During a clinic visit, a client reports to the practical nurse (PN) that they felt a solid mass in their breast during self-examination, but it was not
... [Show More] painful. What instruction should the PN reinforce with the client?
A. Continue to monitor the mass until the next scheduled annual exam.
B. Notify the PCP if the mass becomes soft or painful or starts to drain.
C. Schedule an appointment with the PCP for evaluation
D. Breast masses are usually insignificant if they feel soft or are easily moveable. - ANSWER c. Schedule an appointment with the health care provider for evaluation.
A painless breast mass is an abnormal finding, and the PN should instruct the client to obtain prompt medical evaluation.
The health care provider informed a client diagnosed with stage 4 liver cancer that the cancer has spread to their spine. The client states to the practical nurse, "I have a cancer, but it is not malignant." What is the best initial nursing action?
A. Encourage the client to attend a cancer education program
B. Perform a complete history and physical assessment
C. Ask the client to explain his understanding of the term malignancy.
D. Offer the client emotional support to deal with the diagnosis
Submit - ANSWER c. Ask the client to explain his understanding of the term malignancy.
The best initial action is to assess the client's knowledge of the term malignancy when used to describe cancer. The client appears to have inaccurate knowledge. Stage 4 cancer means the cancer has spread (metastasized) from where it has started to another body part.
A client diagnosed with osteoarthritis. Which intervention should the practical nurse implement to help relieve joint pain and stiffness?
a. Encourage the client to perform weight-bearing exercises.
b. Teach the client how to perform range-of-motion exercises.
c. Explain the use of ice and massage for pain relief.
d. Instruct the client to take an analgesic before walking daily - ANSWER d. Instruct the client to take an analgesic before walking daily.
Adequate pain management is important for the success of an exercise program. Keeping the joints active decreases pain, so taking an analgesic and walking daily is likely to help decrease joint pain and stiffness.
A client diagnosed with prostate cancer is prescribed radioactive seed implantation (brachytherapy). What is the most important nursing action for the practical nurse (PN) to do?
a. Follow radiation exposure precautions
b. Encourage regular meals
c. Collect all urine in sealed containers
d. Avoid touching the client. - ANSWER a. Follow radiation exposure precautions.
Clients being treated for prostate cancer with brachytherapy (radioactive seeds implant) should be placed on radiation exposure precautions. The PN needs to follow the institution's protocols put in place regarding the amount of time and distance needed to prevent excessive exposure that would pose a hazard to others.
A client diagnosed with emphysema that is oxygen-dependent lives alone at home and manages self-care with no difficulty. Which finding should prompt the home health practical nurse to consult the registered nurse case manager?
a. A pulse oximetry reading of 91% on oxygen at 2 L/m
b. A weight loss of 5 pounds since the last monthly home visit
c. The client reports feeling as tired as at the last visit by the nurse
d. Upon entering the home, the PN noticed dirty dishes and clothing scattered around the home. - ANSWER b. A weight loss of 5 pounds since the last monthly home visit
A weight loss of 5 pounds in 1 month is a concern. Clients with COPD need additional calorie intake because they are using up a lot from the energy they are using to breath. The practical nurse needs to consult with the registered nurse case manager for a nutrition consult
The nurse has reinforced instructions to a client with diabetes mellitus on how to self-monitor for symptoms of diabetic ketoacidosis (DKA). The nurse realizes the instructions have been effective if the client can list which symptoms? (Select all that apply.)
a. Fruity breath odor
b. Rapid, weak pulse
c. Cold, clammy skin
d. Extreme thirst
e. Urinary frequency
f. Protruding eyeballs - ANSWER a. Fruity breath odor
b. Rapid, weak pulse
d. Extreme thirst
e. Urinary frequency
Diabetic ketoacidosis is caused by a profound deficiency of insulin. Some common characteristics include a sweet, fruity breath odor, a rapid weak pulse, extreme thirst, urinary frequency, and sunken-appearing eyeballs.
