NCLEX Hurst Readiness Exam 1

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? Progesterone 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? Flail chest Which client can a nurse manager safely transfer from the telemetry unit to the obstetrical unit in order to receive a new admit? Client diagnosed with seizure disorder. 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? gradually. Check shoes for rough spots in the lining. File toenails straight across. Break in new shoes When caring for young adult clients, which developmental tasks would the nurse expect to see? Developing meaningful and intimate relationships. Giving and sharing with an individual without asking what will be given or shared in return. What symptoms does the nurse expect to see in a client with bulimia nervosa? Feelings of self-worth unduly influenced by weight. Recurrent episodes of binge eating. Recurrent inappropriate compensatory behavior to prevent weight gain. A client who has had a laparoscopic cholecystectomy develops pain in the left shoulder. Vital signs, laboratory studies, and an electrocardiogram are within normal limits. What does the nurse recognize as a contributing cause of the pain? Carbon dioxide used intraperitoneally is irritating the phrenic nerve. 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? Respiratory alkalosis An unlicensed assistive personnel (UAP) has explained how to prevent the spread of infection to the charge nurse. Which statement by the UAP indicates that further teaching is needed? "When caring for a client who has a suppressed immune response, a N95 mask should be worn." 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? Salami Which nurse is providing cost effective care to a client? Providing palliative care to a terminally ill client. Beginning discharge planning on admit. Counseling clients on cigarette smoking cessation. Educating a group of parents on the importance of childhood immunizations. A client is admitted for observation following an unrestrained motor vehicle accident. A bystander stated that the client lost consciousness for 1-2 minutes. On admission, the client reports a headache and had a Glasgow coma scale (GCS) of 14. The GCS is now 12. What is the priority nursing intervention for this client? Notify the primary healthcare provider. The nurse is assessing a client who is being treated with a non-steroidal antiinflammatory medication (NSAID) for an acute flare-up of gout. Which finding is expected in the assessment? Dramatic decrease in pain after beginning medications. 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? Use simple words. The nurse is preparing a client for surgery. Which methods are appropriate for the nurse to use in removing excessive body hair? Removing the hair with clippers. Using a depilatory cream. 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? "Come to the clinic now so that we can help you." The primary healthcare provider instructs the nurse to place body tissue obtained from a biopsy into a container with formalin prior to sending it to pathology. The nurse has not handled formalin before. What would be the nurse's best action? Read about formalin on the Material Safety Data Sheet (MSDS). 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? Scared and lonely and grabs the nurse's hand for comfort. 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? Anxiety The nurse reassesses the client's pain level after administering an oral analgesic. The client states that the pain is better but continues to report a backache. Which non-pharmacologic interventions may help the client's backache? Assisting the client into a side lying position. Providing a back massage. Providing heat therapy. Using distraction techniques. The nurse is caring for a client on the pediatric unit. The primary healthcare provider prescribes phenytoin 30 mg by mouth every 8 hours for a client weighting 18 kg. The recommended dosage is 5 mg/kg/day. What does the nurse determine is the safe dosage for the child in mg/day? Round your answer to the nearest whole number. 5mg x 18 kg = 90 mg/day Which client diagnosis would require the nurse to initiate droplet precaution? Whooping cough Which finding would indicate to the nurse that a client is at nutritional risk and should receive a dietary consult? Six year old who had surgery 5 days ago, receiving clear liquid diet since surgery. A nurse observes a fire has started in the trash can of a client's room. What steps should the nurse take? Place steps in priority from first to last. First, remove the client from the room. Second, activate the fire alarm. Third, close the door to the client's room. Fourth, obtain the fire extinguisher. Fifth, extinguish the fire. What laboratory results would the nurse anticipate finding in a client receiving chemotherapy who is experiencing pancytopenia? White blood cell count of 3,800 (3.8 x 109/L) Platelet count of 90,000/μL (90 x 109/L) Red blood cell count of 3.0 million/mcL (3.0 x 1012/L) 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? Elevated reticulocyte count Which client should the nurse, working the Emergency Department (ED), see first? Client with adrenal insufficiency who feels weak. 