LPN NCLEX MULTIPLE CHOICE

The nurse is preparing a client for a scheduled colonoscopy. Which

prescription should the nurse anticipate from the primary healthcare

provider (PHCP) while the client is preparing for this procedure?

A. docusate

B. loperamide

C. polyethylene glycol 3350

D. famotidine

polyethylene glycol 3350

Polyethylene glycol 3350 is an osmotic laxative commonly used before a colonoscopy. This powder is typically dissolved in a sports drink and can be consumed by the client. Efficacy is usually within one hour. Fluid and electrolyte disturbance is unlikely as the powdered solution contains electrolytes.When administering this medication, it should be dissolved in water or Gatorade and may chill in the refrigerator to increase palatability.

3 multiple choice options

A patient with a crush injury to her left arm calls the nurse's station and

requests pain medication. An hour after administration, the patient is still

complaining of intense pain. What is the next nursing action?

A. Ask the patient to describe the pain in quality and intensity.

B. Offer the patient a distraction, such as a book or television.

C. Tell the patient she can have more medication in three hours.

D. Tell the patient crush injury victims should expect intense pain.

Ask the patient to describe the pain in quality and intensity.

A crush wound is a wound caused by a force that leads to compression or disruption

of tissues. It is often associated with fractures. Usually, there is minimal to no break

in the skin. While other external symptoms, such as bruising or edema, may be

visible, nurses should also rely on subjective symptoms reported by the patient.

Choice A is correct. Unrelieved pain is an indication of a complication. Patients who

experience a crush injury are at risk for developing compartment syndrome.

Therefore, asking the patient to be specific about the quality and intensity of pain is

vital in re-evaluating the patient's status.

3 multiple choice options

Which of the following situations is an example of negligence?

A. The UAP (Unlicensed Assistive Personnel) fills a water basin with

warm water while the patient with depression combs her hair.

B. A nurse transcribes a new medication order: Questran powder 2

oz bid with wet food or one full glass of water.

C. The nurse checks the distal pulses of a patient's legs two hours

after they have returned from a cardiac catheterization.

D. The nurse observes a UAP enter the room of a patient on contact [4%]

precautions wearing gloves and a gown.

C. The nurse checks the distal pulses of a patient's legs two hours after they have returned from a cardiac catheterization.

The nurse should have checked the patient's distal pulse

immediately after the cardiac catheterization.

3 multiple choice options

The nurse is caring for the following assigned clients. Which client should the

nurse follow up with first?

A. The patient going for an echocardiogram and is allergic to

contrast dye.

B. The patient refusing to eat their meal following an injection of

glargine insulin.

C. The patient scheduled for discharge in three hours and needs

transportation.

D. The patient requesting diphenhydramine after starting an

intravenous antibiotic.

D. The patient requesting diphenhydramine after starting an

intravenous antibiotic.

A client requesting diphenhydramine following the initiation of

an antibiotic requires immediate follow-up because the client could be experiencing an allergic reaction ranging from mild to severe. Thus, the nurse should quickly assess the client.

3 multiple choice options

Which of the following statements should the nurse use to best describe a

very low-calorie diet?

A. "This is a long-term treatment measure that assists obese people [30%]

who can't lose weight."

B. "A VLCD contains very little protein."

C. "This diet can be used only when there is close medical

supervision."

D. "This diet consists of solid food that is pureed to facilitate

digestion and absorption."

C. "This diet can be used only when there is close medical

supervision."

Very Low-Calorie Diets (VLCD) are used in the clinical treatment of obesity under close medical supervision. The diet is low in calories, high in quality proteins, and has a minimum of carbohydrates to spare protein and prevent ketosis. Very low-calorie diets, generally providing fewer than 800 kcal per day, became widely available for outpatient use in treating adult obesity in the 1980s. These diets, sometimes called protein-sparing modified fasts, were associated with significant

medical risks (electrolyte abnormalities, arrhythmias, and sudden death). They became widely marketed as part of many commercial weight loss programs. Despite their overall success in supporting rapid weight loss, most patients experienced

subsequent weight regain once the very low-calorie diet was discontinued. These extremely hypocaloric diets have been used on a limited basis in the pediatric population, generally in an inpatient setting, with close medical supervision. Given the deficient daily caloric intake associated with the VLCD, this diet requires almost a full liquid approach. Patients are often on 3-5 shakes daily, with multivitamin and mineral supplementation. Side effects include fatigue, hair loss, dizziness, constipation, and risk for cholelithiasis secondary to rapid weight loss. The

VLCD usually results in >20% weight loss within the first 3-4 months. Although rapid weight loss is seen, it is not regularly well maintained, with many patients gaining up to 50% of that weight back within the subsequent 12 months; and gaining all of it back in less than five years. LCDs are not as extreme, and with almost twice as many calories allowed (1200-1500 kcal/day), the weight loss is modest.

3 multiple choice options

How should the nurse assess for the presence of thrombophlebitis in a

patient who reports having pain in the left lower leg?

A. By palpating the skin over the tibia and fibula.

B. By documenting daily calf circumference measurements.

C. By recording vital signs obtained four times a day.

D. By noting difficulty with ambulation.

B. By documenting daily calf circumference measurements.

Inflammation from thrombophlebitis increases the size of the

affected extremity and can be assessed regularly by measuring calf circumference. Thrombophlebitis is an inflammation of a vein associated with thrombus formation. Thrombophlebitis from venous stasis is most commonly seen in the legs of

postoperative patients. Manifestations of thrombophlebitis are pain and cramping in the calf or thigh of the involved extremity, redness and swelling in the affected area, elevated temperature, and an increase in the involved extremity's diameter. Each shift, nurses should assess the legs for swelling and tenderness, measure bilateral calf or thigh circumference, and determine if they experience any chest pain or dyspnea. The patient should be instructed not to massage the legs.

3 multiple choice options

The nurse is removing a nasogastric tube (NGT). The nurse should take which

action?

A. Deflate the balloon

B. Irrigate the tube with 200 mL of water

C. Instruct the client to take a deep breath and hold it.

D. Assess the gag reflex

C. Instruct the client to take a deep breath and hold it.

Prior to removing the NGT, it would be appropriate for the

nurse to tell the client to take a deep breath and hold it as the tube is removed. The

nurse should then pinch the tube and remove the tube quickly and steadily over 3-6

seconds while the client holds their breath or during exhalation.

3 multiple choice options

A patient is scheduled for an IV pyelogram. He asks the nurse what he needs

to do to prepare for the test. Which of the following is the correct response?

A. "You need to have a full bladder for the test to be successful."

B. "You need to alert the technician if you feel any burning after the

dye is injected."

C. "You will receive a bowel preparation before the test can be

performed."

D. "You must lie on your back for four hours after the test is

performed."

C. "You will receive a bowel preparation before the test can be

performed."

Bowel prep is necessary to make sure the x-rays are clear and

that urinary structures are not obstructed by bowel contents. An IV pyelogram is an x-ray that is used to view the urinary structures.

3 multiple choice options

The nurse is assisting in the placement of an indwelling foley catheter in a

male patient. She knows to inflate the balloon on the catheter at which of the

following points in the procedure?

A. Upon meeting resistance

B. As soon as urine is observed in the tubing

C. After advancing to the point of bifurcation

D. After fully advancing the length of the catheter

C. After advancing to the point of bifurcation

The nurse should inflate the balloon on the catheter once she

reaches the point of bifurcation. This is achieved by slowly advancing the catheter,

observing the tubing for urine to appear, and then continuing to advance to the

point of bifurcation after urine is observed. This will ensure the balloon is in the

bladder before the nurse inflates it.

3 multiple choice options

The licensed practical/vocational (LPN/VN) assists a registered nurse (RN) in

planning a staff educational conference about indwelling urinary catheters. Which of the following information should be included?

A. Sterile gloves should be used to perform urinary catheter care.

B. Urinary specimens may be collected from a catheter bag.

C. You may irrigate a catheter with warm water for poor outflow.

D. Daily use of soap and water should be used around the urinary

D. Daily use of soap and water should be used around the urinary

Daily cleaning of the urinary meatus with soap and water is

recommended for catheter care. Sterile gloves do not need to be used for this

process as it is a clean procedure. Soap and water is an acceptable practice for daily

catheter care as alcohol, CHG, and other antiseptics may be highly irritating to the

urinary meatus.

3 multiple choice options

Which of the following sexual complications is a patient with chronic renal

failure at risk of developing?

A. Retrograde ejaculation

B. Decreased testosterone

C. Hypertrophy of the testicles

D. Feelings of euphoria

B. Decreased testosterone

Chronic renal failure causes decreased testosterone levels.

Sexuality has physical and emotional components, both of which can be affected by chronic kidney disease. Kidney disease can cause chemical changes in the body, affecting circulation, nerve function, hormones, and energy levels. Any underlying health conditions that contribute to CKD, like hypertension or diabetes, can affect male sexuality. Fatigue is one of the most common symptoms of men with kidney

disease experience. Since kidney disease affects the endocrine system, changes in hormone levels may result in decreased sex drive. An estimated 20 to 30 million men in the U.S. have problems with impotence. ED can happen when blood vessels and nerves to the penis become damaged. Without proper blood flow, the penis cannot maintain an erection. Diabetes and high blood pressure affect blood flow and weaken blood vessels. Feeling sexual or attractive becomes more complicated when the body undergoes unexpected changes. This can affect how people interact with others and their ability to develop intimate relationships. Men may feel worried,

anxious, and depressed when faced with CKD. This is normal, but these emotions may cause a loss of energy and lower interest in activities, including sex.

