RNSG 2331 - Exam-4-Capstone-1. (100% correct answers)

RNSG 2331 - Exam-4-Capstone-1 Question: The client has been working on weight loss for 8 months and has been successful in losing 35 lbs (15.9 kg). The client is now entering the maintenance phase of the health promotion plan. Which strategies are important for the nurse to emphasize as the client enters this phase? You answered this question Correctly 3. Discontinue programmatic exercise plan. 1., 2., 4. & 5. Correct: The person must have ongoing support to prevent a relapse. The weigh-ins increase accountability for prolonged behavioral change. Anytime that a new behavior is instituted, there is a chance that the person will return to old habits. Having a plan in place may help the person to stay on track. Ongoing peer support can be very helpful as the client continues in the maintenance phase. 3. Incorrect: Programmatic exercise, although reduced in frequency perhaps, should still be available. If this is taken away or reduced too much, the client may return to old habits. Question: Which client in the Labor, Delivery, Recovery, and Postpartum Unit (LDRP) should the nurse see first? You answered this question Correctly 2. Multigravida at term who is dilated to six centimers and at minus one station with moderate contractions every five to ten minutes. 3. Primipara at 38 weeks gestation who is dilated to five centimeters and at zero station with strong contractions every four minutes. 4. Multigravida at 36 weeks gestation with pregestational diabetes in for a biophysical profile for fetal well being. 1. Correct: Minus two station is high with the presenting part not engaged. This client is at high risk for prolapsed cord, which would require relieving pressure on the cord and emergency cesarean delivery. 2. Incorrect: Contractions are not close enough for this client to be an emergent situation. Also, since this is a multigravida client and not fully dilated yet, she is not a high risk client. 3. Incorrect: This client is in the active phase of labor, but there is much work to be done before she is fully dilated and engaged for delivery. 4. Incorrect: This client is not in labor and is a non-emergent client, particularly compared to client #1. Question: The nurse is preparing to discharge a client who has been placed on tranylcypromine. The nurse teaches the client about food to avoid while taking this medication. What food choice by the client confirms appropriate understanding of the teaching? You answered this question Correctly 1. Cottage cheese 3. Baked chicken 4. Potatoes 2. Correct: The client taking a monoamine oxidase inhibitor (MAOI) such as tranylcypromine should avoid foods rich in tyramine or tryptophan. These include: cured foods, those that have been aged, pickled, fermented, or smoked. These can precipitate a hypertensive crisis. 1. Incorrect: Clients taking MAOIs can eat cottage cheese in reasonable amounts. 3. Incorrect: Clients taking MAOIs can eat baked chicken. 4. Incorrect: Clients taking MAOIs can eat potatoes. Question: What task by the RN should be performed first? You answered this question Correctly 1. Changing a burn dressing that is scheduled every four hours. 2. Administering scheduled IV antibiotic. 3. Teaching a new diagnosed diabetic about diet and exercise. 4. Correct: The admit assessment should be done first. It is important to initiate the assessment and physical exam within one hour of being admitted to the unit or floor. The assessment and plan of care should be completed within 8 hours of admission. 1. Incorrect: The other clients' needs are important, but are scheduled and established in a routine. These routines can be continued once the new client’s assessment has been completed. 2. Incorrect: This is not a priority based on the information in the question. The scheduled IV antibiotic administration can be administered within the appropriate time frame. 3. Incorrect: A newly diagnosed diabetic is not always ready for teaching, so this is not priority. The nurse should identify when the client is ready to learn. This teaching session can occur prior to or after assessing the new client. Question: A client is admitted to the intensive care unit after overdosing on meperidine. What is the nurse's first priority? You answered this question Incorrectly 1. Maintain continuous cardiac monitoring. 3. Provide alprazolam 0.25 mg PO PRN. 4. Initiate intravenous fluid resuscitation with lactated ringers at 125 mL/hr. 2. Correct: The respiratory status of the client takes priority. The administration of naloxone will block the opioid, initiating a reversal of the central nervous system (CNS) and respiratory depression. 1. Incorrect: Continuous cardiac monitoring is appropriate, however, airway takes priority. 3. Incorrect: Alprazolam will worsen respiratory depression. Alprazolam is a benzodiazepine. The action of this drug may depress the CNS. 4. Incorrect: IV fluids will be initiated, but airway takes priority. Question: A client is admitted to the medical unit with an acute onset of fever, chills and RUQ pain. Vital signs are: T 99.8°F (37.7°C), P 132, RR 34, B/P 142/82. ABG results are: pH- 7.53, PaCO2 30, HCO3 22. The nurse determines that this client is in what acid/base imbalance? You answered this question Correctly 1. Respiratory acidosis 3. Metabolic acidosis 4. Metabolic alkalosis 2. Correct: This client has a severe infection. Hyperventilation due to anxiety, pain, shock, severe infection, fever, and liver failure can lead to respiratory alkalosis. pH > 7.45, PCO2 < 35, HCO3 normal. 1. Incorrect: Not acidosis with hyperventilation and pH of 7.53. 3. Incorrect: Not a metabolic related acid/base imbalance since the HCO3 is in normal range and is not acidosis. 4. Incorrect: Not a metabolic related acid/base imbalance since the HCO3 is in normal range. Question: A new mother calls the clinic and tells the nurse, “I don’t have any help taking care of my 3 week old baby. I don’t know what to do. I just feel like I can’t take care of him anymore. I wish I never had him sometimes. Maybe then my husband would spend more time at home.” What would be the nurse's best response? You answered this question Correctly 1. "You are experiencing maternity blues, which will go away on its own." 2. "You are just tired. Tell your husband that you need his help." 4. "Have you thought about getting a family member to help with the baby?" 3. Correct: This client is exhibiting signs of postpartum psychosis. Post partum psychosis is characterized by depressed mood, agitation, indecision, lack of concentration, guilt, and an abnormal attitude toward bodily functions. There is a lack of interest in or rejection of the baby, or a morbid fear that the baby may be harmed. Risks of suicide and infanticide should not be overlooked. 1. Incorrect: Maternity blues includes tearfulness, despondency, anxiety and subjectivity with impaired concentration. 2. Incorrect: This ignores a potentially life-threatening problem. The client is not just tired. 4. Incorrect: This ignores a potentially life-threatening problem. Assume the worse. Think about the safety of mom and baby. Question: A client has a prescription for digoxin 0.125 mg IV push every morning. Prior to administering digoxin, the nurse notes that the digoxin level drawn this morning was 0.9 ng/mL. Which action would be most important for the nurse to take? You answered this question Incorrectly 2. Hold the digoxin. 3. Notify the primary healthcare provider. 4. Repeat the digoxin level. 1. Correct: This is a normal digoxin level. The nurse would administer the prescribed digoxin. The therapeutic serum levels of digoxin range from 0.5 to 2 ng/mL. 2. Incorrect: This is a normal digoxin level. The nurse would administer the prescribed digoxin. 3. Incorrect: There is no need to notify the primary healthcare provider of a normal digoxin level. 