South Texas RNSG 2331 EXAM 4 CAPSTON 1 QUESTIONS AND ANSWERS LATEST UPDATE 2022/2023 BEST, Exams of Nursing

Download South Texas RNSG 2331 EXAM 4 CAPSTON 1 QUESTIONS AND ANSWERS LATEST UPDATE 2022/2023 BEST and more Exams Nursing in PDF only on Docsity! 1. On-going support from weight-loss program personnel. 2. Periodic weigh-ins with the nurse. • • South Texas RNSG 2331 EXAM 4 CAPSTON 1 QUESTIONS AND ANSWERS LATEST UPDATE 2022/2023 BEST EXAM SOLUTION RATED A+ Question: The client has been working on weight loss for 8 months and has been successful in losing 35 lbs (15.9 kg). The client is now entering the maintenance phase of the health promotion plan. Which strategies are important for the nurse to emphasize as the client enters this phase? You answered this question Correctly 3. Discontinue programmatic exercise plan. 4. Relapse prevention plan. 5. Continued peer support. 1., 2., 4. & 5. Correct: The person must have ongoing support to prevent a relapse. The weigh-ins increase accountability for prolonged behavioral change. Anytime that a new behavior is instituted, there is a chance that the person will return to old habits. Having a plan in place may help the person to stay on track. Ongoing peer support can be very helpful as the client continues in the maintenance phase. 3. Incorrect: Programmatic exercise, although reduced in frequency perhaps, should still be available. If this is taken away or reduced too much, the client may return to old habits. Question: Which client in the Labor, Delivery, Recovery, and Postpartum Unit (LDRP) should the nurse see first? You answered this question Correctly 1. Primipara at 39 weeks gestation, who is dilated to three centimeters and at minus two station who states, "I think my water just broke." 2. Salami • • • • 2. Multigravida at term who is dilated to six centimers and at minus one station with moderate contractions every five to ten minutes. 3. Primipara at 38 weeks gestation who is dilated to five centimeters and at zero station with strong contractions every four minutes. 4. Multigravida at 36 weeks gestation with pregestational diabetes in for a biophysical profile for fetal well being. 1. Correct: Minus two station is high with the presenting part not engaged. This client is at high risk for prolapsed cord, which would require relieving pressure on the cord and emergency cesarean delivery. 2. Incorrect: Contractions are not close enough for this client to be an emergent situation. Also, since this is a multigravida client and not fully dilated yet, she is not a high risk client. 3. Incorrect: This client is in the active phase of labor, but there is much work to be done before she is fully dilated and engaged for delivery. 4. Incorrect: This client is not in labor and is a non-emergent client, particularly compared to client #1. Question: The nurse is preparing to discharge a client who has been placed on tranylcypromine. The nurse teaches the client about food to avoid while taking this medication. What food choice by the client confirms appropriate understanding of the teaching? You answered this question Correctly 1. Cottage cheese 3. Baked chicken 4. Potatoes 2. Correct: The client taking a monoamine oxidase inhibitor (MAOI) such as tranylcypromine should avoid foods rich in tyramine or tryptophan. These include: cured foods, those that have been aged, pickled, fermented, or smoked. These can precipitate a hypertensive crisis. 1. Incorrect: Clients taking MAOIs can eat cottage cheese in reasonable amounts. 3. Incorrect: Clients taking MAOIs can eat baked chicken. 4. Incorrect: Clients taking MAOIs can eat potatoes. Question: 2. Respiratory alkalosis 3. "Come to the clinic now so that we can help you." • • • • A client is admitted to the medical unit with an acute onset of fever, chills and RUQ pain. Vital signs are: T 99.8°F (37.7°C), P 132, RR 34, B/P 142/82. ABG results are: pH- 7.53, PaCO2 30, HCO3 22. The nurse determines that this client is in what acid/base imbalance? You answered this question Correctly 1.Respiratory acidosis 3.Metabolic acidosis 4.Metabolic alkalosis 2. Correct: This client has a severe infection. Hyperventilation due to anxiety, pain, shock, severe infection, fever, and liver failure can lead to respiratory alkalosis. pH > 7.45, PCO2 < 35, HCO3 normal. 1. Incorrect: Not acidosis with hyperventilation and pH of 7.53. 3. Incorrect: Not a metabolic related acid/base imbalance since the HCO3 is in normal range and is not acidosis. 4. Incorrect: Not a metabolic related acid/base imbalance since the HCO3 is in normal range. Question: A new mother calls the clinic and tells the nurse, “I don’t have any help taking care of my 3 week old baby. I don’t know what to do. I just feel like I can’t take care of him anymore. I wish I never had him sometimes. Maybe then my husband would spend more time at home.” What would be the nurse's best response? You answered this question Correctly 1. "You are experiencing maternity blues, which will go away on its own." 2. "You are just tired. Tell your husband that you need his help." 4. "Have you thought about getting a family member to help with the baby?" 3. Correct: This client is exhibiting signs of postpartum psychosis. Post partum psychosis is characterized by depressed mood, agitation, indecision, lack of concentration, guilt, and an abnormal attitude toward bodily functions. There is a lack of 1. Administer the digoxin. • • interest in or rejection of the baby, or a morbid fear that the baby may be harmed. Risks of suicide and infanticide should not be overlooked. 1. Incorrect: Maternity blues includes tearfulness, despondency, anxiety and subjectivity with impaired concentration. 2. Incorrect: This ignores a potentially life-threatening problem. The client is not just tired. 4. Incorrect: This ignores a potentially life-threatening problem. Assume the worse. Think about the safety of mom and baby. Question: A client has a prescription for digoxin 0.125 mg IV push every morning. Prior to administering digoxin, the nurse notes that the digoxin level drawn this morning was 0.9 ng/mL. Which action would be most important for the nurse to take? You answered this question Incorrectly 2.Hold the digoxin. 3.Notify the primary healthcare provider. 4.Repeat the digoxin level. 1. Correct: This is a normal digoxin level. The nurse would administer the prescribed digoxin. The therapeutic serum levels of digoxin range from 0.5 to 2 ng/mL. 2. Incorrect: This is a normal digoxin level. The nurse would administer the prescribed digoxin. 3. Incorrect: There is no need to notify the primary healthcare provider of a normal digoxin level. 4. Incorrect: There is no need to repeat a normal laboratory value. Question: Which member of the multi-disciplinary team oversees and coordinates the healthcare delivery process and organizes the delivery of healthcare services to the client? You answered this question Correctly 1.Clinical nutritionist 2. Primary nurse each shift 3. Primary healthcare provider 4. Hang a familiar object on the door to enhance room recognition. • • • • 4. Case manager 4. Correct: An important role of the case manager in the multi-disciplinary team care approach is coordination of client care. The case manager oversees the process of healthcare delivery and organizes and coordinates the delivery of healthcare services to the client. 1. Incorrect: The clinical nutritionist is a member of the multi-disciplinary team, but does not coordinate and organize the delivery of care outside of the client's nutritional needs. 2. Incorrect: The primary nurse each shift develops and executes the plan of care for the client, but is not the organizer and coordinator of all the services to the client. 3. Incorrect: The primary healthcare provider is a member of the multi- disciplinary team, but is responsible for prescribing healthcare for the client, not organizing the services. Question: The unlicensed assistive personnel (UAP) reports to the nurse that a client with Alzheimer's has been walking into rooms on the unit and stating, "This is my room, so get out!" What is the best instruction the nurse can give to the UAP? You answered this question Correctly 1.Calmly sit with the client and have the client repeat the room number at frequent intervals. 2.Have the client remain in the room so the client can become familiar with it. 3. Place a sign on the client's door that clearly has the client's name so the client can identify it. 4. Correct: A client with Alzheimer's is likely to recognize a familiar object before reading the name on the door. 1. Incorrect: You can make the client repeat the room number over and over, but he or she will not remember it particularly since it is short-term current memory. This is the part of memory that goes first with the Alzheimer's client. 2. Incorrect: Stay in your room until you get used to it? No, this is non- therapeutic for a client with Alzheimer's and could increase their confusion and moody behavior. 3. Following the prescribed dwell time, lower the bag to allow the fluid to drain out. 4. The fluid that is returned should be clear in appearance. 1. Measles, mumps and rubella (MMR) vaccine 4. RH0(D) immune globulin • • What should the nurse include when teaching a client in renal failure about peritoneal dialysis? You answered this question Incorrectly 1. Instill 250 ml of fluid into the peritoneal cavity over 30 minutes. 2. Use cool effluent when instilling into the peritoneal cavity. 5. If all the fluid does not drain out, place the bed in the Trendelenburg position. 6. A sweet taste may be experienced when peritoneal dialysis is used. 3, 4, & 6 Correct: Once the prescribed dwell time has ended, the bag is lowered and the fluids, along with the toxins, are drained out into a bag over a period of 15 – 30 minutes. The fluid should be clear in appearance (should be able to read a paper through it). Cloudy return could indicate infection. Since the dialysate has a lot of glucose in it, the client frequently reports a constant sweet taste. 1. Incorrect: The amount of fluid used in peritoneal dialysis is about 2000 to 2500 ml at a time. This filling of the peritoneal cavity is often completed in 10 minutes. 2. Incorrect: Cool fluids would cause vasoconstriction. The effluent should be warmed to body temperature to promote blood flow to enhance the exchange (the more blood flow, the more toxin removal). 5. Incorrect: If all of the fluid does not come out, the client should turn side to side to promote drainage. The Trendelenburg position would cause the fluids to pool in the upper peritoneal area and not drain adequately. Question: A client has just delivered a newborn. Based on the primary healthcare provider’s notation, what prescriptions does the nurse anticipate administering to the mother? You answered this question Correctly 2. Hepatitis A vaccine 3. Hepatitis B immune globulin 5. Tetanus toxoid 1. Nervousness 6. Hot and sweating • • 1. , & 4. Correct: A client who has a titer of less than 1:8 is administered a subcutaneous injection of rubella vaccine, or measles, mumps and rubella vaccine (MMR) during the postpartum period to protect a subsequent fetus from malformations. Clients should not get pregnant for 4 weeks following the vaccination. All Rh negative moms who have Rh positive newborns must be given RH0(D) immune globulin IM within 72 hours of newborn being born to suppress antibody formation in the mother. 