adv med surg final set 3

A nurse is reading the report for a chest x-ray study in a client who has just been intubated. The report states that the tip of the endotracheal tube lies 1 cm above the carina. The nurse determines that the tube is positioned above which area of the respiratory system? 1. The first tracheal cartilaginous ring 2. The bifurcation of the right and left main bronchi 3. The point at which the larynx connects to the trachea 4. The area connecting the oropharynx to the laryngopharynx

2 The carina is a cartilaginous ridge that separates the openings of the two main (right and left) bronchi. If an endotracheal tube is inserted past the carina, the tube will enter the right main bronchus as a result of the natural curvature of the airway. This is hazardous because then only the right lung will be ventilated. Incorrect tube placement is easily detected because only the right lung will have breath sounds and rise and fall with ventilation. Options 1, 3, and 4 are incorrect interpretations.

354. A male client with COPD smokes two packs of cigarettes per day and is admitted to the hospital for a respiratory infection. He complains that he has trouble controlling respiratory distress at home when using his rescue inhaler. Which comment from the client indicates to the nurse that he is not using his inhaler properly?

"After I squeeze the inhaler and swallow, I always feel a slight wave of nausea, bit it goes away"

The nurse is giving discharge instructions to the parents of a newborn with a prescription for home phototherapy. Which statement by a parent indicates understanding of the phototherapy?

"I will keep the baby's eyes covered when the baby is under the light." Neonatal jaundice is related to subcutaneous deposition of fat-soluble (indirect) bilirubin, which is converted to a water-soluble form when the skin is exposed to an ultraviolet light, so the infant's eyes should be protected (C) by closing the eyes and placing patches over them before placing the baby under the phototherapy light source. The baby's position should be changed about every two hours, not (A), so that the light reaches all areas of the body to promote conversion to a water-soluble form of bilirubin, which is excreted in the urine. The infant can be removed from the light for feedings and diaper changes, but should receive phototherapy exposure for 18 hours a day (B). The baby should be naked or dressed in only a diaper to expose as much skin as possible to the light (D).

A nurse is caring for a group of clients with myasthenia gravis, Guillain-Barré syndrome, and amyotrophic lateral sclerosis (ALS). Which information should the nurse consider when planning care for this group of clients? 1 Progressive deterioration until death 2 Deficiencies of essential neurotransmitters 3 Increased risk for respiratory complications 4 Involuntary twitching of small muscle groups

3. All three share increased risk for respiratory complications. As a result of muscle weakness, the vital capacity is reduced, leading to increased risk of respiratory complications; impaired swallowing can also lead to aspiration. Although ALS is progressive, clients with myasthenia gravis may be stable with treatment, and clients with Guillain-Barré syndrome may experience a complete recovery. None of these diseases are caused by a lack of neurotransmitters; only myasthenia gravis is associated with a decreased number of receptor sites. Twitching is not expected with myasthenia gravis or Guillain-Barré syndrome.

A client is newly diagnosed with multiple sclerosis. The client is obviously upset with the diagnosis and asks, "Am I going to die?" Which is the nurse's best response? 1 "Most individuals with your disease live a normal life span." 2 "Is your family here? I would like to explain your disease to all of you." 3 "The prognosis is variable; most individuals experience remissions and exacerbations." 4 "Why don't you speak with your healthcare provider? You probably can get more details about your disease."

3. "The prognosis is variable; most individuals experience remissions and exacerbations." "The prognosis is variable; most individuals experience remissions and exacerbations" is a truthful answer that provides some realistic hope. The response "Most individuals with your disease live a normal life span" provides false reassurance; repeated exacerbations may reduce the life span. The response "Is your family here? I would like to explain your disease to all of you" avoids the client's question; the family did not ask the question. The response "Why don't you speak with your healthcare provider? You probably can get more details about your disease" avoids the client's question and transfers responsibility to the practitioner.

The registered nurse (RN) is caring for a client with renal calculi. Which healthcare professional is most suitable to be delegated the task of administering urinary alkalinizer by mouth to the client? 1 Certified technician 2 Patient care associate Correct3 Licensed practical nurse 4 Unlicensed assistive personnel

Administering oral medications such as urinary alkalinizer can be safely delegated to a licensed practical nurse (LPN) or licensed vocational nurse (LVN) as per guidelines. Certified technician is a licensed assistive personnel whose scope of practice is limited for administering medications. The scope of practice of the patient care associate and unlicensed assistive personnel is limited to performing basic care, feeding, and hygiene.

538. A nurse receive a shift report about a male client with Obsessive compulsive disorder (OCD). The nurse does morning rounds and reaches the client while he is repeatedly washing the top of the same table. What intervention should the nurse implement?

Allow time for the behavior and then redirect the clients to other activities

119. An older male comes to the clinic with a family member. When the nurse attempts to take the client's health history, he does not respond to questions in a clear manner. What action should the nurse implement first?

Assess the surroundings for noise and distractions.

While the RN is preparing to take the VS of a newly admitted client with heart failure, a practical nurse enters the client's room and reports to the RN that another client pulled out his central venous catheter and the UAP is in the room with the client. The RN knows that the newly admitted client is to receive a stat dose of an oral anti anxiety medication. How should the RN assign the needed care? A. The UAP should remain with the client who removed the central venous catheter while the pN administers the stat medication, and the RN finishes the admission VS. B. The RN should provide care for the client who removed the central venous catheter while the PN administers the stat medication and the UAP obtains the newly admitted client's VS. C. The PN should provide care for the client who removed the central venous catheter while the UAP obtains the VS of the newly admitted client and the RN administers the stat medication D. The PN should provide care for the client who removed the central venous catheter while the RN completes the admission assessment and administers the stat medication

B

445. After a routine physical examination, the healthcare admits a woman with a history of Systemic Lupus Erythematous (SLE) to the hospital because she has 3+ pitting ankle edema and blood in her urine. Which assessment finding warrants immediate intervention by the nurse?

Blood pressure 170/98

456. The nurse notes an increase in serosanguinous drainage from the abdominal surgical wound from an obese client. What action should the nurse implement?

Observe the wound for dehiscence

The registered nurse suggested that a newly hired registered nurse delegate tasks to nursing assistants. Which is an element that fosters effective delegation decisions by the newly hired registered nurse? 1 Skills Correct2 Stability 3 Practice 4 Environment

Stability along with safety, critical thinking, and time for decision-making creates an integrative process, which fosters effective delegation decisions. Skills are important for making decisions based on critical thinking. Practice accomplishes safety in delegation. Environment with feedback about performance is the best strategy for shaping the future behavior of individuals.

An elderly client with periods of confusion underwent surgery and requires assistance for feeding. To which healthcare professional should the registered nurse delegate the task? 1 Charge nurse 2 Nurse manager Correct3 Licensed practical nurse Incorrect4 Unlicensed assistive personnel (UAP)

The registered nurse should delegate the task of feeding to the licensed practical nurse. The charge nurse may delegate the task in the absence of a registered nurse, but he/she is not likely to feed the client. The nurse manager is the designated individual to whom all nursing professionals should be answerable regarding a given task. The UAP performs all hygienic tasks. Feeding the client can be performed by the UAP but only for uncomplicated, low-risk clients.

Antipsychotics

Therapeutic effects takes MONTHS FGAs - Nuroleptics - causes high rates of extrapyramidal side effects (EPS) and tardive dyskenesia SGAs - Atypical - Lesser daverse effects than FGAs, serious metabolic effects

A client who has active tuberculosis (TB) is admitted to the medical unit. What action is most important for the nurse to implement?

Active tuberculosis requires implementation of airborne precautions, so the client should be assigned to a negative pressure air-flow room (D). Although (A and C) should be implemented for clients in isolation with contact precautions, it is most important that air flow from the room is minimized when the client has TB. (B) should be implemented when the client leaves the isolation environment.

The nurse plans a teaching session with a client but postpones the planned session based on which nursing problem?

Activity intolerance related to postoperative pain.

TCAs (block NE and S-Ht)

Amitriptyline (Elavil) Clomipramine (Anafranil) Doxepin (Silenor) Imipramine (Tofranil) Trimipramine (Surmontil)

A client newly diagnosed with myasthenia gravis is to begin taking pyridostigmine (Mestinon), a cholinesterase inhibitor. Two days later the client develops loose stools and increased salivation. The nurse concludes that these signs are: Indicative of a myasthenic crisis Cholinergic effects A temporary response Toxic effects of the medication

Cholinergic effects

15. An elderly client seems confused and reports the onset of nausea, dysuria, and urgency with incontinence. Which action should the nurse implement?

Obtain a clean catch mid-stream specimen

23. A client with a history of heart failure presents to the clinic with a nausea, vomiting, yellow vision and palpitations. Which finding is most important for the nurse to assess to the client?

Obtain a list of medications taken for cardiac history

What nursing intervention is anticipated for a client with Guillain-Barré syndrome?

Maintaining ventilator settings to support respiration

479. Which intervention should the nurse include in the plan of care for a client with leukocytosis?

Monitor temperature regularly

379. A client with acute renal failure (ARF) is admitted for uncontrolled type 1 diabetes Mellitus and hyperkalemia. The nurse administers an IV dose of regular insulin per sliding scale. Which intervention is the most important for the nurse to include in this client's plan of care?

Monitor the client's cardiac activity via telemetry.

CHOLinesterase Inhibitors drug interactions

First gen antihistamines, TCA, conventional antipsychotics

530. The nurse caring for a client with dysphagia is attempting to insert an NG tube, but the client will not swallow and is not gagging. What action should the nurse implement to facilitate the NGT passage into the esophagus?

Flex the client's head with chin to the chest and insert.

217. When development a teaching plan for a client newly diagnosed type 1 diabetes, the nurse should explain that an increase thirst is an early sing of diabetes ketoacidosis (DKA), which action should the nurse instruct the client to implement if this sign of DKA occur?

Give a dose of regular insulin per sliding scale

Which action should the nurse perform when preparing a patient with supraventricular tachycardia for cardioversion who is alert and has a blood pressure of 110/66 mm Hg?

Give a sedative before cardioversion is implemented.

469. A client whose wrists are sutured from a recent suicide attempt is been transferred from a medical unit. Which nursing diagnosis is of the highest priority?

Risk for self-directed violence related to impulsive actions

What test is used to differentiate a cholinergic crisis from a myasthenic crisis

Tensilon testing

A nurse-manager sees a colleague taking drugs from the unit. What action should the nurse-manager take?

Report the incident to the immediate supervisor.

After providing a patient with discharge instructions on the management of a new permanent pacemaker, the nurse knows that teaching has been effective when the patient states

"I won't lift the arm on the pacemaker side up very high until I see the doctor."

A nurse takes a female client to the examination room and asks her to remove her clothes and put on an examination gown with the front open. The woman states, "I have special undergarments that I do not remove for religious reasons." How should the nurse respond?

"Tell me about your undergarments so we can discuss how you can have your examination comfortably.

64. A 10 year old who has terminal brain cancer asks the nurse, "What will happen to my body when I die?" How should the nurse respond?

"The heart will stop beating & you will stop breathing."

A 9-year-old is hospitalized for neutropenia and is placed in reverse isolation. The child asks the nurse, "Why do you have to wear a gown and mask when you are in my room?" How should the nurse respond?

"To protect you because you can get an infection very easily."

519. The nurse is conducting the initial assessment of an ill client who is from another culture.... What response should the nurse provide?

"What practices do you believe will help you heal?"

The nurse is preparing content for a community health fair on risk factors for heart disease. What should the nurse include as nonmodifiable risk factors? Select all that apply

1) Age 4) Ethnic background 5) Parents' health history

Preoperatively, a client is to receive 75 mg of meperidine (Demerol) IM. The Demerol solution contains 50 mg/mL. How much solution should the nurse administer?

1.5 mL.

560. A client currently receiving an infusion labeled Heparin Sodium 25,000 Units in 5% Dextrose Injection 500 mL at 14 mL/hour. A prescription is received to change the rate of the infusion to 900 units of Heparin per hour. The nurse should set the infusion pump to deliver how many mL/hour? (Enter numeric value only).

18

Which client should be assigned to the traveling nurse, new to neurologic nursing care, who has been on the neuro unit for 1 week

A 68 year old with chronic ALC

A client with myasthenia gravis asks the nurse why the disease has occured, what pathology underlies the nurses reply?

A decreased number of functioning acetylcholine receptor sites

125. A nurse with 10 years experience working in the emergency room is reassigned to the perinatal unit to work an 8 hour shift. Which client is best to assign to this nurse?

A mother with an infected episiotomy

A 56-year-old female client is receiving intracavitary radiation via a radium implant. Which nurse should be assigned to care for this client?

A nurse with Marfan's syndrome who is postmenopausal.

The patient with GBS describes a chronological progression of motor weakness that started in the legs and then spread to the arms and the upper body, which type of GBS do these symptoms indicate

Ascending

A client with Guillain-Barré syndrome has been hospitalized for 3 days, which assessment finding indicates a need for more frequent monitoring?

Ascending weakness

79. A postoperative female client has a prescription for morphine sulfate 10 mg IV q3 hours for pain. One dose of morphine was administered when the client was admitted to the post anesthesia care unit (PACU) and 3 hours later, the client is again complaining of pain. Her current respiratory rate is 8 breaths/minute. What action should the nurse take?

Administer Naxolone IV

130. The nurse caring for a 3-month-old boy one day after a pylorotomy notices that the infant is restless, is exhibiting facial grimaces, and is drawing his knees to his chest. What action should the nurse take?

Administer a prescribed analgesia for pain.

Which interventions are appropriate to protect a patient with MG from corneal abrasions

Administer artificial tears to keep corneas moist

495. The healthcare provider prescribes heparin protocol at18 units/kg/hr for a client with a possible pulmonary embolism. This client weighs 144 pounds. The available solution is labeled, heparin sodium 25,000 units in 5% dextrose 250 ml. the nurse should program the pump to deliver how many ml/hr? (Enter numeric value only. If rounding is require round to the nearest whole number.)

Answer 12

382. A client is receiving and oral antibiotic suspension labeled 250 mg/2ml. The healthcare provider prescribes 200mg every 6 hours. How many ml should the nurse administer at each dose? (Enter numerical value only. If rounding is required, round to the nearest tenth)

Answer: 1.6

141. The nurse uses the parkland formula (4ml x kg x total body surface area = 24 hours fluid replacement) to calculate the 24-hours IV fluid replacement for a client with 40% burns who weighs 76kg. How many ml should the client receive? (Enter numeric value only.

Answer: 12160

A retired office worker is admitted to the psychiatric inpatient unit with a diagnosis of major depression. The initial nursing care plan includes the goal, "Assist client to express feelings of anger." Which nursing intervention is most important to include in the client's plan of care?

Ask client to describe triggers of anger.

216. Which intervention should the nurse implement during the administration of vesicant chemotherapeutic agent via an IV site in the client's arm?

Assess IV site frequently for signs of extravasation

497. The nurse is arranging home care for an older client who has a new colostomy following a large bowel resection three day. The clients plan to live with a family member. Which action should the nurse implement? Select all that apply

Assess the client for self-care ability Provide pain medication instructions Teach care of ostomy to care provider

475. During the transfer of a client who had major abdominal surgery this morning, the post anesthesia care unit (PACU) nurse reports that the client, who is awake and responsive continues to report pain and nausea after receiving morphine 2 mg IV and ondansetron 4 mg IV 45 mints ago. Which elements of SBAR communication are missing from the report given by the PACU nurse? (Select all that apply)

Background Assessment Recommendation

62. After changing to a new brand of laundry detergent, an adult male reports that he has a fine itchy rash. Which assessment finding warrants immediate intervention by the nurse?

Bilateral Wheezing.

Drugs for BPH alpha1 blockers Selective: Silodosin, Tamsulosin Nonselective: Alfuzosin, Doxazosin, Terazosin

Block alpha1 receptor reducing BPH symptoms RAPIDLY but does not delay progression Adverse effects include abnormal ejaculation (volume, failure, retrograde), risk of floppy iris syndrome during cataract surgery hypoTN, fainting, dizziness, nasal congestion

474. Which information is more important for the nurse to obtain when determining a client's risk for (OSAS)?

Body mass index

148. A client is receiving mesalamine 800 mg PO TID. Which assessment is most important for the nurse to perform to assess the effectiveness of the medication?

Bowel patterns

A patient with GBS has been intubated for the respiratory failure, the nurse must suction the patient, in assessing for risk of vagal nerve stimulation, what does the nurse closely monitor the patient for

Bradycardia

289. When assessing a multigravida the first postpartum day, the nurse finds a moderate amount of lochia rubra, with the uterus firm, and three fingerbreadths above the umbilicus. What action should the nurse implement first?

Check for a destined bladder

After eye drops are instilled, which instruction should the nurse provide to the client?

Close your eyelids.

326. A client exposed to tuberculosis is scheduled to begin prophylactic treatment with isoniazid. Which information is most important for the nurse to note before administering the initial dose?

Current diagnosis of hepatitis B.

What clinical indicators should a nurse expect to identify in a client with acute respiratory distress syndrome (ARDS)? Select all that apply. 1 Crackles 2 Atelectasis 3 Hypoxemia 4 Severe dyspnea 5 Increased pulmonary wedge pressure

Crackles, Atelectasis, Hypoxemia, & Severe dyspnea

113. The nurse note a visible prolapse of the umbilical cord after a client experiences spontaneous rupture of the membranes during labor. What intervention should the nurse implement immediately?

Elevate the presenting part off the cord.

502. The nurse manager is conducting an in-services education program on the fire evacuation of the newborn recovery. What intervention should the nurse manager disseminate to the staff?

Evacuate each infant with mother via wheelchair

31. A female client reports that her hair is becoming coarse and breaking off, that the outer part of her eyebrows have disappeared, and that her eyes are all puffy. Which follow-up question is best for the nurse to ask?

Have you noticed any changes in your fingernails?

A client is admitted to the hospital with multiple signs and symptoms associated with a cardiac problem. What clinical finding alerts the nurse that the health care provider probably will insert a pacemaker? 1 Angina 2 Chest pain 3 Heart block 4 Tachycardia

Heart block

The nurse is preparing to administer a high volume saline enema to a client. Which information is most important for the nurse to obtain prior to administering the enema?

History of inflammatory bowel disorders.

504. A client with severe full-thickness burns is scheduled for an allografting procedure. Which information should the nurse provide the client?

Human source grafts require monitoring for signs of graft rejection

492. A male client is admitted with burns to his face and neck. Which position should the nurse place the client to prevent contract?

Hyperextended with neck supported by a rolled towel.

The nurse is planning a wellness program aimed at primary prevention in the community. Which action should the nurse implement?

Immunizations that decrease occurrences of many contagious diseases Primary prevention involves health promotion and disease prevention activities to decrease the occurrence of illness and enhance general health and quality of life, such as immunization (A).

A client with metastatic cancer is preparing to make decisions about end-of-life issues. When the nurse explains a durable power of attorney for health care, which description is accurate?

It will identify someone that can make decisions for your health care if you are in a coma or vegetative state.

199. The nurse is caring for a client who is taking a macrolide to treat a bacterial infection. Which finding should the nurse report to the healthcare provider before administering the next dose?

Jaundice

357. A client is receiving lactulose (Portalac) for signs of hepatic encephalopathy. To evaluate the client's therapeutic response to this medication, which assessment should the nurse obtain?

Level of consciousness

A patient is being assessed for heart disease. For which laboratory test should the nurse instruct to avoid eating and drinking fluids for 12 hours?

Lipid panel

While auscultating a patient's heart rate the nurse hears scratching sounds. What is most likely causing this sound?

Low level of fluid in the pericardial cavity

Neostigmine (Prostigmin) therapeutic uses

MG Reversal of Neuromuscular blockade

617. What is the nurse's priority goal when providing care for a 2-year-old child experience...

Manage the airway

191. The nurse is auscultating is auscultating a client's heart sounds. Which description should the nurse use to document this sound? (Please listen to the audio file to select the option that applies.)

Murmur

403. The nurse is assessing a postpartum client who is 36 hours post-delivery. Which finding should the nurse report to the healthcare provider?

Oral temperature of 100.6 F

The nurse is reviewing medication orders for a patient with MG, which order does the nurse question

PRN order for milk of magnesia

The nurse is developing a series of childbirth preparation classes for primigravida women and their significant others. What is the priority expected outcome for these classes?

Participants can identify at least three coping strategies to use during labor.

302. During a Woman's Health fair, which assignment is the best for the Practical Nurse (PN) who is working with a register nurse (RN)

Prepare a woman for a bone density screening

The nurse is caring for a client who is one day postoperative after a left total knee arthroplasty (TKA). Which intervention should the nurse include in the plan of care?

Progressive leg exercises to obtain 90-degree flexion

65. The nurse is assessing a 3-month-old infant who had a pylorotomy yesterday. This child should be medicated for pain based on which findings? Select all that apply:

Restlessness Clenched Fist Increased pulse rate Increased respiratory rate.

573. A client with polycystic kidney disease (PKD) receiving antibiotics for an infected cyst is experiencing severe pain. What action should the nurse implement?

Teach the client how to use a dry heating pad over the painful area

After palpating a patient's radial pulses, the nurse proceeds to palpate the brachial, carotid, femoral, popliteal, and posterior tibial pulses. What condition caused the nurse to make this more thorough physical assessment?

Various skin temperatures

194. The public nurse health received funding to initiate primary prevention program in the community. Which program the best fits the nurse's proposal?

Vitamin supplements for high-risk pregnant women.

A patient with MG is having difficulty maintaining an adequate intake of food and fluid because of difficulty chewing and swallowing. Which task for this patient is best to delegate to unlicensed assistive personnel

Weigh patient daily

A nurse is caring for a client who had a nephrectomy because of cancer of the kidney. Which factor will influence the client's ability to deep breathe and cough postoperatively? 1.Location of the surgical incision 2.Increased anxiety about the prognosis 3.Inflammatory process associated with surgery 4.Pulmonary congestion from preoperative medications

1.Location of the surgical incision

When analyzing an electrocardiographic (ECG) rhythm strip of a patient with a regular heart rhythm, the nurse counts 30 small blocks from one R wave to the next. The nurse calculates the patient's heart rate as ____.

50 There are 1500 small blocks in a minute, and the nurse will divide 1500 by 30.

50. Which action should the school nurse take first when conducting a screening for scoliosis?

Inspect for symmetrical shoulder height.

A nurse teaches a client about warfarin. Which information is essential for the nurse to include in the education plan? A. Periodic blood testing is necessary. B. Foods do not affect the medication. C. Physical activities should be limited. D. Daily doses should not be interrupted.

A. Periodic blood testing is necessary.

67. The nurse who is working on a surgical unit receives change of shift report on a group of clients for the upcoming shift. A client with which condition requires the most immediate attention by the nurse?

Abdominal-perineal resection 2 days ago with no drainage on dressing who has fever and chills.

A home care nurse is counseling a client with ALS, what information should the nurse include in the discussion?

Space activities throughout the day, Anticipate the use of alternative ways to communicate

Several experienced registered nurses are serving on a screening committee to interview prospective candidates for a nurse manager position on an acute care inpatient unit. The candidate with which characteristics is probably best for this position? A. Middle child in family; Associate Degree in nursing; Class treasurer in high school B. Oldest child in family; BS in nursing; played on the college volleyball team C. Youngest child in family; Diploma in nursing and certification in nursing; Member of ANA D. Only child in family; Master's in nursing with nurse practitioner certification; ran track in college

B

When blood or blood products are administered, which task can be assigned to the licensed practical nurse (LPN)? A.Initiation of the blood product B.Obtaining vital signs after infusion has begun C.Assessment of client's condition prior to blood administration D.Evaluation of client's response after receiving blood product

B Rationale: Blood and blood products must be initiated by the registered nurse (RN) (B); however, obtaining vital signs may be delegated as long as the results are evaluated by the RN. (A, C, and D) are all part of the nursing process and the scope of the RN.

169. When evaluating a client's rectal bleeding, which findings should the nurse document?

Color characteristics of each stool.

322. A client with osteoporosis related to long-term corticosteroid therapy receives a prescription for calcium carbonate. Which client's serum laboratory values requires intervention by the nurse?

