Hurst Review Test #2 Questions And Answers 2022

Hurst Review Test #2 Questions And Answers 2022 Which pain scale should the nurse use to monitor the pain level of a 3-year old client after surgery? 1. Numerical scale 2. Verbal descriptive scale 3. Visual analo ...

Hurst Review Test #2 Questions And Answers 2022 Which pain scale should the nurse use to monitor the pain level of a 3-year old client after surgery? 1. Numerical scale 2. Verbal descriptive scale 3. Visual analog scale 4. FACES scale - ANS- 4. Correct: Monitoring pain in children requires special techniques. The nurse should use the FACES scale as a tool to assess this client's pain level. Children as young as 3 years of age can use the FACES scale to communicate their pain level to the medical team. The scale has six faces ranging from smiling face to sad, tearful face. 1. Incorrect: Not age appropriate. This scale uses numbers. 2. Incorrect: Not age appropriate. Young children may not understand the word pain. 3. Incorrect: Not age appropriate. This scale requires reading. Which tasks would be appropriate for the LPN/LVN to assign to an unlicensed assistive personnel (UAP)? (SATA) 1. Ask the client diagnosed with dementia memory-testing questions. 2. Collect the urinary output hourly on the client with renal disease. 3. Demonstrate pursed lipped breathing to the client who has emphysema. 4. Give a tepid sponge bath to the client who has a fever. 5. Assess oxygen saturation on a client experiencing angina. - ANS- 2., & 4. Correct: The UAP can obtain hourly urine output on clients and can give a tepid sponge bath to a client. The LPN/VN must know what tasks can be assigned to the UAP. 1. Incorrect: The nurse cannot delegate assessment, evaluation, or teaching. This would be an assessment function for the RN to perform. 3. Incorrect: The UAP cannot teach. Demonstration is a method of teaching. This is an RN task. 5. Incorrect: The UAP cannot assess the client experiencing angina. This is an RN task. What nursing interventions should the nurse implement for a client with Addison's disease? (SATA) 1. Administer potassium supplements as prescribed. 2. Assist the client to select foods high in sodium. 3. Administer Fludrocortisone as prescribed. 4. Monitor intake and output. 5. Record daily weight. - ANS- 2., 3., 4. & 5. Correct: The client with Addison's disease needs sodium due to low levels of aldosterone. Fludrocortisone is a mineralocorticoid that the client will need to take for life. I&O and daily weights are needed to monitor fluid status. 1. Incorrect: Clients with Addison's disease lose sodium and retain potassium, so this client does not need potassium. A licensed practical nurse (LPN) is utilizing the nursing process to care for assigned clients. Which nursing actions should the LPN relate to the implementation step of the nursing process? (SATA) 1. Collecting client data for a nursing history. 2. Reporting client response to a new medication. 3. Procuring equipment for a planned medical procedure. 4. Assigning client care activities to unlicensed assistive personnel. 5. Delivering skilled nursing care according to an established health care plan. - ANS- 3., 4., & 5. Correct: The nurse should relate procuring medical equipment, assigning client care activities, and delivering skilled nursing care to the implementation step of the nursing process. Implementation is the third step of the nursing process and consists of delivering nursing care according to an established health care plan and as assigned by the RN or other person(s) authorized by law. 1. Incorrect: This is not the implementation step of the nursing process. LPNs participate in the assessment step of the nursing process by collecting client data for a nursing, psychological, spiritual, and social histories, comparing the data collected to normal values and findings. 2. Incorrect: This is not the implementation step of the nursing process. LPNs participate in the nursing process by reporting client responses to the RN or supervising healthcare provider. The primary healthcare provider prescribes nafcillin 0.6 gram every 12 hours IM. Available is a vial labeled 200 mg per 1 mL. How many mL should the nurse give? Round your answer to the nearest whole number. - ANS- Changing 0.6 g to mg equals 600 mg. Then 200 mg : 1 mL = 600 mg : x mL 200x = 600 x = 3 The nurse should reinforce which instructions given to the unlicensed assistive personnel (UAP) about care needed to reduce the risk of infection when a client has an indwelling catheter? (SATA) 1. Check catheter for kinks in the tubing when the client is in the bed or chair. 2. Disconnect the catheter from the bag when measuring output. 3. Wash hands before providing personal care to the client. 4. Ensure that catheter remains secured to the thigh. 5. Make sure that the drainage bag is always below the level of the bladder. - ANS1., 3., 4. & 5. Correct: Tubing that becomes obstructed cannot allow adequate urine flow. The urine flow occurs by gravity. Adequate handwashing before providing care is one defense against infection. Tension on the tubing may cause irritation and subsequent infection. The bag should be below the level of the bladder so that urine flows appropriately. 