PN Comprehensive Online Practice 2020 A

ANS: Assure the client that a family member will stay with the body after death RAT: The nurse should assure the client that a family member will remain with the body until burial

PR interval 0.24 seconds.

a client who is experiencing shortness of breath after taking amoxicillin.

admission sheet.

you should increase your fluid intake after this procedure.

you will likely gain weight before you start to get taller.

an infection with gonorrhea may result in infertility.

monitor your blood pressure using your right arm daily.

11.

B.

21.

apply capsaicin cream four times a day.

ANS: Obtain a set of the client's vital signs RAT: The first action the nurse should take when using the nursing process is to collect data from the client. Digoxin can cause bradycardia. By obtaining the client's vital signs, the nurse can identify the need for intervention

ANS: Contact RAT: Hepatitis A is spread by the fecal-oral route. Standard precautions are usually sufficient to prevent the spread of infection. However, if the client who has hepatitis A is also incontinent of stool, then contact precautions are indicated

ANS: Admission sheet RAT: The nurse will find client data, such as date of birth, occupation, and the client's source of health insurance, on the client's admission sheet

ANS: Generalized petechiae RAT: Petechiae are an expected finding over the presenting part of the newborn, such as on the forehead in a brow presentation, and also anywhere on the head of the newborns who has a nuchal cord, which is an umbilical cord around the neck. However, petechiae all over the newborn's body can indicate infection or a decreased platelet count and should be reported to the provider

ANS: "Do you know if you're allergic to iodine?" RAT: The greatest risk to the client is an allergic reaction to the contrast agent, which contains iodine. Therefore, the priority question is to identify the client's allergies

ANS: INR 5.0 RAT: The international normalized ratio (INR) is a measurement of the body's blood clotting ability. A client receiving warfarin to prevent clot formation related to atrial fibrillation should have an INR of 2.0 to 3.0. An INR of 5.0 or greater indicates that the client is at risk for bleeding. Therefore, the nurse should notify the provider about this laboratory value

ANS: Grasps the plug of a device in the client's room to pull it straight out from the wall RAT: The nurse should recognize that by grasping the plug, rather than the cord, the AP is demonstrating an understanding of proper equipment use and preventing risk of injury from electronic equipment.

ANS: "I will soak my child's toothbrush in warm water to soften it before my child uses it." RAT: The nurse should instruct the parents to soften their child's toothbrush in warm water before they use it or allow them to use a sponge-tipped disposable toothbrush. These actions will minimize trauma to the gums and prevent bleeding of the oral cavity

ANS: A client hits another client because they thought the other client was talking about them RAT: The nurse should request a prescription for seclusion for a client who hits another client to protect the client and others from physical injury

ANS: Coronary artery disease RAT: Coronary artery disease is a contraindication to oral contraceptive use because it increases the client's risk for myocardial infarction. Other contraindications for receiving oral contraceptives include gallbladder disease, breast cancer, and hypertension

ANS: 250 mL of sanguineous drainage over the last 3 hr RAT: The nurse should recognize that if more than 3 mL/kg/her of sanguineous drainage occurs for more than 3 consecutive hours following surgery, it can indicate active hemorrhaging. Therefore, 250 mL of sanguineous drainage from the child's chest tube is excessive and the nurse should report this finding to the provider immediately

ANS: Polyuria RAT: The nurse should identify polypuria as an expected finding of hyperglycemia and report this finding to the provider

ANS: "I will dispose of my needles in a plastic laundry detergent container." RAT: The nurse should instruct the client to dispose of needles in a puncture-proof container, such as a plastic laundry detergent container.

ANS: Encourage the client to reminisce about the past RAT: The client who has Alzheimer's disease has progressive loss of short-term memory and might not be able to recall recent happenings and events. This can lead to increased frustration. However, remote memory remains in place for a longer period of time and can elicit feelings of happiness

ANS: PR interval 0.24 seconds RAT: An expected PR interval is 0.12 to 0.20 seconds. A prolonged PR interval can indicate a heart block; therefore, the nurse should report this finding provider

ANS: Lumbar puncture RAT: The nurse should identify that a client needs to provide consent for general treatment as well as a separate written informed consent for any treatment that has an element of risk, such as a lumbar puncture

