Missed a day? Catch up on the 30 most recent questions below.
The health care provider (HCP) prescribes 5 mg ephedrine IV push. Pharmacy delivers a vial with 50 mg ephedrine in 10 mL normal saline (NS). How many mL equals the prescribed dose?
Answer: B. 1 mL
Rationale: Start by calculating how many mL are in 1 mL.
The nurse working in the newborn nursery is assisting with care of neonate whose mother has a diagnosis of human immunodeficiency virus (HIV) positive. Which of the following nursing actions should be included in the infant's plan of care?
Answer: C. Administer HIV medications stat.
Rationale: Strict standard precautions are used to care for an infant who has been exposed to HIV infection.
The healthcare provider would anticipate which of the following as a treatment option for pneumonitis?
Answer: A. Corticosteroid administration
Rationale: Corticosteroids are often recommended to treat inflammatory conditions such as pneumonitis.
A terminally ill patient tells the nurse, "I'm afraid I won't be allowed into Heaven." What is the nurse's most appropriate response?
Answer: B. "Can you tell me why you feel that way?"
Rationale: When a patient expresses fear or concern, assess the situation before assisting with a solution.
A client weighing 165 lb is admitted with a diagnosis of deep vein thrombosis (DVT). The health care provider (HCP) prescribes an initial heparin bolus of 80 units/kg. How many units will the nurse administer?
Answer: B. 6000 units
Rationale: The nurse will administer 6,000 units of heparin.
A postoperative client has developed thrombophlebitis in a leg. The health care provider (HCP) has prescribed heparin sodium 7500 units SC q 12 hours. Which lab value should the nurse report to the HCP before administering the heparin?
Answer: C. Partial thromboplastin time (PTT)
Rationale: Partial thromboplastin time (PTT) is used to monitor and prescribe varying heparin doses.
The healthcare provider is preparing a patient for a total colectomy and the placement of an ileostomy. The patient asks where the stoma will be located. The healthcare provider identifies which of the following areas as the correct stoma site?
Answer: C. C
Rationale: A total colectomy involves the removal of the large intestine.
After a health care provider (HCP) leaves the hospital unit, one nurse comments to another, "I wouldn't go to that HCP for anything. They're a complete idiot." What legal violation could the first nurse be charged with?
Answer: C. Slander
Rationale: Slander and libel are types of defamatory statements.
A 32-year-old female is admitted to the inpatient psychiatric unit with a diagnosis of bipolar disorder. Her husband is concerned because for the past six weeks, she has been sleeping about three hours a night. She constantly shops online, causing them to be in debt. She has lost ten pounds because she doesn't stop to eat. During the initial assessment, what behavior should the nurse anticipate?
Answer: A. Bold statements about her self-importance
Rationale: During the manic phase of bipolar disorder, clients can display grandiosity and an exaggerated sense of self-worth.
Which of the following statements about the Glasgow Coma Scale (GCS) is FALSE?
Answer: D. The GCS can be used effectively only on adults and children over age 10.
Rationale: The GCS can be applied to children over 5 years old, because they can speak, answer questions, and follow directions.
The LPN/LVN watches a new unlicensed assistive personnel (UAP) care for a post-stroke client with left-sided paralysis. Which action by the UAP requires the nurse to intervene?
Answer: D. The UAP tries to move the client up in bed by placing a hand under the client's left axilla.
Rationale: The nurse should intervene because it is not appropriate to pull a client up in bed by the client's armpits.
The LPN/LVN working in the newborn nursery is caring for an infant born with a cleft palate. What will be the biggest challenge to maintaining optimal nutrition for this infant?
Answer: B. Inadequate suction
Rationale: Cleft palate is a congenital defect where there is an opening or split in the roof of the mouth that occurs when the tissue doesn't fuse together.
The gynecologist prescribes clindamycin oral suspension 600 mg PO qid for a client with bacterial vaginosis. The nurse prepares the medication by adding 100 mL of sterile water that produces 200 mg of clindamycin in 5 mL of oral suspension. How many teaspoons will the client take for each dose?
Answer: B. 3 teaspoons
Rationale: The nurse should instruct the client to take 3 teaspoons of the clindamycin oral suspension at each dose.
According to Bowen's Family Systems Theory, what is differentiation of self?
Answer: B. Individual feelings and thoughts in the family
Rationale: According to Bowen, a family is a system in which each member has a role to play and rules to respect.
The nurse is providing care for a client with an endotracheal tube (ETT) on a ventilator. When suctioning the client's respiratory secretions, what is the MAXIMUM time allowed?
Answer: B. 10 seconds
Rationale: When suctioning through an endotracheal tube or tracheostomy, apply suction for no longer than 10 seconds.
A client asks the LPN/LVN why their health care provider (HCP) has prescribed phenazopyridine for their urinary tract infection. What is the nurse's BEST response?
Answer: D. "It relieves the pain and itching caused by the infection."
