NUR 4455 MODULE 5 NCLEX / NUR4455 MODULE 5 NCLEX (Q & A WITH RATIONALE ): RASMUSSEN COLLEGE (LATEST, 2020)(Verified Answers by GOLD rated Expert, Download to Score A)

NUR 4455 MODULE 5 NCLEX 1. Methylergonovine is prescribed for a woman to treat postpartum hemorrhage. Before the administration of methylergonovine, the nurse should check which priority item? a. Uterine tone b. BP c. Amount of lochia d. Deep tendon reflexes Answer: B Rationale: Methylergonovine, which is an ergot alkaloid, is an agent that is used to prevent or control postpartum hemorrhage by contracting the uterus. It may elevate BP, therefore the priority before giving the medication is checking the blood pressure of the patient. 2. The nurse is monitoring a preterm labor client who is receiving mag sulfate IV. The nurse should monitor for which adverse effects? Select all that apply: a. Flushing b. HTN c. Increased Urine output d. Depressed RR e. Extreme muscle weakness f. Hyperactive deep tendon reflexes Answer: A, D, E Rationale:Mag sulfate is a central nervous system depressant and it relaxes the smooth muscle, including the uterus. It is used to stop preterm labor contractions, and it is used for preeclamptic clients to prevent seizures. 3. A pregnant patient is receiving mag sulfate for the mgt of preeclampsia. The nurse determines that the patient is experiencing toxicity from the medication, if which is noted on data collection? a. Proteinuria of 3 plus b. Deep tendon reflexes c. Serum mag level of 6mEq/L d. RR of 10/min Answer: D Rationale: Mag toxicity can occur because of mag sulfate therapy. Signs of mag sulfate toxicity relate to the central nervous system depressant effects of the medication and include respiratory depression (RR less then 12/min). 4. Epidural analgesia is administered to a woman for pain relief after a cesarean birth. The nurse assigned to care for the woman ensures that which medication is readily available if respiratory depression occurs? a. Betamethasone b. Morphine sulfate c. Narcan d. Meperidine hydrochloride (Demerol) Answer: C Rationale: Opioids are used for epidural analgesia. An adverse effect of epidural analgesia is a delayed respiratory depression. Narcan, is opioid antagonist, which reverse the effects of opioids and is given for respiratory depression. 5. Rh (D) immune globulin (RhoGam) is prescribed for woman after delivery of newborn infant, and the nurse provides info to the woman about the purpose of the medication. The nurse determines that the woman understands the purpose of this medication if the woman states that it will protect her next baby from which condition? a. Having Rh-positive blood b. Developing rubella infection c. Developing physiological jaundice d. Being affected by Rh incompatibility Answer: D Rationale: Rh incompatibility can occur when a Rh-negative mother becomes sensitized to Rh antigen. Sensitization may develop when a Rh-negative woman becomes pregnant with a fetus that is Rh positive. 6. A woman suffering from preeclampsia is receiving mag sulfate. Which indicates to the nurse that the mag therapy is effective? a. Scotomas are present b. Seizures do not occur c. Ankle clonus is noted d. The blood pressure decreases Answer: B Rationale: for a client with preeclampsia, the goal of care is directed at preventing eclampsia (seizures). Mag sulfate is an anticonvulsant rather than an antihypertensive agent. Although a decrease in blood pressure may be noted initially this effect is usually transient. 7. Methylergonovine is prescribed for a patient with postpartum hemorrhage Before administering the medication, the nurse should question administration of the medication if which condition is documented in the client’s medical history? a. Hypotension b. Hypothyroidism c. DM d. Peripheral vascular disease Answer: D Rationale: Methylergonovine is an ergot alkaloid that is used to treat postpartum hemorrhage. Ergot alkaloids are avoided in clients with significant cardiovascular disease, peripheral vascular disease, hypertension, eclampsia, or preeclampsia because these conditions are worsened by the vasoconstrictive. 8. The nursing instructor asks a nursing student to describe the procedure for administering erythromycin ointment to the eyes of a neonate. The instructor determines that the student needs to research this procedure further fi the student makes which statement? a. I will flush the eyes after instilling the ointment b. I will cleanse the neonate’s eyes before instilling the ointment c. The administration of the eye ointment is within 1 hour after delivery d. I will instill the eye ointment into each of the neonate’s conjunctival sacs Answer: A Rationale: Eye prophylaxis protects the neonate against Neisseria gonorrhoeae and chlamydia trachomatis. The eyes are not flushed after instillation of the medication because the flush will wash away the administered medication. Reference: Silvestri, L. A. (2016). Saunders comprehensive review for the NCLEX-PN Examination (6th ed.). St. Louis, MO: Elsevier. Nadia 1. Hypoglycemia Lab numbers are indicated as? a. Glucose of 50 mg/dl or less? b. Glucose of 70 mg/dl or less? c. Glucose of 100 mg/dl or less? d. Glucose of 80 mg/dl or less? i. ANSWER: B. 2. Indications of Hyperglycemia are? a. Cool skin b. Clammy skin c. Fruity breath d. Glucose of 70 mg/dl or less i. ANSWER:C. Hyperlycemia causes hot dry skin and fruity breath. 