2. Incorrect: A closed drainage system should be maintained to prevent entry of microorganisms. Disconnecting the catheter from the bag would be incorrect and potentially cause harm to the client. What should the nurse document after a client has died? (SATA) 1. Time of death 2. Who pronounced the death 3. Disposition of personal articles 4. Destination of body 5. Primary healthcare provider's prescriptions 6. Time body left facility - ANS- 1., 2., 3., 4., & 6. Correct: All of these are correct options that should be documented. In addition to these things, the nurse should also document consideration of and preparation for organ donation, family notified and decisions made, and location of identification tags. 5. Incorrect: The primary healthcare provider's prescriptions do not need to be documented after a client dies. The client states, "I really do not want to have surgery. I have told my children this, but they still want me to go through with the surgery. I do not know what to do." What is the best response for the nurse as client advocate? 1. "Your children are concerned about you. The surgery is the best thing for your health." 2. "You have some genuine concerns about the surgery, and you feel as if your children are not addressing your concerns. You and your family will need to resolve this before you go to surgery." 3. "I can contact your primary healthcare provider so that you can discuss your concerns regarding surgery." 4. "You have some genuine concerns about the surgery, and you feel as if your children are not addressing your concerns. Tell me more about your concerns." - ANS- 4. Correct: The nurse has a duty to advocate for the client if there is a discrepancy between the care or proposed care and the client's wishes regarding treatment. It is important to acknowledge the client's feelings and to demonstrate compassion and a willingness to understand. This presents an opportunity for additional communication to help answer some of the client's questions or set up a client-family conference with the client, the client's family, and the primary healthcare provider. 1. Incorrect: When the nurse agrees with the client's children, the nurse ignores the client's feelings and does not address the issue of the client's treatment wishes. 2. Incorrect: When the nurse restates the client's comment without investigating the client's concerns, the issue goes unresolved. 3. Incorrect: Offering only to contact the primary healthcare provider is an incomplete solution and hints of the nurse not taking responsibility to investigate the client's concerns. The client may be uncomfortable addressing concerns with the primary healthcare provider before resolving the issue of treatment wishes with family members. The nurse makes selections from the hospital menu for a client who is confused and suspicious of others. Which menu choice is best? 1. Ham and vegetable casserole 2. Cheese and crackers 3. Caffeine free tea 4. Packaged sugar free Jell-O - ANS- 4. Correct: A client who is suspicious of others needs foods that are packaged and can see them opened. 1. Incorrect: A client who is suspicious of others needs to be able to identify the ingredients in the food that is being eaten. A casserole contains many ingredients, and the client may fear that something has been added to the food. 2. Incorrect: Finger foods are best for clients that are manic. 3. Incorrect: Drinks and foods with no caffeine are okay for the confused and suspicious client, but this menu choice is not the best choice from the list here. A nurse has reinforced teaching to a client about home dressing changes using a clean technique. Which statement made by a client indicates to the nurse that the client understands this technique? 1. "The wound should be cleaned using a washcloth, soap, and water." 2. "Povidone-iodine should be applied to the wound with each dressing change." 3. "It is important that I wash my hands using soap and water before removing my dressing." 4. "I will use sterile gloves to clean my wound and change the dressings." - ANS- 3. Correct: Clean technique requires washing hands with soap and water prior to removing the dressing. 1. Incorrect: The wound should be cleaned with 4x4's and sterile water. Soap can be very drying to the wound. A washcloth may not be clean as it has been sitting in a cabinet. 2. Incorrect: Povidone-iodine is harsh and damages healthy tissue, so should not be applied to the wound. 4. Incorrect: Sterile gloves are not needed when using clean technique. Clean gloves may be used. When caring for a client on bedrest, which interventions should the nurse implement to decrease the risk of deep vein thrombosis? (SATA) 1. Apply compression hose. 2. Place pillow under knees while supine. 3. Assist client to perform active foot and leg exercises. 4. Place client on intermittent pneumatic compression device. 