ANS: Use lower-body strength RAT: The nurse should instruct the AP to use lower-body strength when lifting a client to reduce stress on the back

ANS: Review clients' charts for their rating of pain before pain medication was administered and 1 hr after administration RAT: The nurse should collect data from clients' charts about pain ratings before and after pain management interventions

ANS: "Your HIV status will be shared with members of your health care team." RAT: The diagnosis of HIV or AIDS is shared with every member of the health care team who provides direct care for the client, just like any other diagnosis

ANS: Suction catheter RAT: The nurse should place suction equipment in the room of a client who has a history of seizures. During a seizure, the client might have excessive oral secretions or might vomit. If the client's airway becomes occluded, then the nurse will need to suction the oral cavity to maintain a patent airway

ANS: A client who has a new colostomy and requires the development of a teaching plan RAT: Developing a client teaching plan is not within the scope of practice for an LPN. The nurse should contact the nursing supervisor to inform them of the client's need for a teaching plan regarding the new colostomy and request that this client be reassigned to an RN. The scope of practice of an LPN does allow the nurse to reinforce teaching once the plan has been established

ANS: Occupational therapist RAT: The nurse should identify the need for a referral to an occupational therapist to teach the client how to use special eating utensils

ANS: Hold the finger for testing in a dependent position RAT: Evidence-based practice indicates that the nurse should first position the testing site to enhance blood flow, which improves the ability to collect an adequate specimen

ANS: Apply the stockings in the morning RAT: The nurse should instruct the client to apply the elastic stockings in the morning and remove them at the end of the day before bedtime

ANS: Store the child's clothing in a separate cubicle when at school. Boil brushes and combs in water for 10 min. Dry bed linens and clothing in a hot dryer for at least 20 min. RAT: Transmission of lice occurs via contact with personal items. Boiling hair care items in hot water for 10 min kills lice and nits. Exposing bedding and clothing to prolonged heat by washing in hot dryer for at least 20 min is an appropriate strategy

ANS: Use intermittent urinary catheterization for the client at regular intervals RAT: A continent urinary diversion contains valves that prevent urine from exiting the pouch; therefore, the nurse should plan to insert a urinary catheter at regular intervals to drain urine from the client's pouch.

ANS: Tell the client they should not experience any discomfort RAT: The nurse applies the handheld scanner over the area of the bladder when performing a bladder scan. This noninvasive procedure should not cause the client any discomfort

ANS: "What have you done to help yourself get through stressful situations before?" RAT: This is a therapeutic response. The nurse is aware that the client is under stress and encourages comparison to investigate whether they have experience dealing with a stressful situation

ANS: Dark greenish-black and viscous RAT: The first stool passed by a newborn is the meconium that develops in utero. It is dark greenish-black and viscous, containing of amniotic fluid, cells, intestinal secretions, and blood

ANS: Witness the client's signature on the informed consent form. RAT: The insertion of a PICC is an invasive procedure with risks and benefits. The nurse should witness the client's signature on the consent form after ensuring the client has an understanding of the procedure, including its risks and benefits

ANS: Spaghetti noodles with red sauce RAT: The nurse should identify that spaghetti noodles with red sauce is appropriate for a client who adheres to a kosher diet.

ANS: Maintain a drainage flow rate to keep the urine diluted to a reddish-pink color RAT: The nurse should maintain the flow rate of the bladder irrigation to keep the urine diluted to a reddish-pink color and the tubing free of clots and bleeding

ANS: Protamine sulfate RAT: The nurse should ensure that protamine sulfate is readily available. Protamine sulfate is the antidote used to reverse the anticoagulant effects of heparin

ANS: Hold the skin taut while removing the barrier RAT: Gently and gradually peeling the skin barrier away while holding the skin taut minimizes discomfort and trauma to the peristomal skin

ANS: "What is your current understanding about the purpose of AA?" RAT: The nurse should identify the client's understanding about the purpose of AA to provide further information about the program and meetings and to facilitate a referral if needed. For treatment to be successful, the nurse should involve the client in the care decision-making process. This ensures the treatment program meets the client's individual needs and demonstrates caring by the nurse

ANS: Yellow-green drainage at the incision line RAT: Yellow-green, purulent, or odorous drainage indicates the wound is infected. The nurse should report this finding to the provider