3. What are the 5 P’s that help identify compartment syndrome? a. Pain, Paralysis, Paresthesia, Pallor, and Pulselessness b. Pain, Purulent drainage, Pallor, Pulselessness, and Paresthesia c. Poor oxygen saturation, Purulent drainage, Pallor, Pulselessness, and paresthesia i. ANSWER: A. Pain that is unrelieved by medication or intensifies, Paresthesia will be symptoms of early tingling or numbness. Paralysis will show nerve damage indicated by weak muscles. Pulselessness is a late symptoms of compartment syndrome. 4. When the human body is upright, the center of gravity is the? a. Shoulders b. Abdomen above the navel c. Pelvis d. Trapezius muscles i. RATIONAL: C PELVIS 5. The safest way to move a client is with? a. 3 Assistants b. Assistive equipment c. Facing above the direction of movement d. Leaning your body weight against the clients i. RATIONAL: B. When possible, use assistive equipment that can help prevent injury. 6. A nurse is caring for a client who is receiving enteral tube feedings due to dysphagia. Which of the following bed positions should the nurse use for safe care of this client? a. Supine b. semi Fowler’s c. semi prone d. Trendelenburg i. RATIONAL: B. the semi Fowler’s position, the client lies supine with the head of the bed elevated 15° to 45° (typically 30°). This position helps prevent regurgitation and aspiration by clients who have difficulty swallowing. This is the safest position for clients receiving enteral tube feeding. 7. A nurse is caring for a client who is sitting in a chair and asks to return to bed. Which of the following actions is the nurse’s priority at this time? a. obtain a walker for the client to use to transfer back to bed. b. call for additional staff to assist with the transfer. c. Use a transfer belt and assist the client back into bed. d. Determine the client’s ability to help with the transfer. i. RATIONAL: D. The first action the nurse should take using the nursing process is to assess or collect data from the client. The nurse should determine the client’s ability to help with transfers and then proceed with a safe transfer. 8. A nurse is completing discharge instructions for a client who has coPD. The nurse should identify that the client understands the orthopneic position when she states that she will do which of the following when she has difficulty breathing at night? a. lie on her back with her head and shoulders on a pillow. b. lie flat on her stomach with her head to one side. c. sit on the side of her bed and rest her arms over pillows on top of her bedside table. d. lie on her side with her weight on her hip and shoulder with her arm flexed in front of her. i. RATIONAL: C. The client is describing the orthopneic position. This position allows for chest expansion and is especially beneficial for clients who have COPD 9. A nurse manager is reviewing guidelines for preventing injury with staff nurses. Which of the following instructions should the nurse manager include? (select all that apply.) a. request assistance when repositioning a client. b. Avoid twisting your spine or bending at the waist. c. Keep your knees slightly lower than your hips when sitting for long periods of time. d. Use smooth movements when lifting and moving clients. e. Take a break from repetitive movements every 2 to 3 hr to flex and stretch your joints and muscles. i. RATIONAL: A. To reduce the risk of injury, at least two staff members should reposition clients. B, Twisting the spine or bending at the waist (flexion) increases the risk for injury. When sitting for long periods of time, it is essential to keep the knees slightly higher, not lower, than the hips to decrease strain on the lower back. D. Using smooth movements instead of sudden or jerky muscle movements helps prevent injury REFERENCES: NCLEX Connection: Safety and Infection Control, Ergonomic Principles Retrieved from Ashley 1. A nurse is teaching a 32-year-old primigravida about proper nutrition during pregnancy. Which instruction is appropriate? Select all that apply. a. Increase caloric intake by 300 calories per day b. Increase protein intake to 76 grams per day c. Don’t increase vitamin intake from prepregnancy requirements d. Increase folic acid intake to 400 milligrams per day e. Increase intake of all minerals, especially iron 2. During an examination, a client who is 32 weeks pregnant becomes dizzy, light-headed, and pale while supine. Which intervention is the nurse’s priority? a. Listen to fetal heart tones b. Take the clients blood pressure c. Ask the client to breathe deeply d. Turn the client on her left side 3. The nurse has just taught a client about the signs of true and false labor. Which client statement indicates that the teaching was effective? a. “false labor contractions are regular.” b. “false labor contractions intensify with walking.” c. “false labor contractions usually occur in the abdomen.” d. “false labor contractions move from the back to the front of the abdomen.” 4. During the prenatal screening of a client with diabetes, the nurse should keep in mind that the client is at increased risk for which complications? Select all that apply. a. Still birth b. Rh incompatibility c. Gestational hypertension d. Placenta previa e. Spontaneous abortion 5. Cervical effacement and dilation aren’t progressing in a client in labor. The physician orders intravenous administration of oxytocin (Pitocin). During oxytocin administration, why must the nurse monitor the client’s fluid intake and output closely? a. Oxytocin causes water intoxication b. Oxytocin causes excessive thirst c. Oxytocin is toxic to the kidneys d. Oxytocin has a diuretic effect 6. A client is progressing through the second stage of labor slowly, and the physician elects to perform an amniotomy. After an amniotomy, which client goal should