3 multiple choice options

X

The nurse is caring for a teenager who is recovering from a tonsillectomy. She

walks in the room, and sees the patient eating chips and salsa from a Mexican

restaurant. Which of the following responses is most appropriate?

A. "I love that restaurant! Their chips are so good."

B. "You cannot eat anything yet, I am sorry"

C. "Chips are not a good choice right now because you need a high

protein diet after your surgery."

D. "Those chips are really hard on the back of your throat where

you had your surgery. I'm worried they could cause you to bleed if

they damage your incision site. Let's get something softer for you

to eat right now."

D. "Those chips are really hard on the back of your throat where you had your surgery. I'm worried they could cause you to bleed if they damage your incision site. Let's get something softer for you to eat right now."

This is the most appropriate response by the nurse. She

correctly explains to the patient that the sharp tortilla chips would be really hard on the patient's surgical site after a tonsillectomy. Allowing patients to eat foods like chips or popcorn after surgery in the back of the throat would put them at risk for damage to the incision and subsequent hemorrhage. Offering the patient something soft, such as jello or soup, is the most appropriate.

3 multiple choice options

The LPN is taking care of a 9-year-old boy who is undergoing testing for acute myeloid leukemia (AML). She is assisting with the positioning of this patient for a lumbar puncture. Which of the following positions should the nurse place her patient in?

A. Prone

B. Trendelenburg

C. Supine

D. Side-lying

D. Side-lying

Side-lying is the most appropriate position listed for a lumbar

puncture (LP). This will allow the health care provider to identify the lumbar vertebrae and insert the needle into the subarachnoid space at the L3-4 or L4-5 interspace.

3 multiple choice options

Among the patients in a long term care facility, which client is at the greatest

risk for developing a decubitus ulcer?

A. An incontinent client who had 3 diarrhea stools.

B. An 80-year-old ambulatory diabetic client.

C. A 79-year-old malnourished client on bed rest.

D. An obese client who uses a wheelchair.

C. A 79-year-old malnourished client on bed rest.

Prolonged inadequate nutrition causes weight loss, muscle

atrophy, and the loss of subcutaneous tissue. These three conditions reduce the amount of padding between the skin and bones, thus increasing the risk of pressure ulcer development. More specifically, inadequate protein intake, carbohydrates, fluids, zinc, and vitamin C contribute to pressure ulcer formation. Several factors

contribute to the formation of pressure ulcers: friction and shearing, immobility, inadequate nutrition, fecal and urinary incontinence, decreased mental status, diminished sensation, excessive body heat, advanced age, and the presence of

certain chronic conditions.

3 multiple choice options

The nurse is caring for a client who is postoperative ordered incentive

spirometry. The nurse understands that this device will help prevent which

complication?

A. Venous thromboembolism

B. Obstructive sleep apnea

C. Hypostatic pneumonia

D. Aspiration pneumonia

C. Hypostatic pneumonia

Hypostatic pneumonia after surgery is best prevented through

incentive spirometry and early mobilization. The purpose of incentive spirometry (IS) is to promote deep breathing to prevent or treat atelectasis in the postoperative client. Hypostatic pneumonia is caused by pulmonary congestion in the dorsal region of the lungs. This type of pneumonia is common for those who are bedridden or have restricted mobility. Hypostatic pneumonia can be prevented through early postoperative ambulation and incentive spirometry.

3 multiple choice options

The primary healthcare provider (PHCP) prescribes a bolus of regular insulin

prior to a continuous infusion. The prescription is for 0.1 units/kg. The client

weighs 256 lbs. How many units of insulin should the nurse administer to the

client? . Round your answer to the nearest whole number.

12 units

The first step is to convert the client's weight from pounds (lbs) to kilograms(kg) 256 lbs 116.36 kg . Next, multiply the prescribed dosage by the client's weight 0.1 units x 116.36 kg = 11.63 units. Finally, take the answer and round it to the nearest whole number 11.63 units = 12 units

Additional Info

Regular insulin intravenously is prescribed to correct the acidosis hyperkalemia. During the infusion of regular insulin, the client should be monitored for hypoglycemia and hypokalemia. Regular insulin is the only insulin that may be administered intravenously.

The nurse has reinforced medication instruction to a client who has been

prescribed enalapril. Which of the following statements, if made by the client,

would indicate a correct understanding of the teaching?

A. "I will notify my prescriber if I develop swelling of the face."

B. "I will need to weigh myself every day while taking this

medication."

C. "I should eat foods high in potassium while I am taking this

medication."

D. "I will need lab work done every so often to evaluate my liver

function."

A. "I will notify my prescriber if I develop swelling of the face

Angioedema is a life-threatening adverse effect that is seen with ACE inhibitors such as enalapril. Angioedema may cause swelling anywhere in the body but swelling in the face, lips, and eyes can be life-threatening.

3 multiple choice options

The primary healthcare provider (PHCP) prescribes one liter of 0.9% saline to

infuse over 6 hours. How many mL per hour will be administered to the

client?

167

Explanation

To solve this problem, the formula of volume / time (hours) will be used.

First, convert the prescribed liters to milliliters to determine the total volume

ordered

1 liter x 1000 mL = 1000 mL

Next, divide the prescribed total volume by the infusion time

1000 mL/6 hours = 166.66

Finally, take the mL/hour and round to the nearest whole number

166.66 167 mL/hr

Additional Info

0.9% saline is an isotonic solution utilized in the treatment of standard

dehydration.

The primary healthcare provider (PHCP) prescribes 150 mL of sterile water to

be administered over one hour. The drop factor is 15 gtts/mL. The nurse sets

the flow rate at how many drops per minute? Round your answer to the

nearest whole number. Fill in the blank.

38

Explanation

To solve this problem, the nurse will use the formula of total volume x drop factor / time in minutes

First, take the prescribed volume and multiply it by the drop factor 150 mL x 15 gtt = 2250 mL

Next, divide the total volume by the minutes

2250 ml / 60 minutes = 37.5 gtts

Finally, perform appropriate rounding (if needed)

37.5 gtts = 38 gtts/minute

i Additional Info

Although rare, sterile water may be administered short-term as it is a hypotonic solution. This is likely to be administered when the client has significant diabetes insipidus.

The nurse is caring for a client diagnosed with Lyme disease. The nurse

anticipates the primary healthcare provider (PHCP) prescribe which

medication?

A. Doxycycline

B. Enalapril

C. Simvastatin

D. Famotidine

A. Doxycycline

Doxycycline is an effective treatment for Lyme disease. Lyme

disease is an infectious disease caused by the Borrelia bacterium, spread by ticks. The most common sign of infection is an expanding area of redness on the skin, known as erythema migrans, that appears at the tick bite site about a week after it occurred. The rash is typically neither itchy nor painful. The rash is classically referred to as a bullseye rash.

3 multiple choice options

A diabetic patient receives ten units of Regular insulin and 20 units of NPH

insulin each day after breakfast. After following the usual preparation steps

for administering insulin, what should the nurse do next?

A. Draw up NPH insulin first because it is clear.

B. Either insulin can be drawn first as long as 30 units are given.

C. Draw up Regular insulin first because it is clear.

D. Administer each type of insulin separately for accuracy.

C. Draw up Regular insulin first because it is clear.

Regular (short-acting) insulin is clear. NPH (intermediate-acting) is cloudy. Giving one injection is more efficient and comfortable for the patient.

REMEMBER: ALWAYS CLEAR BEFORE CLOUDY or remember the mnemonic: RN =

Regular to NPH.

The correct procedure for administering short and long-acting insulins together is:

1. Verify orders for insulin types and doses.

2. Wash hands and put on gloves.

3. Roll NPH (cloudy vial) insulin between palms to mix contents of the bottle. Do NOT shake!

4. Clean the tops of vials with alcohol prep for 5-10 seconds.

5. Inject 20 units of air into the NPH vial and remove the syringe (air equal to the

volume that will be withdrawn from the bottle).

6. Inject ten units of air into the Regular (clear vial) vial and withdraw ten units (air

equal to the volume that will be withdrawn from the bottle). Remove the syringe.

7. Insert the syringe into NPH (cloudy vial) vial and withdraw 20 units.

8. Administer immediately. Within 5-10 minutes, combined insulins may be

affected.

3 multiple choice options

A client comes to the outpatient clinic complaining of abdominal pain,

diarrhea, shortness of breath, and epistaxis. What should the nurse's first

action be?

A. Ask the client about any recent travel to Asia or the Middle East.

B. Screening clients for upper respiratory tract symptoms.

C. Determine whether the client has received all the recommended

immunizations.