5. Assess extremities for negative Homan's sign. - ANS- 1., 3., & 4. Correct. The client will need compression or compression hose and/or intermittent pneumatic compression device. The client should perform leg and foot exercises to decrease stagnation of blood. Compression hose, foot and leg exercises, as well as pneumatic compression devices increase venous return and prevents stasis of blood. Other interventions to decrease deep vein thrombosis (DVT) include early ambulation, passive and active range of motion, isometric exercises, and anticoagulant drugs such as heparin. 2. Incorrect: Do not compromise blood flow by placing pillows under the knees, crossing legs, or sitting for long periods of time. When pillows are left under the knees for an extended time, venous return could be compromised. A pillow under the knees is not a recommended intervention for DVT prevention. 5. Incorrect: Do not assess Homan's sign, as it may dislodge a clot. Homan's sign is not a preventative intervention. Assessing a Homan's sign is considered to be controversial, and this test may contribute to the release or dislodgement of a clot. Which action, if done by a new LPN/VN, needs to be interrupted by the precepting LPN/VN? 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. - ANS- 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, decreases LOC, and can increase the risk of falls. A client with a history of congestive heart failure has an implantable cardioverter defibrillator (ICD) surgically implanted. What teaching points should the nurse reinforce with the client prior to discharge? (SATA) 1. Avoid hot baths and showers. 2. Increase intake of leafy green vegetable products. 3. Avoid magnets directly over the site. 4. Notify primary healthcare provider whenever a shock is delivered by the ICD. 5. Driving is not recommended for 1 year after placement of an ICD. - ANS- 3., & 4. Correct: Magnets can deactivate the defibrillator. Other transmitter devices should also be avoided. Most arrhythmias need only one shock, but the healthcare provider should be notified when a shock is delivered so that monitoring can increase. 1. Incorrect: Hot baths or showers are not contraindicated with ICDs. 2. Incorrect: Increase of leafy green vegetable products would have no relation to the ICD but should be avoided if the client is on warfarin. 5. Incorrect: The client cannot drive for 6 months after implantation of an ICD and cannot drive for 6 months after any shock therapy from the ICD. The nurse is caring for a client with hyperemesis gravidarum. What electrolyte imbalance is most likely? 1. Hypocalcemia 2. Hypomagnesemia 3. Hyponatremia 4. Hypokalemia - ANS- 4. Correct: Hyperemesis gravidarum is characterized by persistent, severe pregnancy related nausea and vomiting. There is a large amount of potassium in the upper GI tract. A client with prolonged vomiting will lose potassium in the emesis. Additionally, the client is unable to replace the lost potassium due to the persistent nausea and vomiting. 1. Incorrect: Hypocalcemia results from any condition that causes a decrease in the production of parathyroid hormone (PTH). Hyperemesis gravidarum does not affect PTH levels. 2. Incorrect: The lower GI tract has a lot of magnesium. Therefore, this client is at risk for hypomagnesemia, but not more than hypokalemia. The client with hyperemesis gravidarum is losing upper GI contents. 3. Incorrect: The client with hyperemesis gravidarum is at high risk for being dehydrated. The electrolyte imbalance associated with dehydration is hypernatremia, not hyponatremia. Remember, this client's blood will be concentrated, and concentrated makes numbers go up (i.e. sodium, hematocrit, and specific gravity). The nurse is preparing the sterile field to assist the primary healthcare provider with a procedure. Which flap of the sterile pack should the nurse open first? 1. Closest to the nurse. 2. To the left of the nurse. 3. To the right of the nurse. 4. Farthest from the nurse. - ANS- 4. Correct: The flap farthest from the nurse should be opened first so that the nurse's arm or hand does not cross the sterile field. 1. Incorrect: The flap closest to the nurse should be opened last so that the sterile field is not crossed by the nurse's arm or hand. 2. Incorrect: The sides should be opened in the 2nd and 3rd steps so that the nurse's hand does not cross the sterile field. 3. Incorrect: The sides should be opened in the 2nd and 3rd steps so that the nurse's hand does not cross the sterile field. When reinforcing teaching, what symptom would the nurse include as being the most common initial visual change associated with glaucoma? 1. Central vision is lost. 2. Progressive tunnel vision occurs. 3. Sudden flashes of light in the eyes. 4. Eye floaters begin to be noticed. - ANS- 2. Correct: If glaucoma is not diagnosed and treated early, an individual starts to lose peripheral vision, or the area of vision outside the central field of sight. People who have glaucoma experience tunnel vision and cannot see objects to the side, near the head, or by their feet. Central vision can be lost later if the disease progresses. 1. Incorrect: Central vision loss is the classic visual disturbance for macular degeneration but peripheral vision is usually maintained. 