RNSG 2331 - Exam 2-Capstone-1. (100% correct answers plus rationale)

RNSG 2331 - Exam 2-Capstone-1 Question: The nurse makes selections from the hospital menu for a client who is confused and suspicious of others. Which menu choice is best? You answered this que stion Correctly 1. Ham and vegetable casserole 2. Cheese and crackers 3. Caffeine free tea 4. Correct: A client who is suspicious of others needs foods that are packaged and can see them opened. 1. Incorrect: A client who is suspicious of others needs to be able to identify the ingredients in the food that is being eaten. A casserole contains many ingredients and the client may fear that something has been added to the food. 2. Incorrect: Finger foods are best for clients that are manic. 3. Incorrect: Drinks and foods with no caffeine are okay for the confused and suspicious client but this menu choice is not the best choice from the list here. Question: Two days after a myocardial infarction, a client begins reporting orthopnea and dyspnea. Further assessment reveals bi-basilar crackles, jugular venous distension, an S3 heart sound, a BP of 100/60 mm Hg, and apical pulse of 90 beats per minute. The urine output has steadily declined over the past 12 hours. What should the nurse do first? You answered this question Correctly 1. Notify the primary healthcare provider. 2. Increase the IV rate. 4. Observe for cardiac arrhythmias. 3. Correct: Elevate the head of the bed first. The client is reporting inability to breathe. (Orthopnea means the client needs to sit up to breathe better.) With ANY client having difficulty breathing, the first intervention for the nurse is to sit the client up. This client is showing s/s of heart failure. 1. Incorrect: Your next step is to call the primary healthcare provider after you do something to try to fix the problem. 2. Incorrect: Increasing the IV rate is contraindicated and would make the problem worse. 4. Incorrect: After an MI, all clients are observed for cardiac arrhythmias. This, however, does not fix the problem. Question: Which menu selection by the client diagnosed with nephrotic syndrome indicates that teaching of proper diet was understood? You answered this question Correctly 1. Pancakes with whipped butter, syrup, bacon, apple juice 3. Grits, fresh fruit, toast, coffee 4. Bagel with jelly, hash browns, tea 2. Correct: Client needs low sodium and increased proteins. 1. Incorrect: This selection is too high in sodium and fats. 3. Incorrect: This selection has no protein. Remember, nephrotic syndrome is the exception to the rule of limiting protein. These clients need increased protein to compensate for the large loss of protein in the urine. 4. Incorrect: This selection has no protein. Remember, nephrotic syndrome is the exception to the rule of limiting protein. These clients need increased protein to compensate for the large loss of protein in the urine. Question: The nurse assesses a multigravida who is four hours postpartum. Findings include that fundus is firm, 1 centimeter above the umbilicus, and deviated to the right side. The lochia is moderately heavy and bright red. Which nursing intervention has priority? You answered this question Correctly 1. Massage the fundus. 2. Administer intravenous oxytocin. 3. Document these normal findings. 4. Correct: These findings are caused by a full bladder, which prevents the uterus from contracting down and achieving homeostasis. Once the bladder is empty, the fundus will contract adequately and return to its normal location at level of umbilicus or 1 finger breadth below the umbilicus and in the midline. A distended bladder will displace the uterus, usually to the right. 1. Incorrect: The nurse may check fundus after client voids to ensure that this fixes the problem. 2. Incorrect: Administering oxytocin is not the first intervention for this issue. 3. Incorrect: These are not normal findings so this would be incorrect information for the nurse to document. Question: What risk factors should the nurse include when conducting a class about type 2 diabetes mellitus? You answered this question Correctly 2. Being underweight. 3. Having type 1 diabetes as a child increases risk for type 2 diabetes. 4. Caucasians are more likely to develop type 2 diabetes than Hispanics. 1. , & 5. Correct: If the body stores fat primarily in the abdomen, risk of type 2 diabetes is greater than if body stores fat elsewhere, such as hips and thighs. Women with polycystic ovary syndrome have increased risk of diabetes. 2. Incorrect: Being overweight is a primary risk factor for type 2 diabetes. The more fatty tissue, the more resistant cells become to insulin. 3. Incorrect: A type 1 diabetic will remain a type 1 diabetic. 4. Incorrect: Blacks, Hispanics, American Indians, and Asian Americans are more likely to develop type 2 diabetes than Caucasians are. Question: What should the nurse include when providing education to a client receiving tetracycline? You answered this question Correctly 2. Take tetracycline on a full stomach. 1. , 3., 4., & 5. Correct: Avoid exposure to sunlight or artificial UV rays (sunlamps or tanning beds). Tetracycline can make your skin more sensitive to sunlight and sunburn may result. Use a sunscreen (minimum SPF 15) and wear protective clothing if you must be out in the sun. Take tetracycline on an empty stomach and do not take iron supplements, multivitamins, calcium supplements, antacids, or laxatives within 2 hours before or after taking tetracycline. These products can make this medicine less effective. Tetracycline can make birth control pills less effective. Use a second method of birth control while you are taking this medicine to keep from getting pregnant. Throw away any unused tetracycline when it expires or when it is no longer needed. Do not take this medicine after the expiration date on the label has passed. Expired tetracycline can cause a dangerous syndrome resulting in damage to the kidneys. 2. Incorrect: Take tetracycline on an empty stomach and do not take iron supplements, multivitamins, calcium supplements, antacids, or laxatives within 2 hours before or after taking tetracycline. These products can make this medicine less effective. Question: A 72 year old client admitted with a diagnosis of bleeding ulcers has been prescribed ranitidine 50 mg IVPB every 8 hours and omeprazole 10 mg po every morning. Based on this data what intervention should the nurse take first? You answered this question Correctly 2. Send the client for a CT scan of the head. 3. Provide oxygen at 2L/NC. 4. Notify the primary healthcare provider. 1. Correct: Ranitidine can cause confusion in the elderly as well as agitation. Stop the infusion, then notify the primary healthcare provider. 2. Incorrect: Confusion is a side effect of ranitidine, so the medication should be stopped and then the healthcare provider notified. 3. Incorrect: The oxygen saturation is not low at 95%. Providing oxygen will not correct the confusion. 4. Incorrect: The primary healthcare provider should be notified after stopping the ranitidine. Question: A nurse invites a friend home one evening. On arrival, the friend sees the nurse's large, white, long-haired cat sitting on the couch and begins to experience palpitations, trembling, nausea, shortness of breath, and a feeling of losing control. What should the nurse do first? You answered this question Correctly 1. Stay with the friend until the friend feels better. 2. Have the friend breathe into a paper bag. 4. Dim the lights in the room. 3. Correct: Remove the source of the panic attack first, then continue to assess the person for symptoms. Removing the cat "fixes" the problem. 1. Incorrect: This is a correct answer, but remove the cat first. 2. Incorrect: This will help hyperventilation if it occurs, but the stem of the question said the client was having "shortness of breath" related to seeing the cat. Remove the cat first as this will fix the problem and alleviate the symptoms. 