A client mentions using garlic daily as an herb to lower cholesterol and triglyceride levels. Which nursing action is a priority?
a. Monitor the client for signs of bleeding.
b. Instruct the client that garlic tends to cause hypertension.
c. This may relieve fever in the same way that acetaminophen does.
d. Remind the patient to use tooth brushing and mouthwash to prevent garlic odor. - ANSWER a. Monitor the client for signs of bleeding.
Garlic inhibits platelet aggregation in the same way that aspirin works, and the client should be monitored for bleeding. Garlic can lower the blood pressure, not raise it. It does not relieve fever. While the client will likely want to avoid garlic odor, it is not a priority.
The practical nurse (PN) is reviewing the health histories of assigned clients. Which factors have a potential for development of throat cancer? (Select all that apply.)
a. Tobacco use
b. Excessive intake of alcohol
c. Intake of hot and spicy foods
d. Human papillomavirus (HPV)
e. Lack of exercise
f. Lack of dietary fiber - ANSWER a. Tobacco use
b. Excessive intake of alcohol
d. Human papillomavirus (HPV)
Rationale:
The most common risk factors for throat cancer are tobacco use, alcohol abuse, human papillomavirus (HPV), a diet lacking in fruits and vegetable, and gastroesophageal reflux disease (GERD). Foods seasoned with herbs and spices have shown to have some health benefits in decreasing the risk of developing cancer.
A client has undergone craniotomy to remove a brain tumor. The client spent several days in the intensive care unit, and is now on the post-surgical unit. The nurse has urgently contact the surgeon to report signs of increasing intracranial pressure (ICP). Which was the most likely EARLY sign that the client was experiencing increased ICP?
a. The client's blood pressure dropped from 128/70 to 124/68, preoperative BP 122/72
b. The client became more confused than he was upon transfer to the post-surgical unit.
c. The client had a large amount of sanguineous drainage noted on the gauze dressings.
d. The client's pulse rate had increased from 70 to 82 beats/min. - ANSWER b. The client became more confused than he was upon transfer to the post-surgical unit.
Rationale:
A change in the level of consciousness is most likely the earliest symptom of increased ICP. Vital sign changes can also occur, with a widening pulse pressure and bradycardia. Neither of these are indicated by data in the options. Sanguineous drainage does not indicate increased ICP.
The home health practical nurse is visiting with a client who has a history of second-degree heart block and pacemaker placement 6 months ago. Which symptom compliant by the client would be indicative of pacemaker failure?
a. Facial flushing
b. Nausea
c. Pounding headache
d. Feelings of dizziness - ANSWER d. Feelings of dizziness
Rationale:
Feelings of dizziness may occur as the result of a decreased heart rate, leading to decreased cardiac output as a result of pacemaker failure.
Which actions demonstrate to the practical nurse that the client understands the correct procedure administration of a metered dose inhaler (MDI)? (Select all that apply.)
a. Sit or stand.
b. Shake the inhaler.
c. Attach the canister of medication to the mouthpiece.
d. Breathe in through the mouth, filling the lungs.
e. Use a spacer attachment and place the mouthpiece in the mouth.
f. Close the lips around the mouthpiece.
g. After inhaling the medication, hold the breath 10 seconds. - ANSWER b. Shake the inhaler.
c. Attach the canister of medication to the mouthpiece.
e. Use a spacer attachment and place the mouthpiece in the mouth.
f. Close the lips around the mouthpiece.
g. After inhaling the medication, hold the breath 10 seconds.
Rationale:
The correct sequence of MDI administration includes shaking the inhaler, attaching the canister to the mouthpiece, attaching the spacer, the client should then let their breath out through the mouth to empty the lungs and place the mouthpiece in the mouth, closing the lips and mouth around the mouthpiece, and inhaling medication and holding the breath for 10 seconds.
The Centers for Disease Control and Prevention (CDC) has issued guidelines for health care workers in relation to protection from HIV. The practical nurse (PN) who suspects they may be pregnant is assigned a client who is HIV+. What action should the PN implement?
a. Make the suspected pregnancy known and request a different client assignment.
b. Wear gloves when coming in contact with the blood or body fluids of a client.
c. Limit contact and interaction with the client and have another nurse bathe the client.
d. Put on all the PPE to include gown and mask when entering the client's room. - ANSWER b. Wear gloves when coming in contact with the blood or body fluids of a client.