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? Are you feeling afraid now? What discharge instruction should a nurse provide to a client diagnosed with Hepatitis B to provide adequate nutrition? Suggest client eat several small meals a day, with the largest at breakfast. 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? select all that apply "Exhale completely before using my inhaler. "Inhale slowly and push down firmly on the inhaler." "Rinse my mouth with water after using my inhaler." 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? Hang a familiar object on the door to enhance room recognition. A client arrives at the emergency department with a pneumothorax. A chest tube is inserted and placed to 20 cm of suction. Two hours later, the nurse notes tidaling in the water-seal chamber. Based on this data, what intervention should the nurse initiate? Document the finding. Which task would be appropriate for the charge nurse to assign to a LPN/VN? Collect data on a new client admit. Bolus feeding a client who has a gastrostomy tube. Reinserting a nasogastric tube (NG) that a client accidentally pulled out. Monitor patient control analgesic (PCA) pump pain medication being delivered to a client. A nurse is teaching a renal transplant client about self care after discharge. As part of the information about transplant rejection, the nurse cautions the client to notify the primary healthcare provider of which occurrence? Tenderness over the kidney An elderly client receives instructions regarding the use of warfarin sodium. Which statement indicates to the nurse that the client understands the possible food interactions which may occur with this medication? "I will have to watch my intake of salads, something that I really love." 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? Notify the primary healthcare provider immediately that the medication prescribed is on the client's list of medication allergies. Stop the medication on the client's medication administration record. Check the client's allergy band against the list of client allergies documented in the medical record. ... A nurse manager notices that unit nurses consistently forget to ask clients to rate their pain level on a scale of 0-10. What strategies could the nurse manager initiate to improve performance? Provides "just in time" posters outlining the importance of pain assessment. Conducts brief in-services for each shift. Counsels nurses when pain level scale is not utilized. Ensures that a complete and clear performance standard exists. Assesses nurses' reasons for not using pain level scale. Which statement by a client scheduled to be discharged home following treatment for alcoholism would indicate to the nurse that further instruction is necessary? "I should go to an Alcoholics Anonymous meeting when I feel the need to drink alcohol." A confused elderly client is brought to the emergency department by a family member who states the client fell down a flight of stairs. In addition to multiple facial contusions, x-rays reveal a spiral fracture of the left forearm. After assisting the primary healthcare provider in applying a short arm cast, the nurse identifies which action as a priority in discharge planning? Notify social services to arrange a home visit. The nurse is teaching a group of clients about selective serotonin reuptake inhibitors (SSRI). Which comment by a client in the group indicates adequate understanding of the effects/side effects of the medications? I may expect increased sweating while taking this drug. Which assessment findings does the nurse expect to find when assessing a client admitted to the emergency department with left sided congestive heart failure? Bibasilar crackles Orthopnea A nurse is teaching a client about post-procedure thoracentesis nursing care. Which statements should the nurse include? Checking your vital signs frequently. Examining the dressing for bleeding. Listening to and percussing your lungs. Palpating around the incision site for air under the skin. A new nurse is documenting in a client's electronic record. Which documentation would the charge nurse evaluate as appropriate documentation by the new nurse? Forty year old admitted with diagnosis of cholecystitis to room 410 for surgical services. Permit signed for laparoscopic cholecystectomy after discussing procedure with surgeon. Transferred to surgical suite per stretcher with side rails up, in stable condition. The nurse has been educating a client on a new prescription for amitriptyline 25 mg PO twice a day. The nurse recognizes that teaching has been successful when the client makes which statement? I will wear long sleeves and a hat when I go for my afternoon walks. A primary healthcare provider has prescribed sterile saline 1.5 mL IM every 4 hours as needed for pain for a client who reports frequent "severe" headaches. What action should the nurse take? Discuss client rights with the primary healthcare provider 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? 