4. Incorrect: There is no need to repeat a normal laboratory value. Question: Which member of the multi-disciplinary team oversees and coordinates the healthcare delivery process and organizes the delivery of healthcare services to the client? You answered this question Correctly 1. Clinical nutritionist 2. Primary nurse each shift 3. Primary healthcare provider 4. Correct: An important role of the case manager in the multi-disciplinary team care approach is coordination of client care. The case manager oversees the process of healthcare delivery and organizes and coordinates the delivery of healthcare services to the client. 1. Incorrect: The clinical nutritionist is a member of the multi-disciplinary team, but does not coordinate and organize the delivery of care outside of the client's nutritional needs. 2. Incorrect: The primary nurse each shift develops and executes the plan of care for the client, but is not the organizer and coordinator of all the services to the client. 3. Incorrect: The primary healthcare provider is a member of the multi-disciplinary team, but is responsible for prescribing healthcare for the client, not organizing the services. Question: The unlicensed assistive personnel (UAP) reports to the nurse that a client with Alzheimer's has been walking into rooms on the unit and stating, "This is my room, so get out!" What is the best instruction the nurse can give to the UAP? You answered this question Correctly 1. Calmly sit with the client and have the client repeat the room number at frequent intervals. 2. Have the client remain in the room so the client can become familiar with it. 3. Place a sign on the client's door that clearly has the client's name so the client can identify it. 4. Correct: A client with Alzheimer's is likely to recognize a familiar object before reading the name on the door. 1. Incorrect: You can make the client repeat the room number over and over, but he or she will not remember it particularly since it is short-term current memory. This is the part of memory that goes first with the Alzheimer's client. 2. Incorrect: Stay in your room until you get used to it? No, this is non- therapeutic for a client with Alzheimer's and could increase their confusion and moody behavior. 3. Incorrect: This seems like an appropriate answer, but clients with Alzheimer's may not recognize their own name or take the time to read. Question: The nurse sees that the new medication noted in a recent prescription is on the client’s list of allergies. In the role of client advocate, what actions should the nurse take to ensure client safety? You answered this question Incorrectly 1. Document the medication with times and doses to be given, then administer the medication as ordered. 5. Call the pharmacy to see if the medication needs to be changed. 2. , 3. & 4. Correct: Administration of a medication that the client is allergic to could result in harm to the client. The primary healthcare provider should be notified immediately of a medication prescription that conflicts with the client’s list of medication allergies. The medication should be discontinued on the medication administration record, and the client’s allergy band checked against the list of allergies documented in the medication record for accuracy. All of these actions place the nurse in the role of client advocate and ensure the client's safety. 1. Incorrect: No, this medication could cause harm to the client. The client is allergic to this medication. 5. Incorrect: No, the primary healthcare provider, not the pharmacy, should be notified for medication changes. The primary healthcare provider is responsible for prescribing the medication. Question: Which suggestion should the nurse provide to a client reporting frequent episodes of constipation? You answered this question Incorrectly 1. Take a stool softener. 3. Monitor elimination habits for the next week. 4. Rest after each meal. 2. Correct: Increased fiber intake may help to establish regular elimination habits. 1. Incorrect: Not the best initial suggestion. It's better to promote health maintenance routines than to just go with a medication, which could be a temporary fix. 3. Incorrect: The nurse should make a suggestion that will assist the client with normal elimination. This option does not suggest a way to fix the problem. 4. Incorrect: Increased activity is likely to result in more normal elimination. Resting after meals would not increase elimination frequency. Question: The nurse is assigned to triage a client presenting to the emergency department who is suspected to have exposure to inhaled anthrax. What assessment findings are expected? You answered this question Correctly 2. Small papule on skin resembling an insect bite. 3. Pustular vesicles on skin. 4. Fatigue. 1. Correct: Inhalation of anthrax spores is very serious, and clients will experience abrupt dyspnea and fever. Treatment must begin immediately. 2. Incorrect: Cutaneous anthrax manifests itself as papules resembling an insect bite that progresses to depressed black ulcers. 3. Incorrect: Pustular vesicles are consistent with smallpox. 4. Incorrect: Fatigue is a vague symptom that is usually not associated with inhaled anthrax. Question: What should the nurse include when teaching a client in renal failure about peritoneal dialysis? You answered this question Incorrectly 1. Instill 250 ml of fluid into the peritoneal cavity over 30 minutes. 2. Use cool effluent when instilling into the peritoneal cavity. 5. If all the fluid does not drain out, place the bed in the Trendelenburg position. 3, 4, & 6 Correct: Once the prescribed dwell time has ended, the bag is lowered and the fluids, along with the toxins, are drained out into a bag over a period of 15 – 30 minutes. The fluid should be clear in appearance (should be able to read a paper through it). Cloudy return could indicate infection. Since the dialysate has a lot of glucose in it, the client frequently reports a constant sweet taste. 1. Incorrect: The amount of fluid used in peritoneal dialysis is about 2000 to 2500 ml at a time. This filling of the peritoneal cavity is often completed in 10 minutes. 2. Incorrect: Cool fluids would cause vasoconstriction. The effluent should be warmed to body temperature to promote blood flow to enhance the exchange (the more blood flow, the more toxin removal). 5. Incorrect: If all of the fluid does not come out, the client should turn side to side to promote drainage. The Trendelenburg position would cause the fluids to pool in the upper peritoneal area and not drain adequately. Question: A client has just delivered a newborn. Based on the primary healthcare provider’s notation, what prescriptions does the nurse anticipate administering to the mother? You answered this question Correctly 2. Hepatitis A vaccine 3. Hepatitis B immune globulin 5. Tetanus toxoid 1. , & 4. Correct: A client who has a titer of less than 1:8 is administered a subcutaneous injection of rubella vaccine, or measles, mumps and rubella vaccine (MMR) during the postpartum period to protect a subsequent fetus from malformations. Clients should not get pregnant for 4 weeks following the vaccination. All Rh negative moms who have Rh positive newborns must be given RH0(D) immune globulin IM within 72 hours of newborn being born to suppress antibody formation in the mother. 2. Incorrect: The mother is negative for hepatitis but current guidelines recommend that the newborn be given the hepatitis B vaccine. Hepatitis A vaccine is not given. 3. Incorrect: The mother is negative for hepatitis. If the newborn had been born to a mom who has hepatitis B, the newborn would receive the hepatitis B vaccine and the Hepatitis B immune globulin within 12 hours of birth. 5. Incorrect: Mom is up to date on tetanus toxoid vaccine. Question: When performing an admission assessment, what should the nurse recognize as signs/symptoms of hyperthyroidism? You answered this question Correctly 2. Weight gain 4. Loss of appetite 5. Constipation 1. , 3., & 6. Correct: With hyperthyroidism, the client has too much energy. They report being nervous and feeling hot. Exophthalmos is an irreversible eye condition where the eyes bulge. This condition is associated with hyperthyroidism that has not been treated early enough to prevent this from occurring. Due to the hypermetabolic state, the client will often report feeling hot and will be sweating. 