Rationale:
The CDC guidelines for standard precautions recommend that health care workers use gloves when coming in contact with blood or body fluids from any client because HIV is infectious before the client becomes aware of symptoms. Pregnancy of a nurse should not inhibit the nurse for taking care of a HIV+ client as long as standard precautions are observed.
A practical nurse (PN) reinforced client teaching regarding the transmission of the HIV virus. Which statement by the client demonstrates an understanding of the reinforced teaching?
a. "To be absolutely safe, I should wear two latex condoms during intercourse with an infected partner."
b. "I may still contract HIV even though I am 62 years old."
c. "Urinating immediately after having sexual relations will help reduce the risk of contracting HIV."
d. "If I take AZT during my pregnancy, I will not give the virus to my unborn baby." - ANSWER b. "I may still contract HIV even though I am 62 years old."
Rationale:
More than 10% of all AIDS cases in the United States are among those older than 50 years of age.
A client is diagnosed with fluid volume deficit. Which findings would the practical nurse document consistent with fluid volume deficit? (Select all that apply.)
a. Tachycardia
b. Diaphoresis
c. Cool skin
d. Heart failure
e. Decreased urine output
f. Increased thirst - ANSWER a. Tachycardia
c. Cool skin
e. Decreased urine output
f. Increased thirst
Rationale:
Fluid volume deficit causes tachycardia because the body tries to compensate and pump blood efficiently. Cool skin is consistent with fluid volume deficit. Decreased urine output results from reduced fluid volume perfusing the kidneys. Thirst will be stimulated by the hypothalamus because of decreased fluid volume.
During a clinic visit, a client reports to the practical nurse (PN) that they felt a solid mass in their breast during self-examination, but it was not painful. What instruction should the PN reinforce with the client?
a. Continue to monitor the mass until the next scheduled annual medical examination.
b. Notify the health care provider if the mass becomes soft or painful or starts to drain.
c. Schedule an appointment with the health care provider for evaluation.
d. Breast masses are usually insignificant if they feel soft or are easily movable. - ANSWER c. Schedule an appointment with the health care provider for evaluation.
Rationale:
A painless breast mass is an abnormal finding, and the PN should instruct the client to obtain prompt medical evaluation.
A hospitalized client is receiving continuous nasogastric tube feedings at 90 mL/hour via a small-bore tube and an enteral infusion pump. Upon entering the client's room, which action should the practical nurse (PN) take first?
a. Auscultate the client's breath sounds for a one minute.
b. Ensure the client's head of bed is raised at least 30 degrees.
c. Check placement of the nasogastric tube.
d. Verify the prescribed feeding is hung. - ANSWER b. Ensure the client's head of bed is raised at least 30 degrees.
Rationale:
The 30 degrees is the minimum degree elevation of the head of the bed for a client receiving continuous tube feedings to prevent aspiration.
The nurse is assisting with data collection for an older adult who is visiting the health care provider today. Which signs and symptoms should the nurse report to the health care provider as possible signs associated with colon cancer? (Select all that apply.)
a. Rectal bleeding
b. Weight gain
c. Abdominal distention
d. Sensation that bowels are not evacuating completely
e. A diet high in vegetables such as cauliflower, cabbage, and kale - ANSWER a. Rectal bleeding
c. Abdominal distention
d. Sensation that bowels are not evacuating completely
Rationale:
Some signs and symptoms associated with colon cancer include rectal bleeding, abdominal distention, and a sensation the bowels are not evacuating completely. A diet high in cauliflower, cabbage, and kale is associated with a reduced, not increased, risk of colon cancer. A client who has colon cancer is more likely to have a weight loss rather than weight gain.