4 mm Hg The nurse is admitting a client with a fifteen year history of poorly controlled diabetes mellitus. During the initial assessment the client reports experiencing "numb feet." What nursing action takes priority? Examine the client's feet for signs of injury. A client is admitted to the intensive care unit after overdosing on meperidine. What is the nurse's first priority? Administer naloxone hydrochloride 0.4 mg IV every 2-3 minutes prn. When performing an admission assessment, what should the nurse recognize as signs/symptoms of hyperthyroidism? Nervousness Exophthalmos Hot and sweating A newly admitted client tells the nurse, "I am hearing voices." Which response by the nurse is most appropriate? Tell me what the voices are saying to you. The nurse in the clinic would recognize which client statement as most indicative of gallbladder disease? "Yesterday, when I ate a hamburger and french fries, my belly really hurt." Which client assignments are most appropriate for the charge nurse to delegate to an LPN/VN who works on the pediatric unit? 10 year old paraplegic in for bowel training. 7 year old in Buck's traction for a femur fracture. The nurse is teaching the family of a newly diagnosed diabetic client about treatment of hypoglycemia at home. Which guidelines should be given to the family of the client? Treat a mild episode with 10-15 grams of carbohydrate. What activities should a nurse recommend to a group of adolescents who have been diagnosed with rheumatoid arthritis? Bicycle riding Swimming The client has suicidal ideations with a vague plan for suicide. The nurse who is teaching the family to care for the client at home should emphasize which points? When the client stops talking about suicide, the risk has increased. Warning signs, even if indirect, are generally present prior to a suicide attempt. One suicide attempt increases the chance of future suicide attempts. Report sudden behavioral changes. After report, the nurse is assigned to care for 4 adult clients. Which client should the nurse assess first? Receiving treatment for dehydration, and is now picking at bedding and IV tubing. A client returned to the unit following a total hip replacement. What statement by the client would indicate to the nurse that teaching has been successful? "I will not elevate the head of the bed. These clients have arrived at the emergency department (ED) following an explosion at a local industrial plant. The ED is operating under disaster protocol. Which client should be treated first? The client with a sucking chest wound and tension pneumothorax. What should the nurse include when teaching a client in renal failure about peritoneal dialysis? Following the prescribed dwell time, lower the bag to allow the fluid to drain out. The fluid that is returned should be clear in appearance. A sweet taste may be experienced when peritoneal dialysis is used. What impaired functions does the nurse expect to observe in the client admitted with an injury to the frontal lobe of the brain? Impaired speech. Decreased concentration. 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? Parent states infant tastes salty. Frequent coughing with thick, blood-streaked sputum. Foul-smelling, greasy stools. No weight gain since last check-up. The emergency responders enter the emergency department with a client in cardiac arrest. One of the responders is performing chest compressions. What is the best assessment for the nurse to determine if the responder is compressing with enough force and depth? Presence of a carotid pulse with each compression As part of the screening process to identify if a client is obese, the nurse calculates the client's body mass index (BMI). Weight - 180 pounds Height - 5' 5" Calculate the BMI to the whole number. Enter the answer for the question below. Rationale Calculate BMI by dividing weight in pounds by height in inches squared and multiplying by a conversion factor of 703. 5'5" = 65" [180 pounds ÷ (65)2 ] x 703 = [180 pounds ÷ 4225] x 703 = 0. x 703 = 29.95 or 30 The nurse approaches a client who entered the emergency department following a fall down a flight of stairs. The client is unresponsive with snoring and wheezes with respirations. How would the nurse best open the client's airway? Jaw thrust maneuver What task by the RN should be performed first? Assessing a newly admitted client. The client is worried and distracted, and explains to the nurse that because of the direct admission from the primary healthcare provider's office there was no preparation to be away from home. The client is concerned about the length of stay, pets that need care, and bills that require payment. Which response from the nurse would be most helpful to this client? An unexpected hospital admission can be very stressful. I will notify the case manager who specializes in helping clients with situations like yours. There