3. Incorrect: Individuals experiencing retinal detachment may have sudden flashes of light in the affected eye, but this is not an initial visual change related to glaucoma. 4. Incorrect: Eye floaters are more common in eye disorders such as retinal detachment or may occur associated with the aging process. The nurse is reinforcing teaching to a client who has been prescribed glucocorticoids for the treatment of Addison's disease. What points should the nurse emphasize? 1. Be aware of the development of hypoglycemia. 2. Test the urine for albumin or other proteins. 3. Take the medication 30 minutes prior to bedtime. 4. Maintain the prescribed dose without interruption in therapy. - ANS- 4. Correct: Glucocorticoids should not be abruptly discontinued due to the risk of adrenal suppression with prolonged use. Doses should be tapered before being discontinued. 1. Incorrect: Increased blood sugar is an adverse effect associated with glucocorticoid therapy, not hypoglycemia. 2. Incorrect: Protein in the urine is not associated with glucocorticoid therapy. 3. Incorrect: Insomnia is an adverse effect associated with glucocorticoid therapy. Daily dosing of glucocorticoids should be done in the morning to decrease this effect. Which electrolyte imbalance would be the nurse's priority concern in the burn client? 1. Hypernatremia 2. Hyperkalemia 3. Hypoalbuminemia 4. Hypermagnesemia - ANS- 2. Correct: Good job. When the cells lyse, they release potassium, and then the serum potassium goes up. And if the kidneys stop functioning, we are in real trouble. 1. Incorrect: Well, hypernatremia does occur when the client becomes very dehydrated, but it's not as dangerous as the potassium one. 3. Incorrect: Low albumin can cause problems keeping fluid in the vascular space, but albumin is not an electrolyte. 4. Incorrect: No, the magnesium doesn't go up unless the kidneys shut down. Which task would be appropriate for the LPN/VN to accept from the Labor, Delivery, Recovery, Postpartum (LDRP) charge nurse? 1. Administer IV pain medication to a client three days postopertive cesarean section. 2. Draw a trough vancomycin level on a client 3 days postpartum with bilateral mastitis. 3. Reinforce how to perform perineal care to a primipara who is four hours postpartum. 4. Draw admission labs on a client admitted in final stages of labor. - ANS- 3. Correct: Client teaching may be reinforced by an LPN/VN on a stable client. 1. Incorrect: Administering IV pain medications is out of the scope of practice of LPN/VN. 2. Incorrect: This client with a severe infection who is only 3 days postpartum is considered an unstable client. Therefore, this client should have the blood drawn and receive care from the RN. 4. Incorrect: Drawing admission labs on a client in the final stages of labor would be inappropriate, because the client is potentially unstable and needs experienced LDRP nursing care. Which action by two unlicensed nursing personnel (UAPs), while moving the client back up in bed, would require intervention by the nurse? 1. Lowers the side rails closest to them. 2. Places hands under client's axilla. 3. Lowers the head of bed. 4. Raises the height of the bed. - ANS- 2. Correct: This action is not appropriate and requires intervention by the nurse. This could damage the brachial plexus nerves under the axilla. Use a draw sheet to prevent this from occurring. 1. Incorrect: This is a correct action. The UAPs will need to lower the side rails closest to them to safely move the client up in bed. Not lowering the rails could result in injury to the UAPs' backs. 3. Incorrect: This action is correct. Moving the client upward with the head of the bed raised works against gravity, requires more force, and can cause back strain. 4. Incorrect: This action is appropriate and would not require intervention by the nurse. Raising the height of the bed brings the client close to the UAPs center of gravity and decreases the chance of back injury. How should the nurse prepare a client for a paracentesis? (SATA) 1. Place client in the Fowler's position. 2. Position client flat with right arm behind the head. 3. Ask the client to empty bladder. 4. Obtain client's vital signs every 4 hours. 5. Maintain NPO status for 4 hours pre-procedure. - ANS- 1., & 3. Correct: The correct position is HOB elevated to allow fluid to pool in one spot for the paracentesis. The nurse knows this is a lower abdominal puncture and the bladder should be empty to avoid puncturing the bladder. 2. Incorrect: The optimal position is HOB elevated to allow the fluid to pool in one spot. If the nurse were to lie the client flat, the fluid would go everywhere. 4. Incorrect: Obtain a set of vital signs immediately prior to the procedure and immediately after the procedure. Vital signs every 4 hours will not give you needed data on the client's status. 5. Incorrect: This procedure does not require NPO status. NPO status is initiated when there is a risk of aspiration during or following the procedure. A client diagnosed with alcoholism was admitted to the medical unit with substancewithdrawal delirium. Two days later, the client decides to leave the hospital against medical advice. What action should the nurse take? 1. Hide the client's clothes so that the client cannot leave. 