A client with cirrhosis is being discharged home, with family members to provide the majority of the client's care. Which instructions are important to reinforce with the family regarding this client's care? (Select all that apply.)
a. Maintain a low-fiber diet.
b. Use a safety razor to shave the client.
c. Avoid soap when bathing the client.
d. Use a soft toothbrush and gentle oral care.
e. Apply moisturizing lotion and turn the client frequently. - ANSWER c. Avoid soap when bathing the client.
d. Use a soft toothbrush and gentle oral care.
e. Apply moisturizing lotion and turn the client frequently.
Rationale:
A client with cirrhosis often has dry itchy skin. Soap can dry and irritate the skin further. To prevent skin breakdown, the skin should be kept moist and the client turned frequently. With cirrhosis, the liver is not able to produce some clotting factors, so bleeding prevention is a priority. The family should be instructed to use electric razors, not a safety razor, and to use a soft toothbrush when providing gentle oral care.
A client who has undergone closed-appendectomy is prescribed to begin ambulation the next day. The next day when the practical nurse (PN) goes to assist the client with ambulation, the client yells they are watching the television and they do not feel like getting out of bed. Which response should the PN provide?
a. "Your health care provider has prescribed ambulation on the first postoperative day."
b. "You must ambulate to avoid serious complications that are much more painful."
c. "I know how you feel—you're angry about having to do this, but it is required."
d. "I'll be back in 30 minutes to help you get out of bed and walk around the room." - ANSWER d. "I'll be back in 30 minutes to help you get out of bed and walk around the room."
Rationale:
Returning within 30 minutes provides a "cooling off" period, is firm, direct, and nonthreatening, and avoids arguing with the client
A client diagnosed with duodenal ulcers is admitted to the hospital. The client was administered ranitidine hydrochloride 150 mg PO at bedtime. Which finding would indicate a therapeutic response of the medication?
a. Gastric secretions pH level below 3.
b. Hemoccult testing is positive on two different occasions.
c. No difficulty falling asleep reported.
d. No complaints of abdominal pain or heartburn verbalized. - ANSWER d. No complaints of abdominal pain or heartburn verbalized.
Rationale:
Lack of abdominal pain within 4 hours after meals indicates decreased duodenal irritation, a positive outcome in the treatment of duodenal ulcer.
The health care provider informed a client diagnosed with stage 4 liver cancer that the cancer has spread to their spine. The client states to the practical nurse, "I have a cancer, but it is not malignant." What is the best initial nursing action?
a. Encourage the client to attend a cancer education program.
b. Perform a complete history and physical assessment.
c. Ask the client to explain his understanding of the term malignancy.
d. Offer the client emotional support to deal with the diagnosis. - ANSWER c. Ask the client to explain his understanding of the term malignancy.
Rationale:
The best initial action is to assess the client's knowledge of the term malignancy when used to describe cancer. The client appears to have inaccurate knowledge. Stage 4 cancer means the cancer has spread (metastasized) from where it has started to another body part.
A client with severe Parkinson disease diagnosed with anorexia, dysphagia, drooling, generalized weakness, and slurred speech is admitted to the unit. Which nursing action should the practical nurse implement first for this client?
a. Provide the client with a word board.
b. Set up a suction and Yankauer at client's bedside.
c. Encourage passive and active range-of-motion exercises.
d. Offer client nutritional milkshakes every 2 hours. - ANSWER b. Set up a suction and Yankauer at client's bedside.
Rationale:
Dysphagia and drooling predispose this client to aspiration. A suction machine and Yankauer should be set up and near the client to be used to help prevent aspiration pneumonia. Aspiration is the primary concern in this situation.
A client diagnosed with epilepsy is admitted to the unit. What intervention should the practical nurse (PN) implement if the client experiences a seizure?
a. Observe the length and activity of the seizure.
b. Insert an oral airway.
c. Gently restrain the client to prevent harm.
d. Call the code team. - ANSWER a. Observe the length and activity of the seizure.
Rationale:
The PN should observe the client as they have their seizure. The length of time and movement by the client needs to be observed and then documented once the client is stable. The client should be placed on their side to help prevent aspiration.