Rationale: Phenazopyridine does not treat the cause of the urinary irritation, but it can help relieve the symptoms while other treatments take effect.
A client with a previous diagnosis of acquired immunodeficiency syndrome (AIDS) presents to the clinic because they are worried that they might have Kaposi's Sarcoma. Which of the following is an early characteristic sign of this disease?
Answer: A. Purple lesions
Rationale: Kaposi's sarcoma (also called Kaposi Sarcoma) is a type of cancer that forms in the lining of blood and lymph vessels and mucous membranes of the GI tract.
The nurse is teaching a client with a new prescription for warfarin 2.5 mg po bid. Which instruction to the client is correct?
Answer: A. "Carry a medication alert card or wear a bracelet at all times."
Rationale: Warfarin (Coumadin) decreases the body’s ability to form blood clots by blocking the formation of vitamin K–dependent clotting factors. The client should carry information at all times regarding warfarin therapy.
A client who has been admitted to the inpatient mental health unit with a diagnosis of bipolar disorder is constantly arranging the client snack area and sweeping the unit's floors. The client also follows the housekeeper, offering advice on the best way to clean. Which activity is MOST appropriate for this client?
Answer: B. Hiking
Rationale: This client is obviously active, so the appropriate activity will allow them to continue to use physical energy.
The nurse will administer 1 L of normal saline over 10 hours. No infusion pumps are available. The IV tubing has a drop factor of 20 gtts/mL. How many drops per minute should be infused? Round to a whole number.
Answer: C. 33 gtts/min
Rationale: The nurse should count 33 gtts/min.
Following an uncomplicated surgery, the health care provider (HCP) orders a client's peripheral intravenous (IV) line to be discontinued. Which of the following actions by the nurse is MOST important?
Answer: D. Don clean gloves before starting.
Rationale: When removing a peripheral IV line, the nurse should first gather supplies, perform hand hygiene, and don clean gloves.
Gestational diabetes mellitus (GDM) is usually managed with
Answer: C. nutritional therapy.
Rationale: Clients with gestational diabetes mellitus (GDM) can usually control their glucose intolerance with diet.
A postoperative client has developed thrombophlebitis in a leg. The physician has ordered heparin sodium 7500 units SC q 12 hours. Which lab value should the nurse report to the physician before administering the heparin?
Answer: C. Partial thromboplastin time (PTT)
Rationale: PTT is used to monitor and prescribe varying heparin doses.
An adolescent is admitted with a diagnosis of rheumatic endocarditis. Which pathogen infection is responsible for this disease?
Answer: D. Streptococcal
Rationale: Rheumatic endocarditis (rheumatic heart disease) starts as a sore throat from a bacterium called Streptococcus pyogenes (group A streptococcus) which can pass easily from person to person in the same way as other upper respiratory tract infections.
The maternity nurse is educating a new mother about caring for her two-day-old son's circumcision. Which of the following statements by the mother would indicate a need for further instruction?
Answer: B. "Applying alcohol daily will keep the site clean."
Rationale: Rubbing alcohol should NOT be used; it would be extremely painful.
A client was admitted to the Mental Health Unit with a diagnosis of depression. After three days, the client is smiling and happy, telling the nurse, "I feel great! I'm ready to go home now." Based on the client's sudden change in behavior, what should the treatment plan include?
Answer: D. Increasing suicide precautions
Rationale: For a client with depression, a sudden change in behavior can indicate the client has made a decision to inflict self-harm.
A parent makes an appointment to bring their 6-year-old child with a diagnosis of autism spectrum disorder (ASD) to the pediatric clinic for a routine check-up. Which intervention will BEST meet the needs of this child?
Answer: C. Offer a walk-through of the office before the appointment.
Rationale: The nurse and clinic staff should offer a visit during a quiet time before the appointment, to reduce anxiety.
The Emergency Department physician inserts a chest tube in a client with a traumatic right-sided pneumothorax. The chest tube is connected to a water-seal drainage unit before the client is transferred to the ICU. When the ICU nurse performs an initial assessment, the nurse notes that the client is tachypneic, experiencing shortness of breath, and has an O2 saturation level of 86%. Breath sounds on the right side are absent. What is the nurse's FIRST action?
Answer: D. Apply O2 by nasal cannula.
Rationale: Remember the ABCs: Airway, Breathing, Circulation.
A client with Stage 3 hypertension has been placed on a low-sodium and low-fat diet. The client tells the nurse, "I hate this diet, and I won't stay on it. It's too hard." What is the nurse's BEST response?
Answer: C. "I can see this is really difficult for you. Let's talk about it."
Rationale: Stage 3 hypertension is 160/100 to 179/109.
A client receiving hemodialysis therapy weighs 78 kg today. The nurse notes that the client's previous weight was 76 kg. What is the percent change? Round to two decimal places.
Answer: A. 2.63%
Rationale: To calculate a percent change, use this formula: (Final - Initial) ÷ Initial x 100% [ (V2 -V1) ÷ V1 x 100].