2. Incorrect: The mother is negative for hepatitis but current guidelines recommend that the newborn be given the hepatitis B vaccine. Hepatitis A vaccine is not given. 3. Incorrect: The mother is negative for hepatitis. If the newborn had been born to a mom who has hepatitis B, the newborn would receive the hepatitis B vaccine and the Hepatitis B immune globulin within 12 hours of birth. 5. Incorrect: Mom is up to date on tetanus toxoid vaccine. Question: When performing an admission assessment, what should the nurse recognize as signs/symptoms of hyperthyroidism? You answered this question Correctly 2. Weight gain 3. Exophthalmos 4. Loss of appetite 5. Constipation 1. , 3., & 6. Correct: With hyperthyroidism, the client has too much energy. They report being nervous and feeling hot. Exophthalmos is an irreversible eye condition where the eyes bulge. This condition is associated with hyperthyroidism that has not been treated early enough to prevent this from occurring. Due to the hypermetabolic state, the client will often report feeling hot and will be sweating. 2. Incorrect: The client with hyperthyroidism has an increased appetite but experiences weight loss due to the excessive energy consumption. 4. Incorrect: Loss of appetite is seen in the client with hypothyroidism. The client with hyperthyroidism has an increased appetite but experiences weight loss due to the excessive energy consumption. 2. Scared and lonely and grabs the nurse’s hand for comfort. 3. Flail chest • • • • 5. Incorrect: Constipation is a sign of hypothyroidism due to slowed GI motility. In hyperthyroidism, the nurse would expect increased GI motility. Question: The nurse is administering medication to an elderly client who has no visitors. The client takes the pills, and, as the client hands the medication cup back to the nurse, grabs onto the nurse's hand tightly. What is the most logical rationale for the client's action? You answered this question Incorrectly 1. Confusion and disorientation. 3. Would like to talk with the nurse. 4. Would like to reminisce with the nurse. 2. Correct: This elderly client with no visitors is most likely scared and lonely. The touch of the nurse's hand is comforting for the client. 1. Incorrect: There is no indication of confusion or disorientation. 3. Incorrect: Grabbing the nurse's hand indicates more than just a desire to talk. This is indicative of needing comfort and personal touch. 4. Incorrect: There is no indication of a desire to reminisce from the information in the question. Question: The client is admitted to the hospital following a motor vehicle accident and has sustained a closed chest wound. The nurse notes paradoxical chest wall movement. Which problem does the nurse suspect? You answered this question Correctly 1. Mediastinal shift 2. Tension pneumothorax 4. Pulmonary contusion 3. Correct: Hallmark of flail chest is paradoxical chest wall movement. This is often described as a see-saw effect when observing the rise and fall of the chest. 3. Broiled white fish, baked potato, mixed salad and tea 1. Decreased anxiety 2. Relief of chest pain • • • • access should be monitored closely due to the risk of necrosis and tissue sloughing with extravasation. Question: A client of Jewish faith has requested a Kosher diet. Which food tray would the nurse provide to the client? You answered this question Correctly 1. Medium rare steak, potato salad, peas and coffee 2. Ham sandwich, chips, fruit salad and juice 4. Baked chicken, vegetable medley, rice and milk 3. Correct: Fish is allowed if it has fins and scales. Shellfish is not kosher. Pasta, potatoes, salads and tea are allowed. 1. Incorrect: Although steak is allowed, all traces of blood must be gone. 2. Incorrect: No pork products are allowed, so no bacon, ham, or sausage. 4. Incorrect: Milk is not allowed at the same time as meat. There should be at least three hours separating the two. Question: The drug nadolol is prescribed for a client with stable angina. Which findings would indicate to the nurse that the drug is effective? You answered this question Correctly 3. Bounding pulses 4. Lowered blood pressure 5. Bradycardia 1., 2., & 4. Correct: Nadolol is a beta-blocking agent. Beta-blockers block the beta 1 adrenergic receptor cells in the heart, thereby decreasing heart rate, contractility, and blood pressure. These effects decrease the workload on the heart. With decreased oxygen demand (workload on the heart), chest pain is relieved. Beta-blockers decrease 2. Use petroleum jelly on the nares and cheeks. • • cardiac contractility, thereby decreasing cardiac output. Beta blockers also relieve anxiety. 3. Incorrect: Bounding pulses would indicate fluid volume excess, thus making the problem worse. 5. Incorrect: Nadolol is a beta-blocking agent, which blocks the beta 1 adrenergic receptor cells in the heart, thereby decreasing heart rate; however, decreasing the heart rate to the point of bradycardia would be an adverse effect. Question: The new nurse is caring for a client receiving oxygen by nasal cannula. Which action would require the charge nurse to intervene? You answered this question Correctly 1. Apply gauze padding beneath the tubing. 3. Provide mouth and nose care every 4 hours as needed. 4. Place the oxygen tubing above the ears. 2. Correct: Petroleum jelly is a combustible substance. It should not be used with oxygen therapy. 1. Incorrect: The charge nurse would not need to intervene if the new nurse applied gauze padding beneath the tubing to protect the client’s skin. This is acceptable. 3. Incorrect: The charge nurse would not need to intervene if the new nurse provided mouth and nose care every four hours as needed to protect the client’s skin and mucous membranes. This is acceptable. 4. Incorrect: The charge nurse would not need to intervene if the new nurse placed the oxygen mask straps well above the client’s ears to protect the client’s skin. This is acceptable. Question: The client with bleeding esophageal varices has a Blakemore tube in place. What piece of equipment should be present at the bedside? You answered this question Incorrectly 1. Tracheostomy set 2. Clamps 2. “I should go to an Alcoholics Anonymous meeting when I feel the need to drink alcohol.” • • • • 3. Surgical scissors 4. Tourniquet 3. Correct: Yes, if the tube gets dislodged and occludes the airway, the balloon must be cut and the tube removed to allow the client to breathe. 1. Incorrect: No, that goes with thyroidectomy and parathyroidectomy, either accidental or intentional. When the parathyroids are removed, hypocalcemia can occur and leads to tight rigid muscles. This also affects the smooth muscle of the airway and leads to stridor, respiratory distress, and possible trach. 2. Incorrect: No, that’s for chest tubes and would be necessary if there was a leak in the chest tube system or in preparation for removal of chest tubes if prescribed. 4. Incorrect: That goes with amputations because there is a risk for massive hemorrhage after an amputation. A tourniquet would be necessary for a limb amputation. There is a risk for excessive hemorrhage after an amputation. Question: Which statement by a client scheduled to be discharged home following treatment for alcoholism would indicate to the nurse that further instruction is necessary? You answered this question Correctly 1. “I will read labels to be sure there is no hidden alcohol in food.” 3. “I can call the clinic or my sponsor whenever I feel tempted to drink alcohol.” 4. “Even one glass of alcohol can cause me to start drinking regularly again.” 2. Correct: This statement indicates the need for further instruction for this client. When discharged home following rehabilitation for alcohol, clients are told to attend at least one AA meeting every single day, whether feeling the need to drink or not. Constant reinforcement is found to increase the rate of success following inpatient rehabilitation. 1.Incorrect: This statement by the client is correct. Many daily products contain small amounts of alcohol, such as salad dressings, cold medications, and even after shave. 3.Incorrect: This is also a correct statement, as clients who are recovering from alcoholism are designated a “sponsor”, or support person, whom they can contact at any time for assistance. Also, there is a 24/7 hotline for most clinics to provide emotional support to clients 4. Incorrect: This statement by the client is also correct. No amount of alcohol is considered “safe” for an alcoholic and even one glass of 1. Bathe the client who is on telemetry. 2. Apply cardiac leads and connect a client to a cardiac monitor. 3. Help position a client for a portable chest x-ray. 1. Provide foods that are soft and tender. 2. Allow client to rest between bites. 3. Encourage client to drink thickened liquids. • • 3. Incorrect: The injector should be placed firmly against the skin; otherwise the client may get an insufficient stick and require another stick. 4. Incorrect: The finger should be in a dependent position to increase blood flow to the site so as to prevent the need for another stick. Question: Which tasks could the nurse working on a cardiac unit delegate to an unlicensed assistive personnel (UAP)? You answered this question Incorrectly 4. Feed a client who is dysphagic. 5. Collect a stool specimen. 1., 2., 3., & 5. Correct: Remember the RN cannot delegate assessment, teaching, evaluation, medications, or an unstable client to the UAP. The UAP could bathe the client who is on telemetry. This is an appropriate assignment. The UAP can apply cardiac leads and connect the client to a cardiac monitor. The UAP can assist with helping the client sit up for a portable chest x-ray as long as the UAP is not pregnant and wears a shield. The UAP can collect specimens, such as a stool specimen. 4. Incorrect: This client has difficulty swallowing and is at risk for choking making the client unstable. Therefore, the nurse should not allow the UAP to feed this client Question: A client is admitted with a diagnosis of myasthenia gravis. What interventions should the nurse include to manage this client's swallowing and chewing impairment? You answered this question Correctly 4. Position upright with head tilted slightly backwards. 5. Dissolve the cholinesterase inhibitor medication in water. 1. Color Changes 2. Drainage 3. Odor 4. Fever • • • • 1., 2., & 3. Correct: Myasthenia gravis is a disorder wherein the postsynaptic neuromuscular junction receptor sites are decreased. This decrease in receptor sites causes decreased muscular depolarization. The clinical manifestations of this disease are progressive muscle weakness and fatigue. Eventually clients may experience difficulty breathing due to weakness and fatigue of the respiratory muscles. Muscle fatigue impairs chewing and swallowing. These actions decrease the risk of aspiration, decrease the work of muscles, and allow for improved swallowing. 