4. Incorrect: This is a correct answer, but remove the cat first. Question: A client being treated for osteoporosis with alendronate reports experiencing slight heartburn after taking the medicine. What should the nurse suggest to reduce this side effect? You answered this question Correctly 1. Stop taking the medication and call the primary healthcare provider. 3. Take the medication before bedtime. 4. Take antacids when taking the medication. 2. Correct: Increased heartburn can be reduced or prevented by drinking plenty of water, sitting upright following the administration of the medication, and avoiding sucking on the tablet. 1. Incorrect: Slight heartburn does not warrant primary healthcare provider report. Extreme pain or difficulty swallowing should be reported, as should heartburn that increases despite suggestions listed above. 3. Incorrect: The client should take in the morning, thus preventing prolonged contact with the esophagus. 4. Incorrect: The absorption of the medication is decreased when it is taken with calcium, iron, and magnesium, or antacids containing calcium, aluminum, or magnesium. Thirty minutes should elapse before taking the antacid following administration of the alendronate. Question: The nurse determines that a client does not have an advance directive. The daughter is designated to make healthcare decisions in the event that the client becomes incapacitated or unable to make informed decisions. Which nursing actions are appropriate for this client? You answered this question Incorrectly 4. Avoid inquiring about a client's advance directive as this could cause the client anxiety and concern. 5. Ask the daughter if she agrees with her mother's decision. 1., 2. & 3. Correct: The nurse should document the client’s statement in the client’s own words. The nurse should provide the client with information on advance directives and assurance that there are hospital personnel to assist with completing the advance directive. 4. Incorrect: The nurse who avoids inquiry about a client’s advance directive is not serving the client’s best interests. The nurse should explain to the client that the law requires all clients be asked about the existence of an advance directive at the time of hospital admission. Preparing an advance directive ensures that the client’s wishes will be followed in the event that the client is unable to make healthcare decisions. 5. Incorrect: Providing information is the appropriate nursing action, not questioning the daughter. Question: Family members have been asking triage nurses if loved ones were admitted to the hospital during a national emergency situation with massive casualties. What response should be made by the nurses? You answered this question Correctly 1. Tell the family members that information about clients cannot be provided. 2. Ask for the victims’ permission before talking with the family members. 3. Instruct the family to wait for public announcements about victims. 4. Correct. The national emergency situation allows waivers for the Health Insurance Portability and Accountability Act (HIPAA) provisions. Due to the emergency situation, the nurse may inform the family members about the status of their loved ones. 1. Incorrect. During a national disaster declared by the President, information may be given to families without client consent. 2. Incorrect. There is no need to make the family more worried if information is known. Waivers for certain elements of HIPAA are allowed during the emergency period. 3. Incorrect. The nurse may legally give information to the family. The triage nurse may provide information concerning their family members Question: What precautions should be taken with computer monitors that display client health information to ensure client's confidentiality? You answered this question Incorrectly 1. Orient the screen facing the client rooms so that healthcare personnel can access the information easily. 3. Turn the computer monitors off when the computer is not in use. 4. The computer should be kept in a secured, locked area. 2. Correct: Computer monitors that display client health information should be positioned away from the view of any visitors or unauthorized persons. Even a well- guarded computer monitor, with an authorized employee sitting in front of it, could be a potential breach of confidentiality, depending on the angle of the monitor screen and who was attempting to view the information on it. The responsibility for keeping health information safe is on every member of the healthcare team. 1. Incorrect: No, this would be easily viewed by unauthorized individuals. 3. Incorrect: Not necessary to turn off if proper precautions are taken. 4. Incorrect: Not necessary to keep in secured area if proper precautions are taken. Question: A home health nurse has taught a client about home dressing changes using a clean technique. Which statement made by a client indicates to the nurse that the client understands this technique? You answered this question Correctly 1. “The wound should be cleaned using a washcloth, soap, and water.” 2. “Povidone-iodine should be applied to the wound with each dressing change.” 4. “I will use sterile gloves to clean my wound and change the dressings.” 3. Correct: Clean technique requires washing hands with soap and water prior to removing the dressing. 1. Incorrect: The wound should be cleaned with 4x4’s and sterile water. Soap can be very drying to the wound. A washcloth may not be clean as it has been sitting in a cabinet. 2. Incorrect: Povidone-iodine is harsh and damages healthy tissue, so should not be applied to the wound. 4. Incorrect: Sterile gloves are not needed when using clean technique. Clean gloves may be used. Question: The nurse is performing CPR on an adult client with facial and neck trauma. Following the administration of rescue breaths, where is the best location for the nurse to assess for a pulse in this client? You answered this question Incorrectly 1. Apical area 2. Carotid artery 4. Radial artery 3. Correct: Pulses that are best palpated are large and close to the trunk of the body. The femoral artery is large and at the trunk (proximal) of the body. 1. Incorrect: It would take too long to use a stethoscope and listen for an apical pulse on the client. A quicker area of checking the pulse would need to be used. 2. Incorrect: The client has bilateral neck trauma. The carotid artery would not be the best site to assess for a pulse. 4. Incorrect: The radial artery is not as large as the femoral artery and is distal to the femoral artery. Question: A client with heart failure and pulmonary edema is given furosemide intravenously. Which assessment indicates that the furosemide has achieved the desired effect? You answered this question Incorrectly 1. Weight has decreased 2 pounds. 2. Systolic blood pressure has decreased. 3. Urinary output has increased. 4. Correct: The goal for diuretic therapy in this client is to prevent/relieve fluid accumulation in the lungs. This answer addresses the most life-threatening sequelae with HF. The number one thing to worry about in clients with HF is pulmonary edema, because this is what can kill the client. 1. Incorrect: Weight loss is a good assessment of fluid loss or gain, especially acute weight changes. The stem of the question, however, asks which is the desired effect? The desired effect is to decrease fluid in the lungs and weight loss alone does not ensure that the lungs are clearing. 2. Incorrect: Lowered blood pressure is an expected finding, but treatment of pulmonary edema is the primary goal. 3. Incorrect: Increased urinary output is an expected finding, but treatment of pulmonary edema is the primary goal. Question: The nurse is planning health promotion strategies for an older client on a limited, fixed income who is trying to increase activity. The client has been cleared for moderate physical activity by the primary healthcare provider. Which strategies would be appropriate for this client? You answered this question Incorrectly 1. Suggest that the client join a local gym for access to equipment and support. 