Creatinine 4 mg/dl (354 micromol/L SI)

Depression

Decreased norepinephrine, dopamin, and serotonin

600. When finding a client sitting on the floor, the nurse calls for help from the unlicensed assistive personnel (UAP). Which task should the nurse ask the UAP to do?

Get a blood pressure cuff.

389. A female client presents in the Emergency Department and tells the nurse that she was raped last night. Which question is most important for the nurse to ask?

Has she taken a bath since the raped occurred?

36. The client with which type of wound is most likely to need immediate intervention by the nurse?

Laceration

A work group is to be formed to determine a care map for a new surgical intervention that is being conducted at the hospital. Which group is likely to be most effective in developing the new care map?

Multidisciplinary group.

347. After receiving report, the nurse can most safely plan to assess which client last? The client with...

No postoperative drainage in the Jackson-Pratt drain with the bulb compressed

593. In determine the client position for insertion of an indwelling urinary catheter, it is most important for the nurse to recognize which client condition?

Orthopnea

311. At 40 week gestation, a laboring client who is lying is a supine position tells the nurse that she has finally found a comfortable position. What action should the nurse take?

Place a wedge under the client's right hip.

Neostigmine (Prostigmin)

Prevents the breakdown of ACh by AChE

A nurse enters the room of a client with myasthenia gravis and identifies the client is experiencing increased dysphagia, what should the nurse do first?

Raise the head of the bed

44. Which intervention should the nurse include in a long-term plan of care for a client with Chronic Obstructive Pulmonary Disease (COPD)?

Reduce risks factors for infection

107. During an annual physical examination, an older woman's fasting blood sugar (FBS) is determined to be 140 mg/dl or 7.8 mmol/L (SI). Which additional finding obtained during a follow-up visit 2 weeks later is most indicative that the client has diabetes mellitus (DM)?

Repeated fasting blood sugar (FBS) is 132 mg/dl or 7.4 mmol/L (SI).

An LPN under your supervision is providing nursing care for a client with GBS, what observation should you instruct the LPN to report immediately?

Shallow respirations and decreased breath sounds

The nurse notes that a patient is scheduled for a brain natriuretic peptide level to be drawn. What patient teaching should the nurse prepare for this patient?

Signs of heart failure

534. While attempting to stablish risk reduction strategies in a community, the nurse notes that the regional studies have indicated....persons with irreversible mental deficiencies due to hypothyroidism. The nurse should seek funding to implement which screening measure?

T4 levels in newborns

486. A school-aged child was recently diagnosed with celiac disease. Which instruction should the nurse give the classroom teacher?

The child should avoid eating homemade cookies and cupcakes during parties

Which documentation indicates that the nurse correctly evaluated a pain medication's effectiveness after administration? The client

reports decrease in pain.

The nurse is planning to conduct nutritional assessments and diet teaching to clients at a family health clinic. Which individual has the greatest nutritional and energy demands?

A pregnant woman.

A client with anorexia nervosa is admitted to the critical care unit following a period of prolonged starvation. What signs or symptoms indicate to the nurse that the client may have hypokalemia? Select all that apply. A. Muscle weakness B. Metabolic alkalosis C. Cardiac dysrhythmias D. Respiratory rate of 24 or higher E. Serum potassium of 5.5 mEq/L (5.5 mmol/L)

A. Muscle weakness C. Cardiac dysrhythmias

A client with type 1 diabetes self-administers NPH insulin every morning at 8 am. The nurse evaluates that the client understands the action of the insulin when the client identifies which time range as the highest risk for hypoglycemia? A. Noon to 8 pm B. 8 pm to noon C. 9 am to 10 am D. 10 am to 11 am

A. Noon to 8 pm

393. A client with a lower respiratory tract infection receives a prescription for ciprofloxacin 500mg PO q 12hours. When the client request an afternoon snack, which dietary choice should the nurse provide?

Cinnamon applesauce

358. When administering an immunization in an adult client, the nurse palpates and administer the injection one inch below the acromion process into the center of the muscle mass. The nurse should document that the vaccine was administered at what site?

Deltoid

37. The nurse is planning care for a client admitted with a diagnosis of pheochromocytoma. Which intervention has the highest priority for inclusion in this client's plan of care?

Monitor blood pressure frequently

Drugs for neuropathic pain in MS

AEDs (carbamezepine (Tegretol), gavapentin (neurontin), oxcarazepin (Trileptal) TCAs (amitriptyline (Elavil), nortriptyline (Pamelor)

271. A client receives a new prescription for simvastatin (Zocor) 5 mg PO daily at bedtime. What action should the nurse take?

Administer the medication as prescribed with a glass of water

417. Which intervention should the nurse implement during the administration of vesicant chemotherapeutic agent via an IV site in the client's arm?

Assess IV site frequently for signs of extravasation

18. Which breakfast selection indicates that the client understands the nurse's instructions about the dietary management of osteoporosis?

Bagel with jelly and skim milk

583. The home health nurse is assessing a male client who has started peritoneal dialysis (PD) 5 days ago. Which assessment finding warrants immediate intervention by the nurse?

Cloudy dialysate output and rebound abdominal pain

When providing suctioning using a Yankauer tip catheter, what action should the nurse include? A. Apply a water soluble lubricant to the catheter B. Instill 3ml of NS before suctioning C. Instruct the client to cough as the suction tip is removed D. Wear protective goggles while performing the procedure

D

Adverse effects of neostigmine

Excessive muscarinic stimulation neuromuscular blockade (paralysis of respiratory muscle can be fatal)

Immunomodulators

interferon beta natalizumab (also used in Chron's dz) Fingolimod

A client with myasthenia gravis has been receiving neostigmine and asks about its actions, what information about its action should the nurse consider when formulating a response

Blocks the action of cholinesterase

Food-drug interactions of Levodopa

Meals high in protein interfere with absorption from the intestine and across the BBB

437. A school-age child who weighs 42 pounds receives a post-tonsillectomy prescription for promethazine (Phenergan) 0.5 mg/kg IM to prevent postoperative nausea. The medication is available in 25 mg/ml ampules. How many ml should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth).

0.4

Pre-administration assessment

increase ability to perform ADLs Assess motor symptoms Skin assessment (levodopa + MAOi --> malignant melanoma) Special consideration to patients with cardiac dz, psychiatric disorders, and patients taking MAOIs

The patient and family are referred to the nurse for education about amyotrophic lateral sclerosis, what information does the nurse include in the educational session

its a progressive disease involving the motor system, the cause of ALS is unknown, there is no cure for ALS

2. A male client with hypertension, who received new antihypertensive prescriptions at his last visit returns to the clinic two weeks later to evaluate his blood pressure (BP). His BP is 158/106 and he admits that he has not been taking the prescribed medication because the drugs make him "feel bad". In explaining the need for hypertension control, the nurse should stress that an elevated BP places the client at risk for which pathophysiological condition?

Stroke secondary to hemorrhage

284. The nurse inserts an indwelling urinary catheter as seen in the video what action should the nurse take next?

Leave the catheter in place and obtain a sterile catheter.

The nurse is reviewing the anatomy of the heart with a patient scheduled for cardiac surgery. Which patient statement indicates additional teaching is required?

"Blood leaves the right ventricle and travels through the pulmonary artery to the lungs."

Which information should the nurse include when documenting the findings of a patient's heart sounds? Select all that apply.

1) Pitch 3) Quality 4) Intensity 5) Location

The nurse is assisting a health care provider with the removal of a chest tube. The nurse should instruct the client to take which action? 1. Exhale slowly. 2. Stay very still. 3. Inhale and exhale quickly. 4. Perform the Valsalva maneuver.

4. Perform the Valsalva maneuver. When the chest tube is removed, the client is asked to perform the Valsalva maneuver (take a deep breath, exhale, and bear down). The tube is quickly withdrawn, and an airtight dressing is taped in place. An alternative instruction is to ask the client to take a deep breath and hold the breath while the tube is removed.

501. When assessing a male client, the nurse notes that he has unequal lung expansion. What conclusion regarding this finding is most likely to be accurate? The client has

A collapsed lung

Which instruction should the nurse include in the discharge teaching for a client who is taking an antipsychotic medication?

A common side effect of antipsychotic medications is constipation, and increasing high-fiber foods in the diet (A) can help to alleviate this problem.

When assessing a normal newborn, which finding(s) should the nurse expect? (Select all that apply.) A.Umbilical cord contains one vein and two arteries B.Slightly edematous labia in the female newborn C.Absence of Babinski reflex D.Presence of white plaques on the cheeks and tongue E.Nasal flaring noted with respirations

A,B Rationale: These are normal findings (A and B). The others indicate abnormalities or complications and should be reported to the primary health care provider (C, D, and E).

95. After repositioning an immobile client, the nurse observes an area of hyperemia. To assess for blanching, what action should the nurse take?

Apply light pressure over the area.

To assess a client's pupillary response to accommodation, a nurse should perform which activity?

Ask the client to look at a distant object and then at an object held 10 cm from the nose.

The nurse prepares to administer acetaminophen oral suspension to a child who weighs 66 pounds. The prescription reads: Administer 15 mg/kg every 6 hours by mouth. The Tylenol is available 150 mg/5 ml. Which is the correct dosage indicated on the image? A.30ml B.15ml C.10ml D.5ml

B Rationale: 66 lb/(2.2 kg/lb) = 30 kg 30 kg × (15 mg/kg) = 450 mg (5 mL/150 mg) × 450 mg = 15 mL or (450 mg/150 mg) × 5 mL = 15 mL

N-methyl-D-aspartate receptor antagonist (NMDA)

Blocks calcium influx by modulating glutamate Well tolerated memantine (moderate-severe)

9. During a home visit, the nurse observed an elderly client with diabetes slip and fall. What action should the nurse take first?

Check the client for lacerations or fractures

Parkinson's Disease

Chemical imbalance (low dopamine and high acetylcholine)

A male client diagnosed with antisocial personality disorder is morbidly obese and is placed on a low fat, low calorie diet. At dinner the nurse notes that he is trying to get other clients on the unit to give him part of their meals. What intervention should the nurse implement?

Confront the client about the consequences of the behavior.

329. A client is admitted with acute pancreatitis. The client admits to drinking a pint of bourbon daily. The nurse medicates the client for pain and monitors vital signs q2 hours. Which finding should the nurse report immediately to the healthcare provider?

Confusion and tremors

Which substance produced by the liver assists in maintaining the colloid osmotic pressure within the vasculature? A. Ammonia B. Bilirubin C. Glycogen D. Albumin

D

A 63-year-old female client whose husband died one month ago is seen in the psychiatric clinic. Her daughter tells the nurse that her mother is eating poorly, sleeps very little at night, and continues to set the table for her deceased husband. What nursing problem best describes this problem?

Denial related to the loss of a loved one.

187. A client arrives on the surgical floor after major abdominal surgery. What intervention should the nurse perform first?

Determine the client's vital sign.

371. The nurse assigned unlicensed assistive personnel (UAP) to apply antiembolism stockings to a client. The nurse and UAP enters the room, the nurse observes the stockings that were applying by the UAP. The UAP states that the client requested application of the stockings as seen on the picture, for increased comfort. What action should the nurse take?

Discussed effective use of the stockings with the client on UAP

601. During the initial newborn assessment, the nurse finds that a newborn's heart rate is irregular. Which intervention should the nurse implement?

Document the finding in the infant's record.

Which clinical finding does the nurse anticipate a client with an exacerbation of multiple sclerosis to experience?

Double vision and scanning speech

AntiCHOLinergic Parkinson Drugs adverse effects

Dry mouth, blurred vision, constipation, urinary retention, tachycardia

189. The nurse is planning a class for a group of clients with diabetes mellitus about blood glucose monitoring. In teaching the class as a whole, the nurse should emphasize the need to check glucose levels in which situation?

During acute illness

The nurse identifies a client's needs and formulates the nursing problem of, "Imbalanced nutrition: less than body requirements, related to mental impairment and decreased intake, as evidenced by increasing confusion and weight loss of more than 30 pounds over the last 6 months." Which short-term goal is best for this client?

Eat 50% of six small meals each day by the end of one week.

52. After a sudden loss of consciousness, a female client is taken to the ED and initial assessment indicate that her blood glucose level is critically low. Once her glucose level is stabilized, the client reports that was recently diagnosed with anorexia nervosa and is being treated at an outpatient clinic. Which intervention is more important to include in this client's discharge plan?

Encourage a low-carbohydrate and high-protein diet

386. A female client is extremely anxious after being informed that her mammogram was abnormal and needs to be repeated. Client is tearful and tells the nurse her mother died of breast cancer. What action should the nurse take?

Encourage the client to continue expressing her fears and concerns.

A female client tells the nurse that she does not know which day of the month is best to do breast self-exams (BSE). Which instruction should the nurse provide?

Five to seven days after menses cease. Due to the effect of cyclic ovarian changes on the breast, the best time for breast self-examination (BSE) is 5 to 7 days after menstruation stops (D) because physiologic alterations in breast size and activity reach their minimal level after menses.

344. When conducting diet teaching for a client who was diagnosed with nutritional anemia in pregnancy, which foods should the nurse encourage the client to eat? (Select all that apply)

Fortified whole wheat cereals, whole-grain pasta, brown rice Spinach, kale, dried raisins and apricots

A patient is recovering from a cardiac catheterization. For which finding should the nurse notify the health-care provider?

Hematoma formation at puncture site

377. The nurse assesses a child in 90-90 traction. Where should did nurse assess for signs of compartment syndrome?

Hot Spot

613. A nurse is caring for a client with Diabetes Insipidus. Which assessment finding warrants immediate intervention by the nurse?

Hypernatremia

A client with a pulmonary embolus is intubated, and mechanical ventilation is instituted. What should the nurse do when suctioning the endotracheal tube? 1 Apply suction while inserting the catheter. 2 Hyperoxygenate with 100% oxygen before and after suctioning. 3 Use short, jabbing movements of the catheter to loosen secretions. 4 Suction two to three times in quick succession to remove most of the secretions.

Hyperoxygenate with 100% oxygen before and after suctioning.

The nurse is reviewing the cerebral spinal fluid results for a patient with probably GBS, which abnormal finding is common in GBS

Increase in CSF protein level

Adverse effects of MAO B inhibitors

Insomnia, Ortho hypoTN, HTN crisis (due to high doses, tyramine, sympathomimetic drugs)

The nurse notes that an older patient's point of maximum impulse is displaced to the left. What age-related change should the nurse suspect as causing this assessment finding?

Left ventricular atrophy

558. A client is admitted to isolation with the diagnosis of active tuberculosis (TB). Which infection control measures should the nurse implement?

Negative pressure environment

Pramipexole

Oral, nonergot DA agonist First line for PD motor symptoms used alone in early PD and combined with levodopa in advanced PD Relieves motor PD symptoms by direct DA receptor in the striatum

483. The nurse delegates to an unlicensed assistive personnel (UAP) denture care for a client with...daily leaving. When making this assignment, which instruction is most important for the nurse to do?

Place a washcloth in the sink while cleaning the dentures

35. A client with cervical cancer is hospitalized for insertion of a sealed internal cervical radiation implant. While providing care, the nurse finds the radiation implant in the bed. What action should the nurse take?

Place the implant in a lead container using long-handled forceps

515. Which intervention should the nurse implement for a client with a superficial (first degree) burn?

Place wet cloths on the burned areas for short periods of time.

90. While assessing a radial artery catheter, the client complains of numbness and pain distal to the insertion site. What interventions should the nurse implement?

Promptly remove the arterial catheter from the radial artery.

396. One year after being discharged from the burn trauma unit, a client with a history of 40% full-thickness burns is admitted with bone pain and muscle weakness. Which intervention should the nurse include in the clients plan of care?

Teach need for dietary and supplementary vitamin D3

The nurse is caring for a client with myasthenia gravis. The nurse expects which test to be ordered to differentiate a myasthenic crisis from a cholinergic crisis? CBC Tensilon Lumbar puncture Magnetic resonance imaging (MRI)

Tensilon

427. A client with a large pleural effusion undergoes a thoracentesis. Following the procedure, which assessment finding warrants immediate intervention by the nurse?

The client has asymmetrical chest wall expansion

312. A client with a history of diabetes and coronary artery disease is admitted with shortness of breath, anxiety, and confusion. The client's blood pressure is 80/60 mmHg, heart rate 120 beats/minute with audible third and fourth heart sounds, and bibasilar crackles. The client's average urinary output is 5 ml/hour. Normal saline is infusing at 124 ml/hour with a secondary infusion of dopamine at mcg/kg/minute per infusion pump. With intervention should the nurse implement?

Titrate the dopamine infusion to raise the BP.

38. When caring for a client who has acute respiratory distress syndrome (ARDS), the nurse elevates the head of the bed 30 degrees. What is the reason for this intervention?

To reduce abdominal pressure on the diaphragm

TCAs

block reuptake of NE, S-HT; also block cholinergic, alpha1, histamine and pain long 1/2 life Therapeutic uses: major depression, bipolar, fibromyalgia, neuropathic pain

A client is admitted to the hospital for myasthenia gravis, for which common early clinical finding should the nurse assess the client

diplopia (double vision)

Interferon beta adverse effects

flu-like symptoms, liver injury, myelosuppression

Adverse effects of FGAs Neuroleptic Malignant Syndrome

muscle rigidity, sudden high fever, sweating dysrhythmia and fluctuations in BP Seizure, coma, respiratory failure TX: Dantrolene (direct-acting muscle relaxant), bromocriptine (relieves CNS toxicity)

TCAs adverse effects

ortho hypoTN, anticholinergic effect, diaphoresis, sedation, cardiotoxicity, seizures, CNS toxicity, hypomania, suicide risk

Natalizumab

progressive multifocal leukoencephalopathy, liver injury

626. A 3-year-old boy with a congenital heart defect is brought to the clinic by his mother...During the assessment, the mother asks the nurse why her child is at the 5th percent...response is best for the nurse to provide?

"His smaller size is probably due to the heart disease"

455. A female client with severe renal impairment is receiving enoxaparin (lovenox) 30 mg SUBQ BID. Which laboratory value due to enoxaparin should the nurse report to the healthcare provider?

.creatinine clearance 25 mL/ minute

346. An infant is receiving penicillin G procaine 220,000 units IM. The drug is supplied as 600,000 units/ml. How many ml should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth)

0.4

The nurse is caring for a client with Parkinson disease. Which is a priority nursing concern? 1 Decreased physical mobility related to stooped posture 2 Risk for injury related to gait disturbances 3 Impaired skin related to drooling 4 Pain related to headache

2 The client with Parkinson disease may fall because of gait disturbances. Decreased mobility and impaired skin are problems but not the priority. Pain is usually not a manifestation of Parkinson disease.

A client is admitted to the hospital with a diagnosis of acute Guillain-Barré syndrome. Which assessment is priority? 1 Urinary output 2 Sensation to touch 3 Neurologic status 4 Respiratory exchange

4. Respiratory exchange The respiratory center in the medulla oblongata can be affected with acute Guillain-Barré syndrome because the ascending paralysis can reach the diaphragm, leading to death from respiratory failure. Although urinary output, sensation to touch, and neurologic status are important, none of them are the priority.

When caring for an 80-year-old client with pneumonia, which finding is of most concern to the nurse? A.Decrease in level of consciousness B.BUN level, 20 mg/dL; creatinine level, 1.0 mg/dL C.Reports of a dry mouth and lips D.Fine crackles auscultated in lung bases

A Rationale: A decrease in level of consciousness is a sign of decreased oxygenation and requires immediate intervention (A). The others are expected findings (B, C, and D).

A client is scheduled to begin chemotherapy 2 weeks after surgery for colon cancer. What explanation does the nurse give to explain the delay following surgery? A. Chemotherapy interferes with cell growth and delays wound healing. B. Because chemotherapy causes vomiting, it endangers the integrity of the incisional area. C. Chemotherapy decreases red blood cell production, and the resultant anemia will add to postoperative fatigue. D. Chemotherapy increases edema in areas distal to the incision by blocking lymph channels with destroyed lymphocytes.

A. Chemotherapy interferes with cell growth and delays wound healing.

Adverse effects of SGAs (Agranulocytosis)

Agranulocytosis: causes gram negative septicemia (monitor WBC and neutrophil q2 weeks for 6 months, then monthly stop clozapine if WBC < 3000; ANC < 1500 Teach patient to monitor s/s of infection

185. In assessing an older female client with complication associated with chronic obstructive pulmonary disease (COPD), the nurse notices a change in the client's appearance. Her face appears tense and she begs the nurse not to leave her alone. Her pulse rate is 100, and respirations are 26 per min. What is the primary nursing diagnosis?

Anxiety related to fear of suffocation.

454. While the nurse is conducting a daily assessment of an older woman who resides in a long-term facility, the client begins to cry and tells the nurse that her family has stopped calling and visiting. What action should the nurse take first?

Ask the client when a family member last visited her.

325. An adult who is 5 feet 5 inches (165.1 cm) tall and weighs 90 lb. (40.8 Kg) is admitted with a diagnosis of chronic anorexia. The client receives a regular diet for 2 days, and the client's medical records indicates that 100% of the diet provided has been consumed. However the client's weight on the third day morning after admission is 89 lb. (40.4 Kg). What action should the nurse implement?

Assign staff to monitor what the client eats.

The health care provider prescribes 1000 mL of a D5W solution to infuse over 8 hours for a client who has had a appendectomy. The IV tubing being using delivers 15 gtt/mL. The nurse should set the flow rate at how many gtt/min? (If rounding is necessary, round to the nearest whole drop.) A.15 B.32 C.64 D.50

B Flow rate = 15 gtt/mL × (1000 mL/8 hr) × (1 hr/60 min) = 32 gtt/min

A nurse is watching the cardiac monitor, and a client's rhythm suddenly changes. There are no P waves; instead there are wavy lines. The QRS complexes measure 0.08 second, but they are irregular, with a rate of 120 beats a minute. The nurse interprets this rhythm as: A. Sinus tachycardia B. Atrial fibrillation C. Ventricular tachycardia D. Ventricular fibrillation

B. Atrial fibrillation is characterized by a loss of P waves; an undulating, wavy baseline; QRS duration that is often within normal limits; and an irregular ventricular rate, which can range from 60 to 100 beats per minute (when controlled with medications) to 100 to 160 beats per minute (when uncontrolled).

A client with Hodgkin disease enters a remission period and remains symptom free for 6 months before a relapse occurs. The client is diagnosed at stage IV. What therapy option does the nurse expect to be implemented? A. Radiation therapy B. Combination chemotherapy C. Radiation with chemotherapy D. Surgical removal of the affected nodes

B. Combination chemotherapy

A nurse teaches a client about the dangers of using sodium bicarbonate regularly. What effect of sodium bicarbonate is the nurse trying to prevent? A. Gastric distention B. Metabolic alkalosis C. Chronic constipation D. Cardiac dysrhythmias

B. Metabolic alkalosis

A nurse is assessing the adequacy of a client's intravenous fluid replacement therapy during the first 2 to 3 days after sustaining full-thickness burns to the trunk and right thigh. What assessment will provide the nurse with the most significant data? A. Weights every day B. Urinary output every hour C. Blood pressure every 15 minutes D. Extent of peripheral edema every 4 hours

B. Urinary output every hour

277. The nurse is evaluating the diet teaching of a client with hypertension. What dinner selection indicates that the client understands the dietary recommendation for hypertension?

Baked pork chop, applesauce, corn on the cob, 2% milk, and key-lime pie

SNRIs

Blocks reuptake of serotonin and NE Venlafaxine (Effexor) Desvenlafaxine (Pristiq) Duloxetine (Cymbalta)

Which clinical manifestation in the client with hyperthyroidism is most important to report to the health care provider? A.Nervousness B.Increased appetite C.Apical heart rate of 130 beats/min D.Insomnia

C Rationale: The apical heart rate of 130 beats/min is a critical finding that could lead to heart failure or other cardiac disorders (C). (A, B, and D) are all expected findings that should also be reported but are not as critical.

Which of the following cardiac rhythms is represented in the image? A.Normal sinus rhythm B.Sinus tachycardia C.Ventricular fibrillation D.Atrial fibrillation

C Rationale: Ventricular fibrillation (C) is a life-threatening arrhythmia characterized by irregular undulations of varying amplitudes. (A, B, and D) are not represented in the image.