ANS: "Journaling about your relationship might help with the grieving process." RAT: Journaling provides a means for the client to identify thoughts and feelings and to recognize and come to terms with the positive and negative aspects the client's relationship with their partner

ANS: Recent confirmation of pregnancy RAT: The nurse should include pregnancy as a characteristic placing a vulnerable person at risk for partner violence. The perpetrator might view the pregnancy as a threat to the relationship due to the attention the child receives

ANS: "You should hold a box close to your body when lifting it up." RAT: The client should hold the box as close to their body as possible to maintain balance and prevent injury

ANS: "Apply a water-based lubricant around the nostrils to prevent irritation." RAT: The client should protect their nares with a water-based lubricant to prevent irritation from the nasal cannula. Petroleum and oil-based products are combustible and should not be used with oxygen therapy

ANS: The client calls their partner to ask what they should wear each day RAT: Clients who have dependent personality disorder have problems making everyday decisions without input from others

ANS: "Would you like for me to talk to the surgeon with you?" RAT: The nurse should advocate for the client's needs by offering to talk to the surgeon with the client. The nurse should also offer moral support and encourage the client to express their concerns and make a more informed decision

ANS: "Client remains NPO until x-ray procedure is complete." RAT: The nurse should use documentation that is specific and uses accepted terminology. The nurse can use the abbreviation "NPO", which is an accepted abbreviation for "nothing by mouth."

ANS: Observe the client's facial expressions during communication RAT: The nurse should observe the client while the interpreter is speaking to the client. Both verbal and nonverbal behaviors, such as facial expressions and body language, can indicate whether the client understands what the interpreter is saying

ANS: Dilated pupils RAT: The nurse should expect a client who has stimulant intoxication to have dilated pupils. Other expected findings of stimulant intoxication include increased energy and hypervigilance

ANS: A client who has pneumonia and is currently receiving oral antibiotics RAT: The nurse should recognize that this client can continue oral antibiotics at home. Therefore, this client is a candidate for discharge in a disaster situation

ANS: Walking outside with a staff member RAT: During the manic phase of bipolar disorder, psychomotor activity is excessive. The nurse should include physical activity, such as walking, in the plan of care. Additionally, the one-on-one nature of the activity provides the client with a sense of security

ANS: Gloves RAT: The greatest risk to the AP is contamination from pathogens that might be present on the PPE. Therefore, the priority actions for the AP to take is to remove the gloves, which are considered the most contaminated of the PPE.

ANS: Strain the urine to collect stone fragments RAT: The client should verify passage of the stones by straining their urine. Laboratory analysis of the stones can provide information to help prevent future stone formation

ANS: Muscle pain RAT: The nurse should instruct the client to report findings of muscle pain or tenderness to the provider. These findings can be manifestations of myopathy, or muscle injury, which is a potential serious adverse effect of atorvastatin

ANS: "I cannot give you this information. You will need to speak with your employee." RAT: Sharing client information with an employer is a violation of client confidentiality. HIPAA ensures that client information is kept confidential once it is disclosed in a health care setting. The nurse should inform the employer they will need to speak with the client directly

ANS: Provide the client with a handheld event marker to record fetal activity RAT: The nurse will provide the client with a handheld event marker for use in documenting fetal movement. The client will press the button everytime they feel the fetus move throughout the test, which is then logged on the paper tracing recording the heart rate and activity of the fetus

ANS: "I should wear a soft scarf around my neck when I am outside." RAT: A client receiving radiation therapy should cover the affected area with loose, soft clothing to protect the skin from sun exposure

ANS: "Rest for 15 minutes between activities." RAT: The nurse should instruct the client to increase activity gradually and to rest for a period of 15 min if fatigue occurs. Clients who have heart failure should balance activity with rest to reduce cardiac workload.

ANS: Upright with arms resting on the overbed table RAT: The nurse should position the client upright with arms resting on the overbed table to widen the intercostal spaces and improve access to the pleural fluid

ANS: Check for documentation that the provider spoke with the client about the DNR RAT: The first action the nruse should take when using the nursing process is to determine whether the provider documented the conversation appropriately. The nurse must ensure the client made an informed decision and that documentation meets legal requirements

ANS: Squatting using an exercise ball. Counterpressure to the sacral area. Pelvic rocking. RAT: Squatting using an exercise ball can help relax the pelvis and perineal area and can relieve pain during contractions. Counterpressure to the sacral area can help decrease pain by relieving pressure on the spinal nerves caused by the fetus's occiput. Pelvic rocking can relieve backache during the first stage of labor. To perform this motion, the client hollows their back and then arches it to relieve back pain.