2. , 3., 4. & 5. Correct: The neighborhood buddy is accessible and can be a source of emotional support too, which increases the likelihood of continuing the plan. This activity is easily accessible and burns calories during the day or evening. Senior centers usually do not cost any money for the client, and other seniors may help motivate the client to increase activity level. The use of ordinary items does not further strain a fixed income. 1. Incorrect: Joining a gym will require monthly fees, thus impacting financial resources in a negative way. Additionally, transportation to and from the gym could impact finances in a negative way. Question: The primary healthcare provider prescribes glycopyrrolate 0.2 mg IM thirty minutes prior to electroconvulsive therapy (ECT). What should be the nurse's response when the client asks why this drug is being given? You answered this question Incorrectly 1. "The action of the medication is complex." 2. "This drug will prevent you from having a seizure." 3. "This medication will relax your muscles so that you do not break a bone." 4. Correct: Glycopyrrolate is an anticholinergic. Glycopyrrolate blocks the activity of acetylcholine which reduces secretions in the mouth, throat, airway, and stomach. It is used prior to procedures to decrease the risk of aspiration. 1. Incorrect: The client has a right to be told the reason the drug is given. This is a nontherapeutic communication response. The nurse should not refuse the client's desire to understand their medications. 2. Incorrect: Glycopyrrolate blocks the secretions in the mouth, throat, airway and stomach. The medication does not prevent the client having a seizure. The ECT will induce a seizure, which is the desire. 3. Incorrect: This is not the drug’s purpose so this would be incorrect information to give to the client. Question: A client who has been on bed rest for several days is ambulating for the first time with assistance. Prioritize the actions the nurse should take by placing them in order from first to last. You answered this question Correctly The Correct Order Your Selected Order In order to keep a client safe, the nurse should first assess the client's orientation to determine the client's ability to follow instructions. Second, to avoid orthostatic hypotension, the nurse should assist the client to sit on the side of the bed. Third, apply the gait belt to ensure safety while ambulating. Fourth, assist the client to stand for a few seconds. The fifth action is to ambulate in the room. Question: The nurse is caring for a client who has pneumonia and is dehydrated. The primary healthcare provider has prescribed IV fluids and IV antibiotics. Based on the primary healthcare provider’s prescription and oral intake, what would be the 24 hour intake for this client? Exhibit You answered this question CorrectlyEnter the answer for the question below. • Rationale • Strategies Answer: 3670_ mls Rationale: The intake would be calculated by adding the following: Azithromycin: 250 mls Ceftriaxone: 50 ml X 2 = 100 mls IV of D51/2 NS at 125 ml/hr: 125mls X 24 hours = 3000 mls Total oral intake is 270 +50 = 320 mls TOTAL INTAKE = 3670 mls Question: The nurse is caring for a client who is to receive an IV infusion of heparin. The client’s dose is based on a sliding scale prescription. What is the priority lab value to check before initiating the heparin infusion? You answered this question Correctly 1. PT and/or INR 3. Platelet count 4. WBC count 2. Correct: The activated partial thromboplastin time (aPTT) is a lab value used to assess pathways in the clotting cascade and is used to monitor Heparin therapy in clients. To maintain a therapeutic level of Heparin, the aPTT should be maintained at 1.5-2.5 times the normal range. 1. Incorrect: The PT and INR are lab values used to monitor warfarin therapy in clients 3. Incorrect: The platelet count measures an individual's total platelet count. Thrombocytopenia is a platelet count of < 100,000. Thrombocytopenia increases the risk of bleeding; however, since the aPTT directly measures heparin therapy, it is the priority value to monitor. 4. Incorrect: The White Blood Cells (WBC) are not involved in the body’s mechanism for clotting. Question: The nurse is caring for a client who has been diagnosed with dissociative identity disorder. What is the most appropriate short term goal? You answered this question Correctly 1. Recovery of memory deficits. 2. Demonstration of the ability to perceive stimuli correctly. 3. Elimination of causative phobia. 4. Correct: In order for therapy to be successful, the client must first acknowledge that there are multiple personalities within the client's personality. 1. Incorrect: This is related to a client with dissociative amnesia. 2. Incorrect: This is related to a client with disturbed sensory perception. 3. Incorrect: This outcome would not be related to this client. Question: A client with gestational diabetes delivers an infant with macrosomia. What is the most vital component of the infant's assessment for the nurse to perform? You answered this question Correctly 1. Evaluation of the infant for cephalhematoma. 2. Determining if the infant sustained a clavicle fracture. 3. Observing for arm movement to evaluate for facial palsy. 4. Correct: Infants of diabetic mothers are at risk for hypoglycemia following birth. Hypoglycemia can trigger seizures and cognitive deficits. 1. Incorrect: Assessing for cephalhematoma is important in macrosomia infants, but not as vital as ensuring stable glucose levels. 2. Incorrect: Assessing for clavicle fracture is important in macrosomia infants, but not as vital as ensuring stable glucose levels. 3. Incorrect: Assessing for facial palsy is important in macrosomia infants, but not as vital as ensuring stable glucose levels. Question: In what order, after initially washing hands, should the nurse change a dressing on an infected abdominal surgical wound that has a Penrose drain and a large amount of purulent drainage? Place in priority order from first to last. You answered this question Correctly The Correct Order Your Selected Order First, apply clean gloves. Second, remove soiled dressings. Third, discard soiled dressings and clean gloves in red bag. Fourth, don sterile gloves. Fifth, clean surgical wound with moistened sterile 4x4’s. Sixth, clean around Penrose drain using circular pattern inside to outside. Seventh, place dry, sterile 4x4’s over surgical wound and Penrose drain. Eighth, apply abdominal dressing pad. Question: When assessing a client, the nurse finds that in response to painful stimuli the upper extremities exhibit flexion of the arm, wrist, and fingers with adduction of the limb, while the lower extremity exhibits extension, internal rotation, and plantar flexion. How would the nurse accurately document this finding? You answered this question Correctly 1. Decerebrate posturing 3. Reflex posturing 4. Superficial posturing 2. Correct: This describes decorticate posturing because they are moving towards the core of the body. 1. Incorrect: Decerebrate posturing occurs when the client is stimulated, and teeth clench and the arms are stiffly extended, adducted, and hyperpronated. The legs are stiffly extended with plantar flexion of the feet. Abnormal extension occurs with lesions in the area of the brain stem. 3. Incorrect: There is no such condition as reflex posturing. This is a distractor and can be ruled out by focusing on the meaning of the terms and similarities in verbiage. 4. Incorrect: There is no such condition as superficial posturing. This is a distractor and can be ruled out by focusing on the meaning of the terms and similarities in verbiage. Question: The nurse is caring for a client admitted to the emergency department with a history of asthma. Which assessment findings would the nurse anticipate? You answered this question Correctly 3. 3 + pitting edema to ankles 4. Kussmaul respirations 1., 2., & 5. Correct: The client with asthma has a pattern of dyspnea (shortness of breath), chest tightness, coughing, wheezing, and increased respiratory rate. 3. Incorrect: There should be no dependent edema with asthma. 