D. Call an ambulance to take the client to the hospital immediately.

A. Ask the client about any recent travel to Asia or the Middle East.

The client's clinical symptoms suggest possible avian influenza (bird flu). If the client has traveled recently to Asia or the Middle East, where outbreaks of bird flu have occurred, you will need to institute airborne and contact precautions immediately. Nursing priority is always patient safety. This includes not only the patient that the nurse is assessing but also those who are present within the facility and the staff. Determining where a patient has been and their recent activities will help pinpoint the possible illness/infection source.

3 multiple choice options

When evaluating developmental milestones for a 6-month-old child, which of

the following should the nurse screen during a routine office visit?

A. Standing while holding onto something/someone

B. Creeping

C. Rolling over

D. Sitting up

C. Rolling over

Rolling over begins between 4 and 6 months of age. The early

years of a child's life are crucial for his or her health and development. Healthy development means that children of all abilities, including those with special health care needs, can grow up where their social, emotional, and educational needs are met. It is important to encourage regular well-child visits so that healthcare. professionals can help monitor for expected developmental milestones. If a sign is missed or delayed, this could be an indication of an underlying problem. When the screening tool is used, a formal developmental evaluation may be necessary if an area of concern is found. During the developmental assessment, specialists look more closely at the child's development and perform a more in-depth evaluation to pinpoint the problem's cause.

1 Month

Makes slight jerk movements Brings his or her hands within the range of eyes and mouth Turns his or hers head when called by a familiar sound and voice Focuses on near by objects (8-12 inches away) Responds to loud sounds

3 Months

Notices their hands by two months Smiles at the sound of a familiar voice by two months Follows moving objects with her eyes by 2-3 months Supports head when on stomach by 3 months Babbles by 3-4 months Attempts to imitate any of

your sounds by 4 months Attentive to new faces, and is frightened by them Imitates some movements and facial expressions

7 Months

Rolls on to back and front Sits without support of the

hands Supports weight on legs Responds to own name

Babbles by 3-4 months. Shows responses to "no" Responds to sound by making sounds

3 multiple choice options

The nurse is preparing to measure the fundal height of a client at 16

gestational weeks. The nurse should prepare the client for this assessment by instructing the client to

A. lay in a side-lying position with the knees bent.

B. prepare for the insertion of an intravenous (IV) catheter.

C. not to eat or drink two hours after this assessment.

D. empty their bladder.

D. empty their bladder.

Measuring the fundal height is a painless and noninvasive way

to evaluate fetal growth patterns and confirm gestational age. For this assessment, the client should empty their bladder to prevent elevation of the uterus.

3 multiple choice options

Hospitalization may affect or delay the progression of which physical

development in a 1-year-old patient?

A. Walking

B. Running

C. Sitting

D. Crawling

A. Walking

At the age of 1 year, children should be starting to walk.

Hospitalization during this age could delay this stage of development.

3 multiple choice options

When discussing the Denver II with a preschooler's parents, which of these

statements would indicate that they correctly understood the teaching?

A. This test will tell me whether or not my child's IQ is normal.

B. This test will tell me what developmental tasks my child can do

today.

C. This test will measure my child's development.

D. This will let me know if my child's development is normal or not.

C. This test will measure my child's development.

The Denver Developmental Screening Test (DDST) was devised

to provide a simple method of screening for evidence of slow development in infants and preschool children. The test covers four functions: gross motor, language, fine motor-adaptive, and personal-social. It has been standardized on 1,036 presumably healthy children (two weeks to six years of age) whose families reflect the occupational and ethnic characteristics of Denver's population.

3 multiple choice options

A patient in the post-anesthesia care unit is semiconscious and dyspneic.

What should the nurse's first action be?

A. Place a pillow under the client's head.

B. Remove the oropharyngeal airway.

C. Administer oxygen by mask.

D. Reposition the client to keep the tongue forward.

D. Reposition the client to keep the tongue forward.

The tongue can obstruct the airway of a semiconscious client.

Repositioning in the side-lying position with the face slightly down will prevent occlusion of the pharynx and allow the drainage of mucus from the mouth.

3 multiple choice options

The nurse is caring for a client newly diagnosed with mastitis. The nurse

anticipates a prescription for which medication?

A. Cephalexin

B. Acyclovir

C. Fluconazole

D. Imiquimod

A. Cephalexin

Mastitis is commonly caused by Staphylococcus aureus,

methicillin-resistant Staphylococcus aureus (MRSA), E. coli, and streptococci. Thus, antibiotics such as cephalexin are effective in the treatment of mastitis.

3 multiple choice options

The patient with tuberculosis is now on isoniazid. Which laboratory test

should be monitored at least monthly?

A. PT and PTT

B. CBC

C. BUN

D. Liver enzymes

D. Liver enzymes

Although it is rare, liver toxicity is a severe adverse effect of

Isoniazid. Healthcare providers should monitor for signs of jaundice, fatigue, elevated liver enzymes, and loss of appetite. Liver enzyme tests are usually performed monthly during therapy to identify early hepatotoxicity. Isoniazid is bacteriocidal for actively growing organisms and bacteriostatic for dormant mycobacteria. It is selective for M. tuberculosis. Isoniazid is used alone for chemoprophylaxis in combination with other antitubercular drugs when treating active disease.

3 multiple choice options

The nurse is collecting data on a male client taking prescribed risperidone.

Which of the following findings would indicate the client is having an adverse

effect?

A. ptosis

B. gingival hyperplasia

C. polycythemia

D. gynecomastia

D. gynecomastia

Risperidone is an atypical (second-generation) antipsychotic

indicated in treating disorders such as schizophrenia, autism with behavioral disturbances, delusional disorder, and bipolar disorder. Risperidone is notorious for causing increased prolactin levels. This increase in prolactin levels may cause a client to develop gynecomastia and/or galactorrhea.

3 multiple choice options

The nurse is caring for a patient newly diagnosed with Rheumatoid Arthritis.

The nurse should anticipate a prescription for which of the following

medications?

A. Calcitonin

B. Glucosamine

C. Allopurinol

D. Methotrexate

D. Methotrexate

Disease-Modifying Anti Rheumatic Drugs (DMARDs) are

indicated in the treatment of Rheumatoid Arthritis. These medications primarily work by suppressing the immune system from attacking the joint spaces. Drugs within this class include methotrexate and hydroxychloroquine.

3 multiple choice options

The nurse is reviewing a new prescription for amphotericin b. The nurse

understands that this medication treats

A. autoimmune infections.

B. fungal infections.

C. viral infections.

D. bacterial infections.

B. fungal infections

Amphotericin B is a powerful antifungal indicated in treating

systemic fungal infections. This medication requires pre-medication with isotonic saline, diphenhydramine, and acetaminophen to help decrease the symptoms of fever, chills, and rigors associated with the infusion.

3 multiple choice options

The nurse is caring for a client who is receiving prescribed risperidone. Which

of the following findings would indicate a therapeutic response? The client

demonstrates

A. a reduction in weight.

B. increased mood lability.

C. an appropriate gait pattern.

D. decreased thoughts of persecution.

D. decreased thoughts of persecution.

Risperidone is an atypical (second generation) antipsychotic

indicated in psychotic disorders such as schizophrenia. If the client reported decreasing thoughts of persecution (and was observed to have fewer thoughts of persecution), this would be a therapeutic effect.

3 multiple choice options

The nurse is reinforcing teaching regarding prescribed risperidone. Which

statement, if made by the client, requires follow-up?

A. "I should report any abnormal movements that I develop."

B. "I will need to have weekly tests to monitor my white blood cells."

C. "If I get muscle stiffness, I should notify my physician."

D. "I will need to chew sugarless gum if I develop a dry mouth."

B. "I will need to have weekly tests to monitor my white blood cells."

Risperidone is a second-generation antipsychotic used in

delirium, schizophrenia, and some childhood disorders. Weekly white blood cell tests are not required with risperidone as this is appropriate teaching for an individual receiving clozapine. Clozapine may cause neutropenia.

3 multiple choice options

The nurse is collecting data on a client receiving prescribed lamotrigine.

Which client finding requires immediate follow-up?

A. Abnormal dreams

B. Skin blistering

C. Dyspepsia

D. Xerostomia

B. Skin blistering

Skin blistering associated with lamotrigine therapy is a critical

finding to report. This is a feature of Steven-Johnson syndrome (SJS). Lamotrigine has been implicated as causing this adverse finding.

3 multiple choice options

While caring for a young boy who was brought in for a fractured leg, the

healthcare team discovers many other fractures in various stages of healing.

They suspect?

A. Neglect

B. Psychological abuse

C. Physical abuse

D. That he is a clumsy child

C. Physical abuse

Physical abuse is any intentional act causing injury or trauma to

another person. In children, multiple fractures in various stages of healing are very suspicious for abuse. This points to repeated injuries over a period of time and needs to be thoroughly investigated.

3 multiple choice options

What complication should the nurse monitor for during the immediate

postoperative time following a thoracentesis?

A. Pneumothorax

B. Infection

C. Dyspnea

D. Aspiration

A. Pneumothorax

The most immediate postoperative risk factor is pneumothorax.