2. Incorrect: The client with hyperthyroidism has an increased appetite but experiences weight loss due to the excessive energy consumption. 4. Incorrect: Loss of appetite is seen in the client with hypothyroidism. The client with hyperthyroidism has an increased appetite but experiences weight loss due to the excessive energy consumption. 5. Incorrect: Constipation is a sign of hypothyroidism due to slowed GI motility. In hyperthyroidism, the nurse would expect increased GI motility. Question: The nurse is administering medication to an elderly client who has no visitors. The client takes the pills, and, as the client hands the medication cup back to the nurse, grabs onto the nurse's hand tightly. What is the most logical rationale for the client's action? You answered this question Incorrectly 1. Confusion and disorientation. 3. Would like to talk with the nurse. 4. Would like to reminisce with the nurse. 2. Correct: This elderly client with no visitors is most likely scared and lonely. The touch of the nurse's hand is comforting for the client. 1. Incorrect: There is no indication of confusion or disorientation. 3. Incorrect: Grabbing the nurse's hand indicates more than just a desire to talk. This is indicative of needing comfort and personal touch. 4. Incorrect: There is no indication of a desire to reminisce from the information in the question. Question: The client is admitted to the hospital following a motor vehicle accident and has sustained a closed chest wound. The nurse notes paradoxical chest wall movement. Which problem does the nurse suspect? You answered this question Correctly 1. Mediastinal shift 2. Tension pneumothorax 4. Pulmonary contusion 3. Correct: Hallmark of flail chest is paradoxical chest wall movement. This is often described as a see-saw effect when observing the rise and fall of the chest. 1. Incorrect: A closed or open tension pneumothorax results from the lung collapsing and air entering into the pleural cavity. This results in pressure shifting toward the unaffected pleural cavity. 2. Incorrect: Tension pneumothorax occurs when there is an accumulation of air in the pleural cavity. The client may exhibit dyspnea, tachycardia, or hypotension. 4. Incorrect: A pulmonary contusion usually results from blunt trauma. Bruising of lung would be demonstrated by pain but not paradoxical chest wall movement. Question: Which intervention should the nurse initiate for a client post liver biopsy? You answered this question Incorrectly 3. Position client on left side. 4. Keep client NPO for 24 hours. 1., 2., & 5. Correct: Anyone who has a liver problem is at risk for bleeding. The clotting factor produced in the liver is prothrombin. Anytime a needle is inserted into the body and removed, bleeding can occur. Whenever there is risk for bleeding, the preventive measure is to apply pressure. The puncture site should be monitored frequently. The client may experience some discomfort once the anesthetic wears off. 3. Incorrect: Lying on the left side does not put pressure on the puncture site. The liver is on the right side, as is the puncture site. 4. Incorrect: The client will be prescribed NPO for 2 hours. The client's usual diet as tolerated will be resumed after the 2 hours Question: One week ago a client was involved in a motor vehicle crash and was brought to the Emergency Department. The client received two sutures to the forehead and was sent home. Today, the client’s spouse notes the client “acts drunk” and cannot control the right foot and arm. Based on this data, what should the nurse suspect? You answered this question Correctly 1. Meningitis 2. Transient ischemic attack 4. Meniere's disease 3. Correct: Yes, subacute subdural hematoma is a head injury with slow venous bleed. The body does not have symptoms until compensation is exhausted. 1. Incorrect: No, fever and nuchal rigidity are symptoms of meningitis. 2. Incorrect: No, because of the motor vehicle crash, the nurse should think subdural hematoma first due to the risk of increasing intracranial pressure (ICP). 4. Incorrect: No, whirling vertigo and vomiting would be expected with Meniere's disease. Question: The nurse is caring for a client prescribed vancomycin for Methicillin- Resistant Staphylococcus Aureus (MRSA) infection. What nursing intervention is appropriate? You answered this question Correctly 1. Provide the client food or a snack to take with the medication 3. Administer an antiemetic prior to vancomycin administration 4. Request the placement of a PICC line for IV administration 2. Correct: Vancomycin is nephrotoxic, caution should be exercised in clients with impaired renal function. BUN and creatinine are specific diagnostic tests that indicate appropriate renal function. 1. Incorrect: Vancomycin is not effective via the oral route for systemic infections. It is taken orally only for the treatment of Clostridium difficile colitis. It does not need to be administered with food when taken orally. 3. Incorrect: Nausea and vomiting are not common side effects of vancomycin administration. 4. Incorrect: Vancomycin may be administered via a peripheral IV line; however, the IV access should be monitored closely due to the risk of necrosis and tissue sloughing with extravasation. Question: A client of Jewish faith has requested a Kosher diet. Which food tray would the nurse provide to the client? You answered this question Correctly 1. Medium rare steak, potato salad, peas and coffee 2. Ham sandwich, chips, fruit salad and juice 4. Baked chicken, vegetable medley, rice and milk 3. Correct: Fish is allowed if it has fins and scales. Shellfish is not kosher. Pasta, potatoes, salads and tea are allowed. 1. Incorrect: Although steak is allowed, all traces of blood must be gone. 2. Incorrect: No pork products are allowed, so no bacon, ham, or sausage. 4. Incorrect: Milk is not allowed at the same time as meat. There should be at least three hours separating the two. Question: The drug nadolol is prescribed for a client with stable angina. Which findings would indicate to the nurse that the drug is effective? You answered this question Correctly 3. Bounding pulses 5. Bradycardia 1., 2., & 4. Correct: Nadolol is a beta-blocking agent. Beta-blockers block the beta 1 adrenergic receptor cells in the heart, thereby decreasing heart rate, contractility, and blood pressure. These effects decrease the workload on the heart. With decreased oxygen demand (workload on the heart), chest pain is relieved. Beta-blockers decrease cardiac contractility, thereby decreasing cardiac output. Beta blockers also relieve anxiety. 3. Incorrect: Bounding pulses would indicate fluid volume excess, thus making the problem worse. 5. Incorrect: Nadolol is a beta-blocking agent, which blocks the beta 1 adrenergic receptor cells in the heart, thereby decreasing heart rate; however, decreasing the heart rate to the point of bradycardia would be an adverse effect. Question: The new nurse is caring for a client receiving oxygen by nasal cannula. Which action would require the charge nurse to intervene? You answered this question Correctly 1. Apply gauze padding beneath the tubing. 3. Provide mouth and nose care every 4 hours as needed. 4. Place the oxygen tubing above the ears. 2. Correct: Petroleum jelly is a combustible substance. It should not be used with oxygen therapy. 1. Incorrect: The charge nurse would not need to intervene if the new nurse applied gauze padding beneath the tubing to protect the client’s skin. This is acceptable. 3. Incorrect: The charge nurse would not need to intervene if the new nurse provided mouth and nose care every four hours as needed to protect the client’s skin and mucous membranes. This is acceptable. 4. Incorrect: The charge nurse would not need to intervene if the new nurse placed the oxygen mask straps well above the client’s ears to protect the client’s skin. This is acceptable. Question: The client with bleeding esophageal varices has a Blakemore tube in place. What piece of equipment should be present at the bedside? You answered this question Incorrectly 1. Tracheostomy set 2. Clamps 4. Tourniquet 3. Correct: Yes, if the tube gets dislodged and occludes the airway, the balloon must be cut and the tube removed to allow the client to breathe. 