4. Incorrect: Tilt head slightly forward (chin tuck, head turn). 5. Incorrect: The cholinesterase inhibitor should not be dissolved in water due to the client's difficulty swallowing. Liquids should be thickened. Question: The nurse is caring for a client with a perineal burn. The skin is not intact. What signs are suggestive of infection? You answered this question Correctly 5. Bleeding 6. Increased Pain 1., 2., 3., 4. & 6. Correct: Infections may cause color changes, drainage, odor, fever, & increased pain. Bleeding is a sign of hemorrhage, trauma, anemia or other blood disorders but not infection. 5. Incorrect: Bleeding is not a sign of infection. It may occur along with an infection but will not be caused by it. Question: A client diagnosed with schizophrenia tells the nurse, "God is going to heal me. I do not need medication." Which response by the nurse would best promote compliance with the prescribed medication regimen? You answered this question Correctly 2. Many people of faith believe that one way God works to heal is through medication. 2. 4 mm Hg • • • • 1. Yes, I believe that God will heal you. 3. We are talking about taking your medications right now. 4. What if God does not heal you and you should have taken the medication? 2. Correct: This allows the client to keep the belief that God will heal but will do it through the medication. This promotes compliance with the prescribed medication regimen. 1. Incorrect: The nurse does not know if God will heal the client and does not promote compliance with the prescribed medication regimen. 3. Incorrect: This approach may make the client angry, which will close the communication between the client and the nurse. It also does not promote compliance with the prescribed medication regimen. 4. Incorrect: This approach is argumentative and puts the client on the defense, which will close the communication between the client and the nurse. Question: A client is being treated in the emergency department for dehydration. Which central venous pressure (CVP) reading would the nurse identify as the desired response to treatment? You answered this question Correctly 1. -1 mm Hg 3. 10 mm Hg 4. 15 mm Hg 2. Correct: This CVP reading is indicative of a normal fluid volume state. This would be the desired response of treatment for dehydration. 1. Incorrect: This CVP reading is indicative of fluid volume deficit. The normal CVP reading is 2-6 mm Hg. 3. Incorrect: The normal CVP reading is 2-6 mm Hg. This CVP reading is high and indicative of fluid volume excess. This is not the desired outcome of treatment for dehydration. 4. Incorrect: The normal CVP reading is 2-6 mm Hg. This CVP reading is high and 1. White blood cell count of 3,800 (3.8 x 109/L) 5. Red blood cell count of 3.0 million/mcL (3.0 x 1012/L) 1. Checking your vital signs frequently. 2. Examining the dressing for bleeding. 3. Listening to and percussing your lungs. • • You answered this question Correctly 2. White blood cell count of 15,000 (15.0 x 109/L) 3. Platelet count of 90,000/µL (90 x 109/L) 4. Platelet count of 450,000/µL (450 x 109/L) 6. Red blood cell count of 7.3 million/mcL (7.3 x 1012/L) 1. , 3., 5. Correct: Pancytopenia is a condition in which there is a concurrent leukopenia (a reduction in white blood cells), thrombocytopenia (a reduction in platelets), and anemia (reduction in red blood cells). The normal white blood cell count is 5,000- 10,000 (5.0 to 10.0 x 109/L), so a level of 3,800 (3.8 x 109/L) represents leukopenia. The normal platelet count is 150,000- 400,000/µL (150 - 450 x 109/L), so a level of 90,000/µL represents thrombocytopenia. The normal red blood cell count for a Female is 4.2 – 5.4 million/mcL ( 4.2 – 5.4 x 1012/L), and the normal red blood count for a Male is 4.7 – 6.1 million/mcL (4.7 – 6.1 X 1012/L). Therefore, a red blood cell count of 3.0 million/mcL (3.0 x 1012/L) is indicative of anemia, regardless of the sex of the client. 2. Incorrect. The normal white blood cell count is 5,000-10,000 (5.0 to 10.0 x 109/L). A WBC count of 15,000 (15.0 x 109/L) is considered leukocytosis (elevated WBC level). 4. Incorrect: The normal platelet count is 150,000-400,000/µL (150 - 450 x 109/L). Therefore, a platelet count of 450,000/µL (450 x 109/L) would be an elevated platelet level (thrombocytosis). 6. Incorrect: The normal red blood cell count for a Female is 4.2 – 5.4 million/mcL (4.2 – 5.4 x 1012/L), and the normal red blood count for a Male is 4.7 – 6.1 million/mcL (4.7 – 6.1 X 1012/L). Therefore, a level of 7.3 million/mcL (7.3 x 1012/L) is elevated (polycythemia). Question: A nurse is teaching a client about post-procedure thoracentesis nursing care. Which statements should the nurse include? You answered this question Incorrectly 4. Positioning you with your affected lung down. 1. Parent states infant tastes salty. 2. Frequent coughing with thick, blood-streaked sputum. 3. Foul-smelling, greasy stools. • • • • 5. Palpating around the incision site for air under the skin. 1., 2., 3., & 5. Correct: Anytime fluid is being removed from a client, there is a risk they could develop a fluid volume deficit, or worse, shock. Checking vital signs frequently is important. Examining the dressing for bleeding is appropriate. Listening to lung sounds is appropriate. The nurse percusses the lungs as part of the respiratory assessment. (Hyperresonance indicates air in the pleural space. Dull percussions indicate fluid in the pleural space) Subcutaneous emphysema could indicate a pneumothorax. There is air leaking into the tissue. 4. Incorrect: Turn the client on the unaffected side for at least one hour to allow the pleural puncture site to heal and promote lung expansion of the affected lung. Question: Which information obtained during a well-baby checkup of a 3 month old infant would the nurse need to report to the primary healthcare provider? You answered this question Correctly 4. Able to hold head upright without head wobbling. 5. No weight gain since last check-up. 1., 2., 3., & 5. Correct: These are signs/symptoms of cystic fibrosis (CF) and should be reported to the primary health care provider. One of the first signs of CF that parents may notice is that their baby's skin tastes salty when kissed. People who have CF have thick, sticky mucus that builds up in their airways. This buildup of mucus makes it easier for bacteria to grow and cause infections. Infections can block the airways and cause frequent coughing that brings up thick mucus or mucus that's sometimes bloody. Mucus can block tubes, or ducts, in the pancreas, preventing enzymes from reaching the intestines. As a result, the intestines can't fully absorb fats and proteins. This can cause ongoing diarrhea or bulky, foul-smelling, greasy stools. A hallmark of CF in children is poor weight gain and growth. These children are unable to get enough nutrients from their food because of the lack of enzymes to help absorb fats and proteins. 4. Incorrect: This is expected at this age. Very little or no head wobbling should be seen in a three-month-old baby when the head is upright. 1. Check shoes for rough spots in the lining. 2. File toenails straight across. 1. “Please tell me how I can best help you control your pain.” • • • • Question: The nurse is teaching a group of clients who have reduced peripheral circulation how to care for their feet. What points should the nurse include? You answered this question Incorrectly 3. Cover feet and between toes with creams to moisten the skin. 4. Break in new shoes gradually. 5. Use pumice stones to treat calluses. 1., 2., & 4. Correct: Rubbing from rough spots in the shoe can lead to corns or calluses. File the toenails rather than cutting to avoid skin injury. File nails straight across the ends of the toes. If the nails are too thick or misshapen to file, consult podiatrist. Break in new shoes gradually by increasing the wearing time 30-60 minutes each day. 3. Incorrect: Cover the feet, except between the toes, with creams or lotions to moisten the skin. Lotion will also soften calluses. A lotion that reduces dryness effectively is a mixture of lanolin and mineral oil. 5. Incorrect: Avoid self-treatment of corns or calluses. Pumice stones and some callus and corn applications are injurious to the skin. Do not cut calluses or corns. Consult a podiatrist or primary healthcare provider first. Question: The nurse is planning to discuss pain management with a client who experiences chronic pain. How should the nurse best begin this discussion? You answered this question Incorrectly 2. “It is my job to teach you how to deal with your pain.” 3. “I will be teaching you how to use guided imagery to decrease your pain.” 4. “Your primary healthcare provider has prescribed pain medication for your pain. I will teach you about this medication.” 1. Correct: This statement sends a couple of messages that are an important part of treatment planning and evaluation of care. First, it places the ownership and 1. Promote maximal stability by utilizing a wide base of support. 2. Maintain a low center of gravity. 3. Use both the arms and the legs when performing strenuous activity. 6. Obtain assistance from other nurses or nurse assistants as needed. 1. Use simple words. • • • • You answered this question Correctly 4. Save effort by lifting rather than rolling, turning, or pivoting. 5. Utilize muscles of the back rather than muscles of the shoulders. 1., 2., 3., & 6. Correct: When in a standing position, the center of gravity is at the center of the pelvis. The wider the base of support and the lower the center of gravity the nurse maintains, the greater the stability for the movement. Using both the arms and the legs provides a sense of balance for the activity. It is always smart to seek more assistance when needed to avoid injury to self. 4. Incorrect: Rolling, turning, and pivoting are less likely to cause injury than attempting to lift. Lifting puts more strain on the back than these other methods. 5. Incorrect: The larger muscles of the thighs, buttocks, and shoulders should be utilized for activity because the smaller muscles such as those in the back and arms are more susceptible to injury. Question: A home care nurse is preparing to perform venipuncture on a client to draw blood. As the nurse gathers supplies, the client begins to experience palpitations, trembling, nausea, shortness of breath and a feeling of losing control. How should the nurse communicate with this client? You answered this question Correctly 2. Speak loudly to the client. 3. Do not speak to the client at this time. 4. Use open-ended questions to ask what is wrong. 1. Correct: Use simple words, because the client cannot comprehend anything but the most elemental communications during a panic attack. 1. "Exhale completely before using my inhaler." • • 2. Incorrect: A calm, low level of intensity to reduce anxiety is needed. Speaking loudly will increase the client's anxiety. 3. Incorrect: Calm, simple words are needed instead of silence which could be interpreted as ignoring the client. 