Symptoms of pneumothorax include dyspnea, chest pain, shortness of breath, and pain. Thoracentesis is a procedure in which a needle is inserted into the pleural space between the lungs and the chest wall. This procedure is done to remove pleural effusion (excess fluid) from the pleural space to ease breathing. Some conditions, such as lung disease/infections, heart failure, and tumors, may cause pleural effusion. All procedures have some risks. The risks of this procedure may include the following: air in the space between the lung covering (pleural space) that causes the lung to collapse (pneumothorax), bleeding, infection, and liver or spleen injury (rare).

3 multiple choice options

The physician has ordered a 24-hour urine specimen. After explaining the

procedure to the client, the nurse collects the first specimen. This specimen is

then :

A. Placed in a separate container and later added to the collection.

B. Discarded, then the collection process begins.

C. Tested, then discarded.

D. Saved as part of the 24-hour collection.

B. Discarded, then the collection process begins.

A 24-hour urine collection may be prescribed to evaluate some renal disorders by showing kidney function at different times of the day and night. The nurse is responsible for providing the collection container and educating the patient on how to collect the specimen.

• The correct answer is B. The patient should collect the first specimen, which is considered "old urine" or urine in the bladder before the test began. After the first discarded specimen, urine is collected for 24 hours.

3 multiple choice options

The risk manager reviews an incident report completed by a nurse regarding a client's fall. Which finding in the report demonstrates inappropriate

documentation?

A. The client's explanation of the event.

B. Subjective factors preceding the fall.

C. Any injuries sustained as a result of the fall.

D. The names of all witnesses present.

B. Subjective factors preceding the fall.

The purpose of an incident report is to provide an objective

account of an incident/occurrence, in order to identify issues with current practices, improve policies, and potentially investigate situations of negligence/malpractice. Subjectivity should be excluded from a report because subjectivity allows for opinions on details that may not be true (example, stating I believe the client fell because he did not follow instruction) would be inappropriate.

3 multiple choice options

An 8-year-old boy diagnosed with hemophilia A is brought into the urgent care clinic for a prolonged episode of hematemesis. Which of the following

describes this symptom?

A. Bleeding into the joints

B. Bleeding from the nose

C. Dark, black, tar-like stools

D. Bloody vomit

D. Bloody vomit

Hematemesis is bloody vomit. This symptom is common with

hemophilia and can lead to severe complications if not treated promptly.

3 multiple choice options

The LPN is caring for a family who just found out that their newborn has

tetralogy of Fallot. They state, "we can't believe our baby is going to die!"

Which of the following statements by the LPN is most appropriate?

A. "Yes, that is so sad. What can I do to help you?"

B. "Your baby will be fine! This is not so serious."

C. "Tetralogy of Fallot can be surgically repaired. Let's talk more

about what you can expect."

D. "Well, at least you get to spend time with your baby now. Some

people don't even get that."

C. "Tetralogy of Fallot can be surgically repaired. Let's talk more about what you can expect."

This statement does not support that the baby will die, but

provides factual information about the treatment plan for the defect and leads into a more detailed conversation about what the parents can expect. It is clear that they do not fully understand tetralogy of Fallot (TOF) and the treatment options, so education is very important for these parents.

3 multiple choice options

While working in the emergency department the nurse assesses a 3 day old

infant brought in by his mother. She states "he is always so sweaty and hot,

and just doesn't want to eat! I think something is wrong." The nurse is unable

to palpate a femoral pulse, but notes +3 brachial pulses. Which congenital

heart defect does the nurse suspect?

A. Hypoplastic left heart syndrome

B. Patent ductus arteriosus

C. Transposition of the great arteries

D. Coarctation of the aorta

D. Coarctation of the aorta

The nurse suspects that this infant has coarctation of the aorta.

In this defect, there is a stricture in the aorta preventing blood flow out of the left ventricle. It usually occurs beyond the blood vessels that branch off to your upper body and before the blood vessels that lead to your lower body. So blood flow to the upper body is abundant, but hardly any can make it to the lower part of the body. Therefore, there are decreased lower extremity pulses and increased upper extremity pulses.

3 multiple choice options

The nurse is caring for a client who is receiving prescribed trazodone. Which

of the following findings would indicate the client is having an adverse effect?

A. Dizziness

B. Sedation

C. Priapism

D. Dry mouth

C. Priapism

Trazodone is a serotonergic medication indicated in the treatment of insomnia. Adversely, this medication may cause priapism which is a prolonged, painful erection of the penis. Prompt treatment is necessary because this may result in ischemia.

3 multiple choice options

The nurse has received the following prescriptions for newly admitted clients.

It would be a priority for the nurse to administer which prescription?

A. Aspirin to a client experiencing an acute myocardial infarction

B. Lisinopril to a client with essential hypertension

C. Risperidone to a client with schizophrenia

D. Levodopa-carbidopa to a client with Parkinson's disease

A. Aspirin to a client experiencing an acute myocardial infarction

A client experiencing a myocardial infarction is an acute

emergency that requires immediate intervention. The standard treatment includes (in no order) morphine, oxygen, nitroglycerin, and aspirin.

3 multiple choice options

A patient who is 2-days postoperative from right femoral popliteal bypass

surgery complains of worsening right leg pain. Upon assessment, the nurse notes swelling and ecchymosis at the incision sites. Which action would be the

nurse's initial priority?

A. Apply pressure to sites with a sandbag

B. Palpate pedal pulses

C. Assess for signs of claudication

D. Apply a warm compress to the incision sites

B. Palpate pedal pulses

The most significant complications that this patient is at risk for

after the revascularization procedure are thrombus, hemorrhage, infection, and arrhythmias. Mild to moderate swelling, bruising, and pain at the surgical site are expected and typically resolve over time as the leaked blood is reabsorbed. The most important action would be to assess the patient's pedal pulses (distal to incisions). If pulses are intact, the nurse would then address the patient's complaint of worsening pain.

3 multiple choice options

The nurse arrives to assist victims following an earthquake. Which victim

would the nurse recognize as the highest priority for immediate treatment?

A. 74-year-old with several heavily bleeding wounds who is

lethargic and pale.

B. 37-year-old who appears anxious and is using neck muscles to

breathe.

C. 16-year-old who is confused, holding her head, and complaining

of nausea.

D. 65-year-old who rates his pain at 10/10 and is guarding his right

leg.

B. 37-year-old who appears anxious and is using neck muscles to breathe.

In the setting of a mass casualty or disaster, triage systems are

essential to prioritize patients. Triage deals with the appropriate allocation of limited resources during a disaster. In a disaster, the highest priority is given to the person with life-threatening injuries who has a high chance of survival if stabilized. The client in option B presents with symptoms highly suspicious of traumatic pneumothorax, using accessory muscles for breathing, and anxiety (due to difficulty

getting enough air). The use of accessory muscles indicates severe respiratory distress. This patient would be the nurse's highest priority and requires rapid chest decompression to allow lung expansion. A needle thoracostomy and subsequent

tube thoracostomy could be life-saving in this situation.

3 multiple choice options

The nurse has received an order to prepare a client for a water deprivation

test. The nurse understands that this test is used to diagnose

A. hyperthyroidism

B. pheochromocytoma

C. diabetes insipidus (DI)

D. syndrome of inappropriate antidiuretic hormone (SIADH)

C. diabetes insipidus (DI)

DI can be divided into either neurogenic (central) or nephrogenic. The water deprivation test is used to help differentiate whether the DI is neurogenic or nephrogenic. In this test, the client is deprived of water for up to eight hours (they may still eat dry foods). Serial labs, including plasma and urine osmolality measurements, are obtained during that time. Additionally, the client's urine volume and weight are meticulously measured hourly. If the client's body weight should decrease, this supports the diagnosis of DI. At the end of the eight hours, a dose of desmopressin is administered. If there is an increase in urine osmolarity and a decrease in urine volume, it is considered central/neurogenic DI (because the problem responded to the DDAVP). If no response is observed after the DDAVP is administered, nephrogenic DI is likely.

3 multiple choice options

The nurse is collecting data on a client with Paget's disease. Which of the

following would be an expected finding?

A. Bone deformities

B. Berry aneurysm

C Heberden's nodes

D. Janeway lesions

A. Bone deformities

Paget's disease is a disease caused by a bone becoming

weakened and remodeled, which may result in deformities. The most common area this inappropriate bone remodeling affects is the skull, pelvis, and spine.

3 multiple choice options

The primary healthcare provider (PHCP) prescribes 250 mL of 0.9% saline to

infuse over 75 minutes. How many mL per hour will be administered to the

client? Fill in the blank.

200 ml

First, convert the minutes to hours

75 minutes / 60 minutes = 1.25 hrs

Next, divide the prescribed total volume by the infusion time

250 mL/1.25 hours = 200 mL/hr

Additional Info

0.9% saline is an isotonic solution utilized in the treatment of standard dehydration.

The primary healthcare provider (PHCP) prescribes dopamine at 2.5

mcg/kg/minute. The client weighs 198 lbs. The medication label reads

dopamine 800 mg in 500 mL of dextrose 5% water (D5W). How many mL per

hour will be administered to the client? Fill in the blank.