1. Incorrect: No, that goes with thyroidectomy and parathyroidectomy, either accidental or intentional. When the parathyroids are removed, hypocalcemia can occur and leads to tight rigid muscles. This also affects the smooth muscle of the airway and leads to stridor, respiratory distress, and possible trach. 2. Incorrect: No, that’s for chest tubes and would be necessary if there was a leak in the chest tube system or in preparation for removal of chest tubes if prescribed. 4. Incorrect: That goes with amputations because there is a risk for massive hemorrhage after an amputation. A tourniquet would be necessary for a limb amputation. There is a risk for excessive hemorrhage after an amputation. Question: Which statement by a client scheduled to be discharged home following treatment for alcoholism would indicate to the nurse that further instruction is necessary? You answered this question Correctly 1. “I will read labels to be sure there is no hidden alcohol in food.” 3. “I can call the clinic or my sponsor whenever I feel tempted to drink alcohol.” 4. “Even one glass of alcohol can cause me to start drinking regularly again.” 2. Correct: This statement indicates the need for further instruction for this client. When discharged home following rehabilitation for alcohol, clients are told to attend at least one AA meeting every single day, whether feeling the need to drink or not. Constant reinforcement is found to increase the rate of success following inpatient rehabilitation. 1.Incorrect: This statement by the client is correct. Many daily products contain small amounts of alcohol, such as salad dressings, cold medications, and even after shave. 3.Incorrect: This is also a correct statement, as clients who are recovering from alcoholism are designated a “sponsor”, or support person, whom they can contact at any time for assistance. Also, there is a 24/7 hotline for most clinics to provide emotional support to clients 4. Incorrect: This statement by the client is also correct. No amount of alcohol is considered “safe” for an alcoholic and even one glass of alcohol or wine can defeat months of rehab since most alcoholics cannot stop at one drink. Question: A client is taking a nonsteroidal anti-inflammatory drug (NSAID) for the relief of joint pain. A gastrointestinal bleed is suspected. Which laboratory value alerts the nurse to the possibility that the client is chronically losing small amounts of blood? You answered this question Incorrectly 1. Prolonged bleeding time 3. Decreased platelet count 4. Elevated bands 2. Correct: Elevated reticulocyte count indicates increased production of RBCs. If a client is chronically losing blood, the body's response is to increase RBC production, so the retic count would increase. 1. Incorrect: Prolonged bleeding times occur with liver problems. 3. Incorrect: A decreased platelet count will cause bleeding but will not tell the nurse if there is chronic bleeding. 4. Incorrect: Elevated bands are a part of the WBC differential and are increased with acute infection. Question: The nurse is preparing to collect a capillary blood specimen for measuring blood glucose. Which action is most likely to result in an adequate stick for the client? You answered this question Correctly 1. Place the finger at heart level when making the stick. 3. Keep the injector loose against the skin. 4. Place the finger above heart level when making the stick. 2. Correct: Warming the finger will increase circulation to the site, thereby increasing blood flow. 1. Incorrect: The finger should be dependent to enhance blood flow to the site, so it needs to be below the level of the heart to be effective. 3. Incorrect: The injector should be placed firmly against the skin; otherwise the client may get an insufficient stick and require another stick. 4. Incorrect: The finger should be in a dependent position to increase blood flow to the site so as to prevent the need for another stick. Question: Which tasks could the nurse working on a cardiac unit delegate to an unlicensed assistive personnel (UAP)? You answered this question Incorrectly 4. Feed a client who is dysphagic. 1., 2., 3., & 5. Correct: Remember the RN cannot delegate assessment, teaching, evaluation, medications, or an unstable client to the UAP. The UAP could bathe the client who is on telemetry. This is an appropriate assignment. The UAP can apply cardiac leads and connect the client to a cardiac monitor. The UAP can assist with helping the client sit up for a portable chest x-ray as long as the UAP is not pregnant and wears a shield. The UAP can collect specimens, such as a stool specimen. 4. Incorrect: This client has difficulty swallowing and is at risk for choking making the client unstable. Therefore, the nurse should not allow the UAP to feed this client Question: A client is admitted with a diagnosis of myasthenia gravis. What interventions should the nurse include to manage this client's swallowing and chewing impairment? You answered this question Correctly 4. Position upright with head tilted slightly backwards. 5. Dissolve the cholinesterase inhibitor medication in water. 1., 2., & 3. Correct: Myasthenia gravis is a disorder wherein the postsynaptic neuromuscular junction receptor sites are decreased. This decrease in receptor sites causes decreased muscular depolarization. The clinical manifestations of this disease are progressive muscle weakness and fatigue. Eventually clients may experience difficulty breathing due to weakness and fatigue of the respiratory muscles. Muscle fatigue impairs chewing and swallowing. These actions decrease the risk of aspiration, decrease the work of muscles, and allow for improved swallowing. 4. Incorrect: Tilt head slightly forward (chin tuck, head turn). 5. Incorrect: The cholinesterase inhibitor should not be dissolved in water due to the client's difficulty swallowing. Liquids should be thickened. Question: The nurse is caring for a client with a perineal burn. The skin is not intact. What signs are suggestive of infection? You answered this question Correctly 5. Bleeding 1., 2., 3., 4. & 6. Correct: Infections may cause color changes, drainage, odor, fever, & increased pain. Bleeding is a sign of hemorrhage, trauma, anemia or other blood disorders but not infection. 5. Incorrect: Bleeding is not a sign of infection. It may occur along with an infection but will not be caused by it. Question: A client diagnosed with schizophrenia tells the nurse, "God is going to heal me. I do not need medication." Which response by the nurse would best promote compliance with the prescribed medication regimen? You answered this question Correctly 1. Yes, I believe that God will heal you. 3. We are talking about taking your medications right now. 4. What if God does not heal you and you should have taken the medication? 2. Correct: This allows the client to keep the belief that God will heal but will do it through the medication. This promotes compliance with the prescribed medication regimen. 1. Incorrect: The nurse does not know if God will heal the client and does not promote compliance with the prescribed medication regimen. 3. Incorrect: This approach may make the client angry, which will close the communication between the client and the nurse. It also does not promote compliance with the prescribed medication regimen. 4. Incorrect: This approach is argumentative and puts the client on the defense, which will close the communication between the client and the nurse. Question: A client is being treated in the emergency department for dehydration. Which central venous pressure (CVP) reading would the nurse identify as the desired response to treatment? You answered this question Correctly 1. -1 mm Hg 3. 10 mm Hg 4. 15 mm Hg 2. Correct: This CVP reading is indicative of a normal fluid volume state. This would be the desired response of treatment for dehydration. 