ANS: A visitor who develops a bruise on their head following a syncopal episode RAT: The nurse should complete an incident report for an injury involving a client or visitor

ANS: "The person you appoint will make health care decisions for you if you cannot do so yourself." RAT: The nurse should instruct the client that a health care proxy designates a surrogate to make health care decisions when the client is no longer able to make decisions for themselves.

ANS: "Tell me how you decided who took your money." RAT: This response by the nurse is an example of therapeutic communication, in which the nurse validates the client's concern by encouraging them to describe their perception

ANS: Flush the feeding tube with water before and after administering the medication RAT: To maintain patency of the feeding tube and to ensure that the client receives all of the medication, the nurse should flush the tubing before and after administration

ANS: Administer PRN analgesics regularly for the first 24 hr. RAT: The nurse should administer analgesics for the first 24 hr even if they are ordered on an as-needed basis. It is necessary to control pain postoperatively. Giving the analgesics regularly provides a steady state of analgesia. With pain being managed, children are more likely to consume fluids, remain hydrated, and avoid delayed discharge or readmissions for fluid volume deficit.

ANS: "You should increase your fluid intake while receiving this medication through the PCA pump." RAT: The client should increase their fluid intake to prevent or relieve the adverse effect of constipation while receiving morphine through the PCA pump

ANS: Level of activity RAT: The nurse should consider the infant's activity level when using the FLACC pain scale. The FLACC score is determined by five categories of behavior: facial expression (F), leg movement (L), activity (A), cry (C), and consolability (C).

ANS: A client who has asthma and had frequent exacerbations on the previous shift RAT: When using the airway, breathing, circulation (ABC) approach to client care, the nurse should prioritize data collection from a client who has asthma. The client experienced several exacerbations of asthma on the previous shift, which can result in an obstruction of the client's airway

ANS: Respiratory depression RAT: Fentanyl, an opioid agonist, rapidly crosses the placenta, and it is present in fetal blood within 1 min. The nurse should monitor the newborn for respiratory depression, which is an adverse effect of fentanyl

ANS: The client takes the medication once daily at bedtime RAT: Montelukast, a leukotriene modifier, is taken once a day for maintenance at bedtime

ANS: Administer atropine to reduce the client's respiratory secretions RAT: The nurse should administer atropine to reduce terminal respiratory secretions and reduce noisy ventilations called "the death rattle."

ANS: The toddler is inadequately dressed for the weather RAT: Inappropriate dress is a suggestive finding of physical neglect. The nurse should collect further data for other indicators of physical neglect

ANS: Keep the client in a side-lying position RAT: The nurse should keep the client in a side-lying position to facilitate drainage of any secretions and prevent aspiration

ANS: Move the arm behind the body with the elbow straight RAT: Hyperextension of the shoulder involves the deltoid, teres major, and latissimus dorsi muscles. The client performs this motion by moving their arm behind their body while keeping the elbow straight

ANS: "I didn't get a good grade because my teacher does not like me." RAT: The nurse should recognize this statement as the use of rationalization by a client. Rationalization is used as a means of justifying unreasonable feelings, thoughts, or actions

ANS: Offer the client a snack of whole grain crackers before bedtime RAT: The nurse should provide the client a light carbohydrate snack, such as whole grain crackers, before bedtime

ANS: Unplug the equipment and remove it from the room RAT: If the nurse identifies a potential safety hazard with the equipment, the nurse should remove the pump from the client's room to prevent injury to the client. The nurse should then follow facility protocol regarding faulty equipment

ANS: "My child goes back to sleep right away." RAT: The nurse should realize that going back to sleep quickly is an indication of sleep terrors, rather than nightmares. A child who is experiencing nightmares has difficulty returning to sleep because of continued fear