4. Incorrect: This respiration classification relates to metabolic acidosis and is seen in DKA. Question: A client received 2nd and 3rd degree burns on both arms and the anterior trunk when pouring gas on a burning trash pile. With the percentage of burns indicated, what should the nurse anticipate? You answered this question Correctly 1. Movement of fluid out of the cells into the vascular space. 3. Rapid fluid shift out of the vascular bed 48 hours after the burn. 4. Severe fluid volume excess in the first 24 hours after the burn. 2. Correct: Using the Rule of Nines, the client would have burned approximately 36% of the body. For burns greater than 20-25% of the total body surface area, the nurse should recognize that significant vascular damage occurs which causes increased permeability. The fluid leaks out of the vascular space and out into the tissues (3rd spacing). The client can go into a severe fluid volume deficit and shock. 1. Incorrect: The movement of fluid is out of the vascular space into the tissues, not out of the cells into the vascular space. 3. Incorrect: The majority of fluid shifts out of the vascular bed occur in the first 24 hours. The diuresis phase begins about 48 hours after the burn injury when fluid is returning to the vascular bed. 4. Incorrect: The client is at risk for fluid volume deficit (not fluid volume excess) in the first 24 hours as the fluid leaks out into the tissue. Question: What should the nurse document after a client has died? You answered this question Correctly 5. Primary healthcare provider’s prescriptions 1., 2., 3., 4., & 6. Correct: All of these should be documented. Also document consideration of and preparation for organ donation; family notified and decisions made; location of identification tags. 5. Incorrect: The primary healthcare provider’s prescriptions do not need to be documented after a client dies. Question: A nurse is teaching a group of small farm owners how to prevent pesticide exposure for field workers. What points should the nurse include? You answered this question Incorrectly 2. Wearing protective clothing while working in the field and at home. 5. Boiling all vegetables for a minimum of 5 minutes prior to eating. 1. , 3. & 4. Correct: The standard precautions of hand hygiene is recommended prior to eating. This will reduce the transmission of pathogens and possible pesticides. The pesticides may be present on their clothing, so the clothing and shoes should be removed. Fruits and vegetables should be washed to remove pathogens and pesticides. All points are important to include when teaching prevention of pesticide exposure. 2. Incorrect: Yes, wear protective clothing while working in the field, but it is not necessary to wear protective clothing at home. 5. Incorrect: No, it is not necessary to boil or cook vegetables to remove chemicals from fresh produce. Washing thoroughly with water is adequate. Question: A nurse is caring for a client who reports fatigue, weight loss, afternoon fevers, night sweats, cough, and hemoptysis. What interventions should the nurse initiate? You answered this question Incorrectly 2. Restrict fluid intake to 500 mL per day. 5. Do not allow visitors for 48 hours. 1. , 3. & 4. Correct: The nurse should suspect that the client is suffering from tuberculosis. Early pulmonary TB is asymptomatic. When the bacterial load increases, nonspecific symptoms of fatigue, weight loss, afternoon fevers, and night sweats may set in. As disease advances, cough, sputum production, and hemoptysis may appear. This client has the classic symptoms of TB and should be placed on airborne precautions. N95 respirator ensures that the nurse does not inhale the TB organism. Placing in a semi-Fowler's position reduces the work of breathing. 2. Incorrect: Unless contraindicated, 3-4 liters of fluid is needed per day to liquefy secretions. 5. Incorrect: Visitors are allowed if standard and airborne precautions are followed. Question: A hysterical college student arrives in the emergency department in bloody soiled clothing. The nursing assessment reveals facial bruising and multiple contusions consistent with the client's report of being raped. Which initial nursing intervention takes priority at this time? You answered this question Incorrectly 1. Notify police of the alleged rape. 2. Allow the client privacy to wash self. 3. Remove clothing and bag for evidence. 4. Correct: Although there are specific protocols that must be followed when dealing with rape clients, it is important to remember that this client had all control taken away during the attack. The emotional effects of rape are as traumatizing as the physical injuries. Allowing the client to first express emotions, such as fear or anxiety, returns a small amount of control to a situation in which the client has little or none. 1. Incorrect: The police will indeed be notified of the situation by the hospital personnel, but the nurse's initial priority is to focus on the client's needs, both physical and emotional. 2. Incorrect: The client will not be permitted to clean self until all evidence has been collected per protocol. However, initial contact between nurse and client should focus on more than just the physical aspects of the situation. 3. Incorrect: Collection of all evidence for the police is a crucial part of treating rape clients and will be completed according to protocols. But it is more important to remember that this client has already been violated during the attack. Removing clothing before addressing emotional needs may further exacerbate that sense of violation. Question: The nurse is caring for a client taking benazepril. Which symptoms would be important for the nurse to report to the primary healthcare provider? You answered this question Correctly 1. BP 150/108 decreases to 138/86 3. Serum sodium level of 139 mmol/L 2. , 4., & 5. Correct: Weight gain of 5 pounds in one week is a s/s of an adverse effect of ACE inhibitor use. Weight gain is a sign of fluid retention. Angioedema is an adverse effect of ACE inhibitors and can be life threatening. This should be reported immediately to the healthcare provider. The potassium level is too high. Hyperkalemia is an adverse effect of an ACE inhibitor and needs to be reported. 1. Incorrect: This is an expected response of an ACE inhibitor. ACE inhibitors block the normal effects of renin-angiotensin-aldosterone system, thereby decreasing the blood pressure. 3. Incorrect: The serum sodium level here is within normal limits. There is no need to report normal lab values. Question: What discharge instructions should the nurse provide to the client post abdominal hysterectomy? You answered this question Correctly 3. Swimming is allowed if staples were used to close the skin. 5. Apply moist heat to surgical site the first couple of days for pain relief. 1., 2., & 4. Correct: The client should get up and move to prevent complications such as deep vein thrombosis (DVT), pneumonia, constipation, etc. The healthcare provider should be notified if the surgical wound is bleeding, red and warm to touch or has a thick, yellow, or green drainage. Pressing a pillow over incision when coughing or sneezing will ease discomfort and protect the incision. 3. Incorrect: Do not go swimming or soak in a bathtub or hot tub until the primary healthcare provider says it is ok. You worry about infection. 5. Incorrect: In the first couple of days, an ice pack may help relieve some pain at the site of surgery. Remember NCLEX wants you to think safety first when it comes to the use of heat. Question: Which assignments would be most appropriate for the RN to delegate to an LPN/VN? You answered this question Correctly 1. Six year old with new onset diabetes. 3. Three month old admitted with severe dehydration. 2. ,4. & 5. Correct: The best assignments for the LPN/VN would be the child with pneumonia admitted two days ago and the child admitted for developmental studies. The twelve year old with post op wound infection taking oral antibiotics is also stable. 