4. Incorrect: Simple communication of reassurance needed. This is not the time for open ended questions and would increase the client's anxiety. Question: The nurse is teaching the client with asthma on proper use of an inhaler. Which statements by the client indicates that teaching has been successful? You answered this question Incorrectly 2. "Use my steriod inhaler before the bronchodilator." 3. "Inhale slowly and push down firmly on the inhaler." 4. "Rinse my mouth with water after using my inhaler." 5. "Wait 5 minutes between puffs." 1. , 3. & 4. Correct: The client should exhale completely before using the inhaler; this response indicates the teaching was effective. The client should inhale slowly and push down firmly on the inhaler when administering the medication; therefore, the teaching was effective. The client should rinse the mouth after using the inhaler to prevent thrush. 2. Incorrect. The client should use the bronchodilator before the steroid inhaler. This response indicates the need for further teaching. 5. Incorrect. For inhaled quick-relief medication (beta2-agonists), wait about one minute between puffs. There is no need to wait between puffs for other medications. Question: Which client should the charge nurse assign to a new RN? You answered this question Incorrectly 1. Child needing pre-operative medication prior to reduction of a fracture. 2. Takes offense to the abrupt nature of the treatment. • • • • 2. Adult client reporting abdominal pain after being beaten up in a fight. 3. Adolescent with sickle cell disease requesting more medication via the patient controlled analgesia device. 4. Child admitted with cystic fibrosis 2 hours ago. 1. Correct: This is the least complicated client that could be given to a new, inexperienced nurse. Even though he client has a fracture, the focus is on giving pain medication prior to a major procedure. 2. Incorrect: This client could have internal bleeding and other complications not diagnosed. This is not the best client to give to the new nurse. 3. Incorrect: This is a more complex client and is least likely to be assigned to a new nurse because of the increased need for pain medications, like narcotics, and use of a technological device. Sickle cell pain episodes will vary in it's intensity and frequency. 4. Incorrect: This is a complex client and should not be given to the new nurse. This client is a new admit at risk for respiratory distress and potential infections due to the chronic long term effects of cystic fibrosis. Question: A Hispanic mother and her child visit the primary healthcare provider's office due to a fever that the child has been having for two or three days. Upon entering the room, the nurse immediately asks what is happening with the child and begins to check the temperature. Which response is likely from the mother? You answered this question Incorrectly 1. Accepts the treatment of the nurse and think that it is appropriate. 3. Thinks that the nurse is busy and needs to rush. 4. Thinks that the nurse is very efficient. 2. Correct: The family is likely to be offended by the abrupt manner of the nurse. The Hispanic culture is present time oriented and desire attention and interaction. It would not be relevant that the nurse may be busy. To overlook this cultural variation is rude and does not treat the mother with dignity. 1. Incorrect: The nurse is not demonstrating cultural sensitivity. The family is not likely to accept this abrupt approach due to the cultural differences related to time and the desire for more genuine personal interaction. The Hispanic mother may be offended by the direct interviewing approach of the nurse. 3. Incorrect: The mother is likely to be offended with this abrupt response. 4. Receiving treatment for dehydration, and is now picking at bedding and IV tubing. • • • • 3. Decreased plasma uric acid levels. 4. Low-grade fever and rash. 1. Correct. The client usually experiences dramatic improvement within 24 hours after beginning NSAIDs. 2. Incorrect. Most clients can tolerate NSAIDs fairly well. If severe pain in experienced, the primary healthcare provider should be notified immediately. 3. Incorrect. NSAIDs do not reduce plasma uric acid levels. 4. Incorrect. This is not an adverse effect of NSAIDs, in fact, most NSAIDs are also antipyretics and would prevent fever. Question: After report, the nurse is assigned to care for 4 adult clients. Which client should the nurse assess first? You answered this question Correctly 1. Admitted 3 hours ago post appendectomy with small amount of drainage on dressing. 2. Diagnosed with early onset of Alzheimer's disease with confusion. 3. Post operative internal fixation of the femur with crust forming on the Steinman pins. 4. Correct: Being restless is an early sign of hypoxia, so oxygen may be necessary. Remember oxygenation takes priority over the other issues with these clients. The client may also be exhibiting manifestations of fluid volume deficit (FVD) 1. Incorrect: This is a stable client, so no indication of immediate distress is indicated. A small amount of drainage on the dressing of a client who had a appendectomy 3 hours ago would not be assessed first. 2. Incorrect: This is a stable client because confusion is part of Alzheimer’s disease. Safety issues for a confused client should be evaluated. The client with dehydration is exhibiting possible manifestations of decreased oxygen level and/or fluid volume deficit (FVD) and should be assessed first. 3. Incorrect: This is a stable client with no indication of immediate distress. Crust forming on the Steinmann pins should be removed from the pin insertion site, however, this client would not be given priority over the client with dehydration. Question: 1. Angina 4. Heat intolerance 5. Tremors 1. Progesterone • • • • What side effects would the nurse expect to find in a client who has received too much levothyroxine? You answered this question Correctly 2. Bradycardia 3. Hypotension 1. , 4., & 5. Correct: These are side effects of too much levothyroxine. Levothyroxine is the replacement hormone for clients with hypothyroidism, so if too much is given, they would exhibit symptoms just like someone with hyperthyroidism. These clients also tend to have coronary artery disease (CAD), which is why angina is a significant side effect. 2. Incorrect: Tachycardia rather than bradycardia will be seen with too much levothyroxine. 3. Incorrect: Hypertension rather than hypotension will be seen with too much levothyroxine. Question: The nurse is teaching a group of pregnant women about hormonal changes during pregnancy. The nurse recognizes that teaching was successful when the women identify which hormone as causing amenorrhea? You answered this question Incorrectly 2. Estrogen 3. Follicle-stimulating hormone (FSH) 4. Human chorionic gonadotropin (hCG) 1. Correct: Progesterone causes amenorrhea. 2. Incorrect: Estrogen renders the female genital tract suitable for fertilization. 3. Incorrect: This stimulates the growth of the graafian follicle in the ovary. 4. Incorrect: This is the hormone present in urine for pregnancy test 1. Blood cultures times two 1. "There are a number of reasons that may contribute to depression, such as a decreased level of chemicals in your brain. " • • • • Question: A child is admitted to the hospital with a temp of 102.2°F ( 39.0°C), lethargic, and no urinary output in 6 hours. Which prescription would be priority for the nurse to initiate for this child? You answered this question Incorrectly 2. Ceftriaxone 250 mg IV every 12 hours 3. Start IV & monitor site. 4. 1/2 normal saline at 40 mL/hr 1. Correct: Immediate blood cultures should be obtained on this child, as sepsis is suspected with any temperature this high. The nurse would also need to get diagnostics before treatment is initiated so that correct interventions are prescribed. 2. Incorrect: The ceftriaxone is administered after the appropriate IV has been initiated. This would be the last intervention to be initiated. 3. Incorrect: The IV can be started at any point, but should be done after the cultures so the blood sample would not be affected in anyway. 4. Incorrect: Fluids will be started after the cultures are obtained and after the IV is started so as not to alter the results of the blood work and ensure correct treatment. Question: A client diagnosed with depression asks the nurse, “What is causing me to be depressed so often?” What is the best response by the nurse? You answered this question Correctly 2. "You experience depression because of your elevated levels of thyroid hormones." 3. "The primary healthcare provider will have to explain to you what is causing your depression." 4. "Tell me what you think causes you to be depressed." 1. Correct: Decreased levels of norepinephrine, dopamine, and serotonin are neurotransmitter implications for depression. By giving this type of information to the 2. Place the client in a negative pressure room. • • diarrheal illnesses, open wounds, Respiratory syncytial virus (RSV)}. Healthcare workers should wear a gown and gloves while in the client’s room. Remove the gown and gloves before leaving the room. Clean hands (hand washing or use hand sanitizer) when entering and leaving the room. Visitors must check with the nurse before taking anything into or out of the room. 2. Incorrect: Airborne isolation precautions are used for diseases or very small germs that are spread through the air from one person to another (examples: Tuberculosis (TB), measles, varicella). Healthcare workers should ensure client is placed in an appropriate negative air pressure room (a room where the air is gently sucked outside the building) with the door shut. Wear a fit-tested NIOSH-approved N-95 or higher level respirator while in the room. Clean hands (hand washing or use hand sanitizer) when they enter the room and when they leave the room. Ensure the client wears a surgical mask when leaving the room. Instruct visitors to wear a mask while in the room. 3. Incorrect: Contact isolation precautions are used for infections, diseases, or germs that are spread by touching the client or items in the room (examples: MRSA, VRE, diarrheal illnesses, open wounds, RSV). Healthcare workers should wear a gown and gloves while in the client’s room. Remove the gown and gloves before leaving the room. Clean hands (hand washing or use hand sanitizer) when entering and leaving the room. Visitors must check with the nurse before taking anything into or out of the room. Question: A client presents to the emergency department (ED) reporting fever, cough, and malaise. The nurse notes that the client has a rash appearing as vesicles, most prominently on the face, palms of the hands, and soles of the feet. In addition to triaging the client as emergent, what should the nurse do? You answered this question Correctly 1. Send the client to the waiting room. 3. Put a surgical mask on the client. 4. Initiate contact precautions. 2. Correct: The client may have smallpox, which is very contagious. Smallpox can also be used as a weapon in biological warfare. The first thing the nurse should do is place the client into a negative pressure room. Doing this first will protect others from potential exposure. 