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The nurse is describing the rationale for the components of aneurysm precautions to a nursing student. The nurse determines that the student needs additional information if the student states that which of the following is an acceptable part of these precautions?
1. Limiting regular coffee to 1 cup per day
2. Keeping the room lighting very dim
3. Avoiding activities involving pushing or straining.
4. Keeping the head of the bed raised to 15 degrees
#1.....Aneurysm precautions include placing the client on bed rest in a quiet setting. Lights kept dim to minimize environmental stimulation. Any activity that could increase the intracranial pressure by increasing the blood pressure or impeding the venous return from the brain is prohibited. Examples of such activities are pushing, pulling, sneezing, coughing, or straining. Stimulants such as caffeine and nicotine are totally prohibited
The LPN is providing instructions to a nursing assistant who is preparing to care for a deceased client. The LPN notes on the clients record that the clients record that the clients eyes will be donated. The nurse determines that the nursing assistant needs additional instruction if the nursing assistant state to:
1. Elevate the head of the bed
2. Close the clients eyes
3. Place wet saline gauze pads and an ice pack on the eyes
4. Close the clients eyes and place a dry sterile dressing over the eyes
#4.... when a corneal donor dies, the eyes are closed and gauze pads wet with saline are placed over them with a small ice pack. Within 2 to 4 hours the eyes are enucleated. The cornea is usually transplanted with 24 to 48 hours. the head of the bed should be elevated.
The client newly diagnosed with gout has been prescribed allopurinol (Zyloprim) The nurse would question the physician if the dosage for which of the following medications already prescribed has not changed?
1. Adenosine (Adenocard)
2. Digxoxin (Lanoxin)
3. Ergonovine maleate (Ergotrate)
4. Warfarin sodium ( Coumadin)
#4.... Allopurinol is an antigout medication that may increase the effect of oral anticoagulants. Warfarin Sodium is an anticoagulant and if this medication is prescribed for the client the nurse should verify the order. the dosage of warfarin sodium may need to be decreased.
A hospitalized client tells the nurse that a living will is being prepared ant that the lawyer will be bringing the will to the hospital today for witness signatures. The client asks the nurse for assistance in obtaining a witness to the will. The most appropriate response to the client is which of the following?
1. "I will sign as a witness to your signature.
2. "You will need to find a witness on your own"
3. "I will call the nursing supervisor to seek assistance regarding your request"
4. "Whoever is available at the time will sign as a witness for you.
#3.... Living wills are required to be in writing and signed by the client . The clients signature must be either witnessed by specified individuals or notarized. Many states prohibit any employee, including a nurse of a facility where the declaring is receiving care, from being a witness.
The client has a cerebellar lesion. The nurse would plan to obtain which of the following for use by this client?
1. Raised toilet seat
2. Slider board
3. Adaptive eating utensils
#4.... the cerebellum is responsible for balance and coordination. A walker provides stability for the client during ambulation.
The nurse is assigned to care for the newly admitted client and is reviewing the physicians orders. The nurse notes that the physician has prescribed a medication that is twice the amount that the client reports taking prior to admission. the most appropriate nursing action is to:
1.Question the client regarding the accuracy of the reported dosage
2. consult with the RN
3. Administer the medication as prescribed
4. Administer half of the prescribed dose and then notify the RN
#2.... if the nurse determines that a physicians order is unclear or if the nurse has a question about an order the nurse should consult with the RN who will then contact the physician prior to implementation of the order. Under no circumstances should the nurse carry out the order unless the order is clarified
The nurse is providing instructions to a mother of a toddler regarding the safe us of a car seat. The nurse determines that the mother understands the sage use of the car seat if the mother states which of the following?
1. the car seat can be placed in a face-forward position when the height of the toddler is 27 inches
2. the car seat should never be placed in a face-forward position
3. the seat can be placed in a face-forward position at any time
4. the car safety seat is suitable for the toddler until the toddler reaches the weight of 40lb
#4.... Once a toddler is able to sit up alone care safety seats can be adjusted to face forward in an upright position. The care safety seat is suitable for the growing toddler until the toddler reaches the weight of 40lb
The nurse is caring for a client with severe cardiac disease. While caring for the client, the client states to the nurse, " If anything should happen to me, please make sure that the doctors do not try to push my chest and revive me." The most appropriate nursing action is to:
1. Tell the client that this procedure cannot legally be refused by a client if the physician feels that it is necessary to save the clients life
2. Tell the client that it is necessary to notify the physician of the clients request
3. Tell the client that the family must agree with the request
4. Plan a client conference with the nursing staff to share the clients request.
#2.... External cardiac massage is one type of treatment that a client can refuse. The most appropriate nursing action is to notify the physician because a written " DO NOT RESUSCITATE (DNR) " order from the physician must be present in the clients record. The DNR order must be reviewed or renewed on a regular basis per agency policy.
The client with osteoarthritis is receiving diclofenac (Voltaren). The LPN reviewing the clients order sheet would plan to verify the order with the RN if which of the following medications was listed?