is a telephone here so that you can contact your family and friends. A client is being admitted with a diagnosis of cirrhosis of the liver. What assessment findings should the nurse anticipate in this client? Firm, nodular liver Ascites Increased serum albumin levels Increased ALT and AST levels Bleeding from the GI tract 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? Pre-term labor client with twins at 28 weeks gestation. Which client in the Labor, Delivery, Recovery, and Postpartum Unit (LDRP) should the nurse see first? Primipara at 39 weeks gestation, who is dilated to three centimeters and at minus two station who states, "I think my water just broke." A client is admitted to the hospital with a platelet count of 132,000 mm3 and a white cell count of 8,495 cells/mcL. What interventions should the nurse implement? Monitor stools for occult blood. Place on fall prevention. Restrict venipunctures. The nurse is caring for a client prescribed vancomycin for Methicillin-Resistant Staphylococcus Aureus (MRSA) infection. What nursing intervention is appropriate? Verify that the client's BUN and creatinine are within normal range 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? 1. Promote maximal stability by utilizing a wide base of support. 2. Maintain a low center of gravity. 3. Use both the arms and the legs when performing strenuous activity. 6. Obtain assistance from other nurses or nurse assistants as needed. The nurse at the wellness clinic is teaching a client newly diagnosed with insulindependent diabetes mellitus. The client asks about beginning an exercise program. The nurse bases the response on the fact that exercise has what effect on the body? 1. Lowers the blood glucose 2. Provides more energy What should the nurse include when educating a client about the use of nitroglycerin sublingual. 1. Do not swallow nitroglycerin. 3. The medication may burn when taken. 4. Sit or lie down when taking this medication. 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? There are a number of reasons that may contribute to depression, such as a decreased level of chemicals in your brain. 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? Blood cultures times two Which client should the charge nurse assign to a new RN? Child needing pre-operative medication prior to reduction of a fracture. The drug nadolol is prescribed for a client with stable angina. Which findings would indicate to the nurse that the drug is effective? 1. Decreased anxiety 2. Relief of chest pain 3. Bounding pulses 4. Lowered blood pressure 5. Bradycardia Rationale 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. Betablockers 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 betablocking 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. The nurse is planning care for a newly admitted client who has an Arabic surname and whose spouse is wearing a traditional head covering. After verifying that the client prescriptions include a regular diet as tolerated, how would the nurse best meet the religious dietary needs for this client? 1. Allow the client to select whatever is acceptable from a regular meal tray. 2. Review the client's admission data to determine any dietary restrictions. 3. Call the dietician to discuss special dietary needs with the client's spouse. 4. Ask the client about dietary preferences needed to meet religious guidelines. Rationale 4. Correct. Nurses must be aware of cultural, religious and spiritual beliefs as an important aspect in clients' health and recovery. This nurse suspects possible cultural or religious implications that may require special dietary alterations for the client, even though the primary health care provider prescribed a regular diet. Asking the client directly about dietary preferences or restrictions is the best approach, since individuals vary when adhering to religious practices. 1. Incorrect. When assessing a newly admitted client, the nurse's responsibility is to determine any special cultural or religious restrictions, which might affect care and recovery. Although the nurse correctly believes certain dietary modifications may be needed for this client, asking the client to select only acceptable items from a regular tray would not meet basic nutritional requirements or cultural expectations. 2. Incorrect. Although there may be some diet information in the hospital admission forms, the nurse must do a thorough assessment when a client arrives on the floor, including determining any special spiritual or cultural needs. Obtaining information from the hospital chart does not ensure accurate or detailed information, and may have errors that would cause the client stress or even offend the client. 