take the highest priority? a. The client will express increased knowledge about amniotomy b. The fetus will maintain adequate tissue perfusion c. The fetus will display no signs of infection d. The client will report relief of pain 7. A 38-year-old primigravida in active labor is being admitted through the emergency department. When participating in care planning for a client in labor, the nurse expects to obtain the client’s blood pressure frequently. Why? a. Decreased blood pressure is a sign of maternal pain b. Alterations in blood pressure affect the fetus c. Blood pressure decreases at the acme of each contraction d. Decreased blood pressure is the first sign of preeclampsia 8. A client in the first stage of labor has an electronic fetal monitor (EFM) in place. What should the nurse do first if variable decelerations are noted on the EFM pattern? a. Call the physician or nurse-midwife b. Prepare the clients for an emergency cesarean birth c. Change the client's position d. Prepare the client for more accurate internal fetal monitoring 1. A pregnant woman should increase her caloric intake by 300 calories per day. The protein requirement (76 g/day) of a pregnancy woman exceeds that of a nonpregnant woman by 30 g/day. All mineral requirements, especially iron, are increased in a pregnant woman. The woman should increase her intake of all vitamins; a prenatal vitamin is usually recommended. Folic acid intake is particularly important to help prevent fetal abnormalities such as neural tube defect; intake should be increased from 400 to 800 mg/day. 2. As the enlarging uterus increases pressure on the inferior vena cava, it compromises venous return, which can cause dizziness, light-headedness, and pallor when the client is supine. It also puts pressure on the aorta and collateral circulation, impending adequate circulation. The nurse can relieve these symptoms by turning the client to the left, which relieves pressure on the vena cava and restores venous return. Although they’re valuable assessments, fetal heart tome and maternal blood pressure measurements don’t correct the problem. Because deep breathing has no effect on venous return, it can't relieve the client's symptoms. 3. False labor contractions are usually felt in the abdomen, are irregular, and are typically relieved by walking. True labor contractions move from the back to the front of the abdomen, are regular, and aren’t relieved by walking. The intensity of true labor contractions are usually increased by walking. 4. Pregnant clients with diabetes are at increased risk for intrauterine fetal death after 36 weeks’ gestation, gestational hypertension, and spontaneous abortion. The risk of Rh incompatibility and placenta previa isn't increased in the client with diabetes. 5. The nurse should monitor fluid intake and output because prolonged oxytocin infusion may cause severe water intoxication, leading to seizure, coma, and death. Excessive thirst results from the work of labor and limited oral fluid intake, not oxytocin. Oxytocin has no nephrotoxic or diuretic effects; in fact, it produces an antidiuretic effect. 6. Amniotomy increases the risk of umbilical cord prolapse, which would impair the fetal blood supply and tissue perfusion. Because the fetus’s life depends on the oxygen carried by that blood, maintaining fetal tissue perfusion takes priority over goals related to increased knowledge, infection prevention, and pain relief. 7. During contractions blood pressure increases and blood flow to the intervillous spaces changes, comprising the fetal blood supply. Therefore, the nurse should obtain the clients blood pressure frequently to determine is it returns to precontraction levels and allows adequate fetal blood flow again. During pain and contractions, the maternal blood supply usually increases rather than decreases. Preeclampsia causes the blood pressure to increase, not decrease. 8. Variable decelerations suggest umbilical cord compression; therefore, changing the client's position may relieve pressure from the cord and should be the first nursing intervention performed. Calling the physician or nurse-midwife is appropriate if changing the client's position is ineffective in relieving the variable decelerations. Preparing the client for an emergency cesarean birth isn't the first action in this situation. Internal fetal monitoring isn't appropriate for monitoring variable decelerations. Source: Lippincott’s NCLEX-PN review cards 4th edition Stephanie 1. The nurse is teaching a group of parents about gross motor development of the toddler. Which behavior is an example of the normal gross motor skill of a toddler? A. She can pull a toy behind her. B. She can copy a horizontal line. C. She can build a tower of eight blocks. D. She can broad-jump. 2. The nurse should observe for side effects associated with the use of bronchodilators. A common side effect of bronchodilators is: A. Tinnitus B. Nausea C. Ataxia D. Hypotension 3. Which of the following conditions is most likely related to the development of renal calculi? A. Gout B. Pancreatitis C. Fractured femur D. Disc disease 4. Which of the following meal choices is suitable for a 6-month-old infant? A. Egg white, formula, and orange juice B. Apple juice, carrots, whole milk C. Rice cereal, apple juice, formula D. Melba toast, egg yolk, whole milk 5. The nurse is caring for a client with detoxification from alcohol. Which medication is used in the treatment of alcohol withdrawal? A. Antabuse (disulfiram) B. Romazicon (flumazenil) C. Dolophine (methodone) D. Ativan (lorazepam) 6. Which diet is