nurse should be careful to ensure the client’s condition is not labile or deteriorating, before allowing the client to eat. The client must be stable.
Category: Physiological Adaptation/Nutrition and Oral Hydration
A client drank 12oz of milk and 110ml of coffee. He had an IV going at 75ml per hour for the last 8 hours. What is the intake? _____ml
Rationale: 12 oz. = 360 mL. 360 mL plus 110 mL = 470 mL. 75 mL x8 hours = 600 mL. 600 mL plus 470ml= 1070ml. Be sure to include all sources of intake, including IV flushes if given.
Category: Physiological Adaptation/Elimination
Rationale: 12 oz. = 360 mL. 360 mL plus 110 mL = 470 mL. 75 mL x8 hours = 600 mL. 600 mL plus 470ml= 1070ml. Be sure to include all sources of intake, including IV flushes if given.
Category: Physiological Adaptation/Elimination
The male nurse is caring for a female Muslim client on the adolescent unit. The nurse senses the client does not feel comfortable with having an assessment completed. What is the best action by the nurse?
Rationale: Female Muslims should not be exposed to males. As a nurse needs to assess the client, which involves listening to heart and lung sounds, it is best if the nurse can request a female caregiver to take over. Many clients won’t feel comfortable directly telling the nurse that they do not want them as a nurse. The nurse needs to be culturally sensitive to all clients.
Category: Health Promotion and Maintenance/Developmental Stages and Transitions
Rationale: Female Muslims should not be exposed to males. As a nurse needs to assess the client, which involves listening to heart and lung sounds, it is best if the nurse can request a female caregiver to take over. Many clients won’t feel comfortable directly telling the nurse that they do not want them as a nurse. The nurse needs to be culturally sensitive to all clients.
Category: Health Promotion and Maintenance/Developmental Stages and Transitions
The nurse is caring for a 3 year old client and wants to complete an assessment. What is the best way for the nurse to obtain buy in from the client?
Rationale: 3 year olds tend to be excited about new items, so the nurse could talk about all of the things the equipment can do. While the nurse interacts with the client, the client will be less nervous and more likely to cooperate with the assessment. The nurse should also communicate findings with the parent, but that does not help the nurse/client relationship. The nurse should think about what type of activities clients will like at a certain developmental age. This may or may not correlate to their actual age.
Category: Health Promotion and Maintenance/Developmental Stages and Transitions
Rationale: 3 year olds tend to be excited about new items, so the nurse could talk about all of the things the equipment can do. While the nurse interacts with the client, the client will be less nervous and more likely to cooperate with the assessment. The nurse should also communicate findings with the parent, but that does not help the nurse/client relationship. The nurse should think about what type of activities clients will like at a certain developmental age. This may or may not correlate to their actual age.
Category: Health Promotion and Maintenance/Developmental Stages and Transitions
The nurse is caring for a 17 year old client and wants to complete an assessment. What is the best way for the nurse to obtain buy in from the client?
Rationale: A 17 year old client has a more realistic perception about the world and healthcare than younger children. The nurse should explain the procedure and the results as they would with any older client. The nurse should make time for questions and answers and present information in a non-judgmental way.
Category: Health Promotion and Maintenance/Developmental Stages and Transitions
Rationale: A 17 year old client has a more realistic perception about the world and healthcare than younger children. The nurse should explain the procedure and the results as they would with any older client. The nurse should make time for questions and answers and present information in a non-judgmental way.
Category: Health Promotion and Maintenance/Developmental Stages and Transitions
The nurse is caring for a 78 year old male client who likes to eat fast food daily. What disorder would the client be most as risk for?
Rationale: Fast food is extremely high in sodium, so clients who eat it on a daily basis would be most at risk for hypertension, due to the salt. If the client eats a diet high in carbohydrates and sugars, then they would be at a higher risk for diabetes, which could lead to kidney disease. It is important to have the client complete a food journal or 24 hour diet recall to get a better picture of the types of foods they are eating.
Category: Health Promotion and Maintenance/Health Promotion/Disease Prevention
Rationale: Fast food is extremely high in sodium, so clients who eat it on a daily basis would be most at risk for hypertension, due to the salt. If the client eats a diet high in carbohydrates and sugars, then they would be at a higher risk for diabetes, which could lead to kidney disease. It is important to have the client complete a food journal or 24 hour diet recall to get a better picture of the types of foods they are eating.
Category: Health Promotion and Maintenance/Health Promotion/Disease Prevention
The nurse is preparing diet teaching for a client who eats fast food every day and has developed hypertension and edema. What teaching should be included for this client’s disorder?
Rationale: The nurse should teach the client to limit their sodium intake to 2000 mg per day. In severe cases of hypertension and fluid overload, the client may need to limit their sodium intake to 1000 mg per day. The physical will review the client outcomes and recommend further changes if needed. The nurse should also be prepared to teach the client about how much sodium is found in fast food items. For example, there is about 134 mg of sodium in a small McDonald’s french fry.
Category: Health Promotion and Maintenance/Health Promotion/Disease Prevention
Rationale: The nurse should teach the client to limit their sodium intake to 2000 mg per day. In severe cases of hypertension and fluid overload, the client may need to limit their sodium intake to 1000 mg per day. The physical will review the client outcomes and recommend further changes if needed. The nurse should also be prepared to teach the client about how much sodium is found in fast food items. For example, there is about 134 mg of sodium in a small McDonald’s french fry.
Category: Health Promotion and Maintenance/Health Promotion/Disease Prevention
The nurse is putting together a community teaching plan for an African American community. The nurse knows that she should include what treatable disorder?