1. Incorrect: This CVP reading is indicative of fluid volume deficit. The normal CVP reading is 2-6 mm Hg. 3. Incorrect: The normal CVP reading is 2-6 mm Hg. This CVP reading is high and indicative of fluid volume excess. This is not the desired outcome of treatment for dehydration. 4. Incorrect: The normal CVP reading is 2-6 mm Hg. This CVP reading is high and indicative of fluid volume excess. This is not the desired outcome of treatment for dehydration. Question: A nurse is caring for a 65 year-old client diagnosed with dehydration. The client has been receiving intravenous normal saline at 150 mL/hour for the past 4 hours. Which finding would the nurse need to notify the primary healthcare provider? You answered this question Correctly 1. Blood pressure 136/84 2. Report of nausea 4. Urinary output at 50 mL/hour 3. Correct: Anxiety, restlessness, or a sense of apprehension is often the first sign/symptoms of acute pulmonary edema. 1. Incorrect: Blood pressure is normal. The number one concern right now is the anxiety: an early sign of pulmonary edema. 2. Incorrect: Although we would want to help the client having nausea, the anxiety is of upmost importance, as it might indicate acute pulmonary edema. 4. Incorrect: The client is dehydrated. A urinary output of 50 mL/hr, although low, is not at a critical level. Signs of pulmonary edema will take priority. Question: Which finding would indicate to the nurse that a client is at nutritional risk and should receive a dietary consult? You answered this question Correctly 2. Twelve year old admitted 5 days ago receiving total parenteral nutrition (TPN). 3. Two year old taking only clear liquids since admission 24 hours ago. 4. Nine month old admitted 2 days ago for diarrhea and now on ½ strength formula. 1. Correct: This child has been receiving only clear liquids for more than 3 days and would be a nutritional risk. Proper nutrients are required for healing after surgery, and only liquids would not be adequate. 2. Incorrect: The child receiving total parenteral nutrition (TPN) has already had a nutritional evaluation receiving supplementation for nutritional needs. After reviewing the nutritional evaluation, the TPN will be formulated accordingly. 3. Incorrect: The two year old taking only clear liquids is acceptable until the child is on liquids for more than 3 days, then would be at nutritional risk. After 3 days the nutritional status of the child should be evaluated due to the food restrictions of a clear liquid diet. 4. Incorrect: The nine month old is being put back on formula at ½ strength. Once this is tolerated, then the strength will be advanced; therefore, this client is not at risk Question: The primary healthcare provider (PHP)has prescribed a saline IM injection for a client who requests pain medication every 2-3 hours. What would be the nurse’s best first action? You answered this question Correctly 1. Administer the injection. 2. Take vital signs. 4. Notify the nursing supervisor. 3. Correct: A placebo is any medication or procedure that produces an effect in clients resulting from its implicit or explicit intent and not from its physical or chemical properties. An example would be a sugar pill or injection of saline. Some professionals try to justify the use of placebos to elicit the desirable placebo effect or in a misguided attempt to determine if the client’s pain is real. These reasons cannot be justified on either a clinical or ethical basis, except in an approved research study. It is deceptive and represents fraudulent and unethical treatment. 1. Incorrect: Giving a placebo is fraudulent and unethical treatment. 2. Incorrect: Taking the vital signs does not take care of the problem of giving a placebo. 4. Incorrect: First, the nurse should discuss the prescription with the primary healthcare provider. Question: What laboratory results would the nurse anticipate finding in a client receiving chemotherapy who is experiencing pancytopenia? You answered this question Correctly 2. White blood cell count of 15,000 (15.0 x 109/L) 4. Platelet count of 450,000/µL (450 x 109/L) 6. Red blood cell count of 7.3 million/mcL (7.3 x 1012/L) 1. , 3., 5. Correct: Pancytopenia is a condition in which there is a concurrent leukopenia (a reduction in white blood cells), thrombocytopenia (a reduction in platelets), and anemia (reduction in red blood cells). The normal white blood cell count is 5,000- 10,000 (5.0 to 10.0 x 109/L), so a level of 3,800 (3.8 x 109/L) represents leukopenia. The normal platelet count is 150,000-400,000/µL (150 - 450 x 109/L), so a level of 90,000/µL represents thrombocytopenia. The normal red blood cell count for a Female is 4.2 – 5.4 million/mcL ( 4.2 – 5.4 x 1012/L), and the normal red blood count for a Male is 4.7 – 6.1 million/mcL (4.7 – 6.1 X 1012/L). Therefore, a red blood cell count of 3.0 million/mcL (3.0 x 1012/L) is indicative of anemia, regardless of the sex of the client. 2. Incorrect. The normal white blood cell count is 5,000-10,000 (5.0 to 10.0 x 109/L). A WBC count of 15,000 (15.0 x 109/L) is considered leukocytosis (elevated WBC level). 4. Incorrect: The normal platelet count is 150,000-400,000/µL (150 - 450 x 109/L). Therefore, a platelet count of 450,000/µL (450 x 109/L) would be an elevated platelet level (thrombocytosis). 6. Incorrect: The normal red blood cell count for a Female is 4.2 – 5.4 million/mcL (4.2 – 5.4 x 1012/L), and the normal red blood count for a Male is 4.7 – 6.1 million/mcL (4.7 – 6.1 X 1012/L). Therefore, a level of 7.3 million/mcL (7.3 x 1012/L) is elevated (polycythemia). Question: A nurse is teaching a client about post-procedure thoracentesis nursing care. Which statements should the nurse include? You answered this question Incorrectly 4. Positioning you with your affected lung down. 1., 2., 3., & 5. Correct: Anytime fluid is being removed from a client, there is a risk they could develop a fluid volume deficit, or worse, shock. Checking vital signs frequently is important. Examining the dressing for bleeding is appropriate. Listening to lung sounds is appropriate. The nurse percusses the lungs as part of the respiratory assessment. (Hyperresonance indicates air in the pleural space. Dull percussions indicate fluid in the pleural space) Subcutaneous emphysema could indicate a pneumothorax. There is air leaking into the tissue. 4. Incorrect: Turn the client on the unaffected side for at least one hour to allow the pleural puncture site to heal and promote lung expansion of the affected lung. Question: Which information obtained during a well-baby checkup of a 3 month old infant would the nurse need to report to the primary healthcare provider? You answered this question Correctly 4. Able to hold head upright without head wobbling. 1., 2., 3., & 5. Correct: These are signs/symptoms of cystic fibrosis (CF) and should be reported to the primary health care provider. One of the first signs of CF that parents may notice is that their baby's skin tastes salty when kissed. People who have CF have thick, sticky mucus that builds up in their airways. This buildup of mucus makes it easier for bacteria to grow and cause infections. Infections can block the airways and cause frequent coughing that brings up thick mucus or mucus that's sometimes bloody. Mucus can block tubes, or ducts, in the pancreas, preventing enzymes from reaching the intestines. As a result, the intestines can't fully absorb fats and proteins. This can cause ongoing diarrhea or bulky, foul-smelling, greasy stools. A hallmark of CF in children is poor weight gain and growth. These children are unable to get enough nutrients from their food because of the lack of enzymes to help absorb fats and proteins. 4. Incorrect: This is expected at this age. Very little or no head wobbling should be seen in a three-month-old baby when the head is upright. Question: The nurse is teaching a group of clients who have reduced peripheral circulation how to care for their feet. What points should the nurse include? You answered this question Incorrectly 3. Cover feet and between toes with creams to moisten the skin. 5. Use pumice stones to treat calluses. 