associated with an increased risk of colorectal cancer? A. Low protein, complex carbohydrates B. High protein, simple carbohydrates C. High fat, refined carbohydrates D. Low carbohydrates, complex proteins 7. The nurse is providing dietary instructions for a client with iron-deficiency anemia. Which food is a poor source of iron? A. Tomatoes B. Legumes C. Dried fruits D. Nuts 8. A newborn weighed 7 pounds at birth. At 6 months of age, the infant could be expected to weigh: A. 14 pounds B. 18 pounds C. 25 pounds D. 30 pounds Tish 1. Severe pulmonary edema can cause the client to experience: a. Mild anxiety b. Moderate anxiety c. Extreme anxiety d. Slight anxiety Rational: Severe pulmonary edema can cause extreme anxiety in patients. The patient may also experience extreme shortness of breath or difficulty breathing, a feeling of suffocating or drowning, a cough that produces frothy sputum, excessive sweating, pale skin, chest pain, and a rapid irregular heart rate. 2. A client who has been prescribed Chlordiazepoxide (Librium) has come into the clinic for a check-up. Which of the following behaviors indicates that the client has been taking the assigned dosage? a. Client feels energetic. b. Client gets easily confused. c. Client is always thirsty. d. Client complains of general fatigue. Rational: A common side effect of Chlordiazepoxide (Librium) is fatigue. The client should not feel energetic, get confused, or always be thirsty in relation to taking the prescribed dosage. 3. The nurse is caring for a patient with severe claustrophobia. What area of the hospital should the nurse avoid with the patient? a. Areas with lots of needles. b. Enclosed areas. c. Areas with lots of people. d. Wide-open areas. Rational: A patient with claustrophobia has a fear of enclosed areas, such as elevators, small rooms, and closets. 4. The most important nursing action included in the care plan for the client taking morphine sulfate for pain is to: a. Monitor the client’s temperature. b. Encourage the client to cough and deep breathe. c. Maintain the client in a supine position. d. Encourage fluids Rational: A patient taking morphine sulfate should control secretions by coughing and breathing deeply. The nurse should also encourage fluids for the patient, however the best answer is encouraging coughing and deep breathing. 5. The success of pericardiocentesis performed to treat cardiac tamponade is indicated by: a. Clear audible heart sounds. b. Client expresses relief. c. Rising blood pressure. d. Rising central venous pressure. Rational: Cardiac tamponade is an acute pericardial effusion where fluid accumulates in the pericardium. Hypotension often occurs due to decreased stroke volume. When this fluid is removed during pericardiocentesis, normal stroke volume should resume, increasing blood pressure. 6. The client in the termination phase of the nurse-client relationship is being very confrontational. How should the nurse interpret this behavior? a. The nurse has done something to offend the client. b. The patient should be admitted to the hospital. c. The treatment should revisit the working phase. d. This behavior is common for a client in the termination phase. Rational: Confrontational behavior is very common for a client in the termination phase. The nurse should not assume that she offended the client, and further action in terms of therapy should not be addressed until completing the termination phase. 7. The nurse wishes to position the casted leg of a patient with a recent fracture. Which would be the appropriate action? a. Keep the leg level. b. Elevated the leg and lower the leg alternately every 4 hours. c. Keep the leg elevated for 24 to 48 hours. d. Keep the leg lowered to improve blood flow. Rational: The nurse should elevate the leg for 24 to 48 hours to reduce swelling and to allow fluid and blood to drain downhill to the patient's heart. 8. It is best if Cyclobenzaprine is used for the following length of time: a. 3-6 months b. 2-3 weeks c. Indefinitely d. 1 year Rational: Cyclobenzaprine should be used for 2-3 weeks. Cyclobenzaprine should be used only for short periods because there is no evidence of effectiveness for administration over a longer period, and because muscle spasm associated with acute and painful muscoskeletal conditions is generally of short duration. Sahara nurse uses the Internet to receive electrocardiogram results from a client living in a nursing home. The nurse knows this type of information technology is best described as which of the following? (a) Encryption (b) Telecommunications (c) Telehealth (d) Nursing informatics Correct answer: (c) Telehealth. Rationale: Telehealth uses transmissions via telecommunications technology to transmit health information remotely. Encryption refers to the conversion of information to code during transmission to keep the information secure. Telecommunications refers to the electronic transmission of data over phone-based lines. Nursing informatics refers to a specialty of nursing that integrates nursing and computer science 2.The nurse in a maternity unit is caring for a client who has just delivered twins. The client voices concern about her ability to manage when she gets home. Which of the following statements best illustrates quality care delivery by the nurse? Select all that apply. (a) "Just focus on how lucky you are to have two healthy babies." (b) "We can arrange for follow-up visits with a home health nurse." (c) "Here is some information on support groups for parents of multiples." (d) "You will find it easier to formula-feed your babies at