4. TPN appears oily in consistency • • 1. Incorrect: Sending this client to the waiting room will expose others to smallpox. Even if you don't recognize these specific disease symptoms, fever and rash should cue you to thinking of this as a potential infectious disease. 3. Incorrect: Having the client wear a surgical mask is not sufficient in this case. All healthcare providers should wear a N95 respirator when in contact with the client. After the client is sequestered, the nurse should notify the ED primary healthcare provider for further treatment instructions. 4. Incorrect: Airborne precautions are necessary because that is the primary transmission mode for smallpox. Question: The nurse is caring for a client receiving total parenteral nutrition (TPN). Which assessment would require the nurse to intervene? You answered this question Correctly 1. TPN has been hanging for 12 hours 2. Central venous catheter's dressing is clean and dry 3. TPN fluid is room temperature when beginning administration 4. Correct: Do not use TPN if it looks curdled, oily, or has particles in it. This is an indication that something is wrong with the solution and could harm the client if given. 1. Incorrect: This TPN does not need to be replaced at 12 hours. It can infuse for 24 hours. 2. Incorrect: This is a description of an occlusive clean dressing at the insertion site. This description would not require intervention. 3. Incorrect: TPN should be at room temperature when beginning administration. Solutions that is too cold could cause vasoconstriction and undue harm to the client Question: Which client assignments are most appropriate for the charge nurse to delegate to an LPN/VN who works on the pediatric unit? You answered this question Correctly 4. 7 year old in Buck's traction for a femur fracture. 3. Bolus feeding a client who has a gastrostomy tube. 4. Reinserting a nasogastric tube (NG) that a client accidentally pulled out. 5. Monitor patient control analgesic (PCA) pump pain medication being delivered to a client. • • • • 1. 10 year old paraplegic in for bowel training. 2. 2 year old with asthma newly admitted with dehydration. 3. 3 month old admitted with possible septicemia. 5. 10 year old transferred from ICU yesterday with a head injury. 1. & 4. Correct: These clients have conditions that the LPN/VN can care for with little assistance from the RN. Bowel training is a health promotion, self care activity that is within the scope of practice for the LPN/VN. Buck's traction is a type of skin traction that is also within the scope of practice for the LPN/VN. 2. Incorrect: This client will probably have IV fluids prescribed that the RN will need to administer. Assessment of lung status would be important since the client is a new admit with asthma. This is a potentially unstable client and would not be appropriate for the LPN/VN. 3. Incorrect: This client, admitted with septicemia, is potentially unstable and will probably require IV antibiotics and very close monitoring due to being very young with a major infection. 5. Incorrect: This client will need close observation and the higher skill level of an RN since there is a head injury and the client spent time in the ICU only one day before. Question: Which task would be appropriate for the charge nurse to assign to a LPN/VN? You answered this question Incorrectly 1. Collect data on a new client admit. 2. Administer morphine IVP to a two day post-op client. 1. , 3., 4., & 5. Correct: All of these tasks are appropriate and within the scope of practice for the LPN/VN. The LPN/VN can collect data on a new admit, and the RN would verify and co-sign to complete the assessment. Bolus feeding by way of a gastrostomy tube and reinserting a nasogastric tube would be appropriate assignments for the LPN/VN 3. Developing meaningful and intimate relationships. 4. Giving and sharing with an individual without asking what will be given or shared in return. • • 4. Incorrect. Two cups of orange juice would equal approximately 52 grams of carbohydrates. This would raise the blood sugar too high Question: When caring for young adult clients, which developmental tasks would the nurse expect to see? You answered this question Incorrectly 1. Satisfying and supporting the next generation. 2. Reflecting on life accomplishments. 5. Developing sense of fulfillment by volunteering in the community. 3. & 4. Correct: In young adulthood, the developmental tasks involve intimacy versus isolation. Intimacy relates more to sharing than to sex. Intimacy produces feelings of safety, closeness, and trust. 1. Incorrect: Parenting is a primary task of middle adulthood. This is the middle adulthood stage of Generativity versus Stagnation, where each adult must find some way to satisfy and support the next generation. 2. Incorrect: During late adulthood, there is refection on life accomplishments. This is the maturity stage of Ego Integrity versus Despair, where there is a reflection of one's life. 5. Incorrect: During middle age, a sense of fulfillment can be found by volunteering in the community. This is part of middle age, where the adult is finding ways to support others. Question: Which action, if done by a nurse, needs to be interrupted by the charge nurse? You answered this question Correctly 1. Mixes diazepam and hydromorphone in one syringe. 2. Administers diazepam before meals. 3. Raises side rails after administering hydromorphone. 4. Instructs client to call for assistance getting out of bed after administration of diazepam. 2. Removing the hair with clippers. • • • • 1. Correct: In this question, you are looking for the answer that is unsafe and should not be done. Diazepam cannot be mixed with any other medication. The charge nurse should intervene. 2. Incorrect: This is an appropriate action. Food in the stomach delays absorption of diazepam so it would need to be given before meals. 3. Incorrect: This would be an appropriate action. Hydromorphone is a narcotic and can decrease level of consciousness (LOC) and increase the risk of falls, so the nurse would be taking appropriate measures to ensure the client's safety. 4. Incorrect: This would be an appropriate action. Diazepam relaxes the muscles and can decrease LOC and increase the risk of falls. Question: The nurse is preparing a client for surgery. Which methods are appropriate for the nurse to use in removing excessive body hair? You answered this question Incorrectly 1. Shaving the hair with a razor. 3. Lathering the skin with soap and water prior to shaving with a razor. 4. Using a depilatory cream. 5. Always use a new, sharp razor. 2. & 4. Correct: Not removing the hair at all is preferred, but if this is not an option the use of clippers or a depilatory cream may be used to prevent trauma to the skin before surgery. 1. Incorrect: Using a razor for hair removal is not recommended because it causes micro-abrasions of the skin. Bacteria multiply in the micro-abrasions, increasing the risk of infection. This is not appropriate for a client going to surgery. 3. Incorrect: Using a razor for hair removal is not recommended because it causes micro-abrasions of the skin. Bacteria multiply in the micro-abrasions, increasing the risk of infection. This is not appropriate for a client going to surgery. 5. Incorrect: Using a razor for hair removal is not recommended because it causes micro-abrasions of the skin. Bacteria multiply in the micro-abrasions, increasing the risk of infection. This is not appropriate for a client going to surgery. • Remove the client from the room. Activate the fire alarm. Close the door to the client’s room. Obtain the fire extinguisher. Extinguish the fire. • • • Remove the client from the room. Activate the fire alarm. Obtain the fire extinguisher. Extinguish the fire. Close the door to the client’s room. • • Question: A nurse observes a fire has started in the trash can of a client’s room. What steps should the nurse take? Place steps in priority from first to last. You answered this question Incorrectly The Correct Order Your Selected Order Remember RACE: Rescue the client; activate the alarm; contain the fire in the client’s room; extinguish the fire. This standard process ensures safety for the client first and then the remaining people in the facility next. First, remove the client from the room. Second, activate the fire alarm. Third, close the door to the client’s room. Fourth, obtain the fire extinguisher. Fifth, extinguish the fire. Question: The nurse is caring for a client with chronic renal failure who receives dialysis treatment. Which findings would indicate to the nurse that the 2. I may expect increased sweating while taking this drug. • • • Verbally tell the client to stop the unaccepting behavior and escort client to another part of the day room. • • Walk the client out to the courtyard. Take the client to the quiet room for a time out. Place client in the isolation room with staff observation. • • • Use four point soft cloth restraints. Restrain client’s arms with wrist restraints. • • First, verbally tell the client to stop the unaccepting behavior and escort client to another part of the day room. This is the least restrictive. Second, walk the client out to the courtyard. This removes the client from the situation while still allowing some freedom. Third, take the client to the quiet room for a time out. This removes the client from the situation but also sets restrictions on where and with whom they can interact. Fourth, place client in the isolation room with staff observation. This is more restrictive than the quiet room, but doesn't require restraints. Fifth, restrain client’s arms with wrist restraints. This is a two point restraint which is much more restrictive than the isolation room. Lastly, use four point soft cloth restraints. This is the most restrictive. Question: The nurse is teaching a group of clients about selective serotonin reuptake inhibitors (SSRI). Which comment by a client in the group indicates adequate understanding of the effects/side effects of the medications? You answered this question Correctly 1. My weight may decrease while taking this drug. 3. I may actually feel more depressed while taking this medication. 4. I should feel better within a couple of days after beginning the medication. 2. Correct. The drug causes temperature dysregulation, with increased sweating in some clients. 1. Incorrect. The medications may cause weight gain in some clients. 2. When the client stops talking about suicide, the risk has increased. 3. Warning signs, even if indirect, are generally present prior to a suicide attempt. 4. One suicide attempt increases the chance of future suicide attempts. 5. Report sudden behavioral changes. 1. Turn every two hours 2. Place a pillow between legs when turning • • 3. Incorrect. The client should have a lessening of depressive symptoms within a few weeks. This is one of the primary indications for taking this classification of medications. 4. Incorrect. The lag time for antidepressants to reach therapeutic effect is usually two to four weeks before the therapeutic effect is reached. The client's comment indicates lack of understanding of the medication effects and side effects Question: The client has suicidal ideations with a vague plan for suicide. The nurse who is teaching the family to care for the client at home should emphasize which points? You answered this question Incorrectly 1. Family members are responsible for preventing future suicidal attempts. 