A client who has been taking ibuprofen for rheumatoid arthritis asks the nurse if acetaminophen can be substituted instead. What is the appropriate nursing response? A. "Acetaminophen is the preferred treatment for rheumatoid arthritis." B. "Acetaminophen irritates the stomach more than ibuprofen does." C. "Ibuprofen has antiinflammatory properties and acetaminophen does not." D. "Yes, both are antipyretics and have the same effect."

C. "Ibuprofen has antiinflammatory properties and acetaminophen does not."

The nurse is preparing to determine a patient's cardiac output. Which measurement should be used for preload?

Central venous pressure

A client with myasthenia gravis asks the nurse what is going to happen to me and my family? What information about what the client can anticipate should be incorporated into the nurses response?

Chronic illness with exacerbation and remissions

The nurse is caring for a client who is the daughter of a local politician. When the nurse approaches a man who is reading the names on the hall doors, he identifies himself as a reporter for the local newspaper and requests information about the client's status. Which standard of nursing practice should the nurse use to respond?

Confidentiality.

220. A client with hyperthyroidism is receiving propranolol (Inderal). Which finding indicates that the medication is having the desired effect?

Decrease in pulse rate

The nurse is preparing to administer atropine, an anticholinergic, to a client who is scheduled for a cholecystectomy. The client asks the nurse to explain the reason for the prescribed medication. What response is best for the nurse to provide?

Decrease the risk of bradycardia during surgery.

622. A male client with cancer, who is receiving antineoplastic drugs, is admitted to the...what findings is most often manifest this condition?

Ecchymosis and hematemesis

432. The nurse administers an oral antiviral to a client with shingles. Which finding is most important for the nurse report to the health care provider?

Elevated liver function tests

70. An adult female client tells the nurse that though she is afraid her abusive boyfriend might one day kill her, she keeps hoping that he will change. What action should the nurse take first?

Explore client's readiness to discuss the situation.

278. A client with type 2 diabetes mellitus is admitted for frequent hyperglycemic episodes and a glycosylated hemoglobin (HbA1c) of 10%. Insulin glargine 10 units subcutaneously once a day at bedtime and a sliding scale with insulin aspart q6h are prescribed. What action should the nurse include in this client's plan of care?

Fingerstick glucose assessment q6h with meals Review with the client proper foot care and prevention of injury Coordinate carbohydrate controlled meals at consistent times and intervals Teach subcutaneous injection technique, site rotation and insulin management

The nurse is teaching staff in a long-term facility home the principles of caring for clients with essential hypertension. Which comment should the nurse include in the inservice presentation about the care of clients with hypertension?

Frequent blood pressure checks, including readings taken by automated machines, are recommended.

282. Oral antibiotics are prescribed for an 18-month-old toddler with severe otitis media. An antipyrine and benzocaine-otic also prescribed for pain and inflammation. What instruction should the nurse emphasize concerning the installation of the antipyrine/benzocaine otic solution?

Have the child lie with the ear up for one to two minute after installation.

321. In assessing a client at 34-weeks' gestation, the nurse notes that she has a slightly elevated total T4 with a slightly enlarged thyroid, a hematocrit of 28%, a heart rate of 92 beats per minute, and a systolic murmur. Which finding requires follow-up?

Hematocrit of 28%.

170. The nurse is auscultating a client's lung sounds. Which description should the nurse use to document this sound?

High pitched or fine crackles.

453. The nurse is evaluating the health teaching of a female client with condyloma acuminate. Which statement by the client indicates that teaching has been effective?

I need to have regular pap smears

102. A client presents in the emergency room with right-sided facial asymmetry. The nurse asks the client to perform a series of movements that require use of the facial muscles. What symptoms suggest that the client has most likely experience a Bell's palsy rather than a stroke?

Inability to close the affected eye, raise brow, or smile

Which action will the nurse include in the plan of care for a patient who was admitted with syncopal episodes of unknown origin?

Instruct the patient to call for assistance before getting out of bed.

184. A client at 30 week gestation is admitted due to preterm labor. A prescription of terbutaline sulfate 8.35 mg is gives subcutaneously. Based on which finding should the nurse withhold the next dose of this drug?

Maternal pulse rate of 162 beats per min

161. A client with cirrhosis of the liver is admitted with complications related to end stage liver disease. Which intervention should the nurse implement? (Select all that apply.)

Monitor abdominal girth. Report serum albumin and globulin levels. Note signs of swelling and edema.

26. The nurse is auscultating a client's heart sounds. Which description should the nurse use to document this sound? (Please listen to the audio first to select the option that applies)

Murmur

The nurse is preparing to auscultate the heart sounds of a patient with mitral valve regurgitation. Which sound should the nurse expect to hear?

Murmur

441. The nurses observes that a postoperative client with a continuous bladder irrigation has a large blood clot in the urinary drainage tubing. What actions should the nurse perform first?

Observe the amount of urine in the client's urinary drainage bag

99. Following a motor vehicle collision, an adult female with a ruptured spleen and a blood pressure of 70/44, had an emergency splenectomy. Twelve hours after the surgery, her urine output is 25 ml/hour for the last two hours. What pathophysiological reason supports the nurse's decision to report this finding to the healthcare provider?

Oliguria signals tubular necrosis related to hypoperfusion

285. A client with coronary artery disease who is experiencing syncopal episodes is admitted for an electrophysiology study (EPS) and possible cardiac ablation therapy. Which intervention should the nurse delegate to the unlicensed assistive personnel (UAP)?

Prepare the skin for procedure.

Managing adverse effects of Levodopa

Presence of dyskinesia will need a decrease in L dopa, give amentadine, or surgery and electrical stimulation

When analyzing the rhythm of a patient's electrocardiogram (ECG), the nurse will need to investigate further upon finding a(n)

QRS interval of 0.14 second

138. A male client with cirrhosis has ascites and reports feeling short of breath. The client is in semi Fowler position with his arms at his side. What action should the nurse implement?

Raise the head of the bed to a Fowler's position and support his arms with a pillow

162. During discharge teaching, the nurse discusses the parameters for weight monitoring with a client who was recently diagnosed with heart failure (HF). Which information is most important for the client to acknowledge?

Report weight gain of 2 pounds (0.9kg) in 24 hours

283. An older adult male is admitted with complications related to chronic obstructive pulmonary disease (COPD). He reports progressive dyspnea that worsens on exertion and his weakness has increased over the past month. The nurse notes that he has dependent edema in both lower legs. Based on these assessment findings, which dietary instruction should the nurse provide?

Restrict daily fluid intake.

195. When assessing and adult male who presents as the community health clinic with a history of hypertension, the nurse note that he has 2+ pitting edema in both ankles. He also has a history of gastroesophageal reflex disease (GERD) and depression. Which intervention is the most important for the nurse to implement?

Review the client's use of over the counter (OTC) medications.

Antipsychotic drugs can cause extrapyramidal side effects. Which responses should the nurse document as indicating pseudoparkinsonism? Select all that apply. Rigidity Tremors Mydriasis Photophobia Bradykinesia

Rigidity Tremors Bradykinesia

A health care provider prescribes antipsychotic medication, and the nurse teaches the client about the possible side effects of the drug. The nurse concludes that the client needs further teaching about these side effects when he states that he should call the clinic if he experiences: Tremors Constipation Blurred vision Ringing in the ears

Ringing in the ears

A nurse is caring for a client in the home who has diagnosis of amyotrophic lateral sclerosis (ALS). Which position should the nurse recommend that the client assume after eating?

Semi-fowlers

303. An adult client present to the clinic with large draining ulcers on both lower legs that are characteristics of Kaposi's sarcoma lesions. The client is accompanied by two family member. Which action should the nurse take?

Send family to the waiting area while the client's history is taking

A client with a history of cardiac dysrhythmias is admitted to the hospital with dehydration. What does the nurse expect to be listed on the client's plan of care? 1 A glass of water every hour until hydrated. 2 Small, frequent intake of juices, broth, or milk. 3 Short-term nasogastric (NG) replacement of fluids and nutrients. 4 A rapid intravenous (IV) infusion of an electrolyte and glucose solution.

Small, frequent intake of juices, broth, or milk.

438. A nurse stops at the site of a motorcycle accident and finds a young adult male lying face down in the road in a puddle of water. It is raining, no one is available to send for help, and the cell phone is in the car about 50 feet away. What action should the nurse take first?

Stabilize the victim's neck and roll over to evaluate his status

41. An older male client with a history of type 1 diabetes has not felt well the past few days and arrives at the clinic with abdominal cramping and vomiting. He is lethargic, moderately, confused, and cannot remember when he took his last dose of insulin or ate last. What action should the nurse implement first?

Start an intravenous (IV) infusion of normal saline

21. The mother of an adolescent tells the clinic nurse, "My son has athlete's foot, I have been applying triple antibiotic ointment for two days, but there has been no improvement." What instruction should the nurse provide?

Stop using the ointment and encourage complete drying of the feet and wearing clean socks.

Which activity of the registered nurse is included in supervision? 1 Performing the given task 2 Allocating a portion of the work 3 Providing information to the delegator Correct4 Providing guidance and oversight in delegating a task

Supervision is defined as "provision of guidance and oversight of a delegated nursing task." It includes open lines of communication between the delegator and the delegatee to provide guidance. Responsibility is the activity of performing a given task. Delegation is the activity of allocating a portion of work. Authority is the activity of providing information to the delegator.

The health care provider prescribes neostigmine (Prostigmin) for a client with myasthenia gravis. The nurse evaluates that the client understands the teaching about this drug when the client says, "I should: Keep the drug in a container in the refrigerator." Take the drug at the exact time that is listed on the prescription." Plan to take the drug between meals to promote absorption." Expect that the onset of the action of the drug will occur several hours after I take it."

Take the drug at the exact time that is listed on the prescription."

467. A client who is recently diagnosed with type 2 diabetes mellitus (DM) ask the nurse how this type of diabetes leads to high blood sugar. What Pathophysiology mechanism should the nurse explain about the occurrence of hyperglycemia in those who have type 2 DM?

The body cells develop resistance to the action of insulin.

160. A client with a prescription for "do not resuscitate" (DNR) begins to manifest signs of impending death. After notifying the family of the client's status, what priority action should the nurse implement?

The client's need for pain medication should be determined.

223. The nurse performs a prescribed neurological check at the beginning of the shift on a client who was admitted to the hospital with a subarachnoid brain attack (stroke). The client's Glasgow Coma Scale (GCS) score is 9. What information is most important for the nurse to determine?

The client's previous GCS score

48. What explanation is best for the nurse to provide a client who asks the purpose of using the log-rolling technique for turning?

The technique is intended to maintain straight spinal alignment.

13. A client who is taking an oral dose of a tetracycline complains of gastrointestinal upset. What snack should the nurse instruct the client to take with the tetracycline?

Toasted wheat bread and jelly

Which statement is true about temporary pacemakers? 1 All temporary pacemakers are transvenous. 2 Transcutaneous pacemakers pace through the skin. 3 Transvenous pacemakers are inserted into the left ventricle. 4 Epicardial pacemakers require two wires for adequate pacing

Transcutaneous pacemakers pace through the skin.

Which information should the nurse provide a client who has undergone cryosurgery for Stage 1A cervical cancer?

Use a sanitary napkin instead of a tampon. Clients should avoid the use of tampons for 3 to 6 weeks (D) after the procedure to reduce the risk of infection. A heavy, watery vaginal discharge is expected during this time, so (A) is unnecessary. Sexual intercourse should be avoided for up to 6 weeks, so (B) is inaccurate. (C) is not a side effect of the procedure but may indicate human papillomavirus or a cancerous lesion and should be reported.

Carbidopa-levodopa (Sinemet) is prescribed for a client with Parkinson's disease. The nurse monitors the client for which side effects of the medication? Select all that apply. Vomiting Anorexia Slow heart rate Changes in mood Peripheral edema

Vomiting Anorexia Changes in mood

Which statement by the community health nurse is most helpful to an adult who is in a crisis situation?

You seem to be more tense these days. Would you like to talk about the problem and how you are dealing with it?

Psychotherapeutic drugs

antipsychotics, antidepressants, mood stabilizers, sedative hypnotics, anti anxiety

585. In conducting a health assessment, the nurse determines that both parents of a child with asthma smoke cigarettes. What recommendation is best to the nurse to recommend to the parents?

avoid smoking in the house

Neostigmine (Prostigmin) muscarinic effects

bradycardia, bronchoconstriction, urinary urgency, increased GI motility, miosis (excessive constriction of the pupil)

A patient has a normal cardiac rhythm and a heart rate of 72 beats/minute. The nurse determines that the P-R interval is 0.24 seconds. The most appropriate intervention by the nurse would be to

document the finding and continue to monitor the patient.

420. The nurse is triaging clients in an urgent care clinic. The client with which symptoms should be referred to the health care provider immediately?

headache, photophobia, and nuchal rigidity

The nurse is teaching the patient and family about factors that predispose the patient to episodes of exacerbation of MG, which factors does the nurse mention

infection, stress, enemas, strong cathartics-p

serotonin syndrome

overstimulation of peripheral serotonin receptors begins 2 - 72 hours after onset of treatment

Positive symptoms

overt symptoms that should not be present: hallucinations, delusions, disorganized thought

More adverse effects of Levodopa

postural hypoTN (increase Na and water, alpha agonist) Dysrhythmias visual hallucinations, nightmaires, paranoid ideation (FGAs decrease psychotic symptoms but increase PD, SGAs are preferred --> clozapine and quetapine) Dark sweat and urine color

CHOLinesterase Inhibitors

prevents breakdown of ACh by inhibiting AChE Cannot cure or stop the progression of Alzheimer's DZ For mild-moderate symptoms Therapeutic affect is mild and short-lasting (exception of donepezil) Rivastagmine Galantamine Donepezil

442. Which medication should the nurse anticipate administering to a client who is diagnosed with myxedema coma?

Intravenous administration of thyroid hormones

449. The first paddle has been placed on the chest of a client who needs defibrillation. Where should the nurse place the second paddle? (Mark the location where the second paddle should be placed on the image).

Hot Spot

After the nurse gives IV atropine to a patient with symptomatic type 1, second-degree atrioventricular (AV) block, which finding indicates that the medication has been effective?

Increase in the patient's heart rate

554. An infant is placed in a radiant warmer immediately after birth. At one hour of age, the nurse finds the infant tachypneic, and hypotonic. What is the first action that the nurse should take?

Determine the infant's blood sugar level

529. A toddler presents to the clinic with a barking cough, strider, refractions with respiration, the child's skin is pink with capillary refill of 2 seconds. Which intervention should the nurse implement?

Administered Nebulized Epinephrine

540. A client admitted to the telemetry unit is having unrelieved chest pain after receiving 3 sublingual nitroglycerin tablets and morphine 8 mg IV. The electrocardiogram reveals sinus bradycardia with ST elevation. In what order should the nurse implement the nursing actions? (Arrange first to last)

1. Call the rapid response team to assist 2. Move the crash cart to the client room 3. Notify the client's healthcare provider 4. Inform the family of the critical situation

117. During the admission assessment, the nurse auscultates heart sounds for a client with no history of cardiovascular disease. Where should the nurse listen when assessing the client's point of maximal impulse (PMI) (Click the chosen location. To change, click on a new location)

Hot spot

334. The nurse is using a straight urinary catheter kit to collect a sterile urine specimen from a female client. After positioning am prepping this client, rank the actions in the sequence they should be implemented. (Place to first action on the top on the last action on the bottom.)

1. Open the sterile catheter kit close to the client's perineum. 2. Don sterile gloves and prepare to sterile field 3. Cleanse the urinary meatus using the solution, swabs, and forceps provided 4. Place distal end of the catheter in sterile specimen cup and insert catheter into meatus

440. The healthcare provider prescribes Morphine Sulfate Oral Solution 38 mg PO q4 hours for a client who is opioid-tolerant. The available 30 mL bottle is labeled, 100 mg/5 mL (20mg/mL), and is packaged with a calibrated oral syringe to provide to provide accurate dose measurements. How many mL should the nurse administer? (Enter the numerical value only. If rounding is required, round to the nearest tenth.)

1.9

430. The nurse is conducting health assessments. Which assessment finding increases a 56-year-old woman's risk for developing osteoporosis?

20 pack-year history of cigarette smoking

A nurse is reviewing laboratory test results for the client with liver disease and notes that the client's albumin level is low. Which nursing action is focused on the consequence of low albumin levels? 1. Evaluating for asterixis 2. Inspecting for petechiae 3. Palpating for peripheral edema 4. Evaluating for decreased level of consciousness

3 A nurse is reviewing laboratory test results for the client with liver disease and notes that the client's albumin level is low. Which nursing action is focused on the consequence of low albumin levels?

The client with a spinal cord injury at the level of T4 is experiencing a severe throbbing headache with a blood pressure of 180/100 mm Hg. What is the priority nursing intervention? 1. Notify the health care provider. 2. Loosen tight clothing on the client. 3. Place the client in a sitting position. 4. Check the urinary catheter tubing for kinks or obstruction.

3 The client is demonstrating clinical manifestations of autonomic dysreflexia, which is a neurological emergency. The first priority is to place the client in a sitting position to prevent hypertensive stroke. Options 2 and 4 can then be done, and option 1 can be completed once initial interventions are done.

A client is scheduled to receive an intravenous (IV) solution of lactated Ringer to run at 150 mL/hr. To deliver the solution, the nurse plans to use an administration set that delivers 15 gtt/mL. At how many drops per minute should the nurse set the IV to administer the prescribed amount of fluid? Record your answer using a whole number. ___ gtt/min.

38

A nurse determines that a client exhibits the characteristic gait associated with Parkinson disease. How should the nurse describe this gait when documenting on the client's progress report? 1 Spastic 2 Steppage 3 Shuffling 4 Scissoring

3. Steps are short and dragging (shuffling); this is seen with defects of the basal ganglia. Spastic gait, short steps with dragging of foot, is associated with neurogenic causes like cerebral palsy. Steppage gait is when foot slaps down and is associated with peroneal nerve injury or paralyzed dorsiflexor muscles. Scissoring gait is associated with bilateral spastic paresis of the legs as occurs in cerebral palsy or hemiplegia.

An intravenous piggyback (IVPB) of cefazolin 500 mg in 50 mL of 5% dextrose in water is to be administered over a 20-minute period. The tubing has a drop factor of 15 drops/mL. At what rate per minute should the nurse regulate the infusion to run? Record your answer using a whole number. Do not include units in your answer. ______ gtt/min

38

A nurse assists a health care provider in performing a liver biopsy. After the procedure, the nurse should place the client in which position? 1. Prone 2. Supine 3. Left side 4. Right side

4 To splint and provide pressure at the puncture site, the client is kept on the right side for a minimum of 2 hours after a liver biopsy. Therefore, options 1, 2, and 3 are incorrect.

414. A young adult who is hit with a baseball bat on the temporal area of the left skull is conscious when admitted to the ED and is transferred to the Neurological Unit to be monitored for signs of closed head injury. Which assessment finding is indicative of a developing epidural hematoma?

Altered consciousness within the first 24 hours after injury.

402. A 154 pound client with diabetic ketoacidosis is receiving an IV of normal saline 100 ML with regular insulin 100 units. The healthcare provider prescribes a rate of 0.1 units/kg/hour. To deliver the correct dosage, the nurse should set the infusion pump to Infuse how many ml/hour? enter numeric value only

7

559. A client is receiving an IV of heparin sodium 25000 units in 5% dextrose injection 500 ml at 14 ml/hour...verify that the client is receiving the prescribed amount of heparin. How many units is the client receiving?

700

A client just had a suprapubic prostatectomy. Which action should the nurse implement to prevent a secondary bladder infection? 1.Observe for signs of uremia 2.Attach the catheter to suction 3.Clamp off the connecting tube 4.Change the dressings frequently

4.Change the dressings frequently

A patient is prescribed a 12-lead electrocardiogram. In which order should the nurse apply the V leads? (Enter the number of each step in the proper sequence

5) 4th intercostal space right of the sternum 4) 4th intercostal space left of the sternum 2) Between V2 and V4 3) Midclavicular line 5th intercostal space 6) Between V4 and V6 anterior axillary line 1) Midaxillary line

458. A nurse is conducting a physical assessment of a young adult. Which information provides the best indication of the individual nutritional status?

Condition of hair, nails, and skin

30. A client is receiving a full strength continuous enteral tube feeding at 50 ml/hour and has developed diarrhea. The client has a new prescription to change the feeding to half strength. What intervention should the nurse implement?

Add equal amounts of water and feeding to a feeding bag and infuse at 50ml/hour

360. A female nurse who took drugs from the unit for personal use was temporarily released from duty. After completion of mandatory counseling, the nurse has asked administration to allow her to return to work. When the nurse administrator approaches the charge nurse with the impaired nurse request, which action is best for the charge nurse to take?

Allow the impaired nurse to return to work and monitor medication administration

A male client who has been taking propranolol (Inderal) for 18 months tells the nurse that the healthcare provider discontinued the medication because his blood pressure has been normal for the past three months. Which instruction should the nurse provide?

Although the healthcare provider discontinued the propranolol, measures to prevent rebound cardiac excitation, such as progressively reducing the dose over one to two weeks (C), should be recommended to prevent rebound tachycardia, hypertension, and ventricular dysrhythmias. Abrupt cessation (A and B) of the beta-blocking agent may precipitate tachycardia and rebound hypertension, so gradual weaning should be recommended. (D) is not indicated.

The nurse is inspecting the external eye structures for a client. Which finding is a normal racial variation?

An African-American client may have slightly yellow sclerae.

43. Which client is at the greatest risk for developing delirium?

An adult client who cannot sleep due to constant pain.

What does the nurse say is the advantage of an appropriate delegation? 1 Assistance 2 Accountability Incorrect3 Empowerment Correct4 Reduced stress

Appropriate delegation reduces stress and increases time efficiency by providing timely care to the client. Assistance or direction is asked by the delegatee to complete the task if the nurse provides limited information on an assigned task. The nurse is accountable and responsible for the task assigned to the delegatee if the delegation does not work properly. Delegation requires empowerment of the delegatee to accomplish a task.

307. A client who had a percutaneous transluminal coronary angioplasty (PTCA) two weeks ago returns to the clinic for a follow up visit. The client has a postoperative ejection fraction ejection fraction of 30%. Today the client has lungs which are clear, +1 pedal edema, and a 5pound weight gain. Which intervention the nurse implement?

Assess compliance with routine prescriptions.

546. A multigravida, full-term, laboring client complains of "back labor". Vaginal examination reveals that the client's 3 cm with 50% effacement and the fetal head is at -1 station. What should the nurse implement?

Apply counter-pressure to the sacral area

336. When should intimate partner violence (IPV) screening occur?

As a routine part of each healthcare encounter

399. A male client with cancer is admired to the oncology unit and tells the nurse that he is in the hospital for palliative care measures. The nurse notes that the client's admission prescription include radiation therapy. What action should the nurse implement?

Ask the client about his expected goals for the hospitalization

The LPN whom you are supervising comes to you and says she gave a client with myasthenia gravis 90 mg of neostigmine instead of 45 mg in which order would you provide the follwing tasks

Assess the patient, notify the physician of the incorrect medication, ask the LPN to explain how an error occurred, complete the medication error report

203. While receiving a male postoperative client's staples de nurse observe that the client's eyes are closed and his face and hands are clenched. The client states, "I just hate having staples removed". After acknowledgement the client's anxiety, what action should the nurse implement?

Attempt to distract the client with general conversation

28. The nurse notes that a client has been receiving hydromorphone (Dilaudid) every six hours for four days. What assessment is most important for the nurse to complete?

Auscultate the client's bowel sounds

A nurse notes that a client with sinus rhythm has a premature ventricular contraction that falls on the T wave of the preceding beat. The client's rhythm suddenly changes to one with no P waves or definable QRS complexes. Instead there are coarse wavy lines of varying amplitude. The nurse assesses this rhythm to be: A. Ventricular tachycardia B. Ventricular fibrillation C. Atrial fibrillation D. Asystole

B. Ventricular fibrillation is characterized by irregular, chaotic undulations of varying amplitudes. Ventricular fibrillation has no measurable rate and no visible P waves or QRS complexes and results from electrical chaos in the ventricles.