home." Correct answer: (b) "We can arrange for follow-up visits with a home health nurse."; and (c) "Here is some information on support groups for parents of multiples." Rationale: A referral to home health care provides the client with opportunities for support and assistance during this transition; and a referral to support groups provides the client with opportunities for support and assistance during this transition. The other options are not appropriate for a new mother expressing concerns about her ability to cope. 3.The nurse is caring for a client newly diagnosed with diabetes, and performs the following tasks. Place the tasks the nurse would perform in the appropriate order. All options must be used. (a) The nurse establishes a goal with the client to be able to self-administer insulin injections. (b) The nurse assesses the client's level of knowledge about how to administer insulin injections. (c) The nurse evaluates the client while self-administering insulin injections. (d) The nurse establishes the diagnosis of knowledge deficit. Correct answer: (b) The nurse assesses the client's level of knowledge about how to administer insulin injections. (d) The nurse establishes the diagnosis of knowledge deficit. (a) The nurse establishes a goal with the client to be able to self-administer insulin injections. (c) The nurse evaluates the client while self-administering insulin injections. Rationale: Nursing process - assessment, diagnosis, establishing outcomes/planning, and evaluation. 4.A nursing team consists of an RN, an LPN/ LVN, and a nursing assistant. The nurse should assign which of the following patients to the LPN/LVN? (a) A 72-year-old patient with diabetes who requires a dressing change for a stasis ulcer. (b) A 42-year-old patient with cancer of the bone complaining of pain. (c) A 55-year-old patient with terminal cancer being transferred to hospice home care. (d) A 23-year-old patient with a fracture of the right leg who asks to use the urinal. Correct answer: (a) A 72-year-old patient with diabetes who requires a dressing change for a stasis ulcer. Rationale: LPN/LVNs assist with implementation of care; performs procedures; differentiates normal from abnormal; cares for stable patients with predictable conditions; has knowledge of asepsis and dressing changes; administers medications. Patient (a) is stable with an expected outcome. Patients (b) and (c) require assessment and nursing judgement; and Patient (d) involves a standard unchanging procedure that can be assigned to the nursing assistant. 5.A registered nurse is planning the client assignments for the day. Which of the following is the most appropriate assignment for the nursing assistant? (a) A client requiring colostomy irrigation (b) A client receiving continuous tube feedings (c) A client who requires stool specimen collections (d) A client who has difficulty swallowing food and fluids Correct answer: (c) A client who requires stool specimen collections Rationale: This question addresses content related to delegation in the subcategory Management of Care in the Client Needs category of Safe and Effective Care Environment. Work that is delegated to others must be done consistent with the individual's level of expertise and licensure or lack of licensure. In this situation, the most appropriate assignment for the nursing assistant is to care for the client who requires stool specimen collections. Colostomy irrigations and tube feedings are not performed by unlicensed personnel. The client with difficulty swallowing food and fluids is at risk for aspiration. Remember, the health care provider needs to be competent and skilled to perform the assigned task or activity. 6. A pregnant woman at 15 weeks' gestation is scheduled for an amniocentesis. As the client is being prepped for the procedure, it becomes clear to the nurse that the client doesn't fully understand the risks and benefits associated with the procedure. Which of the following describe the nurse's role in obtaining informed consent? Select all that apply. (a) Explain the risks and benefits associated with the procedure. (b) Describe alternatives to the procedure. (c) Witness the client's signature on the consent form. (d) Advocate for the client by ensuring she is making an informed decision. Correct answer: (c) Witness the client's signature on the consent form; and (d) Advocate for the client by ensuring she is making an informed decision. Rationale: Some of the nurse's roles in the informed consent process are to witness the signature on the consent form, and to advocate for the client by ensuring she has been provided the necessary information to make an informed decision. It is the physician's duty to provide information to the client-related risks and benefits, and to provide alternatives. 7.A well-known actor has been admitted to an ambulatory surgical unit. The nurse notices a staff member who is not involved in the client's care reading his medical record. The nurse knows she should FIRST do which of the following? (a) Nothing. The staff member has a hospital ID badge and is authorized to read the medical record. (b) Inform the staff member that without a legitimate need for the information, staff should not be reading the medical record. (c) Tell the client his medical records have been read by an unauthorized individual. (d) Page the physician and ask if it's acceptable for the staff member to access the medical records. Correct answer: (b) Inform the staff member that without a legitimate need for the information, staff should not be reading the medical record. Rationale: An individual not involved in the care of the client does not have a legitimate need to access the medical record. The nurse should protect the client's right to privacy by ensuring only authorized individuals access medical records. 