A client diagnosed with a brain tumor is receiving radiation beam treatments to the right frontal area. The practical nurse (PN) should observe this client for which problem during the early post-therapy days?
a. Hemiplegia
b. Headache
c. Hearing loss
d. Dysphagia - ANSWER b. Headache
Rationale:
Radiotherapy is a local treatment, and most side effects are site-specific, such as inflammation of surrounding brain tissue, swelling, headache, and fatigue.
The practical nurse (PN) is assigned a client diagnosed with a hemothorax who had a chest tube inserted 36 hours ago; upon entering the room, the PN observes the client resting comfortably in the semi-Fowler position; respirations appear even and unlabored; the water in the suction chamber is bubbling; and there is serous drainage noted in the collection chamber. What is the best initial action for the PN to take?
a. Measure and document in the drainage in the chamber.
b. Clamp the chest tube while assessing for air leaks.
c. "Milk" the tube to remove any excessive blood clot buildup.
d. Decrease the bubbling in the suction chamber. - ANSWER d. Decrease the bubbling in the suction chamber.
Rationale:
Follow the ABC's (airway, breathing, and circulation) to determine that the airway and breathing are stable, and the next step is to evaluate the extent of the bleeding. It is not necessary to change the amount of bubbling in the suction chamber.
The nurse has reinforced teaching regarding postoperative care for a client who has had a prostatectomy. Which statements indicate the need for further instructions? (Select all that apply.)
a. "If I feel the need to void while the catheter is still in, I should try to void around the catheter."
b. "I should drink about 12 glasses of water a day, once the indwelling catheter is removed."
c. "I should only have intercourse twice weekly once I return home after surgery."
d. "I should report bright red blood and large clots in my urine to my surgeon."
e. "I can expect to have urine that is lightly tinged with blood when I get home." - ANSWER a. "If I feel the need to void while the catheter is still in, I should try to void around the catheter."
c. "I should only have intercourse twice weekly once I return home after surgery."
Rationale:
After prostatectomy, the client should not try to void around the catheter. It is common to feel pressure inside the bladder while the irrigating catheter is still in the bladder. The client should not have intercourse immediately after surgery. The client should drink 12 to 14 glasses of fluid once the catheter is removed. Urine that is lightly blood tinged is common; bright red blood in the urine should be reported to the surgeon.
A client is walking in the hallway and begins experiencing an acute angina attack. Which is the first action for the nurse to take?
a. Administer a nitroglycerine tablet sublingually.
b. Notify the local emergency medical services. (EMS).
c. Assist the client to walk back to the client's room.
d. Ask the client if this attack occurred at the same time as yesterday's. - ANSWER a. Administer a nitroglycerine tablet sublingually.
Rationale:
The first action is to administer nitroglycerine sublingually, in order to dilate the coronary arteries so that more oxygenated blood can be provided to the myocardium. It is not necessary to notify EMS unless the angina pain is unrelieved by three nitroglycerine tablets. The client should rest immediately, not walk back to the room. It is not a priority to determine whether or not the attack occurred at the same time as yesterday's.
A client has had a gastrectomy to treat stomach cancer. The nurse has reinforced instructions on ways to prevent "dumping syndrome." Which client statement indicates the need for further instruction?
a. "My meals need to be mostly protein."
b. "I should walk around after each meal."
c. "I should eat fewer carbohydrates."
d. "I should eat smaller, more frequent meals." - ANSWER b. "I should walk around after each meal."
Rationale:
The client should lie down after meals to avoid syncope. The client should eat more protein and less carbohydrates, and smaller more frequent meals
An adult client is admitted to the emergency department with partial-thickness and full-thickness burns over 40% of the body surface area resulting from a car collision fire. After the health care provider and nurse have intubated the client, which intervention should the practical nurse (PN) do first?
a. Remove all the client's clothing, shoes, and jewelry.
b. Insert indwelling urinary foley.
c. Initiate an intravenous catheter line.
d. Obtain blood work and urine sample - ANSWER a. Remove all the client's clothing, shoes, and jewelry.