The nurse is reviewing data collected during the assessment of an older patient. Which finding should the nurse consider as being an age-related change of the cardiovascular system?

Blood pressure 168/96 mm Hg

Drugs for bowel dysfunction

Bulk-forming laxative: psyllium Enema Stool softeners (docusate sodium) Fatigue (Amantatide, modafinil)

Which nurse follows a client from admission through discharge or resolution of illness and coordinates the client's care between healthcare providers?

Case manager.

During a well-woman exam, a sexually active female client asks the nurse about a recent vaginal infection and says she is afraid she has another sexually transmitted infection. The client discloses her history of previous STI. Which condition should the nurse identify as the most prevalent STI in the United States among women?

Chlamydia. Chlamydia (B) is the most common and fastest spreading sexually transmitted infection (STI) in American women, with an estimated 3 million new cases each year

SSRI Drugs

Citalopram (Celexa) Escitalopram (Lexapro) Fluoxetine (Prozac) Fluvoxamine (Luvox) Paroxetine (Paxil) Sertraline (Zoloft)

505. The nurse is administering a 750 ml cleansing enema to an adult client. After approximately150 ml of enema has informed, the client states, 'stop I can't hold anymore." What action should the nurse take?

Clamp the tubing and instruct the client to breathe deeply before continuing.

The registered nurse (RN) delegates a task to a licensed practical nurse (LPN). Which client task can be assigned to the LPN? 1 Client A Correct2 Client B 3 Client C 4 Client D

Client B is delegated to the LPN to perform sterile dressing changes on acute and chronic wounds. Assessments such as evaluating fluid electrolyte needs in client A with dehydration are performed by the RN. In client C, notifying the registered nurse if the client reports pain is done by unlicensed nursing professional (UAP). In client D with presbycusis, helping the client with hearing aid replacement is performed by the UAP.

149. While in the medical records department, the nurse observes several old medical records with names visible in waste container. What action should the nurse implement?

Contact the medical records department supervisor.

473. A client with end-stage liver failure is declared brain dead. The family wants to discontinue feeding and donate any viable organs. Which action should the nurse take?

Contact the regional organ procurement agency

116. The nurse is developing an educational program for older clients who are being discharged with new antihypertensive medications. The nurse should ensure that the educational materials include which characteristics? Select all that apply

Contains a list with definitions of unfamiliar terms Uses common words with few Syllables Uses pictures to help illustrate complex ideas

552. A 6-year-old child with acute infectious diarrhea is placed on a rehydration therapy...Which action should the nurse instruct the parents to take if the child begins to vomit?

Continue giving ORS frequently in small amounts

460. A newly admitted client vomits into an emesis basin as seen in the picture. The nurse should consult with the healthcare provider before administering which of the client's prescribes medications?

Clopidogrel (Plavix), an antiplatelet agent, given orally Methylprednisolone (solu-medrol), a corticosteroid, to be given IV Enoxaparin (lovenox), a low-molecular weight heparin to be given subcutaneous

204. A male client is admitted for the removal of an internal fixation that was inserted for the fracture ankle. During the admission history, he tells the nurse he recently received vancomycin (vancomycin) for a methicillin-resistant Staphylococcus aureus (MRSA) wound infection. Which action should the nurse take? (Select all that apply.)

Collect multiple site screening culture for MRSA Place the client on contact transmission precautions Continue to monitor for client sign of infection.

A client is to receive donepezil (Aricept) for treatment of dementia of the Alzheimer type. The nurse sits down with the primary caregiver and the client and reviews the purpose of the drug, its dosage, and the usual side effects. What side effect identified by the caregiver leads the nurse to conclude that further teaching is needed? Nausea Dizziness Headache Constipation

Constipation

The charge nurse of a medical surgical unit is alerted to an impending disaster requiring implementation of the hospital's disaster plan. Specific facts about the nature of this disaster are not yet known. Which instruction should the charge nurse give to the other staff members at this time? A.Prepare to evacuate the unit, starting with the bedridden clients. B.UAPs should report to the emergency center to handle transports. C.The licensed staff should begin counting wheelchairs and IV poles on the unit. D.Continue with current assignments until more instructions are received.

D When faced with an impending disaster, hospital personnel may be alerted but should continue with current client care assignments until further instructions are received (D). Evacuation is typically a response of last resort that begins with clients who are most able to ambulate (A). (B) is premature and is likely to increase the chaos if incoming casualties are anticipated. (C) is poor utilization of personnel.

213. An elderly male client is admitted to the mental health unit with a sudden onset of global disorientation and is continuously conversing with his mother, who died 50 years ago. The nurse reviews the multiple prescriptions he is currently taking and assesses his urine specimen, which is cloudy, dark yellow, and has foul odor. These findings suggest that his client is experiencing which condition?

Delirium

126. An infant who is admitted for surgical repair of a ventricular septal defect (VSD) is irritable and diaphoretic with jugular vein distention. Which prescription should the nurse administer first?

Digoxin.

Carbidopa

Enhances Levodopa Prevents decarboxylation of levodopa in the intestine and peripheral tissues --> increasing levodopa availability most effective PD therapy: levodopa + carbidopa = Sinemet or Parcopa

281. Before leaving the room of a confused client, the nurse notes that a half bow knot was used to attach the client's wrist restraints to the movable portion of the client's bed frame. What action should the nurse take before leaving the room?

Ensure that the knot can be quickly released.

222. A community health nurse is concerned about the spread of communicable diseases among migrant farm workers in a rural community. What action should the nurse take to promote the success of a healthcare program designed to address this problem?

Establish trust with community leaders and respect cultural and family values

313. The nurse ends the assessment of a client by performing a mental status exam. Which statement correctly describes the purpose of the mental status exam?

Evaluate the client's mood, cognition and orientation.

411. The nurse ask the parent to stay during the examination of a male toddler's genital area. Which intervention should the nurse implement?

Examine the genitalia as the last part of the total exam.

587. The nurse is developing a plan of care for a middle-aged woman who is diagnosed with type 2 diabetes mellitus (DM). To lower her blood glucose and increase her serum high-density lipoprotein (HDL) levels, which instruction is most important for the nurse to provide?

Exercise at least three times weekly

526. A 2-year-old girl is brought to the clinic for a routine assessment and all findings are within the normal limits. However, the mom expresses concern over her daughter's protruding abdomen and tells the nurse that she is worry that her child is becoming overweight. How should the nurse respond to the mother's comment?

Explain that a protruding abdomen is typical for toddlers

369. A young adult woman visits the clinic and learns that she is positive for BRCA1 gene mutation and asks the nurse what to expect next. How should the nurse respond?

Explain that counseling will be provided to give her information about her cancer risk

323. A clinical trial is recommended for a client with metastatic breast cancer, but she refuses to participate and tells her family that she does not wish to have further treatments. The client's son and daughter ask the nurse to try and convince their mother to reconsider this decision. How should the nurse respond?

Explore the client's decision to refuse treatment and offer support

602. Which assessment finding indicates to the nurse a client's readiness for pulmonary function tests?

Expresses an understanding of the procedure.

A client with late-stage dementia of the Alzheimer type aspirates gastric contents and develops acute respiratory distress syndrome (ARDS). The pathophysiologic changes associated with ARDS progress through expected phases. What phase is characterized by signs of pulmonary edema and atelectasis? 1 Fibrotic 2 Exudative 3 Reparative 4 Proliferative

Exudative

A patient is receiving cholinesterase inhibitor drug for the treatment of MG, what is a nursing implication for the safe administration of this medication

Feed meals 45-60 minutes after administration

165. The nurse is evaluating a client's symptoms, and formulates the nursing diagnosis, "high risk for injury due to possible urinary tract infection." Which symptoms indicate the need for this diagnosis?

Fever and dysuria.

5. A 60-year-old female client with a positive family history of ovarian cancer has developed an abdominal mass and is being evaluated for possible ovarian cancer. Her Papanicolau (Pap) smear results are negative. What information should the nurse include in the client's teaching plan?

Further evaluation involving surgery may be needed

565. An older woman who has difficulty hearing is being discharged from day surgery following a cataract extraction & lens implantation. Which intervention is most important for the nurse to implement to ensure the client's compliance with self-care?

Have the client vocalize the instructions provided.

439. During a well-baby, 6-month visit, a mother tells the nurse that her infant has had fewer ear infections than her 10-year-old daughter. The nurse should explain that which vaccine is likely to have made the difference in the siblings' incidence of otitis media?

Hemophilic Influenza Type B (HiB) vaccine

591. The nurse plans to administer a schedule dose of metoprolol (Toprol SR) at 0900 to a client with hypertension. At 0800, the nurse notes that client's telemetry pattern shows a second degree heart block with a ventricular rate of 50. What action should the nurse take?

Hold the scheduled dose of Tropol and notify the healthcare provider of the telemetry pattern.

The nurse is assessing a client and identifies a bruit over the thyroid. This finding is consistent with which interpretation?

Hyperthyroidism (D) is an enlargement of the thyroid gland, often referred to as a goiter, and a bruit may be auscultated over the goiter due to an increase in glandular vascularity which increases as the thyroid gland becomes hyperactive. A bruit is not common with (A, B, and C).

60. A client is admitted to the intensive care unit with diabetes insipidus due to a pituitary gland tumor. Which potential complication should the nurse monitor closely?

Hypokalemia

If the nurse is considering whether the right equipment and resources are available to complete a task, which delegation right is considered? 1 Task 2 Supervision Correct3 Circumstance 4 Communication

If the right equipment and resources are available to complete a task, it is considered the right circumstance. Task is the delegation right that involves asking if the task is appropriate to delegate based on institutional policies and procedures. Supervision is the delegation right involving the provision of clear feedback related to completion of an assigned task. Communication is the right that involves asking the delegator and delegate to understand a common work-related language.

338. What action should the school nurse implement to provide secondary prevention to a school-age children?

Initiate a hearing and vision screening program for first-graders

422. After placement of a left subclavian central venous catheter (CVC), the nurse receives report of the x-ray findings that indicate the CVC tip is in the client's superior vena cava. Which action should the nurse implement?

Initiate intravenous fluid as prescribed

198. A client experiencing withdrawal from the benzodiazepines alprazolam (Xanax) is demonstrating severe agitation and tremors. What is the best initial nursing action?

Initiate seizure precautions

621. The daughter of an older female client tells the clinic nurse that she is no longer able to care for her mother since her mother has lost the ability to perform activities of daily living (ADLs) due to aging. Which options should the nurse discuss with the daughter?

Long-term care facility Home health agency

What is the priority expected outcome in a patient with GBS

Maintain airway patency and gas exchange

544. A client delivers a viable infant, but begins to have excessive uncontrolled vaginal...notifying the health care provider of the clients' condition, what information is most....

Maternal blood pressure

448. A nurse is planning discharge care for a male client with metastatic cancer. The client tells the nurse that he plans to return to work despite pain, fatigue, and impending death. Which goals is most important to include in this client's plan of care?

Marinating pain level below 4 when implementing outpatient pain clinic strategies.

46. A female client has been taking a high dose of prednisone, a corticosteroid, for several months. After stopping the medication abruptly, the client reports feeling "very tired". Which nursing intervention is most important for the nurse to implement?

Measure vital signs

12. A 66-year-old woman is retiring and will no longer have a health insurance through her place of employment. Which agency should the client be referred to by the employee health nurse for health insurance needs?

Medicare

173. Ten years after a female client was diagnosed with multiple sclerosis (MS), she is admitted to a community palliative care unit. Which intervention is most important for the nurse to include in the client's plan of care?

Medicate as needed for pain and anxiety.

Levadopa

Most effective in PD when combined with carbidopa Dopamine restoration (increases dopamine levels in the brain that are depleted in Parkinson disease)

273. While monitoring a client during a seizure, which interventions should the nurse implement? (Select all that apply)

Move obstacle away from client Monitor physical movements Observe for a patent airway Record the duration of the seizure

A client is receiving doxepin (Sinequan). For which most dangerous side effect of tricyclic antidepressants should a nurse monitor the client? Mydriasis Dry mouth Constipation Urine retention

Mydriasis

A nurse is monitoring a client admitted with a diagnosis of myocardial infarction (MI) for dysrhythmias. What reason should the nurse consider for the increased incidence of dysrhythmias after an MI? 1 Metabolic alkalosis 2 Myocardial hypoxia 3 Decreased catecholamine secretion 4 Increased parasympathetic nervous system stimulation

Myocardial hypoxia

367. The nurse is preparing a teaching plan for an older female client diagnosed with osteoporosis. What expected outcome has the highest priority for this client?

Names 3 home safety hazards to be resolve immediately.

598. The nurse should observe most closely for drug toxicity when a client receives a medication that has which characteristic?

Narrow therapeutic index.

A dyspneic male client refuses to wear an oxygen face mask because he states it is "smothering" him. What oxygen delivery system is best for this client?

Nasal cannula.

555. A toddler with a history of an acyanotic heart defect is admitted to the pediatric intensive...rate of 60 breaths/ minute, and a heart rate of 150 beats/minute. What action should the nurse take?

Obtain a pulse oximeter reading

180. A male client who was diagnosed with viral hepatitis A 4 weeks ago returns to the clinic complaining of weakness and fatigue. Which finding is most important for the nurse to report to the healthcare provider?

New onset of purple skin lesions.

82. An unlicensed assistive personnel UAP leaves the unit without notifying the staff. In what order should the unit manager implement this intervention to address the UAPs behavior? (Place the action in order from first on top to last on bottom.)

Note date and time of the behavior. Discuss the issue privately with the UAP. Plan for scheduled break times. Evaluate the UAP for signs of improvement.

294. An older adult client with heart failure (HF) develops cardiac tamponade. The client has muffled, distant, heart sounds, and is anxious and restless. After initiating oxygen therapy and IV hydration, which intervention is most important for the nurse to implement?

Notify healthcare provider to prepare for pericardiocentesis

383. Four hours after surgery, a client reports nausea and begins to vomit. The nurse notes that the client has a scopolamine transdermal patch applied behind the ear. What action should the nurse take?

Notify the healthcare provider of the vomiting.

In addition to treatment of the underlying cause, which medical intervention should the nurse anticipate will be included in the management of a client with acute respiratory distress syndrome (ARDS)? 1 Chest tube insertion 2 Aggressive diuretic therapy 3 Administration of beta blockers 4 Positive end-expiratory pressure (PEEP)

PEEP

291. An older male client arrives at the clinic complaining that his bladder always feels full. He complains of weak urine flow, frequent dribbling after voiding, and increasing nocturia with difficulty initiating his urine stream. Which action should the nurse implement?

Palpate the client's suprapubic area for distention

447. In assessing a pressure ulcer on a client's hip, which action should the nurse include?

Photograph the lesion with a ruler placed next to the lesion

409. The charge nurse observes the practical nurse (PN) apply sterile gloves in preparation for performing a sterile dressing change. Which action by the PN requires correction by the charge nurse?

Picking up the second glove

391. The nurse is demonstrating correct transfer procedures to the unlicensed assisted personnel (UAP) working on a rehabilitation unit. The UAPs ask the nurse how to safely move a physically disabled client from the wheelchair to a bed. What action should the nurse recommended?

Place a client's locked wheelchair on the client's strong side next to the bed.

535. After applying an alcohol-based hand rub to the palms of the hand and rubbing the hand together, what action should the nurse do next?

Place one hand on top of the other and interlace the fingers

80. Which intervention is most important for the nurse to include in the plan of care for an older woman with osteoporosis?

Place the client on fall precautions

525. A health care provider continuously dismisses the nursing care suggestions made by staff nurses. As a result...dealing with the healthcare provider. What action should the nurse-manager implement?

Plan an interdisciplinary staff meeting to develop strategies to enhance client care

300. A client who underwent an uncomplicated gastric bypass surgery is having difficult with diet management. What dietary instruction is most important for the nurse to explain to the client?

Plan volume-controlled evenly-space meal thorough the day

341. A client with emphysema is being discharged from the hospital. The nurse enters the client's room to complete discharge teaching. The client reports feeling a little short of breath and is anxious about going home. What is the best course of action?

Provide only necessary information in short, simple explanations with written instructions to take home

A patient with a thymoma had surgery too relieve symptoms of MG, a single chest tube has been inserted into the patients anterior mediastinum. The nurse notes that the patient is restless with diminished breath sounds and decreased chest wall expansion. What is the nurses priority action

Provide oxygen and elevate the head of the bed

296. The nurse is caring for a one week old infant who has a ventriculoperitoneal (VP) shunt that was placed 2 days after birth. Which findings are an indication of a postoperative complication?

Poor feeding and vomiting Leakage of CSF from the incisional site Abdominal distention

92. The nurse finds a client at 33 weeks gestation in cardiac arrest. What adaptation to cardiopulmonary resuscitation (CPR) should the nurse implement?

Position a firm wedge to support pelvis and thorax at 30 degree tilt.

A patient with a blood pressure of 88/50 mm Hg has a heart rate of 112 beats per minute. Which mechanism should the nurse realize is occurring in this patient?

Positive chronotropic effect

280. While assessing a client's chest tube (CT), the nurse discovers bubbling in the water seal chamber of the chest tube collection device. The client's vital signs are: blood pressure of 80/40 mmHg, heart rate 120 beats/minutes, respiratory rate 32 breaths/minutes, oxygen saturation 88%. Which interventions should the nurse implement?

Provide supplemental oxygen Auscultate bilateral lung fields Reinforce occlusive CT dressing

524. Which interventions should the nurse include in a long-term plan of care for a client with COPD?

Reduce risk factors for infection

AntiCHOLinergic Parkinson Drugs

Reduce tremor and possibly rigidity Benztropine Trihexyphenidyl (Artane)

201. A client with diabetic peripheral neuropathy has been taking pregabalin (Lyrica) for 4 days. Which finding indicates to the nurse that the medication is effective?

Reduced level of pain

293. A client who had a below the knee amputation is experiencing severe phantom limb pain (PLP) and ask the nurse if mirror therapy will make the pain stop. Which response by the nurse is likely to be most helpful?

Research indicates that mirror therapy is effective in reducing phantom limb pain

Which component of delegation is considered a "two way process"? 1 Authority 2 Supervision Correct3 Responsibility 4 Accountability

Responsibility is a two way process. Authority is the ability to perform duties in a specific role. Supervision is defined as the "provision of guidance and oversight of a delegated nursing task." Accountability may not be a two-way process. It determines if the actions were appropriate and provides a detailed explanation of what occurred.

394. The healthcare provider prescribes a low-fiber diet for a client with ulcerative colitis. Which food selection would indicate to the nurse the client understands they prescribed diet?

Roasted turkey canned vegetables

SGAs (Atypicals)

Safer than FGAs less EPS and TD effects Serious metabolic effects: weight gain, diabetes, dyslipidemia Other adverse effects: sedation ortho hypoTN, increased risk of death in elderly -zapine, -ridone, Quetapine, Aripiprazole, Ziprasidone

Therapeutic uses of SGAs

Schizophrenia (last resort since it causes fatal agranulocytosis) Levodopa-induced psychosis

178. A young adult client is admitted to the emergency room following a motor vehicle collision. The client's head hit the dashboard. Admission assessment include: Blood pressure 85/45 mm Hg, temperature 98.6 F, pulse 124 beat/minute and respirations 22 breath/minute. Based on these data, the nurse formulates the first portion of nursing diagnosis as " Risk of injury" What term best expresses the "related to" portion of nursing diagnosis?

Shock

193. A client refuses to ambulate, reporting abdominal discomfort and bloating caused by "too much gas buildup" the client's abdomen is distended. Which prescribed PRN medication should the nurse administer?

Simethicone (Mylicon)

56. A school nurse is called to the soccer field because a child has a nose bleed (epistaxis). In what position should the nurse place the child?

Sitting up and leaning forward

100. A nurse-manager is preparing the curricula for a class for charge nurses. A staffing formula based on what data ensures quality client care and is most cost-effective?

Skills of staff and client acuity

A recently hospitalized client with multiple sclerosis is concerned about generalized weakness and fluctuating physical status. What is the priority nursing intervention for this client?

Space activities throughout the day

When engaging in planned change on the unit, what should the nurse-manager establish first?

Staff members are aware of the need for change.

A client is brought into the emergency department following a sudden cardiac arrest. A full code is started. Five minutes later the family arrives with a durable power of attorney signed by the client requesting that no extraordinary measures be taken, including intubation, to save the client's life. What action should the nurse take?

Stop the code immediately.

628. When administering ceftriaxone sodium (Rocephin) intravenously to a client before...most immediate intervention by the nurse?

Stridor

410. A male client reports to the clinic nurse that he has been feeling well and is often "dizzy" his blood pressure is elevated. Based on this findings, this client is at a greatest risk for which pathophysiological condition?

Stroke

151. While visiting a female client who has heart failure (HF) and osteoarthritis, the home health nurse determines that the client is having more difficulty getting in and out of the bed than she did previously. Which action should the nurse implement first?

Submit a referral for an evaluation by a physical therapist.

When caring for a client who has acute respiratory distress syndrome (ARDS), the nurse would implement which measure to promote effective airway clearance? 1 Administer sedatives around the clock 2 Turn client every four hours 3 Increase ventilator settings as needed 4 Suction as needed

Suction as needed

The nurse is caring for a client who has had frequent premature ventricular complexes (PVCs) and monitors the client closely for ventricular fibrillation. The nurse recalls that the risk for ventricular fibrillation is greatest during which phase of the cardiac cycle? 1 P wave 2 T wave 3 P-R interval 4 QRS complex

T wave

The nurse is caring for a client who underwent a hysterectomy and who is admitted to a general medical-surgical unit. Which tasks can be delegated to the unlicensed assistive personnel (UAP)? Select all that apply. Correct1 Oral hygiene Correct2 Assistance with bathing 3 Oral medication administration 4 Intravenous fluid administration 5 Providing treatments with supervision

The UAP is eligible to carry out hygiene tasks such as providing oral hygiene and assisting with bathing. The licensed practical nurse and licensed vocational nurse may provide oral medications and treatments under the supervision of an RN. While treating clients, tasks such as intravenous administration of fluids should be carried out by the RN, as they are associated with potential risk if improperly infused.

Which healthcare team member would the nurse expect can be delegated with the task of administering oral medication to a client per the functional model? Incorrect1 Registered nurse 2 Patient care associate Correct3 Licensed practical nurse 4 Unlicensed assistive personnel

The licensed practical nurse can give oral medication to a client. The registered nurse gives IV medication to a client. Patient care associates assist and monitor vital signs. Unlicensed assistive personnel perform all hygienic tasks.

What should the delegator do when he or she finds that a delegatee is unable to perform the given task? 1 Assign another task to the delegatee 2 Remove the delegatee form the task Incorrect3 Make an effort to complete the task on his or her own Correct4 Make sure to educate and provide feedback to the delegatee

The delegator should educate and guide the delegatee on finding that the delegatee is not competent to perform the task. The delegator should also provide feedback to the delegatee during and after the task to enhance working performance. Assigning the delegatee to another task may lead to poor performance and low quality of output. Removing the delegatee from the task may weaken the working relationship. The delegator has to make an effort to have the task completed by assigning, guiding, and monitoring the delegatee at regular basis.

39. When assessing a mildly obese 35-year-old female client, the nurse is unable to locate the gallbladder when palpating below the liver margin at the lateral border of the rectus abdominal muscle. What is the most likely explanation for failure to locate the gallbladder by palpation?

The gallbladder is normal

A client with chronic osteomyelitis is scheduled for surgery to treat the infection which has not responded to three months of intravenous antibiotic therapy. The client asks the nurse why surgery is necessary. Which is the best response for the nurse to provide?

The infection has walled off into an area of infected bone creating a barrier to antibiotics. A sequestrum (dead bone) is separated from the living bone and has no blood supply, so neither antibiotics nor white blood cells can reach the infected area (D). (A and B) do not address the encasement of the necrotic tissue. Although a sinus tract may occur, (C) does not address the purpose of the surgery.

The nurse is developing a teaching plan for an adolescent with a Milwaukee brace. Which instruction should the nurse include?