1. Incorrect: The diabetic requires much teaching and supervision. This is an unstable client that should not be assigned to an LPN/VN. 3. Incorrect: The child with dehydration will require close intravenous fluid (IVF) monitoring, assessment and evaluation of condition. This client is unstable and should not be assigned to an LPN/VN. Question: The nurse receives new healthcare provider prescriptions on a client diagnosed with Addison’s disease. Which prescriptions should the nurse recognize as being inappropriately written and requiring clarification from the prescriber? You answered this question Correctly 2. IV of normal saline at 125 mL/hr 3. MRI of pituitary gland 5. Dehydroepiandrosterone DHEA sulfate 5 mg by mouth every other day 1. & 4. Correct: Use “daily” or “every day”. QD is an unapproved abbreviation. T.I.W. stands for three times a week; however, it is an unapproved abbreviation. Use “three times a week”. 2. Incorrect: This is a correct action and is written properly. 3. Incorrect: The primary healthcare provider may suggest an MRI scan of the pituitary gland if testing indicates the client might have secondary adrenal insufficiency. This is an approved abbreviation. 5. Incorrect: This is written correctly and may be given to women to treat androgen deficiency. Question: The nurse is preparing to administer iron dextran IM. Which injection site would be best for administration? You answered this question Incorrectly 2. Vastus lateralis site 3. Rectus Femoris site 4. Deltoid site 1. Correct: This site would be used for Z track IM injections. Iron preparations are administered by the Z track technique, preferably in a large, deep muscle such as the ventrogluteal muscle. 2. Incorrect: The vastus lateralis site could be used in adults with enough muscle mass, but ventrogluteal is preferred site. 3. Incorrect: The rectus femoris site can be used in adults when other sites are no longer accessible. It is not the preferred site. 4. Incorrect: The deltoid is a small muscle that is not well developed in many clients. It is not a recommended site for Z track medication administration. Question: A client comes to the clinic reporting palpitations, as well as nausea and vomiting while taking metronidazole. The nurse notes that the client is flushed and has a heart rate of 118 bpm. Based on this information, what is the most important question for the nurse to ask the client? You answered this question Correctly 1. “Do you take metronidazole on an empty stomach?” 3. “How long have you had these symptoms?” 4. “What other medications are you currently taking?” 2. Correct: Flushing, nausea and vomiting, palpitations, tachycardia, psychosis are signs of disulfiram-type reaction seen when using products containing alcohol (cologne, after shave lotion, or path splashes) or ingesting alcohol products while taking metronidazole. 1. Incorrect: Although it is preferable to take metronidazole on an empty stomach, this is not the most important question to ask at this time. 3. Incorrect: How long the client has had these symptoms is not as important as whether the client is using any alcohol containing products. 4. Incorrect: Although the nurse needs to know what other medications the client is taking, it is not as important as knowing if the client is using any alcohol containing products. Question: Which task should the nurse perform first? You answered this question Correctly 2. Changing a colostomy bag that is leaking. 3. Performing an admission assessment on a client. 4. Administering pain medication to a postoperative client. 1. Correct: The tracheostomy tube must be suctioned to keep the client's airway open. Suctioning the tracheostomy should take priority. Remember, airway first. 2. Incorrect: The client may be uncomfortable from the colostomy bag leaking. This task can be delegated. The suctioning of the client does not have priority over airway. 3. Incorrect: Important, but not priority over airway. There is no indication from the question that the new client is in distress. The priority intervention is to maintain the airway. 4. Incorrect: Important, but it does not take priority over airway. Question: What should the nurse do first when caring for a client who is being admitted with a diagnosis of meningococcal meningitis? You answered this question Correctly 1. Assess neuro status. 2. Obtain health history. 4. Orient client to the room and procedures. 3. Correct: Although all the options are appropriate, the priority is to place the client on droplet precaution to prevent the spread of meningococcal meningitis. 1. Incorrect: Placing client in isolation should be done first (actually prior to arriving to room) since the client has a diagnosis of meningococcal meningitis. Assessment of the neuro status can be done next. 2. Incorrect: The health history can be obtained after placing the client on droplet precautions. 4. Incorrect: Orientation can occur after the initiation of droplet precautions. Question: The nurse is caring for a depressed client. The client has a flat affect, apathy, and slowed physical movement. The client has not bathed in several days and there is a malodorous odor noted. Which intervention would be most appropriate at this time? You answered this question Incorrectly 1. Explain the rules about daily showers. 2. Leave the client alone since there is slowed movement. 4. Ask when he or she would like to take a shower. 3. Correct: Depressed clients often have little energy to do or think. Give short, simple commands during this time. 1. Incorrect: Not very therapeutic. This is difficult to comprehend at this time. Give short, clear, simple commands. 2. Incorrect: Do not ignore the problem. You must do what is best for the client and this would not be the best decision. 4. Incorrect: The client will not want to do anything at this time. It will be put off and depressed client's often have difficulty making decisions. Question: A primary healthcare provider prescribed KCL 40 mEq in 100 mL NS to infuse over 30 minutes. What action should the nurse take? You answered this question Correctly 1. Administer the KCL through the lowest IV line port. 3. Mix KCL 40 mEq into the present infusing bag of NS when it reaches 100 mL. 4. Set the infusion pump to 100 mL / hour. 2. Correct: Potassium chloride should be diluted and administered to infuse no faster than 40 mEq per hour. So this prescription would infuse too quickly and may lead to life threatening arrhythmias. 1. Incorrect: This prescription should not be administered as written. The rate of infusion over 30 minutes is too fast. 3. Incorrect: This is dangerous. Nurses should not add KCL to an existing bag of infusing fluid. This prescription should not be administered as written. 4. Incorrect: The nurse should verify the rate prior to initiating the infusion. The rate of administration should be clarified with the primary healthcare provider. Question: A client is diagnosed with new onset grand mal seizures. Which nursing interventions should the nurse implement for this client? You answered this question Correctly 1. Have an unlicensed assisitve personnel stay with the client. 4. Keep a padded tongue blade at the bedside. 2. , 3., & 5. Correct: During a seizure these interventions will help to protect the client from injury. The client may strike the side rails. The bed should be placed in the low position in case the client falls out of the bed. The client would need assistance to the floor if a seizure starts while ambulating. 1. Incorrect: It is not necessary to have someone stay with this client at all times. Place a call light within reach, put the client close to the nurses’ station, and pad the side rails. Have the client call for assistance to bathroom. Maintain bed rest until seizures are controlled or ambulate the client with assistance to protect from injury. 4. Incorrect: Do not place a padded tongue blade in a client’s mouth during a seizure. The padded tongue blade could cause injury. Question: A client diagnosed with schizophrenia who is taking monthly haloperidol injections develops slurred speech, shuffling gait and drooling. Which prescribed PRN medication would the nurse administer? You answered this question Correctly 1. Lorazepam 2. Atropine 4. Chlorpromazine 3. Correct: These signs and symptoms are reflective of pseudoparkinsonism, a form of extrapyramidal side effects which are side effects of the haloperidol. An anticholinergic agent maybe used for treatment. This is an anticholinergic agent that may be used for extrapyramidal side effects. 