3. Incorrect. Unless the client was unconscious, there is no need for the dietician to speak to the spouse, except under certain strict cultural situations in which the spouse is expected to speak for the client. This question does not indicate either of these situations. If the nurse feels the assistance of the dietician is needed to discuss specific foods or food preparation criteria, the dietician should speak directly to the client. A client has been taking enoxaparin 40 mg subcutaneous once a day for 1 week. Which action should the nurse take? exhibit: Hgb - 15 g/dl (2.3 mmol/l) Hct - 42% Platelets - 110,000/ mm3 aPTT - 110 seconds INR - 1.2 1. Administer protamine sulfate 50 mg over 10 minutes. 2. Type and cross match for 2 units PRBCs 3. Increase enoxaparin dose to increase INR 4. Give the scheduled dose of enoxaparin Rationale 1. Correct: Protamine sulfate is given for heparin overdose. It is a heparin antagonist. Overdose is seen with a aPTT of 110 seconds. Depending on therapeutic intent, a client's aPTT levels should be between 60-80 seconds. (Normal aPTT for a client not on an anticoagulant is 25-35 seconds). 2. Incorrect: RBC, Hgb, Hct are normal. Blood transfusion is not indicated. 3. Incorrect: PT is not used to measure the therapeutic effect of enoxaparin, but rather aPTT. PT and INR are used for warfarin. 4. Incorrect: aPTT is too long at 110 seconds. Therapeutic level is 60-80 seconds. 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? 1. Accepts the treatment of the nurse and think that it is appropriate. 2. Takes offense to the abrupt nature of the treatment. 3. Thinks that the nurse is busy and needs to rush. 4. Thinks that the nurse is very efficient. Rationale 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. The nurse is caring for a newly admitted client with diabetes mellitus. The initial assessment reveals that the client is unresponsive, BP is 98/64, Resp 38, HR 100, T 97.2ºF (36.2º C). The nurse notes a fruity smell on the client's breath. The nurse recognizes that the client is in which acid-base imbalance? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic acidosis 4. Metabolic alkalosis Rationale 3. Correct: A diabetic client who is unresponsive with fruity ketone breath is assumed to be in acidosis. Hyperventilation occurs due to excess ketones in the body causing metabolic acidosis. The respiratory rate indicates that the lungs are trying to fix the metabolic acidosis with Kussmaul breathing. The hyperventilation occurs to reduce the arterial pCO2 level. 1. Incorrect: The fruity smelling breath indicates a metabolic problem. This is a result of an increase in the acetone level. The client may develop diabetic ketoacidosis (DKA). 2. Incorrect: The client is in metabolic acidosis. This is not a respiratory imbalance. 4. Incorrect: The client is experiencing a metabolic situation due to the increase in the ketones in the body, the client is in metabolic acidosis. What side effects would the nurse expect to find in a client who has received too much levothyroxine? 1. Angina 2. Bradycardia 3. Hypotension 4. Heat intolerance 5. Tremors Rationale 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. 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? 1. On-going support from weight-loss program personnel. 2. Periodic weigh-ins with the nurse. 3. Discontinue programmatic exercise plan. 4. Relapse prevention plan. 5. Continued peer support. Rationale 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. 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? 1. Administer the injection. 2. Take vital signs. 3. Question prescription with primary healthcare provider. 4. Notify the nursing supervisor. Rationale 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. An alert client presents to the emergency department with vomiting for 3 days and has been unable to keep food or fluids down for the last 24 hours. Which imbalances does the nurse suspect this client has? 1. Hypocalcemia 2. Hypermagnesemia 3. Hypokalemia 4. Metabolic alkalosis 5. Respiratory acidosis Rationale 3., & 4. Correct: Clients who vomit lose acid; therefore, they will have metabolic alkalosis. A client who is not eating and is vomiting will also lose potassium. Potassium is the electrolyte most significantly lost from the upper GI tract. 1. Incorrect: Calcium is not the electrolyte that is altered significantly with vomiting. It is primarily lost from intestinal elimination. 2. Incorrect: Actually magnesium has to be replaced daily just like potassium, so it will be low also. 5. Incorrect: The client is alert and should be breathing ok. The problem is not with the lungs. 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? 1. Place the finger at heart level when making the stick. 2. Warm the finger prior to the stick. 3. Keep the injector loose against the skin. 4. Place the finger above heart level when making the stick. Rationale 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. The nurse administers chemotherapeutic drugs to a client with breast cancer. Where should the nurse dispose of the medication vials? 1. In a puncture-resistant biohazard container 2. In a chemotherapy sharps container 3. In a biohazard waste container 4. In a chemical container Rationale 2. Correct: Empty vials and sharps such as needles and syringes used in delivering chemotherapy agents should be disposed of in a chemotherapy sharps container. These waste containers are designed to protect workers from injuries and are disposed of by incineration at regulated medical waste facilities. 