2. Administer the ordered sedative. 3. Place restraints on the client. 4. Determine why the client wants to leave. - ANS- 4. Correct: Always assess why the client wishes to leave first. This is the only way to fix the problem. 1. Incorrect: By confining a client against his or her wishes, and outside of an emergency situation, the nurse may be charged with false imprisonment. Actions that may invoke these charges include locking an individual in a room, taking a person's clothes for the purposes of detainment, and restraining in mechanical restraints a competent, voluntary client who demands to be released. 2. Incorrect: By confining a client against his or her wishes, and outside of an emergency situation, the nurse may be charged with false imprisonment. Actions that may invoke these charges include locking an individual in a room, taking a person's clothes for the purposes of detainment, and restraining in mechanical restraints a competent, voluntary client who demands to be released. 3. Incorrect: By confining a client against his or her wishes, and outside of an emergency situation, the nurse may be charged with false imprisonment. Actions that may invoke these charges include locking an individual in a room, taking a person's clothes for the purposes of detainment, and restraining in mechanical restraints a competent, voluntary client who demands to be released. Which comment by the client indicates understanding of possible complications of long term hypertension? 1. "I would like to have my serum creatinine checked at this visit." 2. "My blurred vision is part of getting older." 3. "I have leg pain caused by excessive exercise." 4. "Adding salt to my food is permissible." - ANS- 1. Correct: Hypertension is one of the leading causes of end stage renal disease. The client understands that renal function is reflected by serum creatinine levels. This request demonstrates understanding of the disease and possible complications. 2. Incorrect: The appearance of the retina provides important information about the severity and duration of hypertension. Manifestations of severe retinal damage include blurred vision, retinal hemorrhage, and loss of vision. 3. Incorrect: Intermittent claudication is a complication of peripheral vascular disease (PVD). Hypertension speeds up the process of PVD. 4. Incorrect: Increasing the salt intake causes an increase in the sodium levels which can reduce the kidney's ability to remove excess fluid. This can result in a worsening of the hypertension. Lifestyle modifications to reduce hypertension include dietary sodium reduction, weight reduction, Dietary Approaches to Stop Hypertension (DASH) eating plan, moderation of alcohol consumption, regular physical activity, avoidance of tobacco use, and management of psychosocial risk factors. The nurse determines that a client does not have an advance directive. The daughter is designated to make healthcare decisions in the event that the client becomes incapacitated or unable to make informed decisions. Which nursing actions are appropriate for this client? (SATA) 1. Document the client's statement in the client's own words. 2. Provide information on advance directives to the client. 3. Provide personnel for assistance with completing an advance directive. 4. Encourage client to complete advance directive as soon as possible. 5. Determine if the client's daughter agrees with the client's decision. - ANS- 1., 2. & 3. Correct: The nurse should document the client's statement in the client's own words. The nurse should provide the client with information on advance directives and assurance that there are hospital personnel to assist with completing the advance directive. 4. Incorrect: The nurse should explain to the client that the law requires all clients be asked about the existence of an advance directive at the time of hospital admission. Preparing an advance directive ensures that the client's wishes will be followed in the event that the client is unable to make healthcare decisions. The decision about an advance directive is the client's decision to make and not the nurse's decision. 5. Incorrect: Providing information is the appropriate nursing action, not questioning the daughter. A nurse drops a glass bottle, which shatters on the floor in the hallway. What action should the nurse take? 1. Notify housekeeping to clean up the spill. 2. Pick up glass with a broom and dustpan and dispose into a puncture resistant sharps container. 3. Pick up the glass with gloved hands and dispose into a puncture resistant sharps container. 4. Use a wet mop to collect the glass and dispose of it in the garbage can. - ANS- 2. Correct: The nurse must not be cut by the broken glass. Proper removal of glass includes using a dustpan and broom to collect the glass and disposing of it into a puncture resistant sharps container. 1. Incorrect: While waiting for housekeeping, someone could fall or get cut. The nurse should initiate cleanup. 