ANS: Complete a fall risk assessment on the client RAT: The first action the nurse should take when using the nursing process is to collect data from the client. By completing a fall risk assessment, the nurse can identify the client's risk for falls and can then assist in planning interventions to prevent client injury

ANS: 2 Tbsp peanut butter RAT: The nurse should recommend 2 Tbsp of peanut butter because it contains approximately 7 g of proteins

ANS: The client remains relaxed when thinking of the phobia RAT: The purpose of desensitization therapy is to teach the client to use relaxation techinques to overcome the anxiety caused by the phobia. The nurse should recognize the client's lack of anxiety when thinking about the phobia as a positive response to the therapy

ANS: Airborne RAT: The nurse should initiate airborne precautions for a client who has rubeola. This includes a private room with negative-pressure airflow and an air filtration system. Facility personnel are required to wear an N95 respirator while in the client's room

ANS: Drink high-protein and high-calorie nutritional supplements RAT: The nurse should instruct the client to drink high-protein and high-calorie nutritional supplements to maintain respiratory muscle function. COPD causes respiratory stress that can lead to hypermetabolism and wasting of the client's muscle mass

ANS: Shred printouts of client care information when they are no longer needed RAT: Nurses should destroy documents that contain information regarding client care when they are no longer needed to avoid compromising client confidentiality

ANS: Elevate the head of the client's bed RAT: The nurse should elevate the head of the client's bed to decrease the distance the client has to move to sit on the side of the bed

ANS: Place an abduction wedge between the client's legs when in bed RAT: The nurse should place an abduction wedge between the client's legs while in bed to prevent adduction of the legs and hip dislocation following a total hip arthroplasty

ANS: "I will keep my intake of sodium less than 2,300 milligrams per day." RAT: DASH principles include limiting daily sodium intake to less than 2,300 mg/day. Individuals who have an increased risk for hypertension such as clients who have kidney disease and diabetes, should reduce intake of sodium to 1,500 mg/day

ANS: Document the findings as a variance RAT: Whenever a client does not meet the goals or outcomes in the critical pathway due to unexpected findings or a need for additional interventions, the nurse should document the details as a variance in the critical pathway. In this case, it is a negative variance. If the client progresses faster than the pathway specifies, it is a positive variance

ANS: Escort the client to a quiet area on the nursing unit RAT: A client who has Alzheimer's disease experiences chronic confusion. Guiding the client to a quiet, familiar area will help decrease agitation

ANS: pH 7.5 RAT: The nurse should identify that a pH level of 7.5 indicates alkalosis and is above the expected reference range. Excessive ventilation can cause this finding

ANS: Verify the prescription in the client's medical record RAT: The first action the nurse should take when using the nursing process is to collect more data. By verifying the prescription in the client's medical record, the nurse can ensure that the medication is prescribed for the client

ANS: Motor response RAT: The nurse should collect data about the client's motor response and assign the response a score of 1 to 6, according to the Glasgow Coma Scale

ANS: Administer by subcutaneous injection RAT: The nurse should include that enoxaparin should be injected into the subcutaneous tissue

ANS: "I am really cold. May I have another warm blanket?" RAT: The nurse should recognize that a report from the child of feeling cold or having chills is a possible indication of a hemolytic transfusion reaction. This reaction occurs when the RBCs being infused are destroyed by the child's immune system. The nurse should stop the transfusion immediately, take a set of vital signs, and notify the charge nurse and provider

ANS: Ibuprofen RAT: Ibuprofen, or any other nonsteroidal anti-inflammatory medications, can reduce the antihypertensive effects of this medication. Therefore, the nurse should instruct the client who is taking captopril to avoid taking ibuprofen

ANS: Reports a decrease in the number of stools RAT: Pancrelipase is administered as replacement therapy for a deficiency in pancreatic enzymes, which result in steatorrhea, or fatty stools. The nurse should monitor for improved nutrition and a decrease in the number of bowel movements, which would indicate a therapeutic response to the medication

ANS: Notify the client's care team about the threats against their partner RAT: The nurse should notify the client's care team about the threats the client makes toward others. Failure of the nurse to report threats made toward others is considered negligence

ANS: "I can change my health care decisions even if I have advance directives." RAT: The nurse should instruct the client that they are free to make changes to advance directives at any time. Treatment decisions might change as a client's health status changes