1. Incorrect: This is a sedative/hypnotic or antianxiety agent. It is not used for treatment of extrapyramidal side effects. 2. Incorrect: This is an anticholinergic agent, but not one commonly used to treat pseudoparkinsonism, a form of extrapyramidal side effects. It is commonly used to treat arrhythmias and preoperatively to decrease secretions. 4. Incorrect: This is another antipsychotic medication. Question: A nurse is preparing a lecture about suicide. Which target audience would be most appropriate? You answered this question Incorrectly 2. Girl Scout leaders 3. Support group of divorced parents 4. Hispanic immigrant farm workers 1. Correct: Among those who commit suicide, young men between the ages of 15-24 are more likely to commit suicide than young girls and women. The best line of defense is to teach about the warning signs of suicide to high school teachers, students, and parents of teens and young adults, particularly male. 2. Incorrect: Although teenage girls may attempt suicide, they are less likely than males to use a lethal method. Additionally, participation in groups such as the scouts will provide support for girls. 3. Incorrect: Joining a support group will help eliminate stress of being a single parent. Young males are more likely to attempt suicide by lethal means. 4. Incorrect: Hispanics have a lower suicide rate than Caucasians. Question: The six bed Labor and Delivery area is full when the Emergency Department nurse calls for a bed for a woman reporting low back pain, pelvic pressure and increased vaginal discharge at 36 weeks gestation. Which would be the most appropriate action for the charge nurse? You answered this question Correctly 1. Transfer a G4P4 who delivered full-term twins one hour ago to the antepartum/postpartum floor. 3. Transfer an 8 hour postpartum G1P1 on Magnesium Sulfate for eclampsia from the LDR unit to the ante/postpartum unit. 4. Request that the new client be admitted to the antepartum/postpartum floor. 2. Correct: The client and newborn are not in any present distress. Also the delivery occurred 3 hours ago. This client would not be a risk and could be cared for on the antepartum/postpartum floor. 1. Incorrect: This client is at high risk for hemorrhage due to still being in the fourth stage of labor and over distention of her uterus with a term multiple gestation. This client needs to stay in current location for close monitoring. 3. Incorrect: Close monitoring and frequent vital signs are required since central nervous system alterations and respiratory depression are common side effects of Magnesium Sulfate. 4. Incorrect: This client has subtle signs and symptoms of preterm labor and needs close monitoring. Ante and postpartum unit is for stable clients. Question: The home health nurse is assessing the home environment for possible irritants that could increase/precipitate symptoms of respiratory problems. Which assessment questions would be important to determine level of risk? You answered this question Incorrectly 5. Is your water supply treated by a municipal agency? 1., 2., 3. & 4. Correct: Presence of wood smoke could increase respiratory problems. Poorly vented gas heaters could increase carbon monoxide in the environment. Use of solvents or other agents that produce irritating fumes could increase risk. The particles from the sanding could irritate the respiratory tract as well. Second-hand smoke is irritating to the respiratory tract. Aerosols could trigger respiratory problems. 5. Incorrect: Water safety would not necessarily increase respiratory risk. Question: Which electrolyte imbalance would be the nurse’s priority concern in the burn client? You answered this question Correctly 1. Hypernatremia 3. Hypoalbuminemia 4. Hypermagnesemia 2. Correct: Good job. When the cells lyse they release potassium, and then the serum potassium goes up. And if the kidneys stop, we are in real trouble. 1. Incorrect: Well this one does occur when the client becomes very dehydrated, but it’s not as dangerous as the potassium one. 3. Incorrect: Low albumin can cause problems keeping fluid in the vascular space, but albumin is not an electrolyte. 4. Incorrect: No, the magnesium doesn’t go up unless the kidneys shut down. Question: A case manager is evaluating a client diagnosed with hemiplegia due to a cerebral vascular accident who will need assistive devices upon discharge. Which devices should the case manager include for this client? You answered this question Correctly 6. Button closures on clothes 1., 2., 3., 4., & 5. Correct: The goal is to promote self-care by the client as much as possible. The case manager should evaluate the need for assistive devices to help with eating, bathing, dressing, and ambulating. The dinner plate food guard will prevent food from being pushed off the plate. The transfer belt will provide safety for the client to get into a chair or back in bed. A raised toilet seat makes it easier for the client to sit on the toilet without falling. The long-handled shoe horn allows the client to put on shoes without assistance. Wide grip utensils accommodate a weak grip. 6. Incorrect: It is hard for someone with hemiplegia to use buttons. Velcro fasteners are best. Question: A client with a history of congestive heart failure has an implantable cardioverter defibrillator (ICD) surgically implanted. What teaching points should the nurse provide the client prior to discharge? You answered this question Incorrectly 1. Avoid hot baths and showers. 2. Increase intake of leafy green vegetable products. 5. Driving is not recommended for 1 year after placement of an ICD. 3. , & 4. Correct: Magnets can deactivate the defibrillator. Other transmitter devices should also be avoided. Most arrhythmias need only one shock, but the healthcare provider should be notified when a shock is delivered so that monitoring can increase. 1. Incorrect: Hot baths or showers are not contraindicated with ICDs. 2. Incorrect: Increase of leafy green vegetable products would have no relation to the ICD but should be avoided if the client is on warfarin. 5. Incorrect: The client cannot drive for 6 months after implantation of an ICD and cannot drive for 6 months after any shock therapy from the ICD. Question: The oncoming nurse has just received report and is preparing to make initial rounds. Which postpartum client should the nurse see first? You answered this question Correctly 1. A primipara 6 hours postpartum saturating one peripad every two hours 3. A primigravida 12 hours postpartum with the uterine fundus at the umbilicus 4. A multigravida 72 hours postpartum with a brownish pink lochia discharge. 2. Correct: Intense perineal pain is a symptom of a perineal hematoma which is a medical emergency. 1. Incorrect: Expected findings for the postpartum period are described here. This is a normal peripad saturation and does not indicate a problem. 3. Incorrect: Expected findings for the postpartum period are described here. This is the proper position of the fundus 12 hours postpartum. 4. Incorrect: Expected findings for the postpartum period are described here also. A client postpartal 72 hours should have a brownish pink lochia discharge. Question: The nurse educator is teaching a group of nursing students about client advocacy. What should the educator tell the students are the consequences of failure to act as a client advocate? You answered this question Incorrectly 4. Suspension or loss of license to practice medicine. 1., 2., 3. & 5. Correct: The role of client advocate is a nurse’s responsibility. Failure to act as a client advocate could result in a range of complications for the client, including life-threatening or life-ending complications. Failure to act as client advocate exposes the nurse to liability, potential legal action against the nurse and/or healthcare facility, and potential suspension or loss of license to practice nursing. The client advocate protects client autonomy and right to make decisions. 