8 mL/hr

First, convert the weight to kilograms

198/2.2 90 kg

Next, determine the hourly dosage

2.5 mcg x 90 kg x 60 minutes = 13500 mcg

Next, convert the micrograms to milligrams

13500 mcg/1000 mg = 13.5 mg

Next, divide the dose ordered by the amount on hand x the volume

13.5 mg / 800 mg x 500 mL = 8.43 mL/hr

Finally, round the answer to the nearest whole number

8.43 mL/hr 8 mL/hr

i Additional Info

Dopamine is a vasopressor used in the treatment of significant hypotension. It

is essential that the client have a patent IV to prevent serious extravasation.

Which of the following is a priority for assessing a patient who is taking

digoxin and lasix?

A. Night sweats and headache.

B. Vomiting and halos around lights.

C. Stomach upset and headache.

D. Low blood pressure and dark urine.

B. Vomiting and halos around lights.

Lasix causes the patient to lose potassium. If taken with a low

potassium level, Digoxin can become toxic and show signs/symptoms of nausea,

vomiting, and halos around lights.

Furosemide and digoxin are often used together but may require more frequent

evaluation of digoxin, potassium, and magnesium levels. Patients are encouraged to

notify their healthcare provider if they experience any symptoms such as weakness,

tiredness, muscle pains or cramps, nausea, decreased appetite, visual problems, or

irregular heartbeats.

3 multiple choice options

The primary healthcare provider (PHCP) prescribes 125 mcg of digoxin by

mouth, daily. The medication label reads digoxin 0.25 mg per tablet. The nurse

prepares to administer how many tablet(s)? Fill in the blank.

0.5

First, the nurse must convert the prescription to the same units as the medication label (micrograms → milligrams)

125 micrograms → 0.125 mg (divide 125 micrograms by 1000)

Next, take the dose ordered and divide it by the dose on hand and multiply by its volume 0.125 mg / 0.25 mg x 1 tablet = 0.5 tablet

i Additional Info

Digoxin is a cardiac glycoside indicated for the treatment of atrial fibrillation and congestive heart failure (CHF). This medication has lost popularity in recent decades because newer agents do not require therapeutic monitoring.

For a client taking digoxin, the apical pulse needs to be obtained prior to administration. The apical pulse needs to be at least 60/minute for adults;

70/minute for children; 90 for infants.

The primary healthcare provider (PHCP) prescribes a regular insulin infusion.

The prescription is for 4.5 units/hr. The label on the medication reads 250 mL

of 0.9% saline containing 100 units of regular insulin. How many mL/hr should

the client receive? Fill in the blank. Round your answer to the nearest tenth.

11.3

Divide the prescribed amount of medication by what is on hand

4.5 units / 100 units = 0.045 units

Next, take the amount of the medication and multiply it by the volume

0.045 units x 250 mL = 11.25 mL

Finally, take the answer and round it to the nearest tenth.

11.25 mL 11.3 mL

i Additional Info

Regular insulin intravenously is prescribed to correct the acidosis and

hyperkalemia. During the infusion of regular insulin, the client should be

monitored for hypoglycemia and hypokalemia.

Regular insulin is the only insulin that may be administered intravenously.

The nurse caring for a three-year-old with congestive heart failure recognizes

which of the following as an early sign of digitalis toxicity?

A. Bradypnea

B. Tachycardia

C. Vomiting

D. Failure to thrive

C. Vomiting

The earliest sign of digitalis toxicity is vomiting. One episode,

however, does not warrant discontinuing the medication. Digoxin increases the force of myocardial contraction, decreases conduction through the SA and AV nodes, and

prolongs the refractory period of the AV node. The result is increased cardiac output and reduced heart rate. Therapeutic serum digoxin levels range from 0.5-2 ng/mL. Serum levels may be drawn 6-8 hours after a dose is administered, although they are usually drawn immediately before the next dose. In infants, the first symptoms of overdose are typically cardiac arrhythmias. Gastrointestinal symptoms (like vomiting)

are some of the earliest signs.

3 multiple choice options

The patient is using topical glucocorticoids. The nurse should assess for all the

following systemic effects of the medication except:

A. Mood changes

B. Osteoporosis

C. Liver toxicity

D. Adrenal insufficiency

C. Liver toxicity

Liver toxicity is not a systemic effect associated with the use of

glucocorticoids. Topical glucocorticoids or corticosteroids are used in cases of dermatitis and eczema to treat symptoms of burning, itching, and inflammation. They may also be used in conjunction with other medical therapies for the treatment

of psoriasis.

3 multiple choice options

The nurse cares for a client receiving 1300 units/hr of heparin. The bag is

labeled 25,000 units in 500 mL of dextrose 5% in water. How many mL should

the nurse record that the client received in eight hours? Fill in the blank.

208ml

First, determine how many mL/hr the client is receiving (dose ordered / dose on

hand x volume)

1300 units / 25000 units x 500 mL = 26 mL

Next, take the mL/hr the client is receiving and multiply it by 8

26 mL x 8 hours = 208 mL

℗ Additional Info

✓ Intravenous heparin is typically administered as a bolus dose first, then as a

continuous infusion to achieve therapeutic aPTT

✓ A baseline aPTT should be collected 6 hours after the first dose and 6 hours

following any dose adjustments

✓ The goal is to prolong the aPTT from 1.5 to 2.5 times the control value

✓ The normal aPTT value is 30-40

✓ The reversal agent for heparin toxicity is protamine sulfate

The primary healthcare provider (PHCP) prescribes a regular insulin infusion.

for a client. The prescription is for 2 units/hr. The label on the medication

reads 250 mL of 0.9% saline containing 100 units of regular insulin. How many

mL/hr should the client receive?

5 ml

The formula of dose ordered / dose on hand x volume will be utilized to solve this problem.

Divide the prescribed amount of medication by what is on hand

2 units / 100 units = 0.02 units

Next, take the amount of the medication and multiply it by the volume

0.02 units x 250 mL = 5 mL/hr

i Additional Info

Regular insulin intravenously is prescribed to correct the acidosis and

hyperkalemia. During the infusion of regular insulin, the client should be

monitored for hypoglycemia and hypokalemia. Regular insulin is the only insulin that may be administered intravenously.

The nurse is caring for a client receiving nifedipine. Which of the following

findings would indicate a therapeutic response?

A. Sinus rhythm on the electrocardiogram

B. Blood pressure 128/77 mm Hg

C. Total cholesterol 180 mg/dl

D. Weight loss of 2 kilograms'

B. Blood pressure 128/77 mm Hg

Nifedipine is a calcium channel blocker and is indicated for hypertension. A therapeutic effect of this medication would be normal blood pressure. This medication does not lower heart rate compared to other calcium channel blockers (verapamil and diltiazem).

3 multiple choice options

The nurse reinforces teaching to a client with hypertension about the newly

prescribed furosemide. Which of the following should the nurse include in the

teaching?

A. Limit intake of bananas, cantaloupe, and potatoes

B. Avoid taking the medication with grapefruit juice

C. Take this medication in the early part of the day

D. A nagging cough can occur as a side effect of the medication

C. Take this medication in the early part of the day

Furosemide is a loop diuretic and may be indicated for

conditions such as heart failure or hypertension. The client should be instructed to take this medication in the earlier part of the day to avoid nocturia.

3 multiple choice options

The nurse is caring for a client receiving prescribed lactulose. Which of the

following finding would indicate a therapeutic response?

A. Increased liver enzymes

B. Increased level of consciousness

C. Decreased urinary calcium

D. Increased gastric pH

B. Increased level of consciousness

Lactulose is indicated for clients with hyperammonemia secondary to cirrhosis of the liver. Increased ammonia levels cause a patient to develop altered mental status (hepatic encephalopathy). A client receiving this medication will have increased bowel movements as that is the primary way of

excreting the excess ammonia.

3 multiple choice options

The nurse receives the following critical laboratory result for a client with end-

stage renal disease. The nurse anticipates the physician to prescribe which

blood product? See the image below.

Laboratory Result

Hemoglobin 5.6 g/dL

Hematocrit 16.8%

A. Packed Red Blood Cells (PRBCs)

B. Fresh Frozen Plasma (FFP)

C. Albumin

D. Platelets

A. Packed Red Blood Cells (PRBCs)

This hemoglobin and hematocrit are critically low. A transfusion

of PRBCs is typically indicated once the hemoglobin is 7 g/dL or less.

3 multiple choice options

The primary healthcare provider (PHCP) prescribes 100 mL of 0.9% saline to

infuse over 45 minutes. How many mL per hour will be administered to the

client?

133

First, convert the minutes to hours

45 minutes / 60 minutes = 0.75 hrs

Next, divide the prescribed total volume by the infusion time

100 mL / 0.75 hours = 133.33

Finally, take the mL/hour and round to the nearest whole number

133.33 133 mL/hr

i Additional Info

0.9% saline is an isotonic solution utilized for simple dehydration.

X

The nurse has reinforced medication instruction to a client who has been

prescribed enalapril. Which of the following statements, if made by the client,

would indicate a correct understanding of the teaching?

A. "I will notify my prescriber if I develop swelling of the face."

B. "I will need to weigh myself every day while taking this

medication."

C. "I should eat foods high in potassium while I am taking this

medication."