1. Primidone (Mysoline)
2. Calcium carbonate (Tums)
3. Warfarin (Coumadin)
4. Vitamin C supplement
#3....Voltaren is an NSAID medicatin. Interactions may occur with anticoagulants such as warfarin resulting in increased risk of bleeding. The nurse should consult with the RN regarding a potential medication interaction.
The nurse has made an error in documenting an assessment finding on a client and obtains the clients record to correct the error. The nurse corrects the error by:
1.Trying to erase the error for space to write in the correct data
2. Using white correction fluid to delete the error and writing in the correct data
3. Drawing one line through the error, initialing, and dating the line, and then providing the correct information
4. Documenting a late entry into the clients record.
#3.... If the nurse makes an error in documenting in the clients record, the nurse should follow agency policies to correct the error. This included drawing one line through the error, initialing and dating the line, and then providing the correct information. Erasing data from the clients record and using correction fluid are prohibited.
The client has an impairment of cranial nerve II. The nurse tells the clients spouse to do which of the following to maintain client safety in the home?
1. Speak to the client in a loud voice
2. Serve food that is not too hot or too cold
3. Keep traveled paths in the home free of clutter
4. Lower the temperature setting of the water heater
#3.... CN II is the optic nerve which governs vision. The nurse can enhance client safety by encouraging the family to keep pathways free of clutter to prevent falls. Lowering the temperature of the water heater would be useful if the client had peripheral nerve damage.
The nurse employed in a hospital is waiting to receive a report from the laboratory via facsimile (fax) machine. The fax machine activates and the nurse expects the report but receives a sexually oriented photograph. The most appropriate nursing action is to:
1. Cut up the photograph and throw it away
2. call the laboratory and ask for the name of the person who sent the photograph
3. Call the polive
4. call the nursing supervisor and report the incident
4.... Sexual harrassment in the workplace is prohibited by the state and federal laws. Making sexually suggestive jokes, inappropriately touching someone, pressuring a co worker for a date, and openly displaying sexually oriented photos or posters are examples of conduct that could be considered sexual harassment by another worker. if the nurse believes that he or she is being subjected to unwelcome sexual conduct , these concerns should be reported immediately.
A nursing student caring for a 6 month old infant is asked to collect a urinalysis from the infant. The student collects the specimen by:
1. attaching a urinary collection device to the infants perineum for collection
2. obtaining the specimen from the diaper by squeezing the diaper after the infant voids
Catheterizing the infant using the smallest available French Foley catheter
4. Noting the time of the next expexted voiding and prepare to collect the specimen into a cup when the infant voids
1.... Although many methods have been used to collect urine from an infant the most reliable method is the urine collection device. This device is a plastic bag that has an opening that is lined with adhesive so that it may be attached to the perineum.
The nursing staff is sitting in the lounge taking its morning break. A nursing assistant tells the group that she or he heard that the unit secretary has AIDS. The nursing assistant proceeds to tell the nursing staff that the secretary contracted the disease from her husband who is supposedly a drug addict. Which legal tort has the nursing assistant violated?
1.... Defamation takes place when something untrue is said (slander) or written (libel) about a person resulting in injury to that persons good name and reputation.
The LPN is administering medications to a client with chronic rheumatoid arthritis. The client has difficulty swallowing, and the film coated form of diflunisal (Dolobid) is ordered. Which of the following actions by the nurse is most appropriate?
1. give the client a large glass of water to aid in swallowing
2. consult with the RN about contacting the physician regarding the medication
3. crush the tablet and mix with applesauce
4. open the tablet and mix the contents with food
2....Dolobid may be given with water, milk or meals. However the tablets should not be crushed or broken open. The LPN should consult with the RN. I f the client has difficulty swallowing the physician should be notified. It could be dangerous to offer large amounts of water and a capsule to a client with impaired swallowing. This could result in aspiration
The nurse hears a client calling out for help. The nurse hurries down the hallway to the clients room and finds a client lying on the floor. The nurse performs a thorough assessment and assists the client back to bed. The physician is notified of the incident and the nurse completes an incident report. Which of the following would the nurse document on the incident report?
1. the client was found lying on the floor
2. the client climbed over the side rails
3. the client fell out of bed
4. the client became restless and tried to get out of bed
1....The incident report should contain the clients name age and diagnosis. it should contain a factual description of the incident, any injuries experienced by those involved, and the outcome of the situation.
A nursing assistant is measuring the BP of a hypertensive client who is scheduled to be seen by the clinic physician. The nurse would intervene if which of the following actions was observed, which would interfere with accurate measurement of the BP?
1. the cuff used has a rubber bladder that encircles at least 80% of the limb
2. The BP is measured after the client reports just having a cigarette outside the building
3. the client is sitting with arm bared and supported at heart level
4. The BP is measured after the client has sat quietly for 5 minutes.
2.... Th client should not have smoked tobacco or drunk a beverage containing caffeine for 30 minute3s before having the BP measured.