Rationale:
Interventions for moderate to severe burns of deep partial-thickness and full-thickness, once an airway and circulation is established, then the next thing is to remove all the victims clothing, shoes, and jewelry before the edema sets in and they become constricting, also it is possible to cause more severe burns by leaving clothing on.
The practical nurse (PN) is assigned a client with a medical history of diabetes and gangrene who had a right below the knee amputation. At the time of rewrapping and inspecting the stump, the client refuses to look at their stump. The practical nurse (PN) tells the client that the incision is healing well, but the client refuses to talk about it. What is the best response to this client's silence?
a. "It is normal to feel angry and depressed, but the sooner you deal with this surgery, the better you will feel."
b. "Looking at your incision can be frightening, but facing this fear is a necessary part of your recovery."
c. "It is okay if you do not want to talk about your surgery. I will be available when you are ready."
d. "I will ask another person who has had an amputation to come by and share their experiences with you." - ANSWER c. "It is okay if you do not want to talk about your surgery. I will be available when you are ready."
Rationale:
Informing the client that it is okay they do not want to talk about their surgery and stating that the PN is available when they need them, displays sensitivity and understanding without judging the client.
A client comes to the clinic and reports the presence of a painful lesion in the genital area; they described it as a blister 2 days earlier that is now crusty. Which intervention should the practical nurse (PN) implement first?
a. Ask the client if they have had unprotected sex.
b. Prepare the client for a culture and sensitivity test of the lesion.
c. Inform the client this occurrence will have to be reported to the public health department.
d. Prepare to administer penicillin intramuscularly into the dorsogluteal area. - ANSWER a. Ask the client if they have had unprotected sex.
Rationale:
These are typical signs and symptoms of herpes simplex virus 2 (HSV2), a sexually transmitted disease (STD), so the PN should ask the client if they had unprotected sex and if the client has exposed others to the disease.
Which educational materials should the practical nurse select for reinforcement of teaching for secondary prevention? (Select all that apply.)
a. Video that teaches client to do breast self-examinations.
b. Pamphlets describing how to do testicular self-examinations.
c. Chart that emphasizes childhood immunization schedule.
d. Chart that emphasizes childhood immunization schedule.
e. Postcard reminders for clients to get papanicolaou (Pap) smears and mammograms. - ANSWER a. Video that teaches client to do breast self-examinations.
b. Pamphlets describing how to do testicular self-examinations.
e. Postcard reminders for clients to get papanicolaou (Pap) smears and mammograms.
Rationale:
Secondary prevention deals with early diagnosis to treat disease in the beginning of its development. Breast self-examinations, testicular self-examinations, mammograms, and Pap smears are considered secondary prevention methods.
The nurse is assigned the care of a client whose spiritual beliefs are vastly different from the nurse's background. What action should the nurse take?
a. Tell the client "I am uncomfortable with some of the religious items in your room."
b. Tell the client "I will leave you alone most of the day so you can pray uninterrupted."
c. Ask the client "Do you have any spiritual needs or concerns related to your health?"
d. Tell the client "We only have regular food here, but your family can bring you food." - ANSWER c. Ask the client "Do you have any spiritual needs or concerns related to your health?"
Rationale:
During time of illness, spiritual practices may be a source of comfort to the client. The nurse should ask clients if there are any spiritual needs or concerns related to their health that need to be addressed. It is inappropriate for the nurse to mention discomfort with religious items in the client's room. The nurse should not leave the client alone for most of the day, but should ask if there are particular times the client would like to pray or meditate. The nurse can then plan care around those times whenever possible. Referring to facility food as "regular food" insinuates that the client's foods are abnormal. In addition, depending on the client's prescribed diet, the family may or may not be able to bring in additional foods.
A client with a history of emphysema is hospitalized for an exacerbation of the disease. The nurse expects to see which aspect emphasized in the plan of care?
a. Oxygen administered at 6 L/m via nasal cannula.
b. Fluids to be restricted to less than 1500 mL/day.
c. Supine or low Fowler's position while resting in bed.
d. Information on smoking cessation classes and support. - ANSWER d. Information on smoking cessation classes and support.