8.The nurse is learning how to use the hospital's new electronic medication administration record (eMAR). The nurse knows this tool has the potential to do which of the following? Select all that apply. (a) Reduce medication administration errors. (b) Improve access to information at the point of care. (c) Eliminate the need for the nurse to document medication administration. (d) Eliminate the need for the nurse to verify dose calculations. Correct answer: (a) Reduce medication administration errors; and (b) Improve access to information at the point of care. Rationale: eMARs have the potential to reduce medication administration errors and to improve access to client information at the point of care. It is always the nurse's responsibility to document medication administration and to verify doses of drugs being administered Hannah 1. Select the member of the healthcare team that is paired with one of the main functions of this team member. ** Occupational therapist: Gait exercises ** Physical therapist: The provision of assistive devices to facilitate the activities of daily living ** Speech and language therapist: The treatment of swallowing disorders ** Case manager: Ordering medications and treatments Correct Response: C Speech and language therapists assess and treat patients with a swallowing disorder; they also assess and treat patients with speech and communication problems as often occurs after a cerebrovascular accident, or stroke. Occupational therapists assist patients with their activities of daily living and they also provide patients with assistive devices to facilitate eating and dressing. Physical therapists perform rehabilitation and restorative care including help with ambulation and balance/gait exercises. Lastly, case managers coordinate care along the continuum of care and they manage insurance reimbursements. 2. The recommended daily caloric intake for sedentary older men, active adult women and children is: ** 2400 calories ** 1600 calories ** 2800 calories ** 2000 calories Correct Response: D Sedentary older men, active adult women and children should all have 6 ounces of grains, 2½ cups of vegetables, 2 cups of fruits, and 3 cups of milk to help make up their 2000 calorie requirement. Sedentary adolescents require 2400 calories, sedentary women and children require 1600 calories and active adolescents need 2800 calories daily. 3. Ill health, malnutrition, and wasting as a result of chronic disease are all associated with: ** Surgical asepsis ** Catabolism ** Cachexia ** Venous stasis Correct Response: C Ill health, malnutrition, and wasting as a result of chronic disease are all associated with cachexia. Cachexia can also result from dehiscence of a surgical incision or rupture of wound closure. Surgical asepsis refers to using a sterile technique to protect against infection before, during, and after surgery. The breakdown of tissue, especially after severe trauma or crush injuries is known as catabolism. Venous stasis is a disorder related to pooling of blood in a vein of the body; venous stasis typically occurs in the lower extremities and it is one of the many hazards, or complications, of immobilization. 4. Select all the possible opportunistic infections that adversely affect HIV/AIDS infected patients. ** Visual losses ** Kaposi’s sarcoma ** Wilms’ sarcoma ** Tuberculosis ** Peripheral neuropathy ** Toxoplasma gondii Correct Response: B, D, F Kaposi’s sarcoma, tuberculosis, toxoplasma gondii, mycobacterium avium, herpes simplex, histoplasmosis and salmonella infections are HIV/AIDS associated opportunistic infections. Although many affected patients can experience blindness and peripheral neuropathy, these disorders result from impaired nervous system damage rather than an infection. Lastly, Wilms’ tumor is a pediatric form of kidney cancer and it is neither an infection nor something that typically affects the patient with HIV/AIDS. 5. What can help reduce a patient’s anxiety and postsurgical pain? ** Preoperative teaching ** Preoperative checklist ** Psychological counseling ** Preoperative medication Correct Response: A Patient teaching before surgery not only helps to reduce a patient’s anxiety and postsurgical pain but it also decreases the amount of anesthesia needed and a lack of anxiety additionally speeds up wound healing. Preoperative checklists are a form of nursing documentation that is used to guide and document the care of the patient before surgery. Psychological counseling is typically NOT necessary except under highly unusual circumstances and preoperative medication can decrease the amount of anesthetic needed and respiratory tract secretions but it does not help with postoperative pain. 6. Which disease decreases the metabolic rate? ** Cancer ** Hypothyroidism ** Chronic obstructive pulmonary disease ** Cardiac failure Correct Response: B Hypothyroidism causes a decreased metabolic demand, so fewer calories are required. Cancer, chronic obstructive pulmonary disease, or cardiac failure all increase the metabolic demands and the need for added calories. 7. When caring for an infant during cardiac arrest, which pulse must be palpated to determine cardiac function? ** Carotid ** Brachial ** Pedal ** Radial Correct Response: B The brachial pulse is the most accessible pulse on an infant and, therefore, it is the site of choice. The carotid pulse may be difficult to palpate due to the fatty tissue that typically, and often, surrounds an infant’s neck. Lastly, the radial and pedal pulses may not be reliable indicators of cardiac function. 