D. "I will need lab work done every so often to evaluate my liver

function."

A. "I will notify my prescriber if I develop swelling of the face."

Angioedema is a life-threatening adverse effect that is seen with ACE inhibitors such as enalapril. Angioedema may cause swelling anywhere in the body but swelling in the face, lips, and eyes can be life-threatening.

3 multiple choice options

This nurse is caring for a client who is receiving prescribed sitagliptin. The

nurse understands that this medication is intended to treat which condition?

A. Hyperlipidemia

B. Diabetes mellitus

C. Hypothyroidism

D. Hypertension

B. Diabetes mellitus

Sitagliptin is a DPP-4 Inhibitor used in managing diabetes

mellitus type II. This medication reduces blood glucose levels by delaying gastric emptying and slowing the rate of nutrient absorption into the blood.

3 multiple choice options

Common side effects of antidysrhythmic medications include:

A. Dizziness, hypotension, and weakness

B. Headache, hypertension, and fatigue

C. Weakness, fatigue, and hypertension

D. Anorexia, diarrhea, and hypertension

A. Dizziness, hypotension, and weakness

Hypotension may occur when patients are given antidysrhythmics. Hypotension may result in the patient feeling dizzy or weak. Dysrhythmias are abnormalities of electrical conduction in the heart. They encompass several different disorders that range from harmless to life-threatening.

They are classified by their location and the type of rhythm abnormality that they produce. Antidysrhythmic drugs are separated into four primary classes and a diverse group, including:

Sodium channel blockers

Beta-adrenergic blockers

• Potassium channel blockers

Calcium channel blockers

• Miscellaneous antidysrhythmic drugs

3 multiple choice options

The nurse is caring for a client who has just been diagnosed with severe acne

vulgaris. Which of the following medications should the nurse anticipate the

primary health care provider (PHCP) will prescribe?

A. Isotretinoin

B. Acyclovir

C. Ketoconazole

D. Ethambutol

A. Isotretinoin

Isotretinoin is approved for the treatment of moderate to

severe acne vulgaris.

3 multiple choice options

The nurse has attended a continuing education conference regarding

medication administration and meal times. Which statement, if made by the

nurse, would indicate correct understanding?

A. Proton pump inhibitors (PPIs) should be given as the client eats

their breakfast.

B. Glucocorticoids should be given on an empty stomach to prevent

gastrointestinal irritation.

C. Rapid-acting insulins should be administered approximately 10-

15 minutes before meals

D. Levodopa-Carbidopa should be administered with a high-protein

snack to enhance its absorption.

C. Rapid-acting insulins should be administered approximately 10-15 minutes before meals

This is correct because rapid-acting insulin (lispro, aspart, glulisine) should be given within 10-15 minutes before a meal or while the client is actively eating.

3 multiple choice options

The nurse is calculating the 12-hour intake for a client

• The client received 0.45% saline at 85 mL/hr

• One eight-ounce cup of ice chips

• One eight-ounce cup of coffee

• One eight-ounce cup of ice cream

• Three eight-ounce cups of water

• One eight-ounce cup of pureed vegetables

The nurse should calculate the client's total intake as how many mL? Fill in

the blank.

2340

The client received 0.45% saline at 85 mL/hr x 12 hours → 1020 mL

One eight-ounce cup of ice chips →→ 120 mL When determining the total mL for a cup of ice, the nurse should divide the volume by 1/2 since the ice melts

One eight-ounce cup of coffee → 240 mL

One eight-ounce cup of ice cream → 240 mL

Three eight-ounce cups of water → 720 mL

One eight-ounce cup of pureed vegetables → This is excluded from the intake

calculation as pureed food(s) are not a liquid at room temperature

Total → 2340 mL

i Additional Info

When calculating intake for a client, the nurse should include -

✓ Oral liquids (anything that is liquid at room temperature)

✓ Oral liquids that should be tracked include ice cream, gelatin, water, juice,

cola

✓ For ice chips, half of the total volume should be documented as fluid - 1 cup

of ice chips (240 mL) = 1/2 cup of water (120 mL)

✓ Pureed foods are not considered liquid intake

✔ Additional intake that should be counted includes intravenous (IV) fluids,

tube feeding, tube feeding irrigations, and blood products

The licensed practical/vocational nurse (LPN/VN) is collecting data on a client who just received one unit of packed red blood cells (PRBCs). Which of the following findings would indicate a therapeutic response?

A. Bounding peripheral pulses

B. Hematuria

C. Oral temperature 100.4°F (38°C)

D. Capillary refill <3 seconds

D. Capillary refill <3 seconds

A capillary refill of <3 seconds is an optimal physical

assessment finding and would be desired following the administration of PRBCs. PRBCs are indicated for clients with anemia (hemoglobin less than 7 g/dL). Giving a client, PRBCs improves tissue perfusion and may reflect the capillary refill finding.

3 multiple choice options

The nurse reviews prescriptions for packed red blood cell (PRBC) transfusions. Which PRBC transfusion should the nurse question with the primary healthcare provider (PHCP)?

A. with a febrile illness.

B. with pulmonary edema.

C. receiving mechanical ventilation.

D. with a chest tube for a hemothorax

B. with pulmonary edema.

A unit of PRBCs will add fluid volume, and if the client has

pulmonary edema, the unit of blood should be questioned with the PHCP until the edema has resolved. Giving a unit of PRBCs may worsen pulmonary edema. Clients at risk for transfusion-associated circulatory overload (TACO) will need to receive their unit of PRBCs slower and may require diuretics after the blood has been administered.

3 multiple choice options

The primary healthcare provider (PHCP) prescribes lidocaine at 2 mg/min. The

medication label reads lidocaine 1 gram in 500 mL of 0.9% saline. How many

mL per hour will be administered to the client?

Correct Answer(s): 60

First, determine the hourly dosage

2 mg x 60 mins = 120 milligrams

Next, convert the milligrams to grams so the units align

120 milligrams/ 1000 = 0.12 grams

Finally, divide the dose ordered by the amount on hand x the volume

0.12 grams / 1 gram x 500 mL = 60 mL/hr

Additional Info

Lidocaine is an antiarrhythmic utilized in the treatment and prevention of

ventricular arrhythmias. A similar drug to lidocaine is amiodarone.

The nurse cares for a client who intentionally overdosed on their prescribed

lithium. The nurse plans on initially

A. developing a therapeutic rapport with the client.

B. inserting a peripheral vascular access device.

C. obtaining the client's vital signs.

D. collecting a serum lithium level on the client.

C. obtaining the client's vital signs.

An overdose of lithium may be fatal if not treated. Lithium has a

narrow therapeutic index (0.6-1.2 mEq/L), and manifestations of toxicity include gastrointestinal symptoms of nausea, vomiting, diarrhea predominate, and neurologic symptoms are delayed. The neurological findings may consist of confusion, ataxia, and coarse tremors.

3 multiple choice options

The nurse is planning to interview a client interested in establishing care with

a primary healthcare provider (PHCP). The nurse should initially

A. obtain the client's vital signs.

B. identify the client's chief complaint.

C. provide a private area for the interview.

D. inquire about the client's allergies.

C. provide a private area for the interview.

Establishing a therapeutic environment that involves privacy is

essential to ensuring the client feels comfortable discussing their current health

status. The nurse has an obligation to protect client confidentiality by having the

necessary safeguards in place.

3 multiple choice options

A patient is prescribed a calcium channel blocker to treat primary

hypertension. When teaching the patient about the medication, which of

these foods will the healthcare provider advise the patient to avoid?

A. Eggs

B. Milk

C. Grapefruit

D. Bananas

C. Grapefruit

Grapefruit and its juice contain furanocoumarins, which block

the enzymes involved in metabolizing many drugs, including calcium channel blockers. Grapefruit can interfere with other drugs too, including statins (atorvastatin, lovastatin, simvastatin), some antibiotics, and some cancer drugs. Medication blood levels can increase, resulting in toxicity. The calcium channel blockers' levels are increased when grapefruit or grapefruit juice is consumed, potentially causing hypotension.

3 multiple choice options

Which of the following clients should the LPN/LVN attend to first?

A. A client who is newly diagnosed with Hepatitis A that is reporting [2%]

stomach pain and itchy skin.

B. A patient in an arm cast that is 2 days post-op and reports

feeling numbness and tingling in his affected arm.

C. A post-op prostatectomy patient complaining of bladder spasms

and blood in his foley bag.

D. A patient with a newly placed NG tube complaining of pain

around the face and a "plugged" nose.

B. A patient in an arm cast that is 2 days post-op and reports

feeling numbness and tingling in his affected arm.

Numbness and tingling hours or days after a cast is applied may indicate compartment syndrome and should be reported to a doctor right away.

3 multiple choice options

Which of the following is the reason a patient receives nitrous oxide in

addition to thiopental sodium?

A. To provide the additional anesthesia to put him in a sleep-like

state.

B. To increase the effectiveness of each drug at a lower dosage.

C. Thiopental sodium is not effective when used alone.

D. Nitrous oxide is not effective when used alone.

B. To increase the effectiveness of each drug at a lower dosage.

Nitrous oxide may be used for dental procedures or brief

obstetrical or surgical procedures. It may also be used together with other general anesthetics, making it possible to decrease its dosage with greater effectiveness. There are two primary methods of causing general anesthesia. IV agents are usually administered first because they act within a few seconds. After the patient loses consciousness, inhaled agents are used to maintain the anesthesia.