Rationale:
The client should have information provided on smoking cessation classes and support while quitting. Oxygen is given at a low flow rate to prevent respiratory depression due to suppression of the stimulus to breathe. Fluids are encouraged to 3000 mL unless contraindicated. The client should be positioned sitting upright and bending slightly forward to promote breathing.
A client diagnosed with a fracture of the left radius has a plaster cast applied. The nurse has reinforced instructions for drying the cast over the next 24 hours. Which statement by the client indicates the teaching was effective?
a. "I will wrap the cast in plastic wrap for 24 hours."
b. "I will support the cast on a firm surface during the night."
c. "I will not cover it; instead I'll keep the cast surfaces exposed to circulating air."
d. "I can use a blow dryer on medium setting until the plaster cast feels dry to the touch." - ANSWER c. "I will not cover it; instead I'll keep the cast surfaces exposed to circulating air."
Rationale:
The nurse should instruct the client to keep the cast exposed to circulating air and avoid covering it with material that might keep it moist.
A client is diagnosed with acute myocardial infarction (MI). Which diagnostic laboratory value should the practical nurse (PN) anticipate to be the first to elevate to establish a diagnosis of an acute myocardial infarction (MI)?
a. Elevated troponin
b. Elevated creatine kinase-MB (CK-MB) level
c. Prolonged prothrombin time (PT)
d. Elevated serum blood urea nitrogen (BUN) and creatinine - ANSWER a. Elevated troponin
Rationale:
Tissue damage in the myocardium causes the release of cardiac enzymes into the blood system. According to the American College of Cardiology (ACS) and the European Society of cardiology (ESC), an elevation of the troponin will occur within 2 to 3 hours of an MI and is used to establish the diagnosis. It takes the CK-MB level 6 to 9 hours or longer to elevate.
A plan of care for a 56-year-old client who has been diagnosed with osteopenia has been developed. The plan is focused on preventing further bone resorption and increasing bone mass. Which outcome statement should be included in the plan of care?
a. The nurse practitioner will instruct the client on the use of alendronate.
b. The client will decrease the number of cigarettes smoked by 50% within 2 weeks.
c. The client will swim for 30 minutes three to four times per week for the next 2 months.
d. The practical nurse will provide the client with a list of foods that are high in calcium - ANSWER b. The client will decrease the number of cigarettes smoked by 50% within 2 weeks.
Rationale:
A desired outcome statement should be client-centered with a measurable outcome, and the client decreasing the number of cigarettes smoked by 50% within 2 weeks is both client-centered and measurable. Cigarette smoking has a negative effect on bone resorption, so the client should be advised to stop smoking.
In order to provide culturally competent care to a group of clients, what action must the practical nurse do first?
a. Treat each client the same, regardless of race or religion.
b. Ensure that all Native American clients have access to a shaman.
c. Understand one's own world views in addition to the client's.
d. Include the family in the plan of care for older adult clients. - ANSWER c. Understand one's own world views in addition to the client's.
Rationale:
The nurse should understand their own values and views to prevent those beliefs being imparted to others, in addition to understanding the client's cultural views when providing cultural competent care. Treating every client the same or assuming that all clients share the same values does not exhibit cultural competence or sensitivity.
The nurse is reinforcing hygiene instructions to unlicensed assistive personnel (UAP) who will be bathing a client who has been diagnosed with pneumonia. The nurse should instruct the UAP to plan to bathe the client at which time?
a. The client with pneumonia should not be bathed.
b. The client should be bathed according to facility schedule.
c. The client should be bathed after noninfectious clients are bathed.
d. The client should have activities such as bathing, alternated with rest periods. - ANSWER d. The client should have activities such as bathing, alternated with rest periods.
Rationale:
The client should be allowed to rest before activities such as bathing take place. There is no contraindication for bathing a client with pneumonia. Facility schedules are not the primary reason to determine the timing of a client's bath. By using standard and other precautions, it would not matter whether the client with pneumonia is bathed before or after other noninfectious clients.
A client is admitted from the emergency department with a diagnosis of left tibia fracture and the left leg has a splint in place. The client was medicated [Show Less]