4. Incorrect: The nurse does not have a license to practice medicine. The nurse cannot work outside of their scope of practice. This action may result in the possible susp Question: A nurse drops a bottle of IV fluid, which shatters on the floor in the hallway. What action should the nurse take? You answered this question Incorrectly 1. Notify housekeeping to clean up the spill. 3. Pick up the glass with gloved hands and dispose into a puncture resistant sharps container. 4. Use a wet mop to collect the glass and dispose of it in the garbage can. 2. Correct: The nurse must not be cut by the broken glass. Proper removal of glass includes using a dustpan and broom to collect the glass and disposing of it into a puncture resistant sharps container. 1. Incorrect: While waiting for housekeeping someone could fall or get cut. The nurse should initiate cleanup. 3. Incorrect: Hands are never used to pick up glass even if they are gloved because of the increased risk of getting cut. 4. Incorrect: A wet mop will not pick up the glass, and glass pieces will stick to a wet mop. Question: Which nursing task would be appropriate to delegate to an LPN/VN? You answered this question Correctly 2. Administer regular insulin IV to a client in diabetic ketoacidosis. 3. Monitor a client’s closed drainage unit (CDU) for tidaling. 4. Assess a client for tactile fremitus. 1. Correct: The LPN/VN has the knowledge and skill to obtain a wound culture. This is within the scope of practice for the LPN/VN. 2. Incorrect: The LPN/VN cannot administer IV medications to an unstable client. This client needs the RN for close monitoring. 3. Incorrect: The LPN/VN cannot monitor a chest tube and closed drainage unit. This is an RN task. 4. Incorrect: Assessment is the task of an RN. LPN/VN's can collect data, observe, and monitor the client. Question: A client has been prescribed vancomycin 1 gram IV every 12 hours for the treatment of methicillin-resistant staphylococcus aureus (MRSA). Which action by a new nurse when administering this medication would require intervention by the charge nurse? You answered this question Correctly 1. Dilutes medication in NS 100 mL. 2. Delivers medication via an IV pump. 4. Monitors IV site every 30 minutes during infusion. 3. Correct: This dose of medication should be delivered over at least 60 minutes to prevent hypotension and ototoxicity. 1. Incorrect: The minimum dilution for 1 gram is 100 mL, so this action does not need intervention. 2. Incorrect: This is a correct action by the new nurse. A pump is required to ensure that medication is not delivered too rapidly. 4. Incorrect: A peripheral IV site should be monitored for pain, redness or swelling prior to initiating the infusion and every 30 minutes until the completion of the infusion. Question: Which nursing action is likely to improve client satisfaction and demonstrate acts of beneficence? You answered this question Correctly 1. Allowing clients to make their own decisions about care 2. Answering all questions posed by client in an honest manner 3. Reporting faulty equipment to the proper departments 4. Correct: Sitting and listening demonstrates kindness and compassion that are consistent with the ethical term "beneficence." Beneficence is taking positive action to help others and a desire to do good which is the core principle of client advocacy. 1. Incorrect: Autonomy is the ethical principle illustrated here by supporting independent decision making with clients. 2. Incorrect: Fidelity is the ethical principle illustrated here and refers to the concept of keeping a commitment. It is based upon the virtue of caring. 3. Incorrect: Reporting faulty equipment is an act to promote nonmaleficence or to do no harm. This is the core of nursing ethics. Question: A nurse is educating the parents of a child with celiac disease. The nurse knows the teaching is successful if the parents choose which food for their child's dinner? You answered this question Correctly 1. Turkey and lettuce sandwich on rye bread 3. Chicken, vegetables and a whole wheat roll 4. Hotdog and baked beans 2. Correct: Steak and potatoes are gluten free. 1. Incorrect: Client’s with celiac disease should maintain a gluten free diet. Rye bread contains gluten. 3. Incorrect: Client’s with celiac disease should maintain a gluten free diet. Wheat contains gluten. 4. Incorrect: Client’s with celiac disease should maintain a gluten free diet. Processed meats such as hotdogs and most sausages contain gluten. Question: A 68 year old client was admitted two days ago to a long-term care facility. The client has chronic kidney disease, coronary artery disease and chronic obstructive pulmonary disease. Oxygen 2 L/per nasal cannula is being administered. Assistance is needed with activities of daily living. The primary healthcare provider visits today and writes new prescriptions. Who is the best person for the charge nurse to delegate carrying out these prescriptions? You answered this question Incorrectly 1. Unlicensed assistive personnel (UAP) 3. RN 4. Charge Nurse 2. Correct. All the nursing responsibilities associated with the healthcare provider’s prescriptions are within the scope of practice of the LPN/LVN. 1. Incorrect. Giving medications is out of the scope of practice of the Unlicensed assistive personnel (UAP). 3. Incorrect. All the nursing responsibilities associated with the healthcare provider’s prescriptions are within the scope of practice of the LPN/LVN. The RN would need to be assigned to more unstable clients than this one. 4. Incorrect. The charge nurse is responsible for assuring that all client care is provided during the shift, so carrying out these prescriptions is not the best use of time and resources available to the charge nurse. Question: Following surgery, a client refuses to ambulate as prescribed. What action should the nurse take? You answered this question Incorrectly 1. Notify the primary health care provider of client’s refusal to ambulate. 2. Offer the client pain medication. 4. Perform passive range of motion exercises. 3. Correct: The nurse should educate the client about complications that can be prevented with ambulation, such as constipation, pneumonia, or deep vein thrombosis (DVT). 1. Incorrect: The first action should be for the nurse to educate the client so an informed decision can be made. This would put the nurse in an advocacy role and would more likely persuade the client to comply with ambulation. 2. Incorrect: The first action should be for the nurse to educate the client so that he/she can make an informed decision. Offering pain medication would be appropriate if pain is impeding the client's ability to move; however, pain medications may make the client at risk for falls so safety precautions would be priority. 4. Incorrect: The first action should be for the nurse to educate the client so that an informed decision can be made. Passive range of motion would not be the best option at this time. Question: The nurse recognizes that treatment has been successful in resolving fluid volume excess based on which assessment findings? You answered this question Correctly 1. Continued lethargy 2. Heart rate 112/min 5. Increased thirst 3. & 4. Correct: Urinary output should increase with decreasing shortness of breath as hydration is corrected, and BP should be normal. 1. Incorrect: Level of consciousness (LOC) should improve with perfusion to the brain. 2. Incorrect: Heart rate should decrease if hydration is corrected. 5. Incorrect: Thirst level should be decreased if hydration is corrected. Question: A client has been on the mental health unit for three days and is requesting to leave against medical advice (AMA). It has been determined that the client is not suicidal. What should the nurse do? You answered this question Correctly 2. Make arrangements for a commitment hearing, as soon as possible. 3. Tell the client the primary healthcare provider must discharge the client prior to leaving. 4. Call the primary healthcare provider and request a discharge order. 