Rationale: Hypertension is one of the number one conditions in the African American community, and it is something that can be treated. If left untreated, it can lead to retinopathy and kidney disease which results in dialysis. It can also lead to stroke. It is important for the nurse to teach the community about ways to control hypertension to prevent the side effects.
Category: Health Promotion and Maintenance/Health Screening
Rationale: Hypertension is one of the number one conditions in the African American community, and it is something that can be treated. If left untreated, it can lead to retinopathy and kidney disease which results in dialysis. It can also lead to stroke. It is important for the nurse to teach the community about ways to control hypertension to prevent the side effects.
Category: Health Promotion and Maintenance/Health Screening
The nurse is caring for a client who has a 30 year history of smoking a pack of cigarettes per day. How should the nurse document this on the chart?
Rationale: Pack year is calculated by multiplying the number of packs of cigarettes smoked per day by the number of years the person has smoked. For example, 1 pack year is equal to smoking 1 pack per day for 1 year, or 2 packs per day for half a year, and so on. The nurse will need to calculate this information to determine the possible cancer risk in the client.
Category: Health Promotion and Maintenance/High Risk Behaviors
Rationale: Pack year is calculated by multiplying the number of packs of cigarettes smoked per day by the number of years the person has smoked. For example, 1 pack year is equal to smoking 1 pack per day for 1 year, or 2 packs per day for half a year, and so on. The nurse will need to calculate this information to determine the possible cancer risk in the client.
Category: Health Promotion and Maintenance/High Risk Behaviors
The nurse is caring for a client who has a 30 pack year history of cigarette smoking. The nurse is planning teaching for the client. What should the nurse teach the client about?
Rationale: Due to the constrictive effects of nicotine, the client who smokes is at a higher risk of cardiac events and strokes. When working with a client with a history of smoking, the nurse always needs to think about vessel constriction and ischemia. Many of these clients will present to the hospital with cardiac events.
Category: Health Promotion and Maintenance/High Risk Behaviors
Rationale: Due to the constrictive effects of nicotine, the client who smokes is at a higher risk of cardiac events and strokes. When working with a client with a history of smoking, the nurse always needs to think about vessel constriction and ischemia. Many of these clients will present to the hospital with cardiac events.
Category: Health Promotion and Maintenance/High Risk Behaviors
The nurse is preparing teaching for client who came to the Planned Parenthood clinic for birth control. The client is being sent home with a prescription for estrogen/progesterone pills. What information provided by the client would require revision of the birth control plan?
Rationale: Being over the age of 35 and smoking are both contraindications for the use of hormonal contraception. These factors can cause blood clots, stroke, or a heart attack in the client. These clients need to be placed on a non-hormonal type of birth control such as an IUD or condoms.
Category: Health Promotion and Maintenance/Lifestyle Choices
Rationale: Being over the age of 35 and smoking are both contraindications for the use of hormonal contraception. These factors can cause blood clots, stroke, or a heart attack in the client. These clients need to be placed on a non-hormonal type of birth control such as an IUD or condoms.
Category: Health Promotion and Maintenance/Lifestyle Choices
The nurse is working with the spouse of a dementia client, who reports feeling overwhelmed but wants to be near her loved one. What should the nurse recommend?
Select all that apply.
Rationale: The nurse should recommend any action that will provide some relief for the spouse, but will still allow her to keep the family member in the home. The spousal support group will not relieve the spouse of any duties, but will give her people to talk with about her difficulties and receive some stress. There may be more alternatives, depending on the client’s financial resources.
Category: Health Promotion and Maintenance/Self Care
Rationale: The nurse should recommend any action that will provide some relief for the spouse, but will still allow her to keep the family member in the home. The spousal support group will not relieve the spouse of any duties, but will give her people to talk with about her difficulties and receive some stress. There may be more alternatives, depending on the client’s financial resources.
Category: Health Promotion and Maintenance/Self Care
Carla, RN administers blood to a client. What is best practice for assessing the client when administering blood?
Rationale: Most transfusion reactions occur within the first 15 minutes of initiating the infusion. The nurse will need to stay with the client during that timeframe. The UAP is unable to assess the client and therefore should not be delegated to collect vital signs during this critical period. The UAP may collect vital signs at hourly intervals after the client is found to be stable.
Category: Pharmacological and Parenteral Therapies/Blood and Blood Products
Rationale: Most transfusion reactions occur within the first 15 minutes of initiating the infusion. The nurse will need to stay with the client during that timeframe. The UAP is unable to assess the client and therefore should not be delegated to collect vital signs during this critical period. The UAP may collect vital signs at hourly intervals after the client is found to be stable.
Category: Pharmacological and Parenteral Therapies/Blood and Blood Products
A client is receiving blood and becomes febrile and short of breath. What action should the nurse take? Place the actions in order.
1. Flush the IV line
2. Stop the blood
3. Call the physician for orders
4. Stay with the client
5. Disconnect the tubing
Rationale: It is important to stop the transfusion immediately to prevent the reaction from progressing due to lengthened exposure to the allergen. The nurse should flush the IV line to remove traces of the blood from the IV and then disconnect the blood tubing. The physician should be notified after all of these things have occurred. When a client is experiencing a life threatening emergency, the nurse should never leave their side.
Category: Pharmacological and Parenteral Therapies/Blood and Blood Products
Rationale: It is important to stop the transfusion immediately to prevent the reaction from progressing due to lengthened exposure to the allergen. The nurse should flush the IV line to remove traces of the blood from the IV and then disconnect the blood tubing. The physician should be notified after all of these things have occurred. When a client is experiencing a life threatening emergency, the nurse should never leave their side.
Category: Pharmacological and Parenteral Therapies/Blood and Blood Products