8. The patient should be sitting when deep breathing and coughing because this position: ** Is physically more comfortable for the patient ** Helps the patient to support their incision with a pillow ** Loosens respiratory secretions ** Allows the patient to observe their area and relax Correct Response: B The patient should be sitting when deep breathing and coughing because this position allows the patient to be better able to splint the incision with a pillow which provides abdominal support during coughing. It also allows the lungs to more fully expand because the diaphragm drops. The most comfortable position for the patient is the supine position; however, this position does not permit the lungs to fully expand. There is no association or correlation between loosening respiratory secretions or relaxation with this sitting position Mackenzie 1. The nurse should explain to a client that tolbutamide (Orinase) is effective for diabetics who A. can no longer produce any insulin B. produce minimal amounts of insulin C. are unable to administer their injections D. have a sustained decreased blood glucose. B correct–oral hypoglycemic agents are administered to type II (non-insulindependent) clients who are able to produce minimal amounts of insulin 2. A woman at 38-weeks gestation comes to the emergency room with complaints of vaginal bleeding. Which of the following statements, if made by the client, would suggest to the nurse placenta previa as the cause of the bleeding? A. “I feel fine, but the bleeding scares me.” B. “I’ve been more nauseated during the past few weeks.” C. “The bleeding started after I carried four bags of groceries.” D. “I’ve been having severe abdominal cramps.” A. correct–placenta previa is characterized by painless vaginal bleeding 3. The nurse is caring for an 80-year-old client with Parkinson’s disease. Which of the following nursing goals is MOST realistic and appropriate in planning care for this client? A. Return the client to usual activities of daily living B. Maintain optimal function within the client’s limitations C. Prepare the client for a peaceful and dignified death D. Arrest progression of the disease process in the client. B. correct–irreversible disease that leads to permanent physical limitations 4. When using restraints for an agitated/aggressive patient, which of the following statements should NOT influence the nurse’s actions during this intervention? A. The restraints/seclusion policies set forth by the institution B. The patient’s competence C. The patient’s voluntary/involuntary status D. The patient’s nursing care plan. C. correct–the need for restraints is based on patient’s behavioral status and condition, not the patient’s voluntary/involuntary status 5. A 12-year-old boy injured his right knee yesterday during a soccer game. He is brought to the outpatient clinic by his mother. His right knee is painful, swollen, and bruised. During the interview, the nurse learns that the boy has hemophilia A. Which of the following medications would be BEST for this patient? A. Oxycodone terephthalate (Percodan) B. Ibuprofen (Motrin) C. Enteric-coated aspirin D. Cphosphate (Paveral). D. correct–analgesic used for moderate to severe pain 6. The parents of a one-month-old boy bring their son to the clinic for evaluation of a possible right dislocated hip. If a diagnosis of unilateral dislocation of the right hip is made, which of the following symptoms will the nurse observe? A. Limited adduction of the right leg B. Uneven gluteal fold and thigh creases C. Increase in length of the right limb D. Internal rotation of the right leg. B. correct–folds and creases will be longer and deeper on affected side 7. The nurse is administering terbutaline (Brethine) to a client in labor. Prior to administration of the medication, the nurse assesses the client’s pulse to be 144. The nurse’s priority action should be to A. withhold the medication B. decrease the dose by half C. administer the medication D. wait 15 minutes, then recheck the rate. A. correct–maternal tachycardia is a side effect of Brethine; other maternal side effects include nervousness, tremors, headache, and possible pulmonary edema; fetal side effects include tachycardia and hypoglycemia; Brethine is usually preferred over ritodrine (Yutopar) because it has minimal effects on blood pressure 8. The nurse is supervising the staff providing care for an 18-month-old hospitalized with hepatitis A. The nurse determines that the staff’s care is appropriate if which of the following is observed? A. The child is placed in a private room B. The staff removes a toy from the child’s bed and takes it to the nurse’s station C. The staff offers the child french fries and a vanilla milkshake for a midafternoon snack D. The staff uses standard precautions. A. correct–contact precautions required for diapered or incontinent clients Jennifer: 1. The nurse is caring for a client with a health care–associated infection caused by methicillin-resistant Staphylococcus aureus who is on contact precautions. The nurse prepares to provide colostomy care to the client. Which protective items will be required to perform this procedure? 