Missed a day? Catch up on the 30 most recent questions below.
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.
Following extensive bloodwork, a client is informed that she has cancer. She tells the nurse, "I think these results are wrong. I ate lunch before the blood was drawn, so we should test again." The nurse knows the client is using which defense mechanism?
Answer: D. Rationalization
Rationale: Defense mechanisms soften the blow of bad news by changing reality.
When a nurse is administering medication to an inpatient with paranoid schizophrenia, which is the best method?
Answer: C. Leave the patient's door open.
Rationale: When working in mental health settings, the safety of the patients and staff comes first.
If a drug is 50% protein-bound, it means that
Answer: A. 50% of the drug is available.
Rationale: The percentage of the drug that is NOT protein bound is the amount of the drug that is free to work as expected.
The Emergency Department nurse attends a training on treatment of clients who are contaminated with anthrax during a bioterrorism event. If a client presents to the ED with possible anthrax contamination, which action should the nurse take FIRST?
Answer: C. Initiate decontamination protocols
Rationale: With suspected anthrax contamination, decontamination protocols are the priority: placing the client away from others; removing and destroying clothing; and showering the entire body.
The health care provider (HCP) prescribes heparin 6,789 units subcutaneously q 12 hr. The nurse has a vial of heparin with 10,000 units/mL. How many mL will the nurse draw up and administer? Round the answer to one decimal place.
Answer: B. 0.7 mL
Rationale: The nurse will administer 0.7 mL of heparin.
A father calls the poison control center after discovering that his three-year-old son has taken 12 grape-flavored chewable acetaminophen tablets. What should the nurse instruct the father to do?
Answer: C. Quickly go to the Emergency Department.
Rationale: Acetaminophen overdose carries a risk of severe liver damage.
The LPN/LVN is discussing health issues with a client whose body mass index (BMI) is 33. Which statement by the client indicates the coping mechanism of rationalization?
Answer: D. "My mother and aunts were fat, too. It's genetic, I'm sure."
Rationale: Rationalization is making excuses or explaining a situation in a way that allows a person to avoid taking responsibility for an action or behavior.
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.