2. , 3., 4. & 5. Correct: A common myth is that the person who doesn’t talk about suicide will not attempt it, but this may be a warning sign that the person has a well thought out plan. Warning signs generally exist but may not be recognized by others until after the suicide or attempted suicide. Once a person has made a suicidal attempt, the chances increase that they will attempt it again at a later time. Sudden behavioral changes can signal suicidal intentions, especially if that is the primary focus of their thoughts and feelings. 1. Incorrect: Families should be encouraged to create a safe environment and recognize warning signs, but they may not be able to stop a suicide. Families, in spite of their best efforts, should not be put into a position of guilt if the client is successful with suicide. Question: The nurse is planning care for a client who has a fractured hip. Which nursing interventions should the nurse plan to use for impaired physical mobility? You answered this question Correctly 4. Encourage fluid intake 5. Encourage ankle and foot exercises 1. Fundus 3 cm above umbilicus 2. Excessive lochia 5. Tenderness above symphysis pubis • • • • 3. Sit in a chair three times per day 1., 2., 4. & 5. Correct: The client must be turned every two hours. You may not be able to turn the client totally on the side of the fracture, but you must relieve pressure points. Place pillow between legs to keep affected leg in abducted position. Encourage fluid intake and ankle and foot exercises to prevent deep vein thrombosis (DVT). 3. Incorrect: The client has a fractured hip that has not been surgically fixed. Sitting up in a chair could do more injury and cause more pain Question: Three hours after delivery of a client’s newborn, the nurse assesses for bladder distention. What signs would the nurse note if the client’s bladder is distended? You answered this question Incorrectly 3. Voids 200 mL every 2 hours 4. Fundus in abdominal midline 1., 2., & 5. Correct: Monitor client for signs of distended bladder, such as fundal height above the umbilicus or baseline level, and/or fundus displaced from midline over to the side. Bladder bulges above the symphysis pubis, excessive lochia, tenderness over the bladder area, frequent voiding of less than 150 mL (indicative of urinary retention with overflow) are also sign of distended bladder. 3. Incorrect: Voiding every 2-3 hours should be encouraged to prevent possible displacement of the uterus and the development of atony. The clients ability to do this would prevent bladder distention. 4. Incorrect: Fundus in abdominal midline is what we want and is not a sign of bladder distention. We do not want it displaced over to the side from midline. Question: 3. Client with adrenal insufficiency who feels weak. 4. Ask the client about dietary preferences needed to meet religious guidelines. • • • • 2. Client who is a diabetic and has an infected sore on the foot. 4. Client with a fracture of the forearm that has been placed in a splint. 3. Correct: Adrenal insufficiency with weakness think SHOCK first. This is a client that does not have enough of all their steroids, including glucocorticoids, mineralocorticoids or sex hormones. The most pertinent of these is aldosterone, which causes loss of sodium and water, and leads to shock (fluid volume deficit). Since the client is feeling weak, this is a clear sign of fluid volume deficit (FVD) and potentially for shock. 1. Incorrect: Symptoms of Chronic Obstructive Pulmonary Disease (COPD), include a non-productive cough, because of the chronic inflammation and mucous in the lungs. 2. Incorrect: The presenting problem is the infected sore on the foot, not the client's diabetes. This is not an emergency situation. Therefore, this client would not be the priority. 4. Incorrect: Since the arm is splinted, the client is stable until further assessments and treatments can be completed, such as x-rays, medications, and casting. The client would not be seen first in this situation. Question: The nurse is planning care for a newly admitted client who has an Arabic surname and whose spouse is wearing a traditional head covering. After verifying that the client prescriptions include a regular diet as tolerated, how would the nurse best meet the religious dietary needs for this client? You answered this question Correctly 1. Allow the client to select whatever is acceptable from a regular meal tray. 2. Review the client’s admission data to determine any dietary restrictions. 3. Call the dietician to discuss special dietary needs with the client’s spouse. 4. Correct. Nurses must be aware of cultural, religious and spiritual beliefs as an important aspect in clients’ health and recovery. This nurse suspects possible cultural or religious implications that may require special dietary alterations for the client, even though the primary health care provider prescribed a regular diet. Asking the client 4. "When caring for a client who has a suppressed immune response, a N95 mask should be worn." • • directly about dietary preferences or restrictions is the best approach, since individuals vary when adhering to religious practices. 1. Incorrect. When assessing a newly admitted client, the nurse’s responsibility is to determine any special cultural or religious restrictions, which might affect care and recovery. Although the nurse correctly believes certain dietary modifications may be needed for this client, asking the client to select only acceptable items from a regular tray would not meet basic nutritional requirements or cultural expectations. 2. Incorrect. Although there may be some diet information in the hospital admission forms, the nurse must do a thorough assessment when a client arrives on the floor, including determining any special spiritual or cultural needs. Obtaining information from the hospital chart does not ensure accurate or detailed information, and may have errors that would cause the client stress or even offend the client. 3. Incorrect. Unless the client was unconscious, there is no need for the dietician to speak to the spouse, except under certain strict cultural situations in which the spouse is expected to speak for the client. This question does not indicate either of these situations. If the nurse feels the assistance of the dietician is needed to discuss specific foods or food preparation criteria, the dietician should speak directly to the client. Question: An unlicensed assistive personnel (UAP) has explained how to prevent the spread of infection to the charge nurse. Which statement by the UAP indicates that further teaching is needed? You answered this question Correctly 1. "Soap and water should be used for hand washing when our hands are visibly soiled." 2. "Gloves do not have to be worn when taking a client's vital signs or passing out meal trays." 3. "Standard precautions should be used on all clients." 4. Correct: Standard precautions are needed. If there is a risk for coming in contact with client secretions or excretions, a standard mask may be worn. Routine nursing care does not warrant the use of an N95 mask. This type mask is needed for client's who are placed on Airborne Precautions such as for tuberculosis (TB). 1. Incorrect: This is a correct statement regarding the prevention of infection. Hand washing with soap and water is part of standard precautions. 2. “I will not elevate the head of the bed.” • • 4. Incorrect: Encourage intake of fruit juices, carbonated beverages, and hard candy throughout the day to supply client with extra calories. These may be easier to digest/tolerate than other foods. Question: A client returned to the unit following a total hip replacement. What statement by the client would indicate to the nurse that teaching has been successful? You answered this question Correctly 1. “I will try to keep my legs together as close as possible.” 3. “I know that I cannot ever swim again.” 4. “I can resume my exercises at the gym within one month.” 2. Correct: Flexion of the hip should be avoided after hip surgery. Elevating the HOB would cause flexion, which could cause hip dislocation. 1. Incorrect: The legs should be kept in an abducted (legs apart) position following surgery to keep the head of the femur in the acetabulum (hip in the socket). An abductor pillow is often used to accomplish this and prevent the legs being close together or crossing. 3. Incorrect: Swimming is a non-weight bearing exercise that is encouraged during rehabilitation for post hip replacement clients. Walking is another good exercise for these clients. 4. Incorrect: Stressors on the hip joint should be kept to a minimum for the first 3 to 6 months. Some exercises in the gym could put too much strain on the new hip joint and cause dislocation. Question: As part of the screening process to identify if a client is obese, the nurse calculates the client’s body mass index (BMI). Weight – 180 pounds Height – 5’ 5” Calculate the BMI to the whole number. You answered this question IncorrectlyEnter the answer for the question below. Calculate BMI by dividing weight in pounds by height in inches squared and multiplying by a conversion factor of 703. 5’5” = 65” [180 pounds ÷ (65)2 ] x 703 = 3. Administer “blow-by” oxygen while suctioning. 2. Ferrous sulfate • • [180 pounds ÷ 4225] x 703 = 0.04260355 x 703 = 29.95 or 30 Question: A nurse assesses the 5 minute Apgar on a term, newborn infant. Based on the Apgar score, what should be the nurse’s priority intervention? You answered this question Correctly 1. Continue Apgar scoring every five minutes until 20 minutes of life. 2. Transfer newborn to the neonatal intensive care unit ASAP. 4. Perform cardiopulmonary resuscitation. 3. Correct: An Apgar score of 4, 5, or 6 requires immediate intervention, usually in the form of oxygen and respiratory assistance or in the form of suctioning if breathing has been obstructed by mucus. A source of oxygen called “blow-by” may be placed near but not directly over the nose and mouth of the newborn during suctioning. 1. Incorrect: If the total score is below 7, or any area is scored 0 at 5 minutes, resuscitation efforts should begin immediately and scoring should continue every 5 minutes until 20 minutes of life. Resuscitation is priority. 2. Incorrect: The priority is to begin resuscitation efforts. 4. Incorrect: CPR is not needed at this point as the newborns heart rate is greater than 100 bpm. Question: A client comes into the clinic for a routine check-up during the second trimester of pregnancy. The client reports gastrointestinal (GI) upset and constipation. The nurse reviews the client's medications. Which client medication is most commonly associated with GI upset and constipation? You answered this question Correctly 1. Calcium supplement 3. Folic acid 3. Metabolic acidosis • • • • 4. Cetirizine 2. Correct: Ferrous sulfate commonly causes constipation and GI upset. These side effects can be diminished with proper teaching regarding diet and taking medication with food. 1. Incorrect: Calcium may cause constipation but generally relieves symptoms associated with gastric acid indigestion. Calcium is often used for the treatment of transient acid indigestion and heartburn. 