ANS: Stroke the sole of the newborn's foot upward and toward the great toe RAT: The nurse should stroke upward along the lateral aspect of the sole of the foot, beginning at the heel, to elicit the Babinski reflex

ANS: Respiratory rate 10/min RAT: A respiratory rate of 10/min indicates respiratory depression, which is an adverse effect of morphine

ANS: Ensure the dialysate solution is at room temperature RAT: Evidence-based practice indicates the nurse should administer the dialysate solution at a temperature of 98.6; therefore, the first action the nurse should take is to warm the prescribed solution

ANS: WBC 25,000/mm RAT: The nurse should identify a WBC of 25,000/mm is above the expected reference range and is an indication that the client might have a postoperative infection; therefore, the nurse should report this finding to the provider

ANS: Chlorine bleach solution RAT: The nurse should instruct the AP to use a bleach solution to clean up a blood spill. A 1:10 bleach-to-water solution will destroy all bloodborne pathogens

ANS: Perform daily gum massage RAT: Gingival hyperplasia is a common adverse effect of this medication. Massaging the gums will help minimize this effect

ANS: Edema above the catheter insertion site RAT: Edema above the catheter site indicates infiltration. The nurse should stop the IV infusion

ANS: Place the client in a private room RAT: The nurse should place a client who has viral meningitis in a private room to prevent the transmission of the virus. Direct contact with a contaminated surface or the saliva, mucus, or feces of the person who has the infection transmits viral meningitis

ANS: Chronic constipation RAT: Diverticular disease is a disorder in which pouches or sac-like projections occur in the bowel mucosa through weakened areas of the muscular layer of the intestines. The nurse should identify chronic constipation as a risk factor for diverticular disease

ANS: Perform postmortem care for a client who died 1 hr ago RAT: Performing postmortem care is within the range of function for an AP. Therefore, the nurse should delegate this task to an AP

ANS: The client asks the nurse to help them die peacefully in their sleep RAT: This situation presents an ethical issue for the nurse because the client is asking for a variation of active euthanasia, also known as assisted suicide, which is in violation of the Code of Ethics for Nurses. The nurse is legally and ethically unable to support this decision by the client and should ask for assistance with this dilemma

ANS: Bradycardia RAT: Betaxolol is a beta blocker that can produce systemic effects, such as bradycardia

ANS: Hydration status RAT: Older adults are at risk for dehydration. Therefore, the nurse should be vigilant about monitoring the client's hydration status and include this information in the weekly nursing care summary

ANS: Record the amount of food the client consumes RAT: The nurse should record the amount of food the client consumes to ensure the client is consuming adequate nutrition

Wheeze

1. Clean the burn with mild soap and tepid water 2. Remove any embedded debris 3. Apply an antimicrobial ointment 4. Wrap the hand in a gauze dressing 5. Inform the parent of dressing change schedule

sitting and leaning forward using both hands for support is an expected finding for a 7 month old infant

monitor your blood pressure using your right arm daily

sweating

"Dad, i remember the time we all went fishing at the lake."

A client who is 36 weeks of gestation and reports a painless vaginal bleeding

urine specific gravity of 1.002

Sedation

Recommend the client wear comfortable shoes during the test

hematemesis

Discontinue drinking caffeinated beverages

Identify the client's concerns about receiving the medication

A client who is newly diagnosed with tuberculosis

Moisten the client's conjunctiva with sterile normal saline

Flush the tube with 60 mL of water if it becomes clogged

"Let's give the medicine to your doll first."

"My doctors glasses have lasers that will burn holes in my brain if i look at him."

External rotation

Elevate the head of the client's bed.

Open sterile packages

Cerebrospinal fluid analysis

Administer the medication subcutaneously

Assist the client to a nearby waiting area

Keep the plugged tube above the level of the stomach when the client is ambulating

Fidelity

Apply capsaicin cream 4 times daily

Canned peaches

"I will use condoms in addition to birth control pills to decrease my risk of becoming pregnant."

Say the word "stop" when upsetting thoughts occur.

Headache

Cleanse the clients labia and meatus using a front to back motion Use the nondominant hand to expose the clients urinary meatus Advance the cathter 5-7 in into the clients urinary meatus Ask the client to bear down while inserting the catheter

Select a site in the antecubital fossa