3. Incorrect: Hands are never used to pick up glass, even if they are gloved, because of the increased risk of getting cut. 4. Incorrect: A wet mop will not pick up the glass, and glass pieces will stick to a wet mop. The nurse is preparing to make an occupied bed. Which action by the nurse is important to preserve client's self-esteem during this procedure? 1. Remove the top sheet first and replace with a clean one. 2. Inform the client that they will be uncovered only for a short time. 3. Ask the client to relax as the top sheet is removed and the bottom sheet is changed. 4. Cover the client with a bath blanket before removing any of the sheets on the bed. - ANS- 4. Correct: The client should not be exposed during the bed change. Cover with a bath blanket as the top sheet is removed. 1. Incorrect: The client's self-esteem will not be preserved if uncovered during the procedure. Being exposed to the nurse is very troubling for most clients. 2. Incorrect: The client should be covered throughout the procedure. 3. Incorrect: The client's self-esteem will not be preserved by relaxing. Being exposed is anxiety provoking, and exposure is unnecessary. The nurse is caring for a client taking a selective serotonin reuptake inhibitor (SSRI). The client tells the nurse "I am sweating more than ever!" What is the nurse's best response? 1. This is a common side effect of antidepressant medications. 2. Excessive sweating can have many causes. 3. You should report this side effect to your primary healthcare provider. 4. This symptom should go away within a few days. - ANS- 1. Correct: A common side effect of SSRIs is increased sweating. This option gives the client an explanation. 2. Incorrect: This response shows a lack of understanding of the side effects of antidepressant medications. 3. Incorrect: This option does not acknowledge the client's problem and possible causes. 4. Incorrect: Increased sweating may continue throughout treatment with an antidepressant medication. The nurse is caring for a client with decreased cardiac output secondary to heart failure with fluid volume overload. Which signs/symptoms are an indication to the nurse that treatment has not been effective? (SATA) 1. Diuresis 2. Dyspnea on exertion 3. Persistent cough 4. Warm, dry skin 5. Heart rate irregular at 118/min 6. Alert and oriented - ANS- 2., 3. & 5. Correct: When the cardiac output decreases, renal perfusion decreases, which leads to decreased urine output and fluid retention. This leads to difficulty breathing. Tachycardiac and rhythm irregularity are signs of fluid volume excess (FVE) and decreased output. Persistent cough, wheezing, and pink blood tinged sputum are all signs that the client is still sick. 1. Incorrect: Diuresis is what we want, which indicates that the treatment for FVE is effective. 4. Incorrect: Indication of improved cardiac output. 6. Incorrect: Indication of improved cardiac output. The nurse is monitoring the healing of a full-thickness wound to a client's right thigh. The wound has a small amount of blood during the wet to dry dressing change. What action should the nurse initiate next? 1. Notify the primary healthcare provider. 2. Obtain wound culture. 3. Document the findings. 4. Remove dressing and leave open to air. - ANS- 3. Correct: Look at the clues: full thickness wound, small amount of blood, and wet to dry dressing. With a full thickness wound, there is destruction of the epidermis, dermis, and subcutaneous tissues going down to the bone. So you would expect to see a small amount of blood, or drainage wouldn't you? Yes. This is expected. Simply document this normal finding. 1. Incorrect: Is there really anything to worry about in this situation? No, so you do not need to notify the healthcare provider. Now, with most questions on NCLEX, there is something to worry abou,t but just not with this one. 2. Incorrect: No, bleeding is not a sign of infection, which is what you would be worried about if you got a wound culture. 4. Incorrect: You probably would not remove the dressing and leave the wound open to air. The small amount of blood noted is just a sign of blood flow in the healing wound. Wet to dry dressings help to debride the wound. So, if you remove the dressing, will debridement occur? No. A client diagnosed with Celiac disease is on a gluten-free diet. What statement by the client would indicate to the nurse that reinforcing of diet instructions is needed? 1. "I will still have occasional abdominal discomfort." 2. "I may need to take iron or vitamin supplements." 3. "I can have eggs but no wheat toast for breakfast." 4. "I should avoid fresh apples and strawberries." - ANS- 4. Correct: The nurse is evaluating client statements for any lack of understanding and the need to provide further instruction. With Celiac disease, intestinal villi become inflamed whenever gluten is introduced to the gut through food intake. However, fresh fruits and vegetables do not contain gluten; therefore, fresh apples and strawberries would definitely be acceptable foods for this client. This statement by the client is inaccurate, indicating the need for reinforcing diet instructions by the nurse. 