3. Incorrect: Constipation and GI upset are not generally associated with folic acid administration. 4. Incorrect: Constipation is an adverse effect associated with cetirizine administration, since it is an antihistamine. Question: The nurse is caring for a newly admitted client with diabetes mellitus. The initial assessment reveals that the client is unresponsive, BP is 98/64, Resp 38, HR 100, T 97.2ºF (36.2º C). The nurse notes a fruity smell on the client’s breath. The nurse recognizes that the client is in which acid-base imbalance? You answered this question Correctly 1. Respiratory acidosis 2. Respiratory alkalosis 4. Metabolic alkalosis 3. Correct: A diabetic client who is unresponsive with fruity ketone breath is assumed to be in acidosis. Hyperventilation occurs due to excess ketones in the body causing metabolic acidosis. The respiratory rate indicates that the lungs are trying to fix the metabolic acidosis with Kussmaul breathing. The hyperventilation occurs to reduce the arterial pCO2 level. 1. Incorrect: The fruity smelling breath indicates a metabolic problem. This is a result of an increase in the acetone level. The client may develop diabetic ketoacidosis (DKA). 2. Incorrect: The client is in metabolic acidosis. This is not a respiratory imbalance. 2. Bibasilar crackles 3. Orthopnea 4. Notify the primary healthcare provider. • • • • Question: Which assessment findings does the nurse expect to find when assessing a client admitted to the emergency department with left sided congestive heart failure? You answered this question Correctly 1. Ascites 4. Hepatomegaly 5. Anorexia 2. & 3. Correct: Bibasilar crackles that do not clear with coughing occur with left sided heart failure. Fluid backs up into the lungs. Orthopnea occurs in left sided heart failure when the client lies flat, because fluid backs up into the lungs. 1. Incorrect: Ascites is seen with right sided heart failure because fluid backs up into the systemic venous circulation causing stasis in the abdominal organs. 4. Incorrect: Hepatomegaly is seen with right sided heart failure because of the venous engorgement and stasis in the liver. 5. Incorrect: Anorexia is seen in right sided heart failure due to venous engorgement and venous stasis within the abdominal organs. Question: A client is admitted for observation following an unrestrained motor vehicle accident. A bystander stated that the client lost consciousness for 1-2 minutes. On admission, the client reports a headache and had a Glasgow coma scale (GCS) of 14. The GCS is now 12.What is the priority nursing intervention for this client? You answered this question Correctly 1. Continue to assess every 15 minutes. 2. Stimulate the client with a sternal rub. 3. Administer acetaminophen with codeine for headache. 3. Read about formalin on the Material Safety Data Sheet (MSDS). • • 4. Correct: On the Glasgow coma scale, we like a number between 13 to 15. This assessment score has dropped to 12, so the client is getting worse and the headache could mean increasing intracranial pressure (ICP). This is the only intervention that can fix the problem. 1. Incorrect: Reassessing in 15 minutes is delaying treatment. When neuro changes start happening, they happen rapidly. 2. Incorrect: Stimulating the client will increase the client's ICP. 3. Incorrect: A sedative should be administered. The client's level of conscious has decreased. Question: The primary healthcare provider instructs the nurse to place body tissue obtained from a biopsy into a container with formalin prior to sending it to pathology. The nurse has not handled formalin before. What would be the nurse's best action? You answered this question Incorrectly 1. Call the pathology department for directions on formalin's use and precautions. 2. Look formalin up in the drug handbook 4. Explain to the primary healthcare provider that nurses are not allowed to use formalin. 3. Correct: All hazardous materials must have a MSDS, which includes the identity of the chemical, the physical and chemical characteristics, the physical and health hazards, primary routes of entry, exposure limits, precautions for safe handling, controls to limit exposure, emergency and first-aid procedures, and the name of the manufacturer or distributor. 1. Incorrect: The nurse should look at the MSDS, the best source of information. Calling another department does not ensure that the nurse will get as comprehensive information as the MSDS provides. 2. Incorrect: The drug handbook is for medication, not handling of hazardous material. 4. Incorrect: The nurse can place the biopsy into a container with formalin and is within the scope of practice for the nurse. Question: 3. "I will have to watch my intake of salads, something that I really love." 1. An unexpected hospital admission can be very stressful. I will notify the case manager who specializes in helping clients with situations like yours. There is a telephone here so that you can contact your family and friends. • • An elderly client receives instructions regarding the use of warfarin sodium. Which statement indicates to the nurse that the client understands the possible food interactions which may occur with this medication? You answered this question Incorrectly 1. "I'm going to miss having my evening glass of wine now." 2. "I told my daughter to buy spinach for me. I'll have to eat more servings now." 4. "I am going to begin eating more fish and pork and leave beef alone now." 3. Correct: Clients taking warfarin sodium must watch their intake of vitamin K, which is present in leafy green vegetables and tomatoes. 1. Incorrect: Wine does not affect the use of warfarin sodium. 2. Incorrect: These clients need to monitor their intake of spinach, which is a source of vitamin K. 4. Incorrect: These clients need to monitor their intake of fish, which is a source of vitamin K. Question: The client is worried and distracted, and explains to the nurse that because of the direct admission from the primary healthcare provider's office there was no preparation to be away from home. The client is concerned about the length of stay, pets that need care, and bills that require payment. Which response from the nurse would be most helpful to this client? You answered this question Correctly 2. I know how you feel. I will be sure to tell your night nurse in shift report that you will probably need something to help you sleep tonight. 3. An unexpected hospital admission can be very stressful. Is there anyone who I can call for you? 4. I can call your primary healthcare provider for you and ask if you could go home today, then schedule another date for your hospital admission. • • 2. Correct: This client has a very slow ventricular rate at 40 beats per minute (bmp), due to complete heart block. Cardiac output can be decreased which decreases perfusion to the vital organs and can cause shock. This client should be assessed first. 1. Incorrect: This is atrial fibrillation with a ventricular rate of 100 beats per minute (bmp). Atrial fibrillation is usually not a life threatening situation. This is not as life threatening as the complete heart block with a slow ventricular rate. 3. Incorrect: This client has had one premature ventricular contraction (PVC) which is not life-threatening. We worry about 6 or more PVCs in one minute, and multifocal PVCs. 4. Incorrect: This is atrial flutter and again is not as life threatening as the client with the slow heart rate. In atrial flutter the atria are contracting at a rate of 300 beats per minute (bmp) and at a regular rate. 1. Depersonalization 4. Bicycle riding 5. Swimming • • • • Question: A client who was hospitalized with a diagnosis of schizophrenia tells the nurse, "My veins have turned to stone and my heart is solid!" How would the nurse identify this statement? You answered this question Correctly 2. Echopraxia 3. Neologism 4. Concrete thinking 1. Correct: Depersonalization, which is the unstable self-identity of an individual with schizophrenia may lead to feelings of unreality (the feeling that one’s parts have changed or a sense of seeing oneself from a distance). 2. Incorrect: The client who exhibits echopraxia may purposelessly imitate movements made by others. 3. Incorrect: Neologism is the invention of new words by a psychotic client. 4. Incorrect: Concrete thinking, or literal interpretations of the environment, represents a regression to an earlier level of cognitive development. Question: What activities should a nurse recommend to a group of adolescents who have been diagnosed with rheumatoid arthritis? You answered this question Correctly 1. Jogging 2. Volleyball 3. Tennis 4. Muscle spasms 2. In a chemotherapy sharps container • • 4. , & 5. Correct: Rheumatoid arthritis is an autoimmune disease that affects the joints and other body symptoms. Low impact activities on joints are best such as swimming and bike riding. 1. Incorrect: Jogging is a high impact activity for joints. This is not appropriate for a client with rheumatoid arthritis. 2. Incorrect: Playing volleyball is a high impact activity for joints and would not be appropriate for a client with rheumatoid arthritis. The pressure on the joints may result in additional damage to the joints. 3. Incorrect: Playing tennis is a high impact activity for joints, and tennis should not be a recommended sport for a client with rheumatoid arthritis. Question: The nurse is caring for a client 28 weeks pregnant who reports swollen hands and feet. Which sign or symptom would cause the greatest concern? You answered this question Correctly 1. Nasal congestion 2. Hiccups 3. Blood glucose of 150 4. Correct: This client could have preeclampsia and would be at risk for seizures. 1. Incorrect: This is a common occurrence during pregnancy and is not the greatest concern. 2. Incorrect: Hiccups would be second best answer indicating nerve/muscle irritation but not a common symptom associated with preeclampsia. 3. Incorrect: Not greatest concern with presenting signs and symptoms of swelling. Question: The nurse administers chemotherapeutic drugs to a client with breast cancer. Where should the nurse dispose of the medication vials? You answered this question Incorrectly 1. In a puncture-resistant biohazard container 1. "Yesterday, when I ate a hamburger and french fries, my belly really hurt." 1. Provides "just in time" posters outlining the importance of pain assessment. 2. Conducts brief in-services for each shift. 3. Counsels nurses when pain level scale is not utilized. • • 1. Correct: When taking tricyclic antidepressants such as amitriptyline, the skin may be sensitive to sunburn. Use sunscreens, wear protective clothing and sunglasses. 2. Incorrect: Alcohol should be avoided while taking antidepressant medications. These drugs potentiate the effects of each other. 3. Incorrect: An increase in fluid intake (unless contraindicated) is recommended along with foods high in fiber and exercise to avoid constipation. 