Wear the brace over a T-shirt 23 hours per day. Idiopathic scoliosis is an abnormal lateral curvature of the spine in adolescent females. Early treatment uses a Milwaukee brace that places pressure against the lateral spinal curvature, under the neck, and against the iliac crest, so it should be worn for 23 hours per day over a T-shirt (D) which reduces friction and chafing of the skin. (A, B, and C) reduce the effectiveness of the brace.

Total client care is delegated to a registered nurse. Which member of the healthcare team is responsible for consulting other healthcare professionals in planning and delivering client care? Incorrect1 Charge nurse Correct2 Primary nurse 3 Associate nurse 4 Nurse navigator

The primary nurse is responsible for consulting other healthcare professionals in planning and delivering client care. The charge nurse delegates work to other healthcare team members in the absence of the delegator. The associate nurse is delegated to provide care to the client according to the primary nurse's specifications. The nurse navigator works through the healthcare system to help clients obtain high-quality care.

Which activity performed by the licensed practical nurse (LPN) would be appropriate while caring for a client based on the principle of right task of delegation? 1 Willing to perform the task 2 Providing feedback to the delegator Correct3 Performing the task based on institutional policies 4 Following appropriate supervision while performing the task

The principle of right task of delegation indicates if the task is appropriate to delegate based on institutional policies and procedures. Assessing whether the delegatee is willing to perform the task indicates the principle of right person. Providing feedback to the delegator and following supervision of the delegator indicates right supervision of delegation.

351. A mother brings her 4-month-old son to the clinic with a quarter taped over his umbilicus, and tells the nurse the quarter is supposed to fix her child's hernia. Which explanations should the nurse provide?

This hernia is a normal variation that resolves without treatment.

569. A 2-year-old is bleeding from a laceration on the right lower extremity that occurred as the result of a motor vehicle collision. The nurse is selecting supplies to start an IV access. Which assessment finding is most significant in the nurse's selection of catheter size?

Thready brachial pulse.

308. The RN is assigned to care for four surgical clients. After receiving report, which client should the nurse see first? The client who is

Three days postoperative colon resection receiving transfusion of packed RBCs.

Prior to transferring a client to a chair using a mechanical lift, what is the most important client characteristic the nurse should assess?

Tolerance of exertion.

What early symptoms does the nurse expect to observe in a 50 year old patient recently diagnosed with ALS

Tongue atrophy and dysphagia

What is the cause of a cholinergic crisis

Too many anticholinergic drugs

528. A client admitted with an acute coronary syndrome (ACS) receives eptifibatide, a glycoprotein (GP) IIB IIIA inhibitor, which important finding places the client at greatest risk?

Unresponsive to painful stimuli

272. Which client should the nurse assess frequently because of the risk for overflow incontinence? A client

Who is confused and frequently forgets to go to the bathroom

317. When planning care for a client with acute pancreatitis, which nursing intervention has the highest priority?

Withhold food and fluid intake.

Overactive bladder

detrusor muscle contracts before the bladder is full. do not confuse with incontinence

225. Based on principles of asepsis, the nurse should consider which circumstance to be sterile?

An open sterile Foley catheter kit set up on a table at the nurse waist level

A patient with GBS is receiving IV immunoglobulin, the nurse monitors for which major potential complications of this drug therapy

Anaphylaxis

163. Which problem, noted in the client's history, is important for the nurse to be aware of prior to administration of a newly prescribed selective serotonin reuptake inhibitor (SSRI)?

Aural migraine headaches.

Neostigmine (Prostigmin) pharmacologic effects

CNS - Therapeutic dose causes mild stimulation Toxic dose depresses the CNS (including respiratory)

549. A postpartal client complains that she has the urge to urinate every hour but is only able to void a small amount. What interventions provides the nurse with the most useful information?

Catheterize for residual urine after next voiding

A nurse prepares to administer intravenous (IV) albumin to a client with ascites. What effect does the nurse anticipate? A. Ascites and blood ammonia levels will decrease. B. Decreased capillary perfusion and blood pressure. C. Venous stasis and blood urea nitrogen level will increase. D. As extravascular fluid decreases, the hematocrit will decrease.

D. As extravascular fluid decreases, the hematocrit will decrease.

Two unlicensed assistive personnel (UAP) are arguing on the unit about who deserves to take a break first. What is the most important basic guideline that the nurse should follow in resolving the conflict?

Dealing with the issues which are concrete, not personalities (A) which include emotional reactions, is one of seven important key behaviors in managing conflict. (B, C, and D) do not resolve the conflict when diverse opinions are expressed emotionally.

174. An increased number of elderly persons are electing to undergo a new surgical procedure which cures glaucoma. What effect is the nurse likely to note as a result of this increases in glaucoma surgeries?

Decrease prevalence of glaucoma in the population.

Neuroleptic malignant syndrome is a potentially fatal reaction to antipsychotic therapy. What signs and symptoms of this syndrome should the nurse identify? Select all that apply. Jaundice Diaphoresis Hyperrigidity Hyperthermia Photosensitivity

Diaphoresis Hyperrigidity Hyperthermia

A patient reports increased fatigue and stiffness of the extremities. These symptoms have occurred in the past but resolved and no medical attention was sought, which questions does the nurse ask to assess whether the symptoms may be associated with multiple sclerosis

Do you have persistent sensitivity to cold, do you ever have slurred speech or trouble swallowing, has anyone in your family been diagnosed with MS

111. An Unna boot is applied to a client with a venous stasis ulcer. One week later, when the Unna boot is removed during a follow-up appointment, the nurse observes that the ulcer site contains bright red tissue. What action should the nurse take in response to this finding?

Document the ongoing wound healing.

77. A client is being discharged with a prescription for warfarin (Coumadin). What instruction should the nurse provide this client regarding diet?

Eat approximated the same amount of leafy green vegetables daily so the amount of vitamin K consumed is consistent.

355. A nurse is planning to teach infant care and preventive measures for sudden infant death syndrome (SIDS) to a group of new parents. What information is most important for the nurse to include?

Ensure that the infant's crib mattress is firm

209. The healthcare provider prescribes acarbose (Precose), an alpha-glucosidase inhibitor, for a client with Type 2 diabetes mellitus. Which information provides the best indicator of the drug's effectiveness?

Hemoglobin A1C (HbA1C) reading less than 7%

306. The nurse is assessing a client's nailbeds. Witch appearance indicates further follow-up is needed for problems associated with chronic hypoxia?

Image

The nurse determines that a client's body weight is 105% above the standardized height-weight scale. Which related factor should the nurse include in the nursing problem, "Imbalanced nutrition: more than body requirements?"

Inadequate lifestyle changes in diet and exercise.

40. A woman with an anxiety disorder calls her obstetrician's office and tells the nurse of increased anxiety since the normal vaginal delivery of her son three weeks ago. Since she is breastfeeding, she stopped taking her antianxiety medications, but thinks she may need to start taking them again because of her increased anxiety. What response is best for the nurse to provide this woman?

Inform her that some antianxiety medications are safe to take while breastfeeding

Cholinesterase inhibitors for MG

Neostigmine, pyridostigmine, endrophonium

22. A 26-year-old female client is admitted to the hospital for treatment of a simple goiter, and levothyroxine sodium (Synthroid) is prescribed. Which symptoms indicate to the nurse that the prescribed dosage is too high for this client? The client experiences

Palpitations and shortness of breath

423. The nurse has received funding to design a health promotion project for African-American women who are at risk for developing breast cancer. Which resource is most important in designing this program?

Participation of community leaders in planning the program

620. The nurse is preparing a 50 ml dose of 50% dextrose IV for a client with insulin...medication?

Push the undiluted Dextrose slowly through the currently infusion IV

58. A female client with breast cancer who completed her first chemotherapy treatment today at an out-patient center is preparing for discharge. Which behavior indicates that the client understands her care needs

Rented movies and borrowed books to use while passing time at home

What is the most common electrodiagnostic test performed to detect MG

Repetitive nerve stimulation (RNS)

627. A client with hypertension receives a prescription for enalapril, an angiotensin...instruction should the nurse include in the medication teaching plan?

Report increased bruising of bleeding

153. A child is admitted to the pediatric unit diagnosed with sickle cell crisis. When the nurse walks into the room, the unlicensed assistive personnel (UAP) is encouraging the child to stay in bed in the supine position. Which action should the nurse implement?

Reposition the client with the head of the bed elevated.

316. The nurse is preparing a 4-day-old I infant with a serum bilirubin level of 19 mg/dl (325 micromol/L) for discharge from the hospital. When teaching the parents about home phototherapy, which instruction should the nurse include in the discharge teaching plan?

Reposition the infant every 2 hours.

614. In caring for a client receiving the amino glycoside antibiotic gentamicin, it is most important for the nurse to monitor which diagnostic test?

Serum creatinine

An Insulin infusion for a client with diabetes mellitus who is experiencing hyperglycemic hyperosmolar...in addition to the client's glucose, which laboratory value is most important for the nurse to monitor?

Serum potassium

A nurse is caring for a client with the diagnosis of Guillain-Barré syndrome. The nurse identifies that the client is having difficulty expectorating respiratory secretions. What should be the nurses first intervention?

Suction the clients oropharynx

507. The nursing staff on a medical unit includes a registered nurse (RN), practical nurse (LPN), and unlicensed assistant personnel (UAP). Which task should the charge nurse assign to the RN?

Supervised a newly hired graduate nurse during an admission assessment

190. A 350-bed acute care hospital declares an internal disaster because the emergency generators malfunctioned during a city-wide power failure. The UAPs working on a general medical unit ask the charge nurse what they should do first. What instruction should the charge nurse provide to these UAPs?

Tell all their assigned clients to stay in their rooms.

The registered nurse is assisting a client who is hospitalized with high fever. Which task delegated to the unlicensed assistive personnel (UAP) would be appropriate? Select all that apply. 1 Assessing the vital signs Correct2 Performing all hygiene tasks 3 Administering oral medications Correct4 Helping the client in changing clothes 5 Administering intravenous medications

The UAP does all the hygiene tasks and also helps in changing the clothes. Assessing the vital signs may not be performed by the UAP. Administering the intravenous medications is performed by the registered nurse. Oral administrating of medication is performed by the licensed practical nurse.

The registered nurse is teaching a newly hired nurse about communicating with delegatees during delegation. Which statement made by the newly hired nurse indicates the need for further learning? 1 "I should identify priorities." Incorrect2 "I should specify deviations." Correct3 "I should provide examples of each delegation." 4 "I should specify any performance limitations to the delegatee."

The delegator should ask the delegatee to provide examples of each delegation in order to understand his or her knowledge level. The delegator should identify priorities before delegating the task to the delegatee. The delegator should specify deviations, such as when the delegatee must take an immediate action while performing the task. The delegator should specify the performance limitations to the delegatee, which can help in performing the task effectively.

A patient is prescribed to have capillary blood glucose readings every four hours. What should the nurse include when explaining capillaries to the patient?

The real work of the vascular system occurs at the capillary level.

The registered nurse (RN) delegated a task to a licensed practical nurse (LPN). The LPN completed the task effectively. Which statement made by the RN is appropriate feedback? 1 "Nice job." 2 "Well done." 3 "Your performance was good." Correct4 "You performed that procedure safely and professionally."

The statement, "You performed that procedure safely and professionally," clearly identifies what the LPN did well, so it can shape the future behavior positively. The RN should not include vague statements, such as, "Nice job," or, "Well done." The statement, "Your performance was good," could have a positive impact, but a specific behavior is not mentioned in the statement.

A 76-year-old patient is being treated with carbidopa/levodopa (Sinemet) for Parkinson's disease. Which information is most important for the nurse to report to the health care provider? Shuffling gait Tremor at rest Cogwheel rigidity of limbs Uncontrolled head movement

Uncontrolled head movement

616. A client who is at 36 weeks gestations is admitted with severe preclampsia. After a 6 gram loading dose of magnesium sulfate is administered, an intravenous infusion of magnesium sulfate at a rate of 2 grams/hour is initiated. Which assessment finding warrants immediate intervention by the nurse?

Urine output 20 ml/hour

The nurse is providing dietary instructions to a client hospitalized for pancreatitis. Which food should the nurse instruct the client to avoid? 1. Chili 2. Bagel 3. Lentil soup 4. Watermelon

1 The client with pancreatitis needs to avoid alcohol, coffee and tea, spicy foods, and heavy meals, which stimulate pancreatic secretions, producing attacks of pancreatitis. The client is instructed in the benefit of eating small, frequent meals that are high in protein, low in fat, and moderate to high in carbohydrates.

A client with end-stage renal disease is hospitalized. For what signs and symptoms of complications should the nurse monitor the client? (Select all that apply.) 1.Anemia 2.Dyspnea 3.Jaundice 4.Anasarca 5.Hyperexcitability

1.Anemia 2.Dyspnea 4.Anasarca

219. An adult client experiences a gasoline tank fire when riding a motorcycle and is admitted to the emergency department (ED) with full thickness burns to all surfaces of both lower extremities. What percentage of body surface area should the nurse document in the electronic medical record (EMR)?

36 %

The nurse is caring for the client who suffered a spinal cord injury 48 hours ago. What should the nurse assess for when monitoring for gastrointestinal complications? 1. A history of diarrhea 2. A flattened abdomen 3. Hyperactive bowel sounds 4. Hematest-positive nasogastric tube drainage

4 Development of a stress ulcer also can occur after spinal cord injury and can be detected by Hematest-positive nasogastric tube aspirate or stool. The client is also at risk for paralytic ileus, which is characterized by the absence of bowel sounds and abdominal distention. A history of diarrhea is irrelevant.

A nurse is planning to teach self-care measures to a female client about prevention of yeast infections. Which instructions should the nurse provide?

Avoid tight-fitting clothing and do not use bubble-bath or bath salts.

599. Following insertion of a LeVeen shunt in a client with cirrhosis of the liver, which assessment finding indicates to the nurse that the shunt is effective?

Decrease abdominal girth

594. The nurse is reviewing a client's electrocardiogram and determines the PR interval (PRI) is prolonged. What does this finding indicate?

Inability of the SA node to initiate an impulse at the normal rate

362. A client who is admitted to the intensive care unit with a right chest tube attached to a THORA-SEAL chest drainage unit becomes increasingly anxious and complain of difficulty breathing. The nurse determine the client is tachypneic with absent breath sounds in the client's right lungs fields. Which additional finding indicates that the client has developed a tension pneumothorax?

Tracheal deviation toward the left lung.

157. A client in the postanesthesia care unit (PACU) has an eight (8) on the Aldrete postanesthesia scoring system. What intervention should nurse implement?

Transfer the client to the surgical floor.

A client has been admitted to the hospital with a diagnosis of acute pancreatitis and the nurse is assessing the client's pain. What type of pain is consistent with this diagnosis? 1. Burning and aching, located in the left lower quadrant and radiating to the hip 2. Severe and unrelenting, located in the epigastric area and radiating to the back 3. Burning and aching, located in the epigastric area and radiating to the umbilicus 4. Severe and unrelenting, located in the left lower quadrant and radiating to the groin

2 The pain associated with acute pancreatitis is often severe and unrelenting, is located in the epigastric region, and radiates to the back. The other options are incorrect.

The emergency department nurse is assessing a client who has sustained a blunt injury to the chest wall. Which finding would indicate the presence of a pneumothorax in this client? 1. A low respiratory rate 2. Diminished breath sounds 3. The presence of a barrel chest 4. A sucking sound at the site of injury

2 This client has sustained a blunt or closed-chest injury. Basic symptoms of a closed pneumothorax are shortness of breath and chest pain. A larger pneumothorax may cause tachypnea, cyanosis, diminished breath sounds, and subcutaneous emphysema. Hyperresonance also may occur on the affected side. A sucking sound at the site of injury would be noted with an open chest injury.

The nurse is preparing for the admission to the unit of a client with a diagnosis of seizures and is preparing to institute full seizure precautions. Which item is contraindicated for use if a seizure occurs? 1. Oxygen source 2. Suction machine 3. Padded tongue blade 4. Padding for the side rails

3 Full seizure precautions include bed rest with padded side rails in a raised position, a suction machine at the bedside, having diazepam (Valium) or lorazepam (Ativan) available, and providing an oxygen source. Objects such as tongue blades are contraindicated and should never be placed in the client's mouth during a seizure.

A client with the diagnosis of multiple sclerosis (MS) develops hand tremors. When performing a history and physical assessment, which finding should the nurse expect the client to report? 1 The tremors increase when I fall asleep. 2 The tremors increase when I feel fatigued. 3 The tremors increase when I become nervous. 4 The tremors increase when I perform an activity.

4 Multiple foci of demyelination cause interruption or distortion of the impulse, resulting in intention tremors (tremor when performing an activity). There are no tremors when the client is asleep. Fatigue will exacerbate the signs and symptoms of multiple sclerosis, but it will not precipitate intention tremors. Intention tremors are associated with muscle contraction, not feelings; however, stress can exacerbate the signs and symptoms of multiple sclerosis.

The nurse is performing an assessment on a client with a suspected diagnosis of acute pancreatitis. The nurse will direct the assessment to look for which as a hallmark sign of this disorder? 1. Hypothermia 2. Epigastric pain radiating to the neck area 3. Severe abdominal pain relieved by vomiting 4. Severe abdominal pain that is unrelieved by vomiting

4 Nausea and vomiting are common presenting manifestations of acute pancreatitis. A hallmark symptom is severe abdominal pain that is not relieved by vomiting. The vomitus characteristically consists of gastric and duodenal contents. Fever also is a common sign but usually is mild, with temperatures less than 39° C. Epigastric pain radiating to the neck area is not a characteristic symptom.

24. The healthcare provider prescribes an IV solution of isoproterenol (Isuprel) 1 mg in 250 ml of D5W at 300 mcg/hour. The nurse should program the infusion pump to deliver how many ml/hour? (Enter numeric value only.)

75 ml/hour

Which statement by the U.S. Food and Drug Administration (FDA) is an example of a black box or black label warning for the drug clopidogrel (Plavix)? A.This drug could cause heart attack or stroke when taken by patients with certain genetic conditions. B.Clopidogrel helps prevent platelets from sticking together and forming clots in the blood. C.This drug can be taken in combination with aspirin to reduce the risk of acute coronary syndrome. D.Clopidogrel can reduce the risk of a future heart attack when taken by patients with peripheral artery disease.

A Rationale: A black box warning is a notice required by the FDA on a prescription drug that warns of potentially dangerous side effects (A). (B, C, and D) are all desired effects of the drug.

The nurse is assessing a client at 20 weeks' gestation. Which measurement should be compared with the client's current weight to obtain the most accurate data about her weight gain during pregnancy? A.Usual prepregnant weight B.Weight at the first prenatal visit C.Weight during previous pregnancy D.Recommended pattern of weight gain

A Rationale: Comparing the client's current weight with her prepregnant weight (A) allows for the calculation of weight gain. By the time of the first prenatal visit (B), she may have already gained weight. (C) may not be relevant to weight gain with the current pregnancy. (D) should be evaluated based on serial weights, not just a single current weight.

An 8-year-old child is receiving digoxin (Lanoxin) for congestive heart failure (CHF). In assessing the child, the nurse finds that her apical heart rate is 80 beats/min, she complains of being slightly nauseated, and her serum digoxin level is 1.2 ng/mL. What action should the nurse take? A.Because the child's heart rate and digoxin level are within normal range, assess for the cause of the nausea. B.Hold the next dose of digoxin until the health care provider can be notified because the serum digoxin level is elevated. C.Administer the next dose of digoxin and notify the health care provider that the child is showing signs of toxicity. D.Notify the health care provider that the child's pulse rate is below normal for her age group.

A Rationale: Nausea and vomiting are early signs of digoxin toxicity. However, the normal resting heart rate for a child 8 to 10 years of age is 70 to 110 beats/min and the therapeutic range of serum digoxin levels is 0.5 to 2 ng/mL. Based on the objective data, (A) is the best of the choices provided because the serum digoxin level is within normal levels. (B) is not warranted by the data presented. The digoxin level is within the therapeutic range and the child is not showing signs of toxicity (C). The child's pulse rate is within normal range for her age group (D).

When the nurse-manager posts a schedule for volunteers to be on call, one staff member immediately signs up for all available 7-to-3 day shifts. Other staff members complain to the charge nurse that they were not permitted the opportunity to be on call for the day shift. What action should the nurse-manager implement? A.Speak privately with the nurse. B.Hold a staff meeting to discuss this issue. C.Review the nurse's current salary. D.Nominate the nurse for employee of the month.

A The nurse-manager should speak privately with the nurse (A) to assess the nurse's motives and to discuss allowing other team members the opportunity to be on call for the day shift. (B) might become confrontational. (C) is irrelevant. (D) is not warranted.

A client with a prescription for "do not resuscitate" (DNR) begins to manifest signs of impending death. After notifying the family of the client's status, what priority action should the nurse implement? A. The impending signs of death should be documented B. The client's need for pain medication should be determined C. The nurse manager should be updated on the client's status D. The client's status should be conveyed to the chaplain

B

A client with non-Hodgkin's lymphoma has been prescribed cyclophosphamide (Cytoxan) IV for therapy. Which assessment finding would need to be reported immediately to the oncologist? A.Sores on the mouth or tongue B.Chills, fever, and sore throat C.Loss of appetite or weight with diarrhea D.Changes in color of fingernails or toenails

B Rationale: Cyclophosphamide (Cytoxan) is an immunosuppressive drug used to treat lymphoma and puts the client at risk for infection. Signs and symptoms of an infection should be reported to the oncologist immediately (B). These are expected signs and symptoms of non-Hodgkin's lymphoma (A and C). (D) is a normal side effect of cyclophosphamide.

The nurse performs tracheostomy suctioning on a comatose client. Place the interventions in order from first to last. A. Gently insert the catheter without suction using sterile technique. B. Hyperoxygenate using a manual reservoir-equipped resuscitation bag (MRB). C. Check the suction regulator and adjust suction pressure to 120 to 150 mm Hg. D. Apply suction intermittently while withdrawing the catheter. A. B, C, A, D B. A, C, B, D C. C, B, A, D D. D, C, B, A

C Equipment should be set up and adjusted prior to beginning the procedure (C). Hyperoxygenation using an MRB should be completed prior to inserting the catheter (B). After preoxygenation, the catheter can be inserted (A) and suction can be applied intermittently (D).

Which finding should be reported to the primary health care provider when caring for a client who has a continuous bladder irrigation after a transurethral resection of the prostate gland (TURP)? A.The client reports a continuous feeling of needing to void. B.Urinary drainage is pink 24 hours after surgery. C.The hemoglobin level is 8.4 g/dL 3 days postoperatively. D.Sterile saline is being used for bladder irrigation.

C Rationale: A hemoglobin level of 8.4 g/dL is abnormally low and may indicate hemorrhage (C). The others are all expected findings after a TURP (A, B, and D).

The nurse is caring for a client with heart failure who develops respiratory distress and coughs up pink frothy sputum. Which action should the nurse take first? A.Draw arterial blood gases. B.Notify the primary health care provider. C.Position in a high Fowler's position with the legs down. D.Obtain a chest X-ray.

C Rationale: Positioning the patient in a high Fowler's position with dangling feet will decrease further venous return to the left ventricle (C). The other actions should be performed after the change in position (A, B, and D).

553. A client is receiving oxytocin (Pitocin) to augment early labor. Which assessment is most important time the infusion rate is increases?

Contraction pattern

A client with hemiplegia who is on bed rest is turned to the supine position, and the nurse determines that the client's hips are externally rotated. Which intervention is most important for the nurse to implement? A.Request a prescription for a bed board to provide increased back support. B.Reposition the client so that both feet are supported by the bed board. C.Move the trapeze bar to allow the client to pull with the upper extremities. D.Place trochanter rolls on the lateral aspects of the client's thighs.

D Trochanter rolls (D) should be placed on the lateral aspects of the thighs to prevent external rotation of the hips when the client is in a supine position. Although (A, B, and C) are supportive equipment used to maintain proper positioning of the client who is immobile, it is most important to maintain the lower extremities in the aligned anatomical position. A bed board (A) provides increased back support, especially with a soft mattress. The footboard (B) maintains the feet in dorsiflexion and prevents foot drop. The trapeze bar (C) allows the client to participate while turning in the bed, during transfers in and out of bed, or performing upper arm exercises.

