Missed a day? Catch up on the 30 most recent questions below.
When using an alcohol-based hand sanitizer, the Centers for Disease Control and Prevention (CDC) recommends which MINIMUM percentage of alcohol?
Answer: C. 60%
Rationale: For general use of alcohol-based hand sanitizers, the CDC recommends a minimum of 60% alcohol.
When a nurse is trying to communicate with a client who does not speak English, what is the nurse's best action?
Answer: A. Request a translator to assist.
Rationale: A translator should be used when communicating with a client who does not speak English or has poor English skills.
The nurse suggests to a client with a new diagnosis of diabetes that their family attend the clinic's diabetes education classes with the client. The client asks why their family should be included. What is the nurse's BEST response?
Answer: C. "Your family members can become part of your health care team."
Rationale: Family members, partners, and significant others can be very helpful as part of the health care team.
After teaching a client who has had eye surgery how to avoid an infection, which statement by the client would indicate that the client needs further education?
Answer: B. "I'll wear an eye patch for 3 days after my surgery."
Rationale: Generally, eye patches are worn to protect the eyes while the client sleeps, not at all times during the immediate postoperative phase.
The wound care nurse is performing a dressing change for a client with a stasis ulcer. As the nurse observes that the wound appears smaller. Which of the following ALSO indicates that healing is taking place?
Answer: A. The area in the wound cavity is pink.
Rationale: Granulation (pink) tissue is an important component in the wound healing process.
An adult female client with a severe mental developmental delay will be scheduled for surgery. Which action should the nurse take first to obtain informed consent?
Answer: D. Verify the identity of the client's legal guardian.
Rationale: It is the surgeon's responsibility to provide informed consent.
A client with a diagnosis of possible appendicitis is a direct admit from the clinic. The nurse knows that a positive sign of appendicitis is
Answer: D. Psoas.
Rationale: A positive Psoas sign indicates the presence of inflammation of the psoas muscle.
When you are caring for an indwelling urinary catheter, which of the following nursing interventions to prevent infection is CORRECT?
Answer: C. Disinfect the sampling port before obtaining specimens.
Rationale: According to the Agency for Healthcare Research and Quality (AHRQ), interventions to prevent infection in an indwelling urinary (Foley) catheter include the following: practice proper hand hygiene and use gloves; empty the collection bag regularly, or at least once every shift; use mild soap and water to gently clean the periurethral area; do not change the catheter and drainage bag at fixed intervals; disinfect the sampling port before obtaining specimens; and label the drainage bag with the client's ID and the date.
The nurse is preparing a client for a liver biopsy. Which instruction regarding the procedure is correct?
Answer: C. The client will be placed on the right side after the procedure.
Rationale: Following a routine liver biopsy, the client is placed on the right side to minimize bleeding.
When using an alcohol-based hand sanitizer, the Centers for Disease Control and Prevention (CDC) recommends which MINIMUM percentage of alcohol?
Answer: C. 60%
Rationale: For general use of alcohol-based hand sanitizers, the CDC recommends a minimum of 60% alcohol.
The health care provider (HCP) prescribes a keep vein open (KVO) rate of 10 mL/hr at 0800. There are 135 mL remaining in a bag of 0.9% NS. What time will the bag of solution be infused?
Answer: A. 2130 (9:30 pm)
Rationale: The remaining solution should be completely infused at 2130 (9:30 pm).
EMS transports a client with complaints of chest pain and dyspnea to the Emergency Department. She is receiving O2 via nasal cannula at 2 L/min. As the nurse assesses the client, which finding would demand immediate nursing action?
Answer: B. Restlessness and anxiety
Rationale: Restlessness and anxiety require immediate nursing action because they indicate very low oxygenation of body tissues and are often the first indications of impending cardiac or respiratory arrest.
A client is brought by his friends to the Emergency Department. They tell the nurse that he has been shouting, "I am God!" The nurse knows the client is experiencing
Answer: C. a delusion.
Rationale: Delusion is a false belief.
When planning care for a client diagnosed with Alzheimer's disease (AD), which of these interventions is MOST therapeutic?
Answer: A. Encouraging both verbal and nonverbal communication
Rationale: The nurse and health care team should encourage the client to communicate in as many ways as possible.
The health care provider (HCP) prescribes furosemide for an elderly client with a recent diagnosis of congestive heart failure (CHF). The client asks the nurse, "Why am I taking this pill?" What is the nurse's response?
Answer: C. "It'll remove extra fluid from your body."
Rationale: Furosemide is one of the loop diuretics (also known as water pills).
A client has recently been told he has terminal cancer. As the nurse enters the room, he yells, “My legs are cold, and I’m tired of having my sleep interrupted by noisy nurses!” The nurse may interpret the client’s behavior as
Answer: A. an expression of the anger stage of dying.
Rationale: In the anger stage of Kubler-Ross’s stages of dying, the individual resists the loss and may strike out at everyone and everything – in this case, the nurse.