The nursing student who will be graduating in 2 months is conducting a clinical conference and the topic of discussion is professional liability insurance. The student tells the group:
1. To obtain their own individual malpractice insurance
2. That malpractice insurance is not required and is expensive
3. To discuss liability insurance with the employment agency
4. That most lawsuits are filed against physicians
1.... Nurses need their own liability insurance against malpractice lawsuits. Nurses erroneously assume that they are protected by an agencys professional liability policies. Usually when a nurse is sued, the employer is also sued for the nurses actions or inactions. Even though this is the norm, nurses are encouraged to have their own malpractice insurance.
The nurse is applying a cooling blanket to a child with a fever. The nurse avoids which of the following when performing this procedure?
1. Places the cooling blanket on the bed and covers it with a sheet.
2. Checks the skin condition of the child before turning on the cooling blanket
3. Keeps the covers off the child
4. Brings towels and fresh linen into the childs room to keep the child dry while on the cooling blanket
3.... While on the cooling blanket the child should be covered lightly to maintain privacy and reduce shivering.
A nurse who works on the night shift enters the medication room and finds a coworker with a tourniquet wrapped around the upper arm. The coworker is about to insert a needle, attached to a syringe containing a clear liquid, into the antecubital area. The most appropriate initial action by the nurse is which of the following.
1. call the police
2. call security
3. lock the coworker into the medication room until help is obtained
4. call the nursing supervisor
4.... Nurse Practice acts require reporting impaired nurses. The Board of Nursing has jurisdiction over the practice of nursing and may develop plans for treatment and supervision. This incident needs to be reported to the nursing supervisor, who will then report to the Board of Nursing and other authorities as required.
The LVN is reviewing the medical record of a newly assigned client. The nurse notes that the client is receiving cyclobenzaprine hydrochloride (Flexeril) for the treatment of muscle spasms. The LVN questions the order if which of the following disorders is noted in the admission history?
1. Angle-closure glaucoma
3. Chronic bronchitis
4. Recurrent pneumonia
1.... Because cyclobenzaprine has anticholinergic effects, it should be used cautiously in clients with a history of urinary retention, angle-closure glaucoma, and increased intraocular pressure. I t is intended for short term therapy.
The nurse gives an inaccurate dose of a medication to a client. Following assessment of the client, the nurse completes an incident report. The nurse notifies the nursing supervisor of the medication error and calls the physician to report the occurrence. The nurse who administers the inaccurate medication dose understands that the:
1. Error will result in suspension
2. Incident report is a method of promoting quality care and risk management
3. Incident will be reported to the Board of Nursing
4. Incident will be documented in the personnel file
2....Proper documentation of unusual occurrences, incidents, and accidents and the nursing actions taken as a result is internal to the institution or agency and allows the nurse and administration to review the quality of care and determine any potential risks. Based on the information provided in the question, the nurses error will not result in suspension nor will it be documented in the personnel file. The error and the situation presented in the question are not a reason for notifying the Board of Nursing
The nurse is assisting at a code blue where the client is in ventricular fibrillation. A physician is about to defibrillate the client, and the nurse hears the physician say in a loud clear voice "CLEAR". The nurse should take which of the following immediate actions?
1. step away from the bed and ensure that all others have done the same
2. prepare to place conductive gel pads for defibrillation on two areas of the clients chest
3. prepare to shut off the IV infusion going into the clients arm
4. prepare to shut off the mechanical ventilator
1....It is essential for the safety of all personnel to be clear of the client or the clients bed/stretcher when the defibrillator paddles are being discharged. Otherwise, ancillary personnel may be defibrillated along with the client. It is the primary responsibility of the person defibrillating to communicate the "clear" message loudly enough for all to hear and to ensure their compliance. All personnel must immediately comply with this command.
The client asks the nurse to describe the preferred provider organization model of care because the client is unsure of the procedure involved in this form of health care. Which of the following statements , if made by the nurse, indicates an inaccurate description of this form of organization?
1. It represents an arrangement between employers and insurance companies
2. it provides member services from a selected group of providers
3. Member can commonly elect to see any participating physician without prior authorization
4. Beneficiaries are limited to those providers who are participating physicians for any required health care services
3.... in the PPO beneficiaries are limited to those providers who are participating physicians for any required health care services. If members elect to see physicians outside the preferred provider group, services may not be covered
The nurse is assisting in preparations for administering ribavirin (Virazole) to a child with respiratory syncytial virus (RSV). Which of the following supplies will the nurse obtain for the administration of this medication?
1. An IV pole
2. In intramuscular IM syringe
3. A pair of goggles
4. A protective isolation gown
3....Some caregivers experience headaches, burning nasal passages and eyes, and crystallization of soft contact lenses as a result of administration of ribavirin ( Virazole). Specific to this medication is the use of goggles. A mask may be worn. Handwashing is to be performed before and after any child contact.
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