17. Before preparing a client for the first surgical case of the day, a part-time scrub nurse asks the circulating nurse if a 3 minute surgical hand scrub is adequate preparation for this client. Which response should the circulating nurse provide?

Direct the nurse to continue the surgical hand scrub for a 5 minute duration

520. The nurse is caring a client with NG tube. Which task can the nurse delegate to the UAP?

Disconnect the NG suction so the client can ambulate in the hallway

485. When changing a diaper on a 2-day-old infant, the nurse observes that the baby's legs are... this finding, what action should the nurse take next?

Notify the healthcare provider

407. A client on a long-term mental health unit repeatedly takes own pulse regardless of the circumstance. What action should the nurse implement?

Overlook the client's behavior.

493. A male client is discharged from the intensive care unit following a myocardial infarction, and the healthcare provider low-sodium diet. Which lunch selection indicates to the nurse that this client understands the dietary restrictions?

Turkey salad sandwich.

The nurse plans to suction a male client who has just undergone right pneumonectomy for cancer of the lung. Secretions can be seen around the endotracheal tube and the nurse auscultates rattling in the lungs. What safety factors should the nurse consider when suctioning this client?

Use a soft-tip rubber suction catheter and avoid deep vigorous suctioning.

A nurse is assessing a client with Parkinson disease. Which assessment finding indicates the presence of bradykinesia? 1 Intention tremor 2 Muscle flaccidity 3 Paralysis of the limbs 4 Lack of spontaneous movement

4 Bradykinesia is a slowing down in the initiation and execution of movement. Tremors are more prominent at rest and are known as nonintention, not intention, tremors. Cogwheel rigidity, not flaccidity, occurs because the disorder causes sustained muscle contractions. The limbs are rigid and move with a jerky quality; the limbs are not paralyzed.

A nurse has taught the client with chronic pancreatitis about risk factor modification to reduce the incidence of recurrences. The nurse should determine that the client has understood the information if the client states that it will be necessary to control which factor? 1. Alcohol intake 2. Duodenal ulcer 3. Crohn's disease 4. Diabetes mellitus

1 Chronic pancreatitis is aggravated by continued alcohol intake. Each of the other options is not associated with pancreatitis.

Which clinical findings does the nurse anticipate a client with an exacerbation of multiple sclerosis will experience? Select all that apply. 1 Double vision 2 Resting tremors 3 Flaccid paralysis 4 Scanning speech 5 Mental retardation

1, 4 Diplopia (double vision) and nystagmus (involuntary, rapid, rhythmic eye movements) are experienced by clients with multiple sclerosis as a result of demyelination. Scanning (clipped) speech occurs with multiple sclerosis as a result of demyelination. These clients exhibit the Charcot triad: intention tremor, nystagmus, and scanning speech. Clients experience intention, not resting, tremors. Clients experience spastic paralysis because upper motoneurons are involved. Although emotional affect and speech are affected, intelligence remains intact.

A nurse is assessing a client with multiple sclerosis. Which common initial clinical effects should the nurse expect to find? Select all that apply. 1 Headaches 2 Nystagmus 3 Skin infections 4 Scanning speech 5 Intention tremors

1,4,5 Involuntary, rhythmic movements of the eyes (nystagmus) and other visual disturbances, such as diplopia and blurred vision, are common initial symptoms of optic nerve lesions. Some common initial signs of multiple sclerosis are scanning speech, intention tremors, and nystagmus. These adaptations are associated with disseminated demyelination of nerve fibers of the brain and spinal cord. Although this is a neuromuscular disorder, headaches are not a common symptom. Pressure ulcers may occur late, not early, in the progression of the illness because of immobility, and these pressure ulcers may become infected.

A client has a kidney transplant. The nurse should monitor for which signs associated with rejection of the transplant? (Select all that apply.) 1.Fever 2.Oliguria 3.Jaundice 4.Moon face 5.Weight gain

1.Fever 2.Oliguria 5.Weight gain

210. The nurse assesses a client with new onset diarrhea. It is most important for the nurse to question the client about recent use of which type of medication?

Antibiotics

A nurse is caring for a client with a chest tube drainage system. The nurse notes a fluctuating water level on inspiration and expiration in the submerged tube in the water seal chamber of the chest tube system. Which nursing action is appropriate? 1. Suction the client. 2. Increase the suction. 3. Document the findings. 4. Encourage coughing and deep breathing.

3 With normal breathing, the water level rises with inspiration and falls with expiration. The opposite—a water level that falls with inspiration and rises with expiration—occurs when the client is on positive-pressure mechanical ventilation. This is an expected, normal occurrence in a chest tube drainage system; therefore no action is necessary except to document the findings.

A child is having a generalized tonic-clonic seizure. Which action should the nurse take? A.Move objects out of the child's immediate area. B.Quickly slip soft restraints on the child's wrists. C.Insert a padded tongue blade between the teeth. D.Place in the recovery position before going for help.

A The first priority during a seizure is to provide a safe environment, so the nurse should clear the area (A) to reduce the risk of trauma. The child should not be restrained (B) because this may cause more trauma. Objects should not be placed in the child's mouth (C) because it may pose a choking hazard. Although (D) should be implemented after the seizure, the nurse should not leave the child during a seizure to get help.

324. An adult client with severe depression was admitted to the psychiatric unit yesterday evening. Although the client ran one year ago, his spouse states that the client no longer runs, bur sits and watches television most of the day. Which is most important for the nurse to include in this client's plan of care for today?

Assist client in identifying goals for the day.

The registered nurse is assigning tasks to a healthcare team to provide care for a group of clients in hospice care. How should the registered nurse help the healthcare team attain an effective outcome in the hospice care? Correct1 Assisting the healthcare team in planning 2 Assisting the healthcare team in interpreting 3 Assisting the healthcare team to enhance the ability Incorrect4 Assisting the healthcare team to achieve optimal functioning

Assisting the healthcare team in planning a task by the registered nurse can be beneficial in managing the effective outcome of the hospice care. Assisting in interpreting is beneficial in affirming of the outcome. Assisting to enhance ability will help in renewing the outcome. Assisting to achieve optimal functioning will be beneficial in achieving workable unity.

The nurse administers regular insulin (human), 8 units subcutaneously, to a client at 8:00 am, 30 minutes before breakfast. At what time is the client most at risk for a hypoglycemic reaction? A.9:30 am B.10:30 am C.12:00 pm D.3:00 pm

B Rationale: Regular insulin is short-acting and peaks between 2 and 3 hours after administration (B). The client is most at risk for a hypoglycemic reaction during the peak times. (A, C, and D) are not high-risk times for the client to experience hypoglycemia because they do not fall within the peak time.

The nurse prepares to administer digoxin (Lanoxin), 0.125 mg PO, to an adult client with heart failure and notes that the digoxin serum level in the laboratory report is 1 ng/mL. Which action should the nurse take? A.Discontinue the digoxin. B.Notify health care provider. C.Administer the digoxin. D.Reverify the digoxin level.

C Rationale: A therapeutic range for digoxin is 0.5 to 2 ng/mL (C). The digoxin should be continued to maintain a therapeutic range (C). The others actions are not indicated for a therapeutic range (A, B, and D).

140. A client with a chronic health problem has difficulty ambulating short distance due to generalized weakness, but is able to bear weight on both legs. To assist with ambulation and provide the greatest stability, what assistive device is best for this client?

Crutches with 4 point gait.

136. After a colon resection for colon cancer, a male client is moaning while being transferred to the Postanesthesia Care Unit (PACU). Which intervention should the nurse implement first?

Determine client's pulse, blood pressure, and respirations

380. A client with C-6 spinal cord injury rehabilitation. In the middle of the night the client reports a severe, pounding headache, and has observable piloerection or "goosebumps". The nurse should asses for which trigger?

Full bladder

71. In caring for a client with Cushing syndrome, which serum laboratory value is most important for the nurse to monitor?

Glucose

155. After six days on a mechanical ventilator, a male client is extubated and place on 40% oxygen via face mask. He is awake and cooperative, but complaining of a severe sore throat. While sipping water to swallow a medication, the client begins coughing, as if strangled. What intervention is most important for the nurse to implement?

Hold oral intake until swallow evaluation is done.

330. The nurse is teaching a mother of a newborn with a cleft lip how to bottle feed her baby using medela haberman feeder, which has a valve to control the release of milk and a slit nipple opening. The nurse discusses placing the nipple's elongated tip in the back of the oral cavity. What instructions should the nurse provide the mother about feedings?

Hold the newborn in an upright position

548. A male infant born at 28-weeks gestation at an outlying hospital is being prepared for transport to a respiration are 92 breaths/minute and his heart rate is 156 beats/minute. Which drug is the transport administration to this infant?

Instill beractant 100 mg/kg in endotracheal tube.

468. During a left femoral artery aortogram, the healthcare provider inserts an arterial sheath and initiate. Through the sheath to dissolve an occluded artery. Which interventions should the nurse implement?

Instruct the client to keep the left leg straight Observe the insertion site for a hematoma Circle first noted drainage on the dressing

156. The nurse is interacting with a female client who is diagnosed with postpartum depression. Which finding should the nurse document as an objective signs of depression? (Select all that apply)

Interacts with a flat affect. Avoids eye contact. Has a disheveled appearance.

CHOLinesterase Inhibitors adverse effects

Nausea, vomiting, diarrhea dyspepsia, dizziness, headache Bronchoconstriction (caution in Asthma and COPD) Bradycardia, hypoTN, syncope (fall risk)

539. The nurse is caring for a client immediately after inserting a PICC line. Suddenly, the client becomes anxious and tachycardiac, and loud churning is heard over the pericardium upon auscultation. What action should the nurse take first?

Place client in Trendelenburg position on the left side.

114. A client who had a right hip replacement 3 day ago is pale has diminished breath sound over the left lower lung fields, a temperature of 100.2 F, and an oxygen saturation rate of 90%. The client is scheduled to be transferred to a skilled nursing facility (SNF) tomorrow for rehabilitative critical pathway. Based on the client's symptoms, what recommendation should the nurse give the healthcare provider?

Reassess readiness for SNF transfer.

286. Fallowing an outbreak of measles involving 5 students in an elementary school, which action is most important for the school nurse to take?

Restrict unvaccinated children from attending school until measles outbreak is resolved.

Which factors does the registered nurse consider in the decision to delegate process? Select all that apply. 1 Evaluation Incorrect2 Nursing judgment Correct3 Predictability of outcomes Incorrect4 Pervasive functions of assessment Correct5 Complexity of the task to be performed

Two factors responsible for the decision to delegate process are predictability of outcomes and complexity of the task to be performed. Evaluation, nursing judgment, and pervasive functions are not factors in the decision to delegate process.

The healthcare team is caring for a client with neutropenia. Which task is delegated to unlicensed assistive personnel? 1 Administering antibiotics Correct2 Assisting with personal hygiene Incorrect3 Monitoring for signs and symptoms of infection 4 Teaching the client and caregivers about how to avoid infection

Unlicensed assistive personnel assisting with the client's personal hygiene. The licensed practical nurse administers antibiotics. Monitoring for signs and symptoms is performed by the licensed practical nurse. The registered nurse teaches the client and caregivers how to avoid infection.

A low potassium diet is prescribed for a client. What foods should the nurse teach this client to avoid?

A serving of dried prunes (D) contains more than 300 mg of potassium, and should be avoided. The richest dietary sources of potassium are unprocessed foods (especially fruits), many vegetables, and some dairy products, so the client should avoid these food groups. Servings of foods containing less than 150 mg of potassium, such as (A, B, and C), are good choices for a low potassium diet.

589. The nurse assesses a 78-year-old male client who has left sides heart failure. Which symptoms would the nurse expect this client to exhibit?

Dyspnea, cough, and fatigue.

A chest tube is inserted into a client who was stabbed in the chest and is attached to a closed-drainage system. Which is an important nursing intervention when caring for this client? a. Observe for fluid fluctuations in the water-seal chamber. b. Obtain a prescription for morphine to minimize agitation. c. Apply a thoracic binder to prevent excessive tension on the tube. d. Clamp the tubing securely to prevent a rapid decline in pressure.

a Fluctuations occur with inspiration and expiration until the lung is fully expanded. If these fluctuations do not occur, the chest tube may be clogged or kinked; coughing should be encouraged.

The nurse assesses a client who is taking indomethacin (Indocin) for arthritic pain. Which of the following is most important to report to the primary health care provider? A.Takes medication with milk B.Blood pressure, 104/64 mm Hg C.Elevated liver enzyme levels D.Hemoglobin level, 13 g/dL

C Rationale: Indomethacin is an antiinflammatory drug and can cause liver damage. Elevated liver enzyme levels indicate a complication with the drug (C). This medication should be taken with food or milk to reduce gastrointestinal (GI) side effects (A). (B and D) are normal findings.

A licensed practical nurse (LPN) was hired recently. Which strategy should be applied by the registered nurse (RN) to open lines of communication between them? 1 Telling 2 Selling Correct3 Asking 4 Offering

Asking is the first strategy and begins with questions that open lines of communication between the newly hired LPN and RN. Telling is helpful when the delegatee and delegator have a new relationship. Selling is the supervision by the delegator when the delegator and delegatee have a long relationship and have been working together for a while. Offering is also a strategy that can be followed after using the asking strategy by making a suggestion.

The nurse reviews the medical records of four male clients and concludes that the client that is at highest risk of developing prostate cancer is the: 1.Black 55-year-old 2.White 45-year-old 3.Asian 55-year-old 4.Hispanic 45-year-old

1.Black 55-year-old

The nurse is caring for a client four days after the client had a cystectomy and formation of a continent diversion. After observing mucous threads in the client's urine, the nurse should: 1.Recognize that this is an expected response 2.Report this to the health care provider immediately 3.Obtain a specimen for culture and sensitivity 4.Increase the client's fluid intake for the next 12 hours

1.Recognize that this is an expected response

The nurse provides discharge instructions to a male client that had a ureterolithotomy. The client has a history of recurrent urinary tract infections (UTIs). The teaching should include that indicators of a UTI are: 1.Urgency or frequency of urination 2.The inability to maintain an erection 3.Pain radiating to the external genitalia 4.An increase in the alkalinity of the urine

1.Urgency or frequency of urination

428. A client is receiving an IV solution labeled Heparin Sodium 20,000 Units in 5% dextrose injection 500 ml at 25 ml/hour. How many units of heparin is the client receiving each hour?

1000 units/hour

A hospitalized client with liver disease has a dietary protein restriction. The nurse encourages intake of which complete proteins to maximize the availability of essential amino acids? 1. Nuts 2. Meats 3. Cereals 4. Vegetables

2 Complete proteins contain all of the essential amino acids, which are acids that the body cannot produce from other available sources. Complete proteins derive from animal sources, such as meat, cheese, milk, and eggs. Incomplete proteins can be found in fruits, vegetables, nuts, cereals, breads, and legumes.

The nurse is preparing a teaching tool about the cardiac electrical conduction system. In which order should the nurse explain the route of the action potential? (Enter the number of each step in the proper sequence

2) Sinoatrial node fires in the right atrium 6) Impulse spreads through atrial myocardium 5) Impulse travels to the atrioventricular node 1) Impulse travels to the bundle of His 4) Impulse travels through bundle branches 3) Impulse extends through Purkinje fibers

When receiving hemodialysis, the complication of the removal of too much sodium may occur. For which clinical findings associated with hyponatremia should the nurse assess the client? (Select all that apply.) 1.Chvostek sign 2.Muscle cramps 3.Extreme fatigue 4.Cardiac dysrhythmias 5.Increased temperature

2.Muscle cramps 3.Extreme fatigue

A client has suffered a head injury affecting the occipital lobe of the brain. The nurse anticipates that the client may experience difficulty with which sense? 1. Smell 2. Taste 3. Vision 4. Hearing

3 The occipital lobe is responsible for reception of vision and contains visual association areas. This area of the brain helps the individual to visually recognize and understand the surroundings. The other senses listed are not a function of the occipital lobe.

A 40-year-old office worker who is at 36 weeks' gestation presents to the occupational health clinic complaining of a pounding headache, blurry vision, and swollen ankles. Which intervention should the nurse implement first? A.Check the client's blood pressure. B.Teach her to elevate her feet when sitting. C.Obtain a 24-hour diet history to evaluate for the intake of salty foods. D.Assess the fetal heart rate.

A The blood pressure (A) should be assessed first. Preeclampsia is a multisystem disorder, and women older than 35 years and have chronic hypertension are at increased risk. Classic signs include headache, visual changes, edema, recent rapid weight gain, and elevated blood pressure. (B, C, and D) can be done if the blood pressure is normal.

A client is admitted to the hospital with the diagnosis of hypokalemia. Which clinical manifestation is most significant? A.Heart palpitations B.Leg cramps C.Nausea D.Tetany

A Rationale: Hypokalemia can cause heart palpitations, which are indicative of a dysrhythmia that could progress to a medical emergency (A). (B and C) are also of concern but are not as life threatening. (D) is a symptom of hypocalcemia.

34. Following surgery, a male client with antisocial personality disorder frequently requests that a specific nurse be assigned to his care and is belligerent when another nurse is assigned. What action should the charge nurse implement?

Advise the client that assignments are not based on clients requests

FGA drug interactions

Anticholinergics: antihistamines, OTC sleep aids CNS Depressants: antihistamines, BZDs, barbiturates Levodopa and direct DA receptor agonists (most Parkinson medications) - counteract antipsychotic effects

A client is admitted to the mental health unit with a chief complaint of crying, depressed mood, and sleeping difficulties. While talking about the death of a friend, the client states, "I can't believe this happened." Which statement by the nurse is most therapeutic? A."It sounds like you're feeling very sad." B."Tell me more about how you're feeling." C."How often do you have crying spells?" D."Do you want to talk about these feelings?"

B It is most therapeutic to ask an open-ended question and encourage the client to explore his or her feelings (B). (A) is a leading response, and the client may not be feeling sad. (C and D) are close-ended questions that do not facilitate communication.

A health care provider prescribes famotidine for a client with dyspepsia. What is important to include about this medication in a teaching program for this client? A. Lowers the stress level B. Neutralizes gastric acidity C. Reduces gastrointestinal peristalsis D. Decreases secretions in the stomach

D. Decreases secretions in the stomach

374. To prevent infection by auto contamination during the acute phase of recovery from multiple burns, which intervention is most important for the nurse to implement?

Dress each wound separately.

101. When performing postural drainage on a client with Chronic Obstructive Pulmonary Disease (COPD), which approach should the nurse use?

Explain that the client may be placed in five positions

551. Artificial rupture of the membrane of a laboring reveals meconium-stained fluid, what is... the priority?

Have a meconium aspirator available at delivery

146. The mother of a 7-month-old brings the infant to the clinic because the skin in the diaper area is excoriated and red, but there are no blisters or bleeding. The mother reports no evidence of watery stools. Which nursing intervention should the nurse implement?

Instruct the mother to change the child's diaper more often.

429. The nurse is preparing a client for discharge from the hospital following a liver transplant. Which instruction is most important for the nurse to include in this client's discharge teaching plan?

Monitor for an elevated temperature

279. Which problem reported by a client taking lovastatin requires the most immediate fallow up by the nurse?

Muscle pain

320. After the risk and benefits of having a cardiac catheterization are reviewed by the healthcare provider, an older adult with unstable angina is scheduled for the procedure. When the nurse presents the consent form for signature, the client asks how the wires will keep a heart heating during the procedure. What action should the nurse take?

Notify the healthcare provider of the client's lack of understanding.

142. A client with leukemia undergoes a bone marrow biopsy. The client's laboratory values indicate the client has thrombocytopenia. Based on this data, which nursing assessment is most important following the procedure?

Observe aspiration site.

Lasix 20 mg PO is prescribed for a client at 0600. The medication is available in a scored tablet of 40 mg. Before breaking the tablet, what action should the nurse take?

Perform hand hygiene

The patient with GBS is in the plateau period. Which intervention is best for the nurse to delegate to the nursing assistant

Perform passive range of motion every 2-4 hours

482. A female client who was mechanically ventilated for 7 days is extubated. Two hours later...productive cough, and her respirations are rapids and shallow. Which intervention is most important?

Prepare the client for intubation

A 16-year-old male client is admitted to the hospital after falling off a bike and sustaining a fractured bone. The healthcare provider explains the surgery needed to immobilize the fracture. Which action should be implemented to obtain a valid informed consent?

The client is a minor and cannot legally sign his own consent unless he is an emancipated minor, so the consent should be obtained from the guardian for this client, which is the custodial parent (B). (A) is not a legal option. A stepparent is not a legal guardian for a minor unless the child has been adopted by the stepparent (C). The non-custodial parent does not need to co-sign this form (D).

Which information will the nurse include when teaching a patient who is scheduled for a radiofrequency catheter ablation for treatment of atrial flutter?

The procedure will use electrical energy to destroy areas of the conduction system.

477. A client in septic shock has a double lumen central venous catheter with one liter of 0.9% Normal Saline Solution infusing at 1 ml/hour through one lumen and TPN infusing at 50 ml/hr. through one port. The nurse prepared newly prescribed IV antibiotic that should take 45 mints to infuse. What intervention should the nurse implement?

Use a secondary port of the Normal Saline solution to administer the antibiotic.

The nurse is caring for a patient with a chest tube in place. Over the past hour the drainage from the tube was 110 mL. What is the nurse's best action? a. Gently "milk" the tubing to remove clots b. Check the chest tube system for leaks c. Instruct the patient to cough and deep-breathe d. Notify the surgeon immediately

d

Adverse effects: darifenacin, oxybutin, solifenacin

mydriasis, blurred vision, dry eyes, dry mouth, urinary retention, constipation

Neostigmine (Prostigmin) neuromuscular effects

therapeutic dose increases the force of contraction Toxic dose decreases the force of contraction

A patient reports dizziness and shortness of breath for several days. During cardiac monitoring in the emergency department (ED), the nurse obtains the following electrocardiographic (ECG) tracing. The nurse interprets this heart rhythm as

third-degree atrioventricular (AV) block.

557. To obtain an estimate of a client's systolic B/P. What action should the nurse take first?

Palpate the client's brachial pulse

523. The nurse is assessing a 4-year-old boy admitted to the hospital with the diagnosis of possible nephrotic syndrome. Which statement by the parents indicates a likely correlation to the child's diagnosis?

"I couldn't get my son's socks and shoes on this morning"

It is determined that a client with heart block will require implantation of a permanent pacemaker to assist heart function. The client expresses concern about having an increased risk of accidental electrocution. How should the nurse respond? 1 "No one has been electrocuted yet by a pacemaker." 2 "New technology prevents electrocution from occurring." 3 "The pacemaker is pretested for safety before it is inserted." 4 "The voltage emitted is not strong enough to electrocute."

"The voltage emitted is not strong enough to electrocute."

418. A client with a serum sodium level of 125 meq/mL should benefit most from the administration of which intravenous solution?

0.9% sodium chloride solution (normal saline)

Prior to insertion of an indwelling urinary catheter, what client information is most important for the nurse to obtain? A. Client allergies to antiseptic solutions B. Previous hx of urinary tract infections C. Client's ability to increase fluid intake D. Color, clarity and odor of urine

A

388. The charge nurse is planning for the shift and has a registered nurse (RN) and a practical nurse (PN) on the team. Which client should the charge nurse assign to the RN?

A 30 year old depressed client who admits to suicide ideation.

45. Which location should the nurse choose as the best for beginning a screening program for hypothyroidism?

A business and professional women's group.

Which assessment should the nurse obtain before administering digoxin to a client? A. Apical heart rate B. Radial pulse on the left side C. Radial pulse in both right and left arms D. Difference between apical and radial pulses

A. Apical heart rate

129. After several hours of non-productive coughing, a client presents to the emergency room complaining of chest tightness and shortness of breath. History includes end stage chronic obstructive pulmonary disease (COPD) and diabetes mellitus. While completing the pulmonary assessment, the nurse hears wheezing and poor air movement bilaterally. Which actions should the nurse implement? (Select all that apply.)

Administer PRN nebulizer treatment. Obtain 12 lead electrocardiogram. Monitor continuous oxygen saturation.