1., 2., & 4. Correct: Rubbing from rough spots in the shoe can lead to corns or calluses. File the toenails rather than cutting to avoid skin injury. File nails straight across the ends of the toes. If the nails are too thick or misshapen to file, consult podiatrist. Break in new shoes gradually by increasing the wearing time 30-60 minutes each day. 3. Incorrect: Cover the feet, except between the toes, with creams or lotions to moisten the skin. Lotion will also soften calluses. A lotion that reduces dryness effectively is a mixture of lanolin and mineral oil. 5. Incorrect: Avoid self-treatment of corns or calluses. Pumice stones and some callus and corn applications are injurious to the skin. Do not cut calluses or corns. Consult a podiatrist or primary healthcare provider first. Question: The nurse is planning to discuss pain management with a client who experiences chronic pain. How should the nurse best begin this discussion? You answered this question Incorrectly 2. “It is my job to teach you how to deal with your pain.” 3. “I will be teaching you how to use guided imagery to decrease your pain.” 4. “Your primary healthcare provider has prescribed pain medication for your pain. I will teach you about this medication.” 1. Correct: This statement sends a couple of messages that are an important part of treatment planning and evaluation of care. First, it places the ownership and responsibility for controlling pain on the client. Second, it acknowledges that the client may be the best judge of what is needed, respecting the cultural meaning of pain, and acceptable ways of expressing/controlling pain. Third, it establishes the nurse’s role in helping the client be more comfortable and in control of their condition. 2. Incorrect: This statement does not include or even consider the client. This statement reflects the role of the nurse. The focus should be on the client's needs. 3. Incorrect: This statement begins with what the nurse is planning to accomplish. This statement does not include or even consider the client. 4. Incorrect: What does the client think might help relieve the pain? What other options are there? The nurse begins the teaching session by what the primary healthcare provider has ordered. The nurse should assess the client's knowledge about pain management. Question: What instruction is most important to include when teaching a child how to self administer a combined dose of isophane suspension and regular insulin subcutaneously? You answered this question Correctly 1. Alternate the injection sites from one body area to another with each dose. 2. Draw up the isophane suspension insulin first and then regular insulin into the same insulin syringe. 3. Massage the injection site after the medication is injected. 4. Correct: Insulin syringes and needles should be stored at room temperature. The potential benefits or risks of refrigerating the syringe are unknown. 1. Incorrect: Insulin injection sites are rotated, but within a chosen site e.g., the abdomen. Once all the sites in that area are used, then another area of the body is selected e.g., the arm. 2. Incorrect: As a rule, remember clear before cloudy; that is, draw up the regular (clear) insulin first, and then draw up the long acting insulin, isophane suspension (cloudy). 3. Incorrect: Gently blot any blood with a gauze pad. Do not massage the site. Massaging or rubbing the site will alter the rate of absorption of the medication. Question: The nurse is caring for a client on the medical unit. The client has an IV of 1000 mL D5W with 50,000 units heparin. The infusion is to run at 60 mL per hour. How many units/hour is the client receiving? Round answer to the nearest whole number. You answered this question CorrectlyEnter the answer for the question below. Question: A newly admitted client with schizophrenia tells the nurse, "The doctor is trying to steal my organs for science." Which response by the nurse would be most therapeutic? You answered this question Correctly 2. I am here with you. 3. Let's discuss something else. 4. You know that is not true. 1. Correct: The nurse should speak to the underlying feeling of the client’s statement which is fear. 2. Incorrect: The nurse is offering self. This does not respond to the underlying message in the client’s statement that indicates fear and false information. 3. Incorrect: The nurse is changing the subject. This is a non-therapeutic response by the nurse that will decrease communication between the nurse and the client. 4. Incorrect: The nurse is arguing with the client. This is a non-therapeutic response by the nurse that will decrease communication between the nurse and the client. Question: In order to prevent injury or discomfort and maximize overall performance, what essential elements of ergonomic principles should the nurse utilize when caring for clients? You answered this question Correctly 4. Save effort by lifting rather than rolling, turning, or pivoting. 5. Utilize muscles of the back rather than muscles of the shoulders. 1., 2., 3., & 6. Correct: When in a standing position, the center of gravity is at the center of the pelvis. The wider the base of support and the lower the center of gravity the nurse maintains, the greater the stability for the movement. Using both the arms and the legs provides a sense of balance for the activity. It is always smart to seek more assistance when needed to avoid injury to self. 4. Incorrect: Rolling, turning, and pivoting are less likely to cause injury than attempting to lift. Lifting puts more strain on the back than these other methods. 5. Incorrect: The larger muscles of the thighs, buttocks, and shoulders should be utilized for activity because the smaller muscles such as those in the back and arms are more susceptible to injury. Question: A home care nurse is preparing to perform venipuncture on a client to draw blood. As the nurse gathers supplies, the client begins to experience palpitations, trembling, nausea, shortness of breath and a feeling of losing control. How should the nurse communicate with this client? You answered this question Correctly 2. Speak loudly to the client. 3. Do not speak to the client at this time. 4. Use open-ended questions to ask what is wrong. 1. Correct: Use simple words, because the client cannot comprehend anything but the most elemental communications during a panic attack. 2. Incorrect: A calm, low level of intensity to reduce anxiety is needed. Speaking loudly will increase the client's anxiety. 3. Incorrect: Calm, simple words are needed instead of silence which could be interpreted as ignoring the client. 4. Incorrect: Simple communication of reassurance needed. This is not the time for open ended questions and would increase the client's anxiety. Question: The nurse is teaching the client with asthma on proper use of an inhaler. Which statements by the client indicates that teaching has been successful? You answered this question Incorrectly 2. "Use my steriod inhaler before the bronchodilator." 5. "Wait 5 minutes between puffs." 1. , 3. & 4. Correct: The client should exhale completely before using the inhaler; this response indicates the teaching was effective. The client should inhale slowly and push down firmly on the inhaler when administering the medication; therefore, the teaching was effective. The client should rinse the mouth after using the inhaler to prevent thrush. 2. Incorrect. The client should use the bronchodilator before the steroid inhaler. This response indicates the need for further teaching. 5. Incorrect. For inhaled quick-relief medication (beta2-agonists), wait about one minute between puffs. There is no need to wait between puffs for other medications. Question: Which client should the charge nurse assign to a new RN? You answered this question Incorrectly 2. Adult client reporting abdominal pain after being beaten up in a fight. 3. Adolescent with sickle cell disease requesting more medication via the patient controlled analgesia device. 4. Child admitted with cystic fibrosis 2 hours ago. 1. Correct: This is the least complicated client that could be given to a new, inexperienced nurse. Even though he client has a fracture, the focus is on giving pain medication prior to a major procedure. 