1. Gloves and a gown 2. Gloves and goggles 3. Gloves, a gown, and goggles 4. Gloves, a gown, and shoe protectors 3 Rationale: Goggles are worn to protect the mucous membranes of the eye during interventions that may produce splashes of blood, body fluids, secretions, and excretions. In addition, contact precautions require the use of gloves, and a gown should be worn if direct client contact is anticipated. Shoe protectors are not necessary. 2. The nurse enters a client’s room and finds that the wastebasket is on fire. The nurse immediately assists the client out of the room. Which is the next nursing action? 1. Call for help. 2. Extinguish the fire. 3. Activate the fire alarm. 4. Confine the fire by closing the room door. 3 Rationale: The order of priority in the event of a fire is to rescue the clients who are in immediate danger. The next step is to activate the fire alarm. The fire is then confined by closing all doors. Finally, the fire is extinguished. 3. The nurse is caring for a client who has hand restraints. How often should the nurse assess the skin integrity of the restrained hands? 1. Every 2 hours 2. Every 3 hours 3. Every 4 hours 4. Every 30 minutes 4 Rationale: The nurse needs to assess restraints and skin integrity every 30 minutes. Therefore, options 1, 2, and 3 are incorrect. Agency guidelines regarding the use of restraints should always be followed. 4. A mother calls a neighborhood nurse and tells the nurse that her 3-year-old child has just ingested liquid furniture polish. Which action should the nurse instruct the mother to take first? 1. Induce vomiting. 2. Call an ambulance. 3. Call the poison control center. 4. Bring the child to the emergency department. 3 Rationale: If a poisoning occurs, the poison control center should be contacted immediately. Vomiting should not be induced without instructions to do so if the victim is unconscious or the substance ingested is a strong corrosive or petroleum product. Bringing the child to the emergency department or calling an ambulance would not be the initial action because this would delay treatment. The poison control center may advise the mother to bring the child to the emergency department; if this is the case, the mother should call an ambulance. 5. The nurse obtains a prescription from the health care provider (HCP) to restrain a client using a jacket (safety) restraint and instructs the unlicensed assistive personnel (UAP) to apply the restraint. Which observation, if made by the nurse, should indicate unsafe application of the restraint? 1. A safety knot is made in the restraint strap. 2. The restraint straps are safely secured to the side rails. 3. The jacket restraint strap does not tighten when force is applied against it. 4. The jacket restraint is secure, and two fingers can easily slide between the restraint and the client’s skin. 2 Rationale: A half-bow or safety knot should be used when applying a restraint, because it does not tighten when force is applied against it and allows for the quick and easy removal of the restraint in case of an emergency. The restraint strap is secured to the bed frame (never to the side rail) to avoid accidental injury in case the side rail is released. The jacket restraint should be secure, and one to two fingers should easily slide between the restraint and the client’s skin. 6. The nurse should institute which type of precaution for a client diagnosed with Clostridium difficile? 1. Droplet 2. Contact 3. Airborne 4. Neutropenic 2 Rationale: Contact precautions are necessary for colonization or infection with a multidrug-resistant organism. This includes enteric infection with Clostridium difficile. Droplet or airborne precautions are not necessary because the organism is not transferred via the respiratory route. Neutropenic precautions are used when the client needs protection from contracting an infection from others. 7. A client is diagnosed with cancer and is told that surgery followed by chemotherapy will be necessary. The client states to the nurse, “I have read a lot about complementary therapies. Do you think I should try any?” The nurse should respond by making which appropriate statement? 1. “I would try anything that I could if I had cancer.” 2. “You need to ask your health care provider about it.” 3. “No, because it will interact with the chemotherapy.” 4. “Let’s talk more about the different forms of complementary therapies.” 4 Rationale: Complementary (alternative) therapies include a wide variety of treatment modalities that are used in addition to conventional treatment to treat a disease or illness. These therapies complement conventional treatment, but they should be approved by the person’s health care provider (HCP) to ensure that the treatment does not interact with prescribed therapy. Although the HCP should approve the use of a complementary therapy, it is important for the nurse to explore the complementary therapies first with the client, which would eliminate option 2. The statement in option 3 is inappropriate. Similarly, option 1 is an inappropriate response to the client. Option 4 addresses the client’s question and encourages discussion. 8. The nurse is assisting with collecting data from an African-American client admitted to the ambulatory care unit who is scheduled for a hernia repair. Which information about the client is of least priority during the data collection? 1. Respiratory 2. Psychosocial 3. Neurological 4. Cardiovascular 2 Rationale: The psychosocial data is the least priority during the initial admission data collection. In the African-American culture, it is considered intrusive to ask personal questions during the initial contact or meeting. Additionally, respiratory, neurological, and cardiovascular data include physiological assessments that would be the priority.