511. The healthcare provider prescribes oxycodone/ aspirin 1 tab PO every 4h as needed for pain, for a client with polycystic kidney disease. Before administering this medication, which component of the prescription should the nurse question?

Aspirin content.

424. The home care nurse provide self-care instruction for a client chronic venous insufficiency cause by deep vein thrombosis. Which instructions should the nurse include in the client's discharge teaching plan? Select all that apply

Avoid prolonged standing or sitting Use recliner for long period of sitting continue wearing elastic stocking

A client is waiting for a kidney transplant. What explanation should the nurse include when teaching the client about the transplant? A. "Production of urine will be delayed after surgery." B. "You will require immunosuppressive drugs daily for the rest of your life." C. "Symptoms of rejection include a decrease in temperature and blood pressure." D. "You will need to modify your program of work and recreation, including sports."

B. "You will require immunosuppressive drugs daily for the rest of your life."

What should the nurse monitor when a client is receiving a platelet aggregation inhibitor such as clopidogrel? A. Nausea B. Epistaxis C. Chest pain D. Elevated temperature

B. Epistaxis

A nurse is watching the cardiac monitor and notices that the rhythm suddenly changes. There are no P waves, the QRS complexes are wide, and the ventricular rate is regular but over 100. The nurse determines that the client is experiencing: A. Premature ventricular contractions B. Ventricular tachycardia C. Ventricular fibrillation D. Sinus tachycardia

B. Ventricular Tachycardia Ventricular tachycardia is characterized by the absence of P waves, wide QRS complexes (usually greater than 0.14 second), and a rate between 100 and 250 impulses per minute. The rhythm is usually regular.

Fingolimod

Bradycardia, infection, liver injury Macular edema

On admission to the ICU for sepsis caused by ruptured appendix, a female client's temp is 39.8 C and her BP is 68/42. Other hemodynamic findings: Cardiac op of 10.7 L/min, systemic vascular resistance (SVR) of 480, and WBC of 28,000. Which classification of meds should the nruse evaluate for stabilization? A. ACE inhibitor B. Negative inotrope C. Vasoconstrictor D. Diuretic

C

The nurse reviews the comprehensive metabolic panel for a client with an electrolyte imbalance. Which data requires the most immediate intervention by the nurse? A.Potassium level, 3.9 mEq/dL B.Creatinine level,1.1 mg/dL C.Sodium level, 125 mEq/L D.Calcium level, 9 mg/dL

C Rationale: The normal serum sodium level is 135 to 145 mEq/L (C). This value indicates hyponatremia. Symptoms of hyponatremia include nausea and vomiting, headache, confusion, and seizures, which can be severe and need immediate attention. (A, B, and D) are all within normal parameters.

200. A client with Alzheimer's disease (AD) is receiving trazodone (Desyrel), a recently prescribed atypical antidepressant. The caregiver tells the home health nurse that the client's mood and sleep patterns are improved, but there is no change in cognitive ability. How should the nurse respond to this information?

Confirm the desired effect of the medication has been achieved.

Which approach should the nurse use when preparing a toddler for a procedure?

Demonstrate the procedure using a doll.

108. A new mother tells the nurse that she is unsure if she will be able to transition into parenthood. What action should the nurse take?

Determine if she can ask for support from family, friend, or the baby's father.

To what does the nurse contribute the increased risk of respiratory complications in clients with myasthenia gravis?

Ineffective coughing

120. The nurse caring for a client with acute renal fluid (ARF) has noted that the client has voided 800 ml of urine in 4 hours. Based on this assessment, what should the nurse anticipate that client will need?

Large amounts of fluid and electrolyte replacement.

A client is admitted to the hospital with a diagnosis of Type 2 diabetes mellitus and influenza. Which categories of illness should the nurse develop goals for the client's plan of care?

One chronic and one acute illness.

491. During a cardiopulmonary resuscitation of an intubated client, the nurse detects a palpable pulse throughout the two minutes cycle chest compression and absent breath sounds over the left lung. What action should the nurse implement?

Prepare for the endotracheal tube to be repositioned

A client with osteoarthritis is given a new prescription for a nonsteroidal antiinflammatory drug (NSAID). The client asks the nurse, "How is this medication different from the acetaminophen I have been taking?" Which information about the therapeutic action of NSAIDs should the nurse provide?

Provide antiinflammatory response.

186. A client with a cervical spinal cord injury (SCI) has Crutchfield tongs and skeletal traction applied as a method of closed reduction. Which intervention is most important for the nurse to include in the client's a plan of care?

Provide daily care of tong insertion sites using saline and antibiotic ointment

S/S of Myasthenia Gravis

Ptosis Difficulty swallowing Weakness of skeletal muscle (including respiratory muscles)

A client with a tentative diagnosis of myasthenia gravis is scheduled to receive edrophonium (Enlon) to confirm the diagnosis. What response should the nurse anticipate will confirm myasthenia gravis? Brief exaggeration of symptoms Improvement in ptosis of the eyelids Prolonged symptomatic improvement Rapid but brief symptomatic improvement

Rapid but brief symptomatic improvement

579. When gathering for a group therapy session at 1400 hours, a female client complains to the nurse that a smoking break has not been allowed all day. The nurse responds that 15 minute breaks were called over the unit intercom after breakfast and after lunch. The nurse is using what communication technique in responding to the client?

Reflection

A client with myasthenia gravis continues to become weaker despite treatment with neiostigmine. What reason should the nurse identify for the health care providers prescription for edrophonium

Rule out cholinergic crisis

Drugs for Depression in MS

SSRIs (fluoxetine (Prozac), sertraline (Zoloft0, Buproprion (Wellbutrin), TCAs (treat pain, insomnia, incontinence) -->amitriptyline (Elavil), Nortripyline (Pamelor)

Which laboratory result for a patient with multifocal premature ventricular contractions (PVCs) is most important for the nurse to communicate to the health care provider?

Serum potassium 2.9 mEq/L

The nurse is assessing a patient with a diagnosis of Guillain-Barré syndrome, which signs and symptoms are consistent with GBS

Sudden onset of weakness in the legs, decreased deep tendon reflexes, ataxia

The legal authority wants a record of the tasks performed by the delegatees and asks the delegatees to maintain a record of completed tasks. Which task is marked by the licensed practical nurse (LPN)? Correct1 Task A 2 Task B 3 Task C 4 Task D

The LPN is a licensed nursing professional whose scope of practice includes tasks such as the administration of oral medications. Admission of the client to the ophthalmology department is under the scope of a registered nurse. Collection of the data that is used for the assessment of the client is a task that can be performed by an unlicensed nursing practitioner. Provision of basic hygiene care is the task that is to be performed by nursing assistive personnel.

A nurse is caring for several clients who have severe psychiatric disorders. What is the major reason that a health care provider prescribes an antipsychotic medication for these clients? To improve judgment To promote social skills To diminish neurotic behavior To reduce the positive symptoms of psychosis

To reduce the positive symptoms of psychosis

The nurse is conducting a drug education class for junior high school students. Which statement, provided by one of the student participants, best describes the primary characteristic of addiction?

Wanting the drug is all that matters to an addict.

85. The healthcare provider prescribes the antibiotic cephradine 500mg PO every 6 hours for a client with a postoperative wound infection. Which foods should the nurse encourage this client to eat?

Yogurt and/or buttermilk.

Dyskenesia

impaired movement

The nurse obtains a rhythm strip on a patient who has had a myocardial infarction and makes the following analysis: no visible P waves, P-R interval not measurable, ventricular rate 162, R-R interval regular, and QRS complex wide and distorted, QRS duration 0.18 second. The nurse interprets the patient's cardiac rhythm as

ventricular tachycardia.

The health care provider has determined that a client with hepatitis has contracted the infection from contaminated food. The nurse understands that this client is most likely experiencing what type of hepatitis? 1. Hepatitis A 2. Hepatitis B 3. Hepatitis C 4. Hepatitis D

1 Hepatitis A is transmitted by the fecal-oral route via contaminated food or infected food handlers. Hepatitis B, C, and D are transmitted most commonly via infected blood or body fluids.

A nurse is caring for a client with cirrhosis. As part of dietary teaching to minimize the effects of the disorder, the nurse teaches the client about foods that are high in thiamine. The nurse determines that the client has the best understanding of the material if the client states to increase intake of which food? 1. Pork 2. Milk 3. Chicken 4. Broccoli

1 Thiamine is present in a variety of foods of plant and animal origin. Pork products are especially rich in the vitamin. Other good sources include peanuts, asparagus, and whole grain and enriched cereals.

While changing the tapes on a tracheostomy tube, the client coughs and the tube is dislodged. Which is the initial nursing action? 1. Call the health care provider to reinsert the tube. 2. Grasp the retention sutures to spread the opening. 3. Call the respiratory therapy department to reinsert the tracheotomy. 4. Cover the tracheostomy site with a sterile dressing to prevent infection.

2. Grasp the retention sutures to spread the opening. If the tube is dislodged accidentally, the initial nursing action is to grasp the retention sutures and spread the opening. If agency policy permits, the nurse then attempts immediately to replace the tube. Calling ancillary services or the HCP will delay treatment in this emergency situation. Covering the tracheostomy site will block the airway.

A client who has been taking digoxin for 20 years is hospitalized. The client exhibits signs of dehydration, and laboratory results identify the presence of hypokalemia. The nurse should monitor the client for which clinical finding indicating digoxin toxicity? A. Constipation B. Decreased urination C. Cardiac dysrhythmias D. Metallic taste in the mouth

C. Cardiac dysrhythmias

The nurse is caring for a group of clients on the clinical nursing unit. The nurse interprets that which of these clients is at most risk for the development of pulmonary embolism? 1. A 25-year-old woman with diabetic ketoacidosis 2. A 65-year-old man out of bed 1 day after prostate resection 3. A 73-year-old woman who has just had pinning of a hip fracture 4. A 38-year-old man with pulmonary contusion sustained in an automobile crash

3 Clients frequently at risk for pulmonary embolism include clients who are immobilized. This is especially true in the immobilized postoperative client. Other causes include those with conditions that are characterized by hypercoagulability, endothelial disease, or advancing age.

The low-pressure alarm sounds on a ventilator. The nurse assesses the client and then attempts to determine the cause of the alarm. If unsuccessful in determining the cause of the alarm, the nurse should take what initial action?

3 If at any time an alarm is sounding and the nurse cannot quickly ascertain the problem, the client is disconnected from the ventilator and manual resuscitation is used to support respirations until the problem can be corrected. No reason is given to begin cardiopulmonary resuscitation. Checking vital signs is not the initial action. Although oxygen is helpful, it will not provide ventilation to the client.

To promote optimal cerebral tissue perfusion in the postoperative phase following cranial surgery, the nurse should place the client with an incision in the anterior or middle fossa, in which position? 1. In 15 degrees of Trendelenburg 2. Side-lying with the head of the bed flat 3. With the head of the bed elevated at least 30 degrees 4. With the head of the bed elevated no more than 10 degrees

3 Positioning of the client correctly following cranial surgery is important to avoid increased intracranial pressure and to promote optimal cerebral tissue perfusion. The surgeon's prescription for positioning is always followed. The client with an incision in the anterior or middle fossa should be positioned with the head of bed (HOB) elevated at least 30 degrees. If the incision is in the posterior fossa or burr holes have been made, the client is positioned flat, or with the HOB elevated no more than 10 to 15 degrees. If a craniectomy (bone flap) is performed, the client should not be positioned to the operative side. Trendelenburg position is contraindicated in the postoperative phase following cranial surgery.

Which is the priority assessment for the client with Guillain-Barré syndrome with rapidly ascending paralysis? 1 Monitoring urinary output 2 Assessing nutritional status 3 Monitoring respiratory status 4 Assessing communication needs

3. Monitoring respiratory status The most serious complication of Guillain-Barré syndrome is respiratory failure caused by respiratory muscle paralysis. Urinary retention is common in Guillain-Barré, but monitoring urinary output is of lower priority than monitoring respiratory status. If ascending paralysis impairs the gag reflex, clients may require tube feedings or parenteral nutrition. Assessing nutritional status, however, is of lower priority than monitoring respiratory status. If ascending paralysis impairs cranial nerve functioning, or if the client is intubated, verbal communication abilities are lost.

340. While making rounds, the charge nurse notices that a young adult client with asthma who was admitted yesterday is sitting on the side of the bed and leaning over the bed-side-table. The client is currently receiving at 2 litters/minute via nasal cannula. The client is wheezing and is using pursed-lip breathing. Which intervention should the nurse implement?

Administer a nebulizer Treatment

309. The nurse is preparing an older client for discharge following cataract extraction. Which instruction should be include in the discharge teaching?

Avoid straining at stool, bending, or lifting heavy objects.

A client with a dx of a seizure dz is receiving phenytoin. Which instruction should the nurse provide? A. Take the medication on an empty stomach B. Contact your healthcare provider before trying to get pregnant C. Stop taking the medication if hirsutism occurs D. Decrease fluid intake when taking this medication

B

An 84-year-old female resident of a SNF has become increasingly withdrawn from her friends, cries often, and asks the nurse to call her daughter 3x a day. The nurse's plan of care should be based on the knowledge that she the resident is exhibiting behaviors consistent with which of Erikson's stages? A. Satisfaction vs. Depression B. Integrity vs. Despair C. Trust vs. Mistrust D. Intimacy vs. Isolation

B

The nurse is assessing suicide risk for a client recently admitted to the acute psychiatric unit. Which finding is the most significant risk factor? A.High level of anxiety present B.History of previous suicide attempt C.Family history of depression D.Self-care deficit is noted

B Rationale: A previous history of a suicide attempt is the most significant risk factor for future suicide attempts because the client has previously implemented a plan (B). The others (A, C, and D) may also be risk factors but are not as significant as a history of previous attempts.

A nurse is assessing a client with heart failure who has been prescribed digoxin (Lanoxin) for therapy. Which finding indicates an issue with the medication management? A.Regular heart rate of 88 beats/min B.Serum potassium level, 2.9 mEq/L C.Weight decreases by 1 lb daily D.Serum sodium level, 138 mEq/L

B Rationale: A serum potassium level of 2.9 mEq/L is low, and side effects of digoxin toxicity are exacerbated when the potassium level is low (B). (A, C, and D) are all expected findings when caring for a client with congestive heart failure.

The nurse is caring for a client who is experiencing severe pain. The expected outcome the nurse writes for the client reads, "The client will state my pain is less than 2 within 45 minutes after pain medication has been administered." Formulating the expected outcome is an example of which step in the nursing process? A.Assessment B.Planning C.Implementation D.Evaluation

B Rationale: Planning (B) allows the nurse to set goals for care and elicit the expected outcome by identifying appropriate nursing actions. Assessment, implementation, and evaluation are part of the care for the client but are not the appropriate actions for formulating the expected outcome (A, C, and D).

The nurse is caring for a client with a cerebrovascular accident (CVA) who is receiving enteral tube feedings. Which task performed by the UAP requires immediate intervention by the nurse? A.Suctions oral secretions from mouth B.Positions head of bed flat when changing sheets C.Takes temperature using the axillary method D.Keeps head of bed elevated at 30 degrees

B Rationale: Positioning the head of the bed flat when enteral feedings are in progress puts the client at risk for aspiration (B). The others are all acceptable tasks performed by the UAP (A, C, and D).

The family of a male adult with schizophrenia does not want the client to be involved in decisions regarding his treatment. The nurse should inform the family that the client has a right to be involved in his treatment planning based on which law? A.Social Security Act of 1990 B.American with Disabilities Act of 1990 C.Medicaid Act of 1965 D.Mental Health Act of 1946

B Rationale: The Americans with Disabilities Act (B) guarantees the client the right to participate in treatment planning. (A) is a federal insurance program that provides benefits to retired persons, the unemployed, and the disabled. (C) is a program for eligible individuals and/or families with low income and resources. (D) provides for public education regarding psychiatric illnesses.

When assisting a client who has undergone a right above-knee amputation with positioning in bed, which action should the nurse include? A.Keep the residual limb elevated during positioning. B.Instruct the client to grasp the overhead trapeze bar. C.Maintain alignment with an abduction pillow. D.Use pillow support to prevent turning to a prone position.

B The client will gain upper body strength and independence by using the overhead trapeze bar for positioning (B). Elevation of the residual limb is controversial (A) because a flexion contracture of the hip may result, so it is not necessary to maintain elevation during positioning. (C) is used for alignment following some hip surgeries. A prone position (D) should be encouraged to stretch the flexor muscles and prevent flexion contracture of the hip.

A client is admitted to the hospital with a diagnosis of an exacerbation of asthma. What should the nurse plan to do to best help this client? A. Determine the client's emotional state. B. Give prescribed drugs to promote bronchiolar dilation. C. Provide education about the impact of a family history. D. Encourage the client to use an incentive spirometer routinely.

B. Give prescribed drugs to promote bronchiolar dilation.

A nurse is caring for a client with unstable ventricular tachycardia. The nurse instructs the client to do which of the following, if prescribed, during an episode of ventricular tachycardia? A. Breathe deeply, regularly, and easily B. Inhale deeply and cough forcefully every 1 to 3 seconds C. Lie down flat in bed D. Remove any metal jewelry

B. Inhale deeply and cough forcefully every 1 to 3 seconds. Cough cardiopulmonary resuscitation (CPR) sometimes is used in the client with unstable ventricular tachycardia. The nurse tells the client to use cough CPR, if prescribed, by inhaling deeply and coughing forcefully every 1 to 3 seconds. Cough CPR may terminate the dysrhythmia or sustain the cerebral and coronary circulation for a short time until other measures can be implemented

A hospitalized client is diagnosed with pancreatitis. The nurse plans care, knowing that production of which substance will be elevated in blood studies for this client? 1. Pepsin 2. Lactase 3. Amylase 4. Enterokinase

3 The serum level of amylase, an enzyme produced by the pancreas, increases with pancreatitis. Amylase normally is responsible for carbohydrate digestion. Pepsin is produced by the stomach and is used in protein digestion. Lactase and enterokinase are enzymes produced by the small intestine; lactase splits lactose into galactose and fructose, and enterokinase activates trypsin.

A client is diagnosed with Parkinson disease and asks the nurse what causes the disease. On which underlying pathology does the nurse base a response? 1 Disintegration of the myelin sheath 2 Breakdown of upper and lower neurons 3 Reduced acetylcholine receptors at synapses 4 Degeneration of the neurons of the basal ganglia

4 Parkinson disease involves destruction of the neurons of the substantia nigra, reducing dopamine. The cause of this destruction is unknown. Disintegration of the myelin sheath is associated with multiple sclerosis. Breakdown of upper and lower motor neurons is associated with Lou Gehrig disease or amyotrophic lateral sclerosis. Reduced acetylcholine receptors at synapses are associated with myasthenia gravis.

The nurse teaches a class on bioterrorism. Which method(s) of transmission is(are) possible with the biologic agent Bacillus anthracis (Anthrax)? (Select all that apply.) A.Inhalation of powder form B.Handling of infected animals C.Spread from person to person through coughing D.Eating undercooked meat from infected animals E.Direct cutaneous contact with the powder

A,B,D,E Rationale: Anthrax can be transmitted by the inhalation, cutaneous, and digestive routes (A, B, D, and E); however, the disease is not spread from person to person (C).

An adult female with eroded tooth enamel presents to the clinic with complaints of abdominal discomfort and esophageal pain. The client tells the nurse that her diet consists mostly of high - sugar, high-fat foods that she usually consumes while driving her car. She also describes taking laxatives and eating prunes whenever she overeats. What actions should the nurse take when developing a plan of care for this client (SALA)? A. Ask the client how she prefers to eat B. Encourage the client to record everything she eats C. Ask the client what she would like to do about her eating habits D. Monitor lab values, particularly for electrolytes E. Have the client self-report vomiting incidents

A-C-D

84. Which type of Leukocyte is involved with allergic responses and the destruction of parasitic worms?

Eosinophils

275. An older adult female admitted to the intensive care unit (ICU) with a possible stroke is intubated with ventilator setting of tidal volume 600, PlO2 40%, and respiratory rate of 12 breaths/minute. The arterial blood gas (ABG) results after intubation are PH 7.31. PaCO2 60, PaO2 104, SPO2 98%, HCO3 23. To normalize the client's ABG finding, which action is required?

Increase ventilator rate.

The nurse is supervising a nursing student who is providing care for a thoracotomy patient with a chest tube. What finding would the nurse clearly instruct the nursing student to report immediately? a. Chest tube drainage of 10 to 15 mL/hr b. Continuous bubbling in the water-seal chamber c. Reports of pain at the chest tube site d. Chest tube dressing dated yesterday

b Continuous bubbling indicates an air leak that must be identified. With the health care provider's order, an RN can apply a padded clamp to the drainage tubing close to the occlusive dressing. If the bubbling stops, the air leak may be at the chest tube insertion. which will require the RN to notify the health care provider. If the air bubbling does not stop when the RN applies the padded clamp, the air leak is between the clamp and the drainage system, and the RN must assess the system carefully to locate the leak. Chest tube drainage of 10 to 15 mL/hr is acceptable. Chest tube dressings are not changed daily but may be reinforced. The patient's reports of pain need to be assessed and treated. This is important butt is not as urgent as investigating a chest tube leak.

A client has chest tubes attached to a chest tube drainage system. What should the nurse do when caring for this client? a. Clamp the chest tubes when suctioning b. Palpate the surrounding area for crepitus c. Change the dressing daily using aseptic technique d. Empty the drainage chamber at the end of the shift

b Leakage of air into the subcutaneous tissue is evidenced by a crackling sound when the area is gently palpated. This is referred to as crepitus.

Which intervention should be included in the plan of care for a client admitted to the hospital with ulcerative colitis? A.Administer stool softeners. B.Place the client on fluid restriction. C.Provide a low-residue diet. D.Add a milk product to each meal.

C Rationale: A low-residue diet (C) will help decrease symptoms of diarrhea, which are clinical manifestations of ulcerative colitis. (A, B, and D) are contraindicated and could worsen the condition.

A nurse implements an education program to reduce hospital readmissions for clients with heart failure. Which statement by the client indicates that teaching has been effective? A."I will not take my digoxin if my heart rate is higher than 100 beats/min." B."I should weigh myself once a week and report any increases." C."It is important to increase my fluid intake whenever possible." D."I should report an increase of swelling in my feet or ankles."

D Rationale: An increase in edema indicates worsening right-sided heart failure and should be reported to the primary health care provider (D). Digitalis should be held when the heart rate is lower than 60 beats/min (A). The client with heart failure should weigh himself or herself daily and report a gain of 2 to 3 lb (B). An increase in fluid can worsen heart failure (C).

390. While caring for a client's postoperative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should review which of the client's laboratory values?

Culture for sensitive organisms.

When assessing safety for the older adult, which of the following is of highest priority to the nurse? A.The client has a cataract in the right eye. B.The client is not married and lives alone. C.The client lives in a two-story building. D.The client reports a history of repeated falls.

D Rationale: Risk assessment for falls is a critical element in caring for the older adult. (A, B, and C) are important components in assessing client risk, but a history of prior falls puts the older client at very high risk for falling again (D).

The nurse assesses a client while the UAP measures the client's vital signs. The client's vital signs change suddenly, and the nurse determines that the client's condition is worsening. The nurse is unsure of the client's resuscitative status and needs to check the client's medical record for any advanced directives. Which action should the nurse implement? A.Ask the UAP to check for the advanced directive while the nurse completes the assessment. B.Assign the UAP to complete the assessment while the nurse checks for the advanced directive. C.Check the medical record for the advanced directive and then complete the client assessment. D.Call for the charge nurse to check the advanced directive while continuing to assess the client.

D Because the client's condition is worsening, the nurse should remain with the client and continue the assessment while calling for help from the charge nurse to determine the client's resuscitative status (D). (A and B) are tasks that must be completed by a nurse and cannot be delegated to the UAP. (C) is contraindicated.

When assigning a task, the delegator should understand the delegatee's personal values and align them with the organizational values. Which task can be achieved from this delegation? Correct1 Affirming 2 Managing Incorrect3 Renewing 4 Motivating

In the task of affirming values, sharing the personal values of the delegatee and aligning them with organizational values enables the delegatee to achieve an outcome. In managing, the delegator assists the delegatee with planning. In renewing, the outcome is achieved by enhancing the ability to care for the delegatee. In motivating, the delegatee is inspired to achieve the outcome.