3 multiple choice options

The nurse working on a medical-surgical unit is assigned as a preceptor to

work with a newly hired nurse. Which of the following, if performed first by

the newly hired nurse, would indicate the ability to prioritize appropriately?

A. Initiates a referral for a patient needing home health care.

B. Performs a central line dressing change on a patient receiving

0.9% saline infusion.

C. Collects a urine specimen from a patient's indwelling urinary

catheter.

D. Obtains capillary blood glucose for a patient receiving

continuous regular insulin.

D. Obtains capillary blood glucose for a patient receiving

continuous regular insulin.

A client receiving continuous regular insulin infusion requires

hourly capillary blood glucose checks because of the high risk of hypoglycemia. Regular insulin via intravenous infusion peaks within fifteen to thirty minutes. Thus, the nurse needs to watch for signs of hypoglycemia, including tachycardia, palpitations, and diaphoresis.

3 multiple choice options

Your client is receiving a non-steroidal anti-inflammatory drug (NSAID) in

addition to a narcotic analgesic. The client wonders why an NSAID is

necessary since the narcotic analgesic offers better pain relief. How would

you respond to the client's question?

A. I don't know and I suggest that you ask your doctor when you see

her the next time.

B. You are getting the NSAID because we are trying to wean you off

the narcotic analgesic for moderate to severe pain.

C. You are getting the NSAID, so the effects of the narcotic

analgesic to combat your pain are more effective.

D. You are getting the NSAID because it is a placebo, and it is proven [6%]

to be effective for severe pain.

C. You are getting the NSAID, so the effects of the narcotic

analgesic to combat your pain are more effective.

"You are getting the NSAID, so the effects of the narcotic analgesic to combat your pain are more effective" is an appropriate response to the client's query. An NSAID is an "adjuvant" medication used in combination with narcotic analgesics to treat moderate to severe pain. Adjuvant pain medications are used to enhance pain relief provided by other analgesics. The primary function ofNSAIDs is to reduce inflammation. Therefore, NSAIDs are helpful in treating the pain

caused by inflammation.

3 multiple choice options

The nurse is reviewing leadership and management concepts with a student

nurse. It would require further teaching if the student nurse made which of

the following statements?

A. "The Laissez-faire leadership style is a passive leadership

approach.

B. "A Registered Nurse (RN) may delegate accountability to a

Licensed Practical Nurse (LPN)."

C. "The rights of delegation include task, circumstance, person,

direction, supervision."

D. "The State Nurse Practice Act defines roles and responsibilities of [10%]

nursing professionals."

B. "A Registered Nurse (RN) may delegate accountability to a

Licensed Practical Nurse (LPN)."

An RN may delegate specific responsibilities to an LPN but

cannot delegate accountability. The RN retains accountability when delegating client assignments and tasks but maintains accountability.

3 multiple choice options

Which of the following is the most appropriate way to document a patient's

refusal of medication?

A. "Patient refused the heparin injection when I tried to give it."

B. "Heparin refused during shift. Risks reviewed."

C. "Patient stated she did not want the SQ heparin injection at this

time."

D. "Subcutaneous heparin injection was attempted per the

physician's order. Patient refused medication at this time"

D. "Subcutaneous heparin injection was attempted per the

physician's order. Patient refused medication at this time"

Documentation in healthcare should be objective, thorough,

and direct. It should also be articulated with correct grammar and spelling.

3 multiple choice options

A patient who is taking Lasix knows that he should increase the intake of

what food?

A. Cantaloupe

B. Iceberg lettuce

C. Plums

D. Apples

A. Cantaloupe

Cantaloupe has high levels of potassium in it, which tends to be lower in a patient taking Lasix. Lasix is the most frequently prescribed loop diuretic. It can increase urine output, even when blood flow to the kidneys is diminished. The rapid excretion of large amounts of water caused by loop diuretics may produce adverse effects, such as dehydration and electrolyte imbalances. Potassium loss may result in dysrhythmias. Therefore, potassium supplements and foods high in potassium are encouraged.

3 multiple choice options

The nurse detects an elevated temperature in a patient who is scheduled for

surgery. The patient has been afebrile and has no other symptoms of fever.

What should be the first nursing action?

A. Inform the charge nurse.

B. Inform the surgeon.

C. Validate the finding.

D. Document the finding.

C. Validate the finding.

The nurse should first validate the finding if it is unusual,

deviates from normal, and is unsupported by other data.

3 multiple choice options

The nurse is planning a staff developmental conference about confidentiality.

Which of the following scenarios should the nurse include as a violation of

client confidentiality?

A. Informing a visitor of the room number of a client admitted with

pneumonial

B. Telling a police officer who brought a client into the emergency

department (ED) the urine drug screen results

C. Notifying the pharmacist that a client is HIV positive and may

have a potential drug interaction

D. Informing local authorities that a client is suspected of being a

victim of domestic violence

B. Telling a police officer who brought a client into the emergency department (ED) the urine drug screen results

The results of a UDS are confidential, and that confidentiality

should not be pierced because an individual is a police officer. If the police officer requests the results, they should obtain a legal court order and present it to risk management to obtain the necessary records.

3 multiple choice options

The nurse is caring for a group of assigned clients. The nurse should

immediately follow up on the client who

A. has a closed-chest drainage system and has redness at the

insertion site.

B. is receiving treatment for ulcerative colitis and has had three

bloody stools in the past hour.

C. is being treated for a concussion and reports a headache rated

as 4 on a scale of 0 (no pain) to 10 (severe pain).

D. is being treated for an ischemic stroke and has a blood pressure

of 100/58 mm Hg.

D. is being treated for an ischemic stroke and has a blood pressure of 100/58 mm Hg.

The client with an ischemic stroke will require intense blood

pressure monitoring because a low blood pressure will decrease cerebral perfusion, which is necessary for the unaffected areas of the brain. An optimal blood pressure

for an ischemic stroke is 150/100 mm Hg to ensure cerebral perfusion. Allowing the blood pressure to be this high is considered permissive hypertension. Blood pressure lower than 150/100 mm Hg may cause further injury because of decreased cerebral perfusion. Likewise, the blood pressure should not exceed 185/110 mm Hg in an ischemic stroke because this may cause an extension of the stroke.

3 multiple choice options

The primary healthcare provider (PHCP) prescribes 4 mg of morphine

intramuscular (IM). The medication vial reads morphine sulfate, 10 mg/mL.

The nurse prepares how many milliliters to administer the appropriate

dose?

Correct Answer(s): 0.4

First, divide the prescribed amount of medication by what is on hand

4 mg / 10 mg = 0.4 mL

Finally, multiply it by the volume. If none is listed, multiply the answer by one

(1)

0.4 mL x 1 mL = 0.4 mL

i Additional Info

Morphine is an opioid utilized for moderate to severe pain. It can be given

intravenously, intramuscular, and by mouth. Prior to administering the

medication, the nurse should obtain vital signs

and pay close attention to the client's respiratory rate and blood pressure, as

this medication may lower both. Fall precautions will be necessary after

administering this medication.

A patient presents to the emergency department with a dissecting aortic

aneurysm. The patient needs immediate surgery to save his life. He is unconscious and there is no family contact information on file. Which action is

appropriate for obtaining informed consent for the surgery?

A. There is no need for obtained consent. Send the client to

surgery.

B. Call the hospital lawyer.

C. Search for people who may know the patient and can provide

informed consent.

D. Notify the on-call nursing supervisor and request her permission

to waive informed consent.

A. There is no need for obtained consent. Send the client to

surgery.

When emergency surgery is needed, delaying the surgery to

obtain informed consent may result in the patient's morbidity or death. In such urgent cases, informed consent is unnecessary. It is most appropriate to begin the surgery to save the patient's life.

3 multiple choice options

The nurse is caring for a client who is newly prescribed cimetidine. The nurse

understands that this medication is prescribed to treat which condition?

A. Cystic fibrosis

B. Clostridium difficile

C. H. pylori

D. Crohn's disease

C. H. pylori

Cimetidine is a H2 receptor antagonist indicated in treating

peptic ulcer disease, gastric esophageal reflux disease, or H. pylori infections. This older medication has widely been replaced with newer H2 receptor antagonists because this medication is known to cause significant drowsiness.

3 multiple choice options

The nurse is assessing a patient being treated for hypertension that has poor

gait and impaired balance. What should the nurse do next?

A. Do nothing as this has nothing to do with why the patient was

hospitalized.

B. Speak with the attending physician about his concerns and

request a referral to physical therapy.

C. Speak with the attending physician about his concerns and

request a referral for the patient to go to the hospital gym.

D. Add this issue to the nursing care plan and have daily

gait/balance training as an intervention.

B. Speak with the attending physician about his concerns and

request a referral to physical therapy.