1. Incorrect: Hazardous, drug-contaminated sharps should not be placed in red biohazard containers that are used for infectious wastes, since these are often autoclaved or microwaved. 3. Incorrect: Biohazard waste containers are not designed for sharps and can cause injuries. 4. Incorrect: Chemical containers are not designed for sharps and can cause injuries. The nurse is planning care for a client who has a fractured hip. Which nursing interventions should the nurse plan to use for impaired physical mobility? 1. Turn every two hours 2. Place a pillow between legs when turning 3. Sit in a chair three times per day 4. Encourage fluid intake 5. Encourage ankle and foot exercises Rationale 1., 2., 4. & 5. Correct: The client must be turned every two hours. You may not be able to turn the client totally on the side of the fracture, but you must relieve pressure points. Place pillow between legs to keep affected leg in abducted position. Encourage fluid intake and ankle and foot exercises to prevent deep vein thrombosis (DVT). 3. Incorrect: The client has a fractured hip that has not been surgically fixed. Sitting up in a chair could do more injury and cause more pain. 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? 1. Administer the digoxin. 2. Hold the digoxin. 3. Notify the primary healthcare provider. 4. Repeat the digoxin level. Rationale 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. 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. Enter the answer for the question below. Rationale Step 1 50,000 units: 1000 mL=x units: 60 mL 1000x = 50,000 (60) 1000x = 3,000,,000 x = 3,000 units/hr The client with bleeding esophageal varices has a Blakemore tube in place. What piece of equipment should be present at the bedside? 1. Tracheostomy set 2. Clamps 3. Surgical scissors 4. Tourniquet Rationale 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. A soldier who returned from combat 2 months ago was admitted to a psychiatric unit with a diagnosis of Dissociative Fugue. The police found the client wandering down the street in a daze after fighting with a stranger. Which nursing interventions should the nurse implement? 1. Directly observe the client at least every 4 hours. 2. Maintain a low level of stimuli. 3. Remove all dangerous objects from environment. 4. Convey a calm attitude toward the client. 5. Discourage client's expression of negative feelings. Rationale 2., 3. & 4. Correct: Anxiety rises in stimulating environments. Individuals may be perceived as threatened by a fearful and agitated client. Removing dangerous objects will prevent the confused and agitated client from using them to harm self or others. Anxiety is contagious and can be transmitted from staff to client. 1. Incorrect: The client should be observed closely and frequently to ensure safety for self and others. Every 4 hours is not frequent enough and doesn't ensure the client's safety. 5. Incorrect: Accepting expression of negative feelings is therapeutic and helps the client learn more effective ways of dealing with anger, anxiety or aggression. During shift change the night charge nurse reports to the day charge nurse that a client, admitted with an ingestion of unknown drugs, received a prescription for physical restraint at 3:00 am because the client was incoherent, combative, and attempting to leave the facility. On last assessment at 7:00 am, the client was still combative. What is the best action by the day shift charge nurse? 1. Since the client is still combative, continue the restraints. 2. Remove restraints until the primary healthcare provider writes the prescription. 3. Assign an unlicensed assistive personnel (UAP) to check on the client periodically. 4. Obtain a prescription from the primary healthcare provider. Rationale 4. Correct: A prescription for physical restraints must be renewed every 4 hours if restraints are still needed. Generally, restraints are not used past a 24 hour period. The prescription for the restraint should include why the client requires physical restraints and a time period for using them and no more than 24 hours. 1. Incorrect: Do not assume. The oncoming nurse needs to assess the client in order to determine if restraints are still needed for the safety of this client. 2. Incorrect: If the client is indeed still incoherent and combative, restraints are still warranted to prevent the client from harming self or others. 3. Incorrect: Periodical checks will not keep the client from harming self or others and "periodically" is not an acceptable time frame for this action A client with Graves' disease and exophthalmos returns to the clinic for evaluation. Which assessment indicates to the nurse that the client is adhering to the teaching plan? 1. Moist, shiny, soft hair 2. Resting heart rate of 120 3. Adheres to the prescribed low-sodium diet 4. An absence of corneal irritation