The nurse's neighbor calls the nurse in a panic because their toddler has swallowed a lithium "button" battery. Which of the following is MOST important for the parent to do?
Answer: D. Go to the Emergency Department.
Rationale: The parent should take their child to the Emergency Department immediately.
A client with a diagnosis of congestive heart failure (CHF) is placed on strict intake and output (I&O). The unlicensed assistive personnel (UAP) records the client's intake at lunch as 8 oz. of black coffee, 6 oz. of orange juice, 4 oz. of lime jello, and 4 oz. of vanilla pudding. What is the client's intake?
Answer: A. 540 mL
Rationale: Intake is considered any food that is liquid at room temperature.
After an uneventful pregnancy, the mother delivers an infant who is soon diagnosed with Down Syndrome. When the nurse brings the infant to the parents, the mother's partner tells the nurse, "The doctors here don't know anything. We're taking our baby to a specialist who will fix everything." What is the nurse's BEST response?
Answer: C. "I can see that this diagnosis is very hard for you. I'm wondering how much you know about Down Syndrome."
Rationale: The parents are grieving the loss of "a perfect baby." The nurse should support the parents and allow them to express their feelings.
After an uneventful pregnancy, the mother delivers an infant who is soon diagnosed with Down Syndrome. When the nurse brings the infant to the parents, the mother's partner tells the nurse, "The doctors here don't know anything. We're taking our baby to a specialist who will fix everything." What is the nurse's BEST response?
Answer: C. "I can see that this diagnosis is very hard for you. I'm wondering how much you know about Down Syndrome."
Rationale: The parents are grieving the loss of "a perfect baby." The nurse should support the parents and allow them to express their feelings.
The palliative care nurse is caring for a client with advanced multiple myeloma. Which intervention is MOST appropriate?
Answer: B. Use gentle repositioning techniques.
Rationale: Multiple myeloma occurs when abnormal plasma cells (myeloma cells) collect in several bones.
A 32-year-old client with a diagnosis of type 1 diabetes calls the clinic to report that they have gastroenteritis. To prevent dehydration during the illness, which of the following should the nurse advise the client to do?
Answer: B. Drink 8 to 10 ounces of various fluids every hour while awake.
Rationale: Dehydration must be avoided in a client with diabetes because of the risk of developing diabetic ketoacidosis (DKA).
A nurse in the Emergency Department assesses a client for a possible fractured rib. Which of the following characteristics will support the suspected diagnosis?
Answer: C. Pain on inspiration, with shallow, guarded respirations
Rationale: A client with a fractured rib will complain of pain on inspiration or when moving or coughing.
A patient is brought to the emergency department by a family member. The patient has been agitated for the past several hours and has alternated between grandiosity and expressing a desire to commit suicide. Upon examination, the patient is diaphoretic, hypertensive, and tachycardic. Intoxication with which of the following substances would contribute to these symptoms?
Answer: A. Methamphetamine
Rationale: Methamphetamine intoxication causes a surge of adrenergic stimulation secondary to increased epinephrine and norepinephrine.
A client with a new diagnosis of type 2 diabetes asks the nurse about the difference between type 1 and type 2 diabetes. All of the following statements about type 2 diabetes are true EXCEPT
Answer: B. Management of type 2 diabetes can only be done with insulin shots.
Rationale: Type 2 diabetes results when the pancreas does not produce enough insulin and the insulin doesn't function properly.
A client with a terminal illness and their family ask the nurse the difference between palliative care and hospice care. Which of the following statements by the nurse is CORRECT?
Answer: A. "Palliative care enhances life at all stages of illness."
Rationale: Palliative care is specialized medical care for people living with a serious illness, such as cancer or heart failure.
While making the initial rounds on her assigned clients, the LPN/LVN observes that one client's peripheral intravenous (IV) site is pale, swollen, and cool to the touch. The infusion has stopped. The nurse reports these findings to the RN, suspecting that the cause is
Answer: A. infiltration.
Rationale: Infiltration occurs when IV fluid or medications leak into the surrounding tissue.
At a Senior Citizen health fair, the nurse offers to administer influenza vaccinations. The nurse explains that people over 65 years old should get an annual flu shot because
Answer: C. their immune systems have become weaker.
Rationale: The CDC guidelines for people over age 65 include an annual flu vaccination before the end of October.
After a client has had major surgery, the nurse provides information about the client's condition to a visitor whom the nurse believes is a family member. Later, the nurse finds out that the visitor is not a relative. Which legal violation has occurred?
Answer: D. Disregard of the client's right to privacy
Rationale: Providing information about a client's medical status without the client's permission violates the client's right to privacy and confidentiality.
Before the nurse sends a client for a CT with contrast dye, what is the nurse's most important action?
Answer: A. Check the client's health record for allergies.
Rationale: It is most important to ask the client about allergies and check the client's health record for allergies.