Nurses need to be aware of the patient's needs even if they do

not pertain to the reason for hospitalization and treatment. Observation is a crucial nursing skill. The nurse should always be alert for any changes in a patient's condition, regardless of the patient's initial diagnosis. Being aware of the patient's status will equip the nurse to advocate for patients and request referrals when concerns or issues arise during care.

3 multiple choice options

After reporting to her usual adult medical-surgical floor, the LPN is told she must float to the mother-baby unit. The LPN has never cared for this patient population before. Which of the following actions is most appropriate?

A. Refuse the assignment.

B. Float to the mother-baby unit and identify tasks within her

training that she can safely perform.

C. Call the nurse manager.

D. Float to the mother-baby unit and ensure no one knows her

inexperience.

B. Float to the mother-baby unit and identify tasks within her

training that she can safely perform.

Floating to the mother-baby unit and identifying tasks within

her training that she can safely perform is the correct action. This promotes patient

safety and benefits both the nurse and the unit.

3 multiple choice options

A patient is scheduled to have a thyroidectomy. The nurse understands that the primary reason for giving Lugol's solution to a patient preoperatively is:

A. Decrease the risk of agranulocytosis postoperatively.

B. Prevent tetany while the client is under general anesthesia.

C. Reduce the size and vascularity of the thyroid and prevent

hemorrhage.

D. Potentiate the other preoperative medication's effect so less

medicine can be used while the client is under anesthesia.

C. Reduce the size and vascularity of the thyroid and prevent

hemorrhage.

Reduce the size and vascularity of the thyroid and prevent

hemorrhage. Hyperthyroidism is related to hemodynamic variations, including

increased heart rate and cardiac contractility, and decreased peripheral resistance

due to serum thyroid hormone excess. Preoperative preparation of the patient is

crucial to avoid intraoperative or postoperative complications and decrease the

gland's vascularity. The incidence of complications is low in experienced hands;

however, a small amount of intraoperative bleeding can reduce the visualization and

preservation of the surrounding nerves, vasculature, and parathyroid glands. Lugol's

solution (inorganic iodide) has been given preoperatively to patients to limit

intraoperative bleeding and related complications resulting from thyroid gland

vascularization.

3 multiple choice options

During a busy shift, the nurse appropriately delegates tasks to the unlicensed assistive personnel (UAP) working with her. After delegating, which is the nurse's primary responsibility?

A. Document the completion of the task.

B. Make a list of tasks not yet completed to pass on to the next shift.

C. Observe the UAP for the duration of the task.

D. Follow-up with the UAP to ensure completion of the task by

evaluating the outcome.

D. Follow-up with the UAP to ensure completion of the task by evaluating the outcome.

The nurse should follow-up with the unlicensed assistive

personnel (UAP) to ensure completion of the task, evaluating the outcome. The

ultimate responsibility for any task will always remain with the person who delegated

it. Therefore, after delegating a task, the nurse's primary responsibility will be to

follow up with the UAP.

3 multiple choice options

The nursing student inserts an indwelling urinary catheter for a female patient prior to surgery. Which of the following would require immediate intervention by the nurse?

A. The patient states that she feels the need to urinate.

B. The patient reports a pinching sensation as the catheter is

advanced.

C. The student nurse notes resistance when inflating the balloon.

D. The student separates the labia majora and labia minora with the

non-dominant hand.

C. The student nurse notes resistance when inflating the balloon.

This may indicate the balloon is within the urethra, not the

bladder. If inflated within the urethra, the balloon may cause significant damage. Any

complaints or nonverbal signs of discomfort or resistance are noted by the nurse

during balloon inflation and are indications to stop this procedure immediately.

3 multiple choice options

The nurse is planning a staff developmental conference about confidentiality. Which of the following scenarios should the nurse include as a violation of client confidentiality?

A. Informing a visitor of the room number of a client admitted with

pneumonia

B. Telling a police officer who brought a client into the emergency

department (ED) the urine drug screen results

C. Notifying the pharmacist that a client is HIV positive and may

have a potential drug interaction

D. Informing local authorities that a client is suspected of being a

victim of domestic violence

B. Telling a police officer who brought a client into the emergency

department (ED) the urine drug screen results

The results of a UDS are confidential, and that confidentiality

should not be pierced because an individual is a police officer. If the police officer

requests the results, they should obtain a legal court order and present it to risk

management to obtain the necessary records.

3 multiple choice options

The nurse is working at the triage desk in the emergency department when a

patient arrives and begins speaking in Spanish. The nurse asks if he would like

an interpreter, and he shakes his head 'no.' What is the appropriate action for

the nurse to take?

A. Ask around to see if anyone nearby knows Spanish.

B. Call the receptionist who speaks Spanish to translate.

C. Pull up Google translate on the internet.

D. Request an interpreter from the hospital's interpreter service.

D. Request an interpreter from the hospital's interpreter service.

It is most appropriate to request an interpreter from the

hospital's interpreter service. A certified medical interpreter has the proper training

to quickly and accurately translate the conversation as well as protect client

confidentiality. This is the appropriate action by the nurse.

3 multiple choice options

The nurse is reviewing the physician orders for a client admitted with

anorexia nervosa reporting weakness and abdominal distention. The nurse

should prioritize:

See the image below.

Orders

olanzapine 2.5 mg by mouth daily

• obtain daily weights

• 12-lead electrocardiogram

• consult nutritional services

A. administering olanzapine.

B. consulting nutritional services.

C. performing the 12-lead electrocardiogram.

D. weighing the client.

C. performing the 12-lead electrocardiogram.

The client with anorexia nervosa reporting abdominal distention and weakness is concerning for hypokalemia. The nurse should prioritize performing the 12-lead electrocardiogram because cardiovascular collapse may occur if the client's physical symptoms go unrecognized and untreated. Additional testing is required, including a complete metabolic panel and magnesium level. Features of hypokalemia on the electrocardiogram include U-wave development, ST depression,

and shallow, flat, or inverted T wave.

3 multiple choice options

The nurse is caring for assigned clients. The nurse should immediately follow

up with the client who

A. has influenza and their most recent temperature was 102°F

(39°C).

B. is recovering from a thoracentesis and reports a nagging cough.

C. reports reddish-brown sputum immediately following a

bronchoscopy.

D. has pulmonary tuberculosis and is wearing a surgical mask while

ambulating to radiology.

B. is recovering from a thoracentesis and reports a nagging cough.

Following a thoracentesis, the nurse must assess the client for the most common complication of pneumothorax. Manifestations of a pneumothorax

that are concerning include a nagging persistent cough, increased heart and

respiratory rate, dyspnea, and potentially a feeling of air hunger. The nurse must act quickly because the client's condition may deteriorate. Depending on the size of the

pneumothorax, a chest tube may be needed.

3 multiple choice options

The nurse is in an elevator and observes two staff members discussing a client's condition. The nurse understands that this conversation may potentially violate which ethical principle?

A. Beneficence

B. Confidentiality

C. Autonomy

D. Veracity

B. Confidentiality

This conversation being observed by the nurse may violate the client's confidentiality. Conversations about a client's personal medical information

(PMI) should be kept private and involve only those involved in the client's care. This

is considered the right to know, which mandates that information be safeguarded

and limited in how it is shared.

3 multiple choice options

The nurse has become aware of the following client situations. The nurse

should first assess the client

A. with chronic obstructive pulmonary disease (COPD), who is using

pursed-lip breathing and reporting a productive cough.

B. who had a laparoscopic cholecystectomy three hours ago and is reporting right shoulder pain and abdominal cramping.

C. with ulcerative colitis, who had three bloody stools in the past

two hours and reporting abdominal cramping.

D. two hours postoperative following a tonsillectomy and is

reporting throat pain while vomiting.

D. two hours postoperative following a tonsillectomy and is

reporting throat pain while vomiting.

The client's vomiting following a tonsillectomy requires

immediate follow-up because vomiting and coughing may trigger hemorrhage. This

client requires immediate follow-up so the nurse may treat the vomiting with

prescribed anti-emetics and assess the client for potential hemorrhage.

3 multiple choice options

The nurse is caring for a client with an infected leg pressure ulcer. The initial

priority for the nurse is to

A. Obtain a wound culture

B. Wrap the extremity with a sterile dressing

C. Review the client's risk factors for skin breakdown

D. Obtain a prescription for antibiotic ointment

A. Obtain a wound culture

Obtaining wound culture before wrapping the extremity and applying a prescribed antibiotic ointment is essential. This will assist the primary healthcare provider (PHCP) in determining the most effective antibiotic to

administer.

3 multiple choice options

The nurse is caring for a group of children on the medical-surgical unit. The nurse should initially follow up on the child who

A. is receiving treatment for Hirschsprung's disease and has a

temperature of 101°F (38.3°C).

B. has an indwelling urinary catheter and reports burning at the

insertion site.

C. has scant blood in their newly established ostomy pouch.

D. has friends writing words on their fiberglass cast with different

colored markers.

A. is receiving treatment for Hirschsprung's disease and has a

temperature of 101°F (38.3°C).

A major complication of Hirschsprung's disease is the development of enterocolitis manifested by fever, abdominal distention, vomiting,

and increased abdominal pain. Emergent intervention is necessary because the child

may develop sepsis leading to septic shock.

3 multiple choice options