4. Incorrect: Weight gain is common. Provide instructions for reduced calorie diet. Encourage increased level of activity if appropriate. Question: The nurse in the clinic would recognize which client statement as most indicative of gallbladder disease? You answered this question Correctly 2. "I have been gaining a lot of weight lately." 3. "My stools are darker. Sometimes they are even black." 4. "When I start hurting, it helps if I drink milk or have a small snack." 1. Correct: The gallbladder assists in digestion of fat. When foods high in fat are ingested, bile is released from the gallbladder to assist in digestion. If gallstones are formed in the gallbladder or are blocking the outlet to the gallbladder, the client may experience epigastric discomfort after a meal high in fat. 2. Incorrect: Weight gain is not associated with gallstones. 3. Incorrect: Black stools indicate blood in the stool and should be further investigated. Black stools are not associated with gallstones. 4. Incorrect: When the symptom of drinking milk or having a small snack relieves the abdominal pain, a duodenal ulcer may be a possible diagnosis. Question: A nurse manager notices that unit nurses consistently forget to ask clients to rate their pain level on a scale of 0-10. What strategies could the nurse manager initiate to improve performance? You answered this question Incorrectly 3. Impaired speech. 4. Decreased concentration. • • • • 4. Ensures that a complete and clear performance standard exists. 5. Assesses nurses’ reasons for not using pain level scale. 6. Disciplines offenses through unpaid time off. 1., 2., 3., 4. & 5. Correct: If nurses have been provided the knowledge and performed the skill before, but have not practiced the skill on a regular basis, a different type of education is required. This may take the form of "just in time" tools such as posters or guidelines outlining the critical steps in performing the skill. Brief in-services, videos, or DVDs available on the unit may also be effective in providing on the spot refreshers. Counseling the nurses when pain level scale is not utilized may improve understanding and performance. Ensuring that performance standards exist, are clear and complete, and that they are readily available to staff is essential. The first step in correcting a performance gap is to understand what the difference is between the behavior being exhibited and what the expectations are. Always assess why staff are doing or not doing what is needed for clients. There may be a lack of knowledge or there may be a sense of non-importance. 6. Incorrect: Quality improvement looks at improving processes and does not use intimidation and punishment to improve quality care. Question: What impaired functions does the nurse expect to observe in the client admitted with an injury to the frontal lobe of the brain? You answered this question Correctly 1. Decreased sensation to touch. 2. Impaired vision. 5. Decreased hearing. 3. , & 4. Correct: The frontal lobe is responsible for motor control, ability to speak words, concentration, memory, and judgment. 1. Incorrect: This is the function of the parietal lobe. 2. Incorrect: This is the function of the occipital lobe. 5. Incorrect: This is the function of the temporal lobe. Question: 1. Administer protamine sulfate 50 mg over 10 minutes. 1. Monitor stools for occult blood. 2. Place on fall prevention. • • • • A client has been taking enoxaparin 40 mg subcutaneous once a day for 1 week. Which action should the nurse take? You answered this question Correctly 2. Type and cross match for 2 units PRBCs 3. Increase enoxaparin dose to increase INR 4. Give the scheduled dose of enoxaparin 1. Correct: Protamine sulfate is given for heparin overdose. It is a heparin antagonist. Overdose is seen with a aPTT of 110 seconds. Depending on therapeutic intent, a client's aPTT levels should be between 60-80 seconds. (Normal aPTT for a client not on an anticoagulant is 25-35 seconds). 2. Incorrect: RBC, Hgb, Hct are normal. Blood transfusion is not indicated. 3. Incorrect: PT is not used to measure the therapeutic effect of enoxaparin, but rather aPTT. PT and INR are used for warfarin. 4. Incorrect: aPTT is too long at 110 seconds. Therapeutic level is 60-80 seconds. Question: A client is admitted to the hospital with a platelet count of 132,000 mm3 and a white cell count of 8,495 cells/mcL. What interventions should the nurse implement? You answered this question Incorrectly 3. Place client in protective isolation. 4. Restrict venipunctures. 5. Limit visitors. 1., 2., & 4. Correct: A normal platelet count ranges from 150,000-400,000 mm3. This is a low platelet count, so interventions should focus on bleeding precautions. The white • • • • 2. Correct: Tidaling (fluctuations in the water-seal chamber) with respiratory effort is normal. 1. Incorrect: The lung sounds should be assessed with a pneumothorax. However, look at the hint: The question is talking about tidaling. 3. Incorrect: The primary healthcare provider does not need to be notified. Tidaling in the water-seal chamber is not an abnormal finding. 4. Incorrect: The question gives no indication of the client having active symptoms of respiratory distress. It is not an appropriate intervention. Question: Which nurse is providing cost effective care to a client? You answered this question Incorrectly 1. Providing palliative care to a terminally ill client. 2. Beginning discharge planning on admit. 3. Counseling clients on cigarette smoking cessation. 4. Educating a group of parents on the importance of childhood immunizations. 5. Performing a postop wound dressing change using clean gloves. 1., 2., 3., & 4. Correct. Palliative care is considered cost effective when caring for the terminally ill client. There was a 60% drop reported in the healthcare costs since palliative care was introduced. In comparison to conventional care, palliative care is considered as cost effective in reducing unnecessary utilization of resources. Palliative care has focused on the efficient and the effective care that is centered on the clients. The nurse who begins discharge planning on admit is providing cost effective care. The client may not be able to learn all that is needed if waiting until the day of discharge. Also, supplies and equipment may be needed. If waiting until the day of discharge to determine client needs, then discharge can be delayed. This is costly. Counseling to quit cigarette smoking, colonoscopies, giving beta-blockers to clients after heart attacks are well-established interventions that are effective and also are cost- effective. Two additional preventive interventions were found to be cost-saving: childhood immunization and counseling adults on the use of low dose aspirin. 5. Incorrect. A postop surgical wound dressing change is a sterile procedure: Sterile gloves are necessary and failure to use them could lead to infection, which would then increase the cost of care to a client. Question: 2. Assisting the client into a side lying position. 3. Providing a back massage. 4. Providing heat therapy. 5. Using distraction techniques. 2. Carbon dioxide used intraperitoneally is irritating the phrenic nerve. • • • • The nurse reassesses the client's pain level after administering an oral analgesic. The client states that the pain is better but continues to report a backache. Which non- pharmacologic interventions may help the client's backache? You answered this question Correctly 1. Educating the client regarding pain and pain control. 2. , 3., 4. & 5. Correct: Assisting the client to a side lying position, providing a back massage, providing heat therapy, and using distraction techniques are all proven interventions that can raise the client's pain threshold. In other words, raise the level at which a client first perceives a stimulus as pain. All of these provide comfort, are non- invasive, and show the client that the nurse cares. 1. Incorrect: Education regarding pain control does not help the client's pain and would not be appropriate while the client is experiencing pain. Question: A client who has had a laparoscopic cholecystectomy develops pain in the left shoulder. Vital signs, laboratory studies, and an electrocardiogram are within normal limits. What does the nurse recognize as a contributing cause of the pain? You answered this question Correctly 1. Surgical cannulation of the bile duct is causing spasm and pain. 3. Large abdominal retractors used in the procedure compressed a nerve. 4. Side lying position in the operating room generated pressure damage. 2. Correct: Phrenic nerve irritation can result in referred pain to the left shoulder. Carbon dioxide (CO2) is used to inflate the abdominal/chest wall during the procedure for better visualization of the internal organs. If the CO2 irritates the phrenic nerve, it radiates to the shoulder. 1. Incorrect: Surgical cannulation of the bile duct is not performed during a laparoscopic cholecystectomy. 4. Obtain a prescription from the primary healthcare provider. • • 3. Incorrect: Large abdominal retractors are not used during this procedure. This is done via a small incision to accommodate a scope. 4. Incorrect: The client is turned in several directions during the procedure to prevent damage to the abdominal viscera. Question: During shift change the night charge nurse reports to the day charge nurse that a client, admitted with an ingestion of unknown drugs, received a prescription for physical restraint at 3:00 am because the client was incoherent, combative, and attempting to leave the facility. On last assessment at 7:00 am, the client was still combative. What is the best action by the day shift charge nurse? You answered this question Correctly 1. Since the client is still combative, continue the restraints. 2. Remove restraints until the primary healthcare provider writes the prescription. 3. Assign an unlicensed assistive personnel (UAP) to check on the client periodically. 4. Correct: A prescription for physical restraints must be renewed every 4 hours if restraints are still needed. Generally, restraints are not used past a 24 hour period. The prescription for the restraint should include why the client requires physical restraints and a time period for using them and no more than 24 hours. 1. Incorrect: Do not assume. The oncoming nurse needs to assess the client in order to determine if restraints are still needed for the safety of this client. 2. Incorrect: If the client is indeed still incoherent and combative, restraints are still warranted to prevent the client from harming self or others. 3. Incorrect: Periodical checks will not keep the client from harming self or others and "periodically" is not an acceptable time frame for this action. Question: A home health nurse visits a recently discharged client with right-sided paresis due to a stroke. The nurse discovers that the spouse has been feeding the client. What action should the nurse take? You answered this question Correctly 1. Instruct the spouse to require the client to feed independently. 2. Suggest the spouse hire an aide to feed and bathe the client. 3. Advise the spouse to consider an extended care facility for the client.