2. Incorrect: This client could have internal bleeding and other complications not diagnosed. This is not the best client to give to the new nurse. 3. Incorrect: This is a more complex client and is least likely to be assigned to a new nurse because of the increased need for pain medications, like narcotics, and use of a technological device. Sickle cell pain episodes will vary in it's intensity and frequency. 4. Incorrect: This is a complex client and should not be given to the new nurse. This client is a new admit at risk for respiratory distress and potential infections due to the chronic long term effects of cystic fibrosis. Question: A Hispanic mother and her child visit the primary healthcare provider's office due to a fever that the child has been having for two or three days. Upon entering the room, the nurse immediately asks what is happening with the child and begins to check the temperature. Which response is likely from the mother? You answered this question Incorrectly 1. Accepts the treatment of the nurse and think that it is appropriate. 3. Thinks that the nurse is busy and needs to rush. 4. Thinks that the nurse is very efficient. 2. Correct: The family is likely to be offended by the abrupt manner of the nurse. The Hispanic culture is present time oriented and desire attention and interaction. It would not be relevant that the nurse may be busy. To overlook this cultural variation is rude and does not treat the mother with dignity. 1. Incorrect: The nurse is not demonstrating cultural sensitivity. The family is not likely to accept this abrupt approach due to the cultural differences related to time and the desire for more genuine personal interaction. The Hispanic mother may be offended by the direct interviewing approach of the nurse. 3. Incorrect: The mother is likely to be offended with this abrupt response. Efficiency is not a priority as much as attentiveness and care, particularly with an ill child. The cultural frame of reference is present time in which other events should not interfere with the present situation. Expectations for genuine, personal interaction are also a part of the culture. 4. Incorrect: The mother is likely to interpret the nurse’s actions as rude. The American culture is future time oriented and desires efficiency; the Hispanic culture is more interested in relationships and what is occurring at the present time. Question: A client at 32 weeks gestation is admitted to the obstetric unit with a BP of 142/90 and 1+ proteinurea. Since no private rooms are available, the charge nurse must assign the client to a semi-private room. Which client should the charge nurse assign this client to room with? You answered this question Incorrectly 1. Postpartum woman who delivered at term. 2. Woman in preterm labor at 35 weeks gestation. 3. Woman with placenta previa at 37 weeks gestation. 4. Correct: Both clients are presenting with the possibility of preterm deliveries. The room should be kept quiet to decrease stimulation of the clients. Also, the client with preeclampsia should not be stimulated which could increase her blood pressure. 1. Incorrect: The client will require frequent postpartum assessments and nursing care. The client will likely have a great deal of activity in her room and this would be potentially harmful to the newly admitted client. 2. Incorrect: This client will have a increase of activities in her room as the preterm labor progresses. There is also the potential of an emergency delivery. 3. Incorrect: The client is admitted with placenta previa. Emergency deliveries may occur if the client becomes hypovolemic or there are signs of fetal compromise. Question: The nurse is assessing a client who is being treated with a non-steroidal anti- inflammatory medication (NSAID) for an acute flare-up of gout. Which finding is expected in the assessment? You answered this question Incorrectly 2. Severe abdominal pain following medication administration. 3. Decreased plasma uric acid levels. 4. Low-grade fever and rash. 1. Correct. The client usually experiences dramatic improvement within 24 hours after beginning NSAIDs. 2. Incorrect. Most clients can tolerate NSAIDs fairly well. If severe pain in experienced, the primary healthcare provider should be notified immediately. 3. Incorrect. NSAIDs do not reduce plasma uric acid levels. 4. Incorrect. This is not an adverse effect of NSAIDs, in fact, most NSAIDs are also antipyretics and would prevent fever. Question: After report, the nurse is assigned to care for 4 adult clients. Which client should the nurse assess first? You answered this question Correctly 1. Admitted 3 hours ago post appendectomy with small amount of drainage on dressing. 2. Diagnosed with early onset of Alzheimer's disease with confusion. 3. Post operative internal fixation of the femur with crust forming on the Steinman pins. 4. Correct: Being restless is an early sign of hypoxia, so oxygen may be necessary. Remember oxygenation takes priority over the other issues with these clients. The client may also be exhibiting manifestations of fluid volume deficit (FVD) 1. Incorrect: This is a stable client, so no indication of immediate distress is indicated. A small amount of drainage on the dressing of a client who had a appendectomy 3 hours ago would not be assessed first. 2. Incorrect: This is a stable client because confusion is part of Alzheimer’s disease. Safety issues for a confused client should be evaluated. The client with dehydration is exhibiting possible manifestations of decreased oxygen level and/or fluid volume deficit (FVD) and should be assessed first. 3. Incorrect: This is a stable client with no indication of immediate distress. Crust forming on the Steinmann pins should be removed from the pin insertion site, however, this client would not be given priority over the client with dehydration. Question: What side effects would the nurse expect to find in a client who has received too much levothyroxine? You answered this question Correctly 2. Bradycardia 3. Hypotension 1. , 4., & 5. Correct: These are side effects of too much levothyroxine. Levothyroxine is the replacement hormone for clients with hypothyroidism, so if too much is given, they would exhibit symptoms just like someone with hyperthyroidism. These clients also tend to have coronary artery disease (CAD), which is why angina is a significant side effect. 2. Incorrect: Tachycardia rather than bradycardia will be seen with too much levothyroxine. 3. Incorrect: Hypertension rather than hypotension will be seen with too much levothyroxine. Question: The nurse is teaching a group of pregnant women about hormonal changes during pregnancy. The nurse recognizes that teaching was successful when the women identify which hormone as causing amenorrhea? You answered this question Incorrectly 2. Estrogen 3. Follicle-stimulating hormone (FSH) 4. Human chorionic gonadotropin (hCG) 1. Correct: Progesterone causes amenorrhea. 2. Incorrect: Estrogen renders the female genital tract suitable for fertilization. 3. Incorrect: This stimulates the growth of the graafian follicle in the ovary. 4. Incorrect: This is the hormone present in urine for pregnancy test Question: A child is admitted to the hospital with a temp of 102.2°F ( 39.0°C), lethargic, and no urinary output in 6 hours. Which prescription would be priority for the nurse to initiate for this child? You answered this question Incorrectly 2. Ceftriaxone 250 mg IV every 12 hours 3. Start IV & monitor site. 4. 1/2 normal saline at 40 mL/hr 1. Correct: Immediate blood cultures should be obtained on this child, as sepsis is suspected with any temperature this high. The nurse would also need to get diagnostics before treatment is initiated so that correct interventions are prescribed. 2. Incorrect: The ceftriaxone is administered after the appropriate IV has been initiated. This would be the last intervention to be initiated. 3. Incorrect: The IV can be started at any point, but should be done after the cultures so the blood sample would not be affected in anyway. 