1. Incorrect: The client correctly acknowledges that some episodes of abdominal discomfort may still occur, since it is nearly impossible to totally eliminate gluten. Despite buying "gluten-free" products, occasionally small amounts of gluten may contaminate foods and cause symptoms to resurface. Eating in a restaurant may also be a challenge for those with Celiac disease. The client recognizes these possible symptoms. 2. Incorrect: This is an accurate statement by the client about Celiac disease. Because inflammation of the intestinal villi may lead to poor absorption of nutrients or anemia, clients may, indeed, need to take supplements for extended periods of time. This response does not indicate any problems with the client's comprehension of diet. 3. Incorrect: It is important for a client with Celiac disease to eat as healthy and diverse a diet as possible, since malnutrition occurs secondary to poor nutrient absorption in the bowel. Protein is a vital component in the diet, including such choices as eggs, dairy, and beans. Those foods creating the worst symptoms include grains like wheat, rye, and barley as well as the "malt barley" used as a thickening agent in certain products. The client has precisely stated that a breakfast including eggs but minus the wheat toast would be appropriate, evidence the client understands the diet. A busy LPN instructs an unlicensed assistive personnel (UAP) to obtain daily weights on a client. The LPN provides initial direction for the task, monitors that the task is successfully completed, reviews the results of the daily weight, and reports the results to the RN. Which action has the LPN taken? (SATA) 1. Failed to supervise the actions of the UAP. 2. Improperly assigned a client care task. 3. Appropriately assigned a client care task. 4. Supervised the performance of a client care task. 5. Functioned outside of the LPN scope of practice. - ANS- 3. & 4. Correct: The LPN appropriately assigned the performance of a client care task. The LPN appropriately supervised the performance of a client care task. 1. Incorrect: The LPN appropriately supervised the actions of the UAP. 2. Incorrect: The LPN appropriately assigned the task to the UAP. 5. Incorrect: It is within the scope of practice for the LPN to assign daily weights to a UAP if the UAP has been properly trained to carry out the assigned task and is supervised. Two hours following a lumbar puncture, the client stands up to void and reports a headache rated 8 out of 10 on a pain scale. What priority action should the nurse perform? 1. Instruct the client to drink at least 8 ounces (240 mL) of water. 2. Close room blinds to darken the environment. 3. Assist the client into a supine position in bed. 4. Notify primary healthcare provider of client's complaints. - ANS- 3. Correct: The most frequent cause of headache following a lumbar puncture is loss of, or leaking, of cerebrospinal fluid from the puncture site. Positioning a client is an important nursing responsibility, particularly in this situation since the supine position could help to stop any leaking. Following this, the nurse will pursue additional actions as prescribed by the primary healthcare provider, which may include increasing fluids or even a blood patch. 1. Incorrect: Although increasing fluids may help clients under specific circumstances, it is not the priority action in this situation. Additionally, the primary healthcare provider may order IV fluids rather than PO fluids. 2. Incorrect: A darkened room can be beneficial for clients with severe migraine headaches, but would not be useful to this client. Headaches following a lumbar puncture are caused by the loss of cerebrospinal fluid and would not respond to a quiet, dark environment. So this would not be the priority. 4. Incorrect: Although the primary healthcare provider should indeed be notified of this situation, the nurse's priority action should first focus on stabilizing the client by addressing the cause of this problem and positioning the client. A client, who is having difficulty falling asleep, asks the nurse for a sleeping aid. What is the first action the nurse should provide to the client? 1. Assist client to take a cool bath. 2. Provide a back massage. 3. Administer prescribed triazolam. 4. Give client a crossword puzzle to work. - ANS- 2. Correct: Research indicates that back massage can enhance client comfort, relaxation, and sleep. This is the least invasive option and should be done first. 1. Incorrect: A cool bath would wake a client, whereas, a warm bath would increase relaxation. 3. Incorrect: Triazolam is a short acting benzodiazepine. Do not go to the sleeping pill first. 4. Incorrect: Distraction is a good strategy for drawing a client's attention away from pain but may increase thinking, thus keeping the client awake. The clinic nurse answers a call from a client who is voicing intent to commit suicide. The client tells the nurse, "I am sitting here with a bottle of pain killers in my hand." What response by the nurse is appropriate? (SATA)