1. Correct: Protocols on the unit must be followed when someone is requesting to leave AMA. The first step is to call the primary healthcare provider about the client's desire to leave AMA. 2. Incorrect: The client is not suicidal; however, the primary healthcare provider needs input into their decision to leave AMA. It is not appropriate to prepare for a commitment hearing. 3. Incorrect: If the client is not a threat or potential threat to self or others, the client may leave. The nurse may discuss the decision to leave; however, this statement is not accurate. 4. Incorrect: The nurse should call the primary healthcare provider and discuss the situation. The primary healthcare provider should have input into this decision. Question: A client is reporting pain rated an 8 out of 10 on the numeric pain scale. The nurse administers an oral pain medication to the client and starts a CD of the client’s favorite relaxing music. Fifteen minutes later, the client rates the pain as 2 out of 10 on the numeric pain scale. What type of nonpharmacologic pain relief intervention has the nurse used? You answered this question Correctly 2. Biofeedback 3. Progressive relaxation 4. Cutaneous stimulation 1. Correct: The nurse uses distraction in the form of music while the oral analgesic takes effect. 2. Incorrect: Biofeedback is a behavioral therapy that trains individuals to take control of the physiological responses to stressors. 3. Incorrect: Progressive relaxation uses a combination of breathing exercises and muscle group contractions and relaxation. 4. Incorrect: Cutaneous stimulation uses stimulation of the skin through heat, cold, or even electrical nerve stimulation to decrease or eliminate pain. Question: The nurse is caring for a Native American client who has returned to the surgical floor following abdominal surgery. The nurse is concerned about the level of discomfort that the client is experiencing. Which comment is the nurse likely to hear upon assessment? You answered this question Correctly 1. "The pain is getting worse. I can’t stand it." 2. "I need something for pain as soon as possible." 3. "I hope that the pain will go away soon." 4. Correct: The Native American client is likely to be quiet and less expressive of pain. Native Americans tend to tolerate high levels of pain. 1. Incorrect: This comment is likely to come from the dominant American culture where pain is considered something to be treated. 2. Incorrect: Native Americans tend to tolerate high levels of pain. Abdominal surgery usually results in sensations of pain for most people. 3. Incorrect: The Native American client is likely to be very quiet about the pain being experienced. Question: Post cataract removal a client reports nausea and severe pain in the operative eye. Which nursing intervention takes priority? You answered this question Correctly 1. Administer morphine and ondansetron. 2. Reposition client to non-operative side. 3. Massage the canthus to unblock the lacrimal duct. 4. Correct: Severe pain with nausea indicates an increase in intraocular pressure and needs to be reported at once. Eye damage can result if not resolved quickly. The primary healthcare provider may prescribe medications or take the client back to surgery. 1. Incorrect: This is not the priority as severe pain and nausea indicates an increase in intraocular pressure and needs to be reported at once. 2. Incorrect: Repositioning will not fix the problem. Severe pain with nausea indicates an increase in intraocular pressure and needs to be reported at once. 3. Incorrect: The problem is an increase in intraocular pressure which needs to be reported to the primary healthcare provider. Question: Which nursing intervention should receive priority after a client has returned from having had eye surgery? You answered this question Correctly 1. Administer pain medication around the clock. 3. Apply warm compresses. 4. Instruct on importance of turning, coughing, and deep breathing. 2. Correct: Maintaining head of bed in an elevated position will help to decrease intraocular pressure. Do not lie the client supine as this will increase intraocular pressure. If the intraocular pressure increases too much, damage to the eye structures, including the retina and optic nerve, with resulting loss of vision, may result. 1. Incorrect: Although pain management is important, it is not the priority here. The priority intervention of maintaining the bed at 35° is to reduce the risk of increased intraocular pressure. Unless the pain becomes out of proportion or suddenly worsens, it is an expected finding and would not be cause for alarm or require "priority" attention. 3. Incorrect: Warm and hot compresses could possibly increase intraocular pressure and cause damage to the eye structures. 4. Incorrect: Coughing will increase intraocular pressure and could result in damage to the surgical site and/or the structure within the eye. Loss of vision could result if pressure becomes too great. Coughing is a type of valsalva movement which results in an increase in the intraocular pressure Question: A client is scheduled for plateletpheresis. When taking the client’s history, which information is most significant? You answered this question Correctly 1. Allergies to shellfish 3. Time of last oral intake 4. Blood type 2. Correct: Platelet donors can have plateletpheresis as often as every 14 days. 1. Incorrect: Allergies to shellfish have nothing to do with withdrawing platelets from the client. 3. Incorrect: Time of last oral intake has no bearing on whether or not a client can donate platelets. 4. Incorrect: Blood type has no bearing on whether or not a client can donate platelets. Question: The charge nurse on the pediatric unit is reviewing the protocol for blood administration with a staff nurse. Which actions by the staff nurse indicate understanding of blood administration? You answered this question Correctly 1. The blood infusion time was within 6 hours. 5. One form of client identification were obtained prior to infusion. 2. , 3., & 4. Correct: Filters are used when infusing blood. Two nurses must check the blood product label and blood group. Vital signs are checked frequently during a blood transfusion. For example: A baseline set of vital signs are taken, then again 5 minutes after the initiation of the transfusion, then 15 minutes after transfusion started and every 15 minutes for one hour, then every 30 minutes for one hour, then hourly until infusion is complete. 1. Incorrect: Blood should hang for no longer than 4 hours because it increases the chances of a reaction. 5. Incorrect: At least two methods of proper identification should be obtained, such as asking client his/her name and checking ID band. Question: The home health nurse is caring for a client with a neurological urinary tract dysfunction. What information should be included when teaching the client how to perform intermittent self catheterization? You answered this question Correctly 1. Performed in an emergency department (ED). 2. Prevents urinary catheter infections. 4. Requires using sterile gloves. 3. Correct: Home intermittent catheterization is a clean, not sterile technique when performed in the home environment. Home intermittent catheterization is preferred over continuous use of an indwelling catheter, as an indwelling catheter increases client risk of urinary tract infection (UTI). 1. Incorrect: The client can be taught to do self-catheterization at home. The client does not need to go to the emergency department (ED) to perform the self- catheterization procedure. 2. Incorrect: Performing intermittent self-catheterization at home is recommended for urinary retention. It does not prevent urinary tract infections. 4. Incorrect: Intermittent self-catheterization is a clean procedure, not sterile technique. Question: The nurse is searching for information about the nursing care of a client receiving an experimental drug for the treatment of obesity. Which database is most likely to address this issue? You answered this question Incorrectly 2. Cochrane Library 3. Health and Wellness Resource Center 4. MEDLINE 1. Correct: The Cumulative Index for Nursing and Allied Health Literature (CINAHL) is a source for reviewing nursing