4. Incorrect: Fluids will be started after the cultures are obtained and after the IV is started so as not to alter the results of the blood work and ensure correct treatment. Question: A client diagnosed with depression asks the nurse, “What is causing me to be depressed so often?” What is the best response by the nurse? You answered this question Correctly 2. "You experience depression because of your elevated levels of thyroid hormones." 3. "The primary healthcare provider will have to explain to you what is causing your depression." 4. "Tell me what you think causes you to be depressed." 1. Correct: Decreased levels of norepinephrine, dopamine, and serotonin are neurotransmitter implications for depression. By giving this type of information to the client, it helps with their understanding of the depression and empowers them with knowledge. 2. Incorrect: Elevated levels of thyroid hormones are thought to contribute to panic disorder or manic-type behaviors. Decreased levels of thyroid hormones are affiliated with depression, but not increased levels, so this would be wrong. 3. Incorrect: The nurse can discuss this with the client. This would be ignoring the client's desire to have information and post-pone providing much-needed help to the client. 4. Incorrect: This statement may allow for dialogue, but does not answer the client's question. Question: What should the nurse include when educating a client about the use of nitroglycerin sublingual. You answered this question Incorrectly 2. Keep the medication is a moist, warm place. 5. The most common side effect is vomiting. 1. , 3., & 4. Correct: Nitroglycerin is to be taken sublingually. Do not swallow because this will decrease the effectiveness of the medication. The medication may or may not burn or fizz when placed under the tongue. Because hypotension occurs due to vasodilation, the client should sit or lie down when taking to prevent injuries from falls. 2. Incorrect: Keep nitroglycerin in a dark, glass bottle and a dry and cool place to maintain the effectiveness of the medication. 5. Incorrect: The most common side effect is a headache and should be taught to the client as an expected side effect that does not have to be reported to the primary healthcare provider. Question: A newly admitted client tells the nurse, "I am hearing voices." Which response by the nurse is most appropriate? You answered this question Incorrectly 1. Your head is turned to the side as if you are listening to voices. 2. I don't hear anyone but you speaking. 4. Let's talk about your anxiety right now. 3. Correct: The nurse needs to know what the voices are saying to the client. This is the first thing the nurse would ask if the newly admitted client tells the nurse about hearing voices. The nurse does not know the client or the diagnosis that might be affiliated with this statement. 1. Incorrect: The client has already told the nurse about hearing voices. This also is non-therapeutic and negates the value of what the client is saying. 2. Incorrect: Upon admission, the nurse would not start out with this comment. This would come later. First the nurse needs to know what the voices are telling the client. 4. Incorrect: Again, this would come later after the nurse finds out what the voices are telling the client. Question: Which client diagnosis would require the nurse to initiate droplet precaution? You answered this question Incorrectly 1. Methicillin-resistant Staphylococcus aureus (MRSA) 2. Varicella 3. Vancomycin-resistant enterococci (VRE) 4. Correct: Droplet isolation precautions are used for diseases or germs that are spread in tiny droplets caused by coughing and sneezing (examples: pneumonia, influenza, whooping cough, bacterial meningitis). Healthcare workers should wear a surgical mask while in the room. Mask must be discarded in trash after leaving the room. Clean hands (hand washing or use hand sanitizer) when they enter the room and when they leave the room. 1. Incorrect: Contact isolation precautions are used for infections, diseases, or germs that are spread by touching the client or items in the room {examples: MRSA, VRE, diarrheal illnesses, open wounds, Respiratory syncytial virus (RSV)}. Healthcare workers should wear a gown and gloves while in the client’s room. Remove the gown and gloves before leaving the room. Clean hands (hand washing or use hand sanitizer) when entering and leaving the room. Visitors must check with the nurse before taking anything into or out of the room. 2. Incorrect: Airborne isolation precautions are used for diseases or very small germs that are spread through the air from one person to another (examples: Tuberculosis (TB), measles, varicella). Healthcare workers should ensure client is placed in an appropriate negative air pressure room (a room where the air is gently sucked outside the building) with the door shut. Wear a fit-tested NIOSH-approved N-95 or higher level respirator while in the room. Clean hands (hand washing or use hand sanitizer) when they enter the room and when they leave the room. Ensure the client wears a surgical mask when leaving the room. Instruct visitors to wear a mask while in the room. 3. Incorrect: Contact isolation precautions are used for infections, diseases, or germs that are spread by touching the client or items in the room (examples: MRSA, VRE, diarrheal illnesses, open wounds, RSV). Healthcare workers should wear a gown and gloves while in the client’s room. Remove the gown and gloves before leaving the room. Clean hands (hand washing or use hand sanitizer) when entering and leaving the room. Visitors must check with the nurse before taking anything into or out of the room. Question: A client presents to the emergency department (ED) reporting fever, cough, and malaise. The nurse notes that the client has a rash appearing as vesicles, most prominently on the face, palms of the hands, and soles of the feet. In addition to triaging the client as emergent, what should the nurse do? You answered this question Correctly 1. Send the client to the waiting room. 3. Put a surgical mask on the client. 4. Initiate contact precautions. 2. Correct: The client may have smallpox, which is very contagious. Smallpox can also be used as a weapon in biological warfare. The first thing the nurse should do is place the client into a negative pressure room. Doing this first will protect others from potential exposure. 1. Incorrect: Sending this client to the waiting room will expose others to smallpox. Even if you don't recognize these specific disease symptoms, fever and rash should cue you to thinking of this as a potential infectious disease. 3. Incorrect: Having the client wear a surgical mask is not sufficient in this case. All healthcare providers should wear a N95 respirator when in contact with the client. After the client is sequestered, the nurse should notify the ED primary healthcare provider for further treatment instructions. 4. Incorrect: Airborne precautions are necessary because that is the primary transmission mode for smallpox. Question: The nurse is caring for a client receiving total parenteral nutrition (TPN). Which assessment would require the nurse to intervene? You answered this question Correctly 1. TPN has been hanging for 12 hours 2. Central venous catheter's dressing is clean and dry 3. TPN fluid is room temperature when beginning administration 4. Correct: Do not use TPN if it looks curdled, oily, or has particles in it. This is an indication that something is wrong with the solution and could harm the client if given. 1. Incorrect: This TPN does not need to be replaced at 12 hours. It can infuse for 24 hours. 2. Incorrect: This is a description of an occlusive clean dressing at the insertion site. This description would not require intervention. 3. Incorrect: TPN should be at room temperature when beginning administration. Solutions that is too cold could cause vasoconstriction and undue harm to the client Question: Which client assignments are most appropriate for the charge nurse to delegate to an LPN/VN who works on the pediatric unit? You answered this question Correctly 2. 2