A client is diagnosed with a spontaneous pneumothorax. Which physiologic effect of a spontaneous pneumothorax should the nurse include in a teaching plan for the client? a. Air will move from the lung into the pleural space b. The heart and great vessels shift toward the affected side c. There is greater negative pressure within the chest cavity d. Collapse of the other lung will occur if not treated immediately

a As a person with a tear in the lung inhales, air moves through that opening into the intrapleural space. This creates a positive pressure and causes partial or complete collapse of the lung.

A primary healthcare provider prescribes a diagnostic workup for a client who may have myasthenia gravis. What is the initial nursing goal for the client during the diagnostic phase? 1 Adhere to a teaching plan. 2 Achieve psychologic adjustment. 3 Maintain present muscle strength. 4 Prepare for the development of myasthenic crisis.

3 Until the diagnosis is confirmed, the primary goal should be to maintain adequate activity and prevent muscle atrophy. It is too early to develop a teaching plan; the diagnosis is not yet established. It is too early to achieve psychologic adjustment; the client cannot adjust if a diagnosis is not yet confirmed. Preparing for the development of myasthenic crisis is not a goal.

A client with myasthenia gravis asks the nurse, "What is going to happen to me and to my family?" Which information about what the client can anticipate should be incorporated into the nurse's response? 1 High cure rate with proper treatment 2 Slowly progressive course without remissions 3 Chronic illness with exacerbations and remissions 4 Poor prognosis, with death occurring in a few months

3. Myasthenia gravis is a chronic disorder with remissions and exacerbations that are precipitated by emotional stress, ingestion of alcohol, and physiologic stress such as infection. There is no cure for myasthenia gravis, but it can be managed. The disease is characterized by exacerbations and remissions. The disease is chronic. Death does not occur within a short period.

A client with viral hepatitis is discussing with the nurse the need to avoid alcohol and states, "I'm not sure I can avoid alcohol." What is the most appropriate nursing response? 1. "I don't believe that." 2. "Everything will be all right." 3. "I'm not sure that I understand. Would you please explain?" 4. "I think you should talk more with the health care provider (HCP) about this."

3 Explaining what is vague or clarifying the meaning of what has been said increases understanding for both the client and the nurse. Refusing to consider the client's ideas may cause the client to discontinue interaction with the nurse for fear of further rejection. False reassurance devalues the client's feelings. Placing the client's feelings on hold by referring him or her to the HCP for further information is a block to communication.

A nurse working in a community health setting is performing primary health screenings. Which individual is at highest risk for contracting an HIV infection? A.A 17-year-old who is sexually active with numerous partners B.A 45-year-old lesbian who has been sexually active with two partners in the past year C.A 30-year-old cocaine user who inhales the drug and works in a topless bar D.A 34-year-old male homosexual who is in a monogamous relationship

A Rationale: (A) is at greatest risk for contracting sexually transmitted diseases, including HIV, because the greater the number of sexual partners, the greater the risk for contracting an STD. (B) comprises the group of lowest infected persons because there is little transfer of body fluid during sexual acts. (C), who free-bases, would not be sharing needles, so contracting an STD is not necessarily a risk. A male homosexual in a monogamous relationship has a decreased risk of contracting HIV as long as both partners are monogamous and neither is infected (D).

Which pathophysiologic response supports the contraindication for opioids, such as morphine, in clients with increased intracranial pressure (ICP)? A.Sedation produced by opioids is a result of a prolonged half-life when the ICP is elevated. B.Higher doses of opioids are required when cerebral blood flow is reduced by an elevated ICP. C.Dysphoria from opioids contributes to altered levels of consciousness with an elevated ICP. D.Opioids suppress respirations, which increases Pco2 and contributes to an elevated ICP.

D The greatest risk associated with opioids such as morphine (D) is respiratory depression that causes an increase in Pco2, which increases ICP and masks the early signs of intracranial bleeding in head injury. (A, B, and C) do not support the risks associated with opioid use in a client with increased ICP.

A registered nurse (RN) delegates the task of oral care of a client with stomatitis, to an unlicensed assistive personnel (UAP). Which instruction should be given by the RN to the UAP? 1 "Use a mouthwash containing alcohol with the client." 2 "Teach the client to rinse the mouth once every 4 to 5 hours." Incorrect3 "Avoid using toothpaste containing sodium lauryl sulfate with the client." Correct4 "Be certain to use mouthwash containing sodium bicarbonate with the client."

Since the RN is accountable for the work of the UAP, she or he is giving instructions to the UAP before delegating the task. Sodium bicarbonate is slightly alkaline in nature and is soothing to the client. Alcohol will cause burning and aggravate ulcers, and is therefore contraindicated in clients with stomatitis. The oral cavity should be rinsed with sodium bicarbonate solution once every 2 to 3 hours. Sodium lauryl sulfate should be avoided as it is associated with the risk of stomatitis.

The nurse attempts to notify the healthcare provider about a client who is exhibiting an extrapyramidal reaction to psychotropic medications. When the receptionist for the answering service offers to take a message, which nursing action is best for the nurse to take?

Tell the receptionist to have the healthcare provider return the phone call.

The registered nurse (RN) is caring for a client who is currently hospitalized for a stroke. What is the most effective professional management strategy for the RN to improve the safety and quality of client care? Correct1 Delegation 2 Leadership 3 Supervision 4 Assignment

Delegation is the most effective professional management strategy to implement in clinical practice to improve the safety and quality of client care by the registered nurse. Leadership is the action of leading a group, which is not suitable in this situation. Supervision is the active process of directing, guiding, and influencing the outcomes. Assignment is the transfer of both accountability and the responsibility from one person to another.

A healthcare provider determines that a client has myasthenia gravis. Which clinical findings does the nurse expect when completing a health history and physical assessment? Select all that apply. 1 Double vision 2 Problems with cognition 3 Difficulty swallowing saliva 4 Intention tremors of the hands 5 Drooping of the upper eyelids 6 Nonintention tremors of the extremities

1, 3, 5 Double vision occurs as a result of cranial nerve dysfunction. Facial muscles innervated by the cranial nerves often are affected; difficulty with swallowing (dysphagia) is a common clinical finding. Drooping of the upper eyelids (ptosis) occurs because of cranial nerve III (oculomotor) dysfunction. Myasthenia gravis is a neuromuscular disease with lower motor neuron characteristics, not central nervous system symptoms. Intention tremors of the hands are associated with multiple sclerosis. Nonintention tremors of the extremities are associated with Parkinson disease.

Which should the nurse do when caring for a client with chest tubes attached to a chest drainage system? 1. Empty the drainage collection chamber every shift. 2. Ensure the water level in the water seal chamber is at the 2-cm level. 3. Maintain the drainage collection device at the level of the client's chest. 4. Clamp the chest tube before moving the client from the bed to the chair.

2 The water seal acts a one-way valve. It allows air and fluid to leave the pleural space but prevents re-entry of atmospheric air. The minimum amount needed is 2 cm of water. A closed chest drainage system must remain airtight at all times. The device is kept below the level of the chest. If the device is kept at the level of the chest, there can be backflow of drainage into the pleural cavity. Chest tubes should not be clamped unless specifically prescribed

A nurse is caring for an older bedridden male client who is incontinent of urine. What nursing intervention is the most satisfactory initial approach to managing urinary incontinence? 1.Restricting fluid intake 2.Offering the urinal regularly 3.Applying incontinence pants 4.Inserting an indwelling urinary catheter

2.Offering the urinal regularly

A young adult male was admitted 36 hours ago for a head injury that occurred as the result of a motorcycle accident. In the last 4 hours, his urine output has increased to over 200 ml/hour. Before reporting the finding to the healthcare provider, which intervention should the nurse implement? A. Evaluate the urine osmolality and the serum osmolality values B. Obtain BP and assesses for dependent edema C. Measure oral secretions suctioned during last 4 hours. D. Obtain capillary blood samples q2 hour for glucose monitoring

A

516. What is the primary goal when planning nursing care for a client with degenerative joint disease (DJD)?

Achieve satisfactory pain control.

While on a hike, a rusty nail pierces the sole of a client's foot and he is brought to the emergency department of a local hospital. Tetanus immune globulin is prescribed because the client does not know when the last tetanus immunization was received. What information will the nurse include when teaching the client about this drug? A. It will take about a week to become effective. B. Immune globulin provides lifelong passive immunity. C. It provides immediate, passive, short-term immunity. D. Immune globulins stimulate the production of antibodies.

C. It provides immediate, passive, short-term immunity.

571. A client with a recent colostomy expresses concern about the ability to control flatus. Which intervention is most important for the nurse to include in the client's plan of care?

Avoid foods that caused gas before the colostomy

A client with myasthenia gravis has been receiving neostigmine (Prostigmin) and asks about its action. What information about its action should the nurse consider when formulating a response? Stimulates the cerebral cortex Blocks the action of cholinesterase Replaces deficient neurotransmitters Accelerates transmission along neural sheaths

Blocks the action of cholinesterase

A young woman with MS just rcvd several immunizations in preparation for moving into a college dormitory. Two days later, she reports to the nurse that she is experiencing increasing fatigue and visual problems. What teaching should the nurse provide? A. Plans to move into the dormitory need to be postponed for at least a semester. B. These early signs of an infection may require medical txt with antibiotics. C. These are common side effects of the vaccines and will resolve in a few days. D. Immunizations can trigger a relapse of the disease, so get plenty of extra rest.

D

A delegator, working in collaboration with a delegatee, allots responsibilities and explains the various procedures and techniques needed to accomplish the task. Which action is the delegator performing, according to the Hersey model? 1 Guiding and directing 2 Observing or monitoring Correct3 Explaining and persuading 4 Encouraging or problem solving

Hersey's model describes the leader's behavior as explaining or persuading, which is characterized as "selling." In this situation, the delegator is assigning the work to the delegatee and explaining the various procedures and techniques to accomplish the specified task. A leader's behavior described as guiding or directing is characterized as "telling," in which the delegate simply assigns the task to the delegatee. The leader's behavior of observing or monitoring is characterized as "delegating," in which the delegator is responsible and accountable for the entire task. A leader's behavior that is encouraging or problem solving is characterized as "participating," in which the delegator establishes a working environment in which to complete the task in the specified time.

A nurse is caring for a client who is receiving mechanical ventilation via an endotracheal tube with a high-volume, low-pressure cuff. What problem is prevented when the nurse uses a high-volume, low-pressure cuff? 1 Air leakage 2 Lung infection 3 Mucosal necrosis 4 Tracheal secretion

Mucosal necrosis

The nurse explains to the family of a client suspected of having myasthenia gravis that edrophonium is used to establish the diagnosis. An increase in which factor will confirm diagnosis

Muscle strength

Adverse effects of Levodopa

Nausea, vomiting Dyskinesia (paradoxical effect) - head bobbing, tics, grimace, chorea movement

55. A client is admitted to isolation with the diagnosis of active tuberculosis. Which infection control measures should the nurse implement?

Negative pressure environment

451. The nurse is caring for several clients on a telemetry unit. Which client should the nurse assess first? The client who is demonstrating

Normal sinus rhythm and complaining of chest pain

624. The nurse observes an adolescent client prepare to administer a prescribed corticosteroid medication using a metered dose inhaler as seen in the picture. What action should the nurse take?

Remind the client to hold his breath after inhaling the medication

176. To evaluate the effectiveness of male client's new prescription for ezetimibe, which action should the clinic nurse implement?

Remind the client to keep his appointments to have his cholesterol level checked.

510. The nurse is making a home visit to a male client who is in the moderate stage of Alzheimer's diseases. The client's wife is exhausted and tells the nurse that the family plans to take turns caring for the client in their home, each keeping him for two weeks at a time. How should the nurse respond?

Suggest enrolling the client in adult daycare instead of rotating among family.

The school nurse is reviewing health risks associated with extracurricular activities of grade-school children. Regular participation in which activity places the child at highest risk for developing external otitis?

Swimming lessons in an indoor pool.

The registered nurse (RN) is planning to provide feedback to the licensed practical nurse(LPN). Which questions asked by the RN help in eliciting the LPN's work quality? Select all that apply. 1 "Are you feeling well today?" Correct2 "How did the patient respond?" 3 "Has the task been completed?" 4 "Are you willing to perform the task?" Correct5 "What changes were observed in the client?"

Providing feedback is the best strategy for shaping the future behavior of the individual. To elicit feedback, a series of open-ended questions should be asked by the registered nurse (RN). This will help collect pertinent information from the individuals delegated a portion of client care, such as client's response and the task to be completed. Asking personal questions about the delegatee does not help in eliciting the work quality of the delegatee. Asking whether the task has been completed is not an open-ended question. Willingness to perform the task directly implies the work interest of the delegate, but not the quality of the delegatee's work.

575. The nurse mixes 250 mg of debutamine in 250 ml of D5W and plans to administer the solution at rate client weighing 110 pounds. The nurse should set the infusion pump to administer how many ml per hour only. If rounding is required, round the nearest whole number.)

45

Drugs for OAB

Anticholinergics: Darifenacin, Oxybutin, Solifenacin, Festerodine, Tolterodine, Trospium

A 2-day postpartum mother who is breastfeeding asks, "Why do I feel this tingling in my breasts after the baby sucks for a few minutes?" Which information should the nurse provide? A.This feeling occurs during feeding with a breast infection. B.This sensation occurs as breast milk moves to the nipple. C.The baby does not have good latch-on. D.The infant is not positioned correctly.

B When the mother's milk comes in, usually 2 to 3 days after delivery, women often report they feel a tingling sensation in their nipples (B) when let-down occurs. (A, C, and D) provide inaccurate information.

A male client with Parkinson's disease has been taking the antiparkinsonian agent amantadine HCl (Symmetrel) for 4 months. He tells the home health nurse, "The medicine doesn't seem to be working anymore." Which information should the nurse provide to this client? A.The dosage probably needs to be increased. B.The medication needs to be changed immediately. C.The medication needs to be taken more frequently. D.The effects of this drug tend to decrease after 3 months.

D The beneficial effects of Symmetrel usually decrease in 3 to 6 months (D). It must be discontinued gradually if necessary (B). Sometimes it is discontinued for a period of time and then resumed at a higher dosage, and although (A) is partially correct, (D) is more correct. Sometimes Symmetrel is given with other antiparkinsonian medications as an adjunct, but (C) would have little effect.

611. While performing a skin inspection for a female adult client, the nurse observes a rash that is well circumscribed, has silvery scales and plaques, and is located on the elbows and knees. These assessment findings are likely to indicate which condition?

Psoriasis

The nurse is assessing an older client and determines that the client's left upper eyelid droops, covering more of the iris than the right eyelid. Which description should the nurse use to document this finding?

Ptosis is the term to describe an eyelid droop that covers a large portion of the iris (A), which may result from oculomotor nerve or eyelid muscle disorder.

The nurse is providing care to a client who is being treated for bacterial cystitis. Before discharge, it is most important for the client to: 1.Understand the need to drink 4 L of water per day, an essential measure to prevent dehydration 2.Be able to identify dietary restrictions and plan menus 3.Achieve relief of symptoms and to maintain kidney function 4.Recognize signs of bleeding, a complication associated with this type of procedure

3.Achieve relief of symptoms and to maintain kidney function

183. The charge nurse is making assignment on a psychiatric unit for a practical nurse (PN) and newly license register nurse (RN). Which client should be assigned to the RN?

A young male with schizophrenia who said voices is telling him to kill his psychiatric.

The nurse recognizes which behavior(s) in a client as warning sign(s) of an impending suicide attempt? (Select all that apply.) A.Reports feelings of sadness B.Mood changes from depressed to happy C.Begins giving away possessions D.Becomes compliant with medication regimen E.Independently joins a support group

BC Feelings of elation and giving away possessions are common characteristics of those who have made a plan to commit suicide (B and C). Feelings of sadness are signs of depression but not impending suicide (A). (D and E) are not typically indicative of impending suicide.

A nurse is administering a histamine H2 antagonist to a client who has extensive burns. The nurse explains to the client that this drug is given prophylactically during the first few weeks after extensive burns. What complication of burns will it prevent? A. Colitis B. Gastritis C. Stress ulcer D. Metabolic acidosis

C. Stress ulcer

A client who is admitted to the ICU with a right chest tube attached to a THORA-SEAL chest drainage unit becomes increasingly anxious and complains of difficulty breathing. The nurse determines the client is tachypneic with absent breath sounds in the client's right lung fields. Which additional finding indicates that the client has developed a tension pneumothorax? A. Continuous bubbling in the water-seal chamber. B. Decreased bright red bloody drainage C. Tachypnea with difficulty breathing D. Tracheal deviation toward the left lung

D

A client who is taking clozapine (Clozaril) calls the nurse in the psychiatric clinic to report the sudden development of a sore throat and a high fever. What should the nurse instruct the client to do? Stay in bed, drink fluids, take a dose of aspirin, and ask the health care provider to reduce the dosage of clozapine. Discontinue the medication immediately and see the health care provider as soon as an appointment becomes available. Continue the medication, drink fluids, take aspirin, and see the health care provider in a few days if the symptoms do not improve. Discontinue the medication and, if the health care provider is unavailable today, go to the emergency department for evaluation.

Discontinue the medication and, if the health care provider is unavailable today, go to the emergency department for evaluation.

During shift report the nurse hears that a patient with GBS has a decreased vital capacity that is less than 2/3 of normal and there is a progressive inability to clear and cough up secretions. The physician has been notified and is coming to evaluate the patient, what intervention is the nurse prepared to implement for this patient

Elective intubation

A client with a pulmonary embolus is intubated and placed on mechanical ventilation. What nursing action is important when suctioning the endotracheal tube? 1 Apply negative pressure while inserting the suction catheter. 2 Hyperoxygenate with 100% oxygen before and after suctioning. 3 Suction two to three times in succession to effectively clear the airway. 4 Use rapid movements of the suction catheter to loosen secretions.

Hyperoxygenate with 100% oxygen before and after suctioning.

A client is admitted with a medical diagnosis of Addisonian crisis. When completing the admission assessment, the nurse expects this client to exhibit which clinical manifestations?

Hypotension, rapid weak pulse, and rapid respiratory rate.

Antipsychotics: black box warning

Increases risk of death in the elderly when used to treat dementia-related psychosis Death is mostly contributed by CV (heart failure, sudden death) and infection (pneumonia) factors

603. A young adult male is admitted to the emergency department with diabetic ketoacidosis (DKA). His pH is 7.25, HCO3 is 12 mEq/L or 12 mmol/L (SI), and blood glucose is 310 mg/dl or 17.2 mmol/L (SI). Which action should the nurse implement?

Infuse sodium chloride 0.9% (normal saline)

The patient is a woman in her early 30s who has recently been diagnosed with multiple sclerosis. The nurse has taught the patients husband about the course of the illness and what problems might occur in the future, which statement by the husband indicates the need for additional teaching

Later on she could have intermittent short term memory loss

425. The nurse is interviewing a client with schizophrenia. Which client behavior requires immediate intervention?

Muscle spasms of the back and neck

A female client tells the nurse that her home pregnancy test is positive and her last menstrual period (LMP) was February 14. The client wants to know the expected date of birth (EDB). How should the nurse respond?

November 21. Using Nägele's rule to calculate EDB, subtract 3 months and add 7 days to the first day of the last normal menstrual period.

Two hours after the vaginal delivery of a 7-pound, 3-ounce infant, a client's fundus is 3 cm above the umbilicus, boggy, and located to the right of midline. Which action should the nurse take first?

Palpate above the symphysis for the bladder. Two hours after giving birth, the uterus should be firm, in the midline, and below the umbilicus. If the fundus is high, dextroverted and boggy, urinary retention is likely distending the bladder, so palpating for a full bladder above the symphysis (B) should be implemented first.

315. When conducting diet teaching for a client who is on a postoperative soft diet, which foods should eat? (Select all that apply)

Pasta, noodles, rice. Egg, tofu, ground meat. Mashed, potatoes, pudding, milk.

214. Following an esophagogastroduodenoscopy (EGD) a male client is drowsy and difficult to arouse, and his respiration are slow and shallow. Which action should the nurse implement? Select all that apply.

Prepare medication reversal agent Check oxygen saturation level Apply oxygen via nasal cannula

618. The nurse is preparing to discharge an older adult female client who is at risk for hy...nurse include with this client's discharge teaching?

Report any muscle twitching or seizures Take vitamin D with calcium daily Low fat yogurt is a good source of calcium Keep a diet record to monitor calcium intake

609. A male client recently released from a correctional facility arrives at the clinic with a cough, fever, and chills. His history reveals active tuberculosis (TB) 10 years ago. What action should the nurse implement? (Select all that apply)

Schedule the client for the chest radiograph Obtain sputum for acid fast bacillus (AFB) testing Place a mask on the client until he is moved to isolation.

Which intervention by a new nurse who is caring for a patient who has just had an implantable cardioverter-defibrillator (ICD) inserted indicates a need for more education about care of patients with ICDs?

The nurse assists the patient to do active range of motion exercises for all extremities.

When preparing to defibrillate a patient. In which order will the nurse perform the following steps? (Put a comma and a space between each answer choice [A, B, C, D, E].)

Turn the defibrillator on. Select the appropriate energy level. Place the paddles on the patient's chest. Check the location of other staff and call out "all clear." Deliver the electrical charge.

s/s of serotonin syndrome

altered mental status (agitation, confusion, disorientation, anxiety, hallucinations, poor concentration), incoordination, myoclonus, hyper-reflexia, excessive sweating, tremor, fever

Benign prostatic hyperplasia

restricted urine flow due to enlarged prostate

The nurse teaches a client with diverticulosis to reduce intake of foods containing nuts and seeds. The rationale for this instruction is the prevention of which problem? A. iNFLAMMATION b. hEMORRHOIDS c. iNTERNAL ARICOSITIES D. Allergic rxn

A

The nurse is caring for a pregnant client with hypertension. Which client care tasks are most suitable to be delegated to the patient care associate (PCA)? Correct1 Recording the vital signs 2 Monitoring the blood pressure 3 Administering intravenous fluids 4 Administering antihypertensive medications

A patient care associate (PCA) is an unlicensed assistive personnel whose scope of practice is very limited. A PCA can be delegated the task of recording the vital signs as communicated by the delegator even if the condition of the client is acute or unstable. In stable clients, the PCA may be instructed to monitor the blood pressure, but in this acute condition, only the registered nurse (RN) should monitor the blood pressure. Administration of intravenous fluids or medications is out of scope of practice of the PCA. A PCA is not suitable to be delegated the task of administering any medication to a client.

A nurse performs an initial admission assessment of a 56-year-old client. Which factor(s) would indicate that the client is at risk for metabolic syndrome? (Select all that apply.) A.Abdominal obesity B.Sedentary lifestyle C.History of hypoglycemia D.Hispanic or Asian ethnicity E.Increased triglycerides

A,B,D,E Rationale: Metabolic syndrome is a name for a group of risk factors that increase the risk for coronary artery disease, type 2 diabetes, and stroke (A, B, D, and E). Hypoglycemia is not a risk factor for metabolic syndrome (C).

498. A female client with chronic urinary retention explains double voiding technique to the nurse by stating she voids partially, hold the remaining urine in her bladder for three minutes, then voids again to empty her bladder fully. How should the nurse respond?

Advise the client to empty her bladder fully when she first voids

Which work is automatically increased for the delegator when there is a decrease in direct client care? 1 Leadership Correct2 Supervision 3 Delegation 4 Assignment

After delegating tasks to other members of the health care team, the delegator's care towards the client in a direct way decreases, and the supervisory work of the delegator increases. Leadership work does not necessarily increase when there is a decrease in direct client care. Delegation and assignment of work does not increase, because the work has already been delegated to another health care team member.

506. The nurse requests a meals tray for a client follows Mormon beliefs and who is on clear liquid diet following abdominal surgery. Which meal item should the nurse request for this client? (Select all that apply)

Apple juice Chicken broth.

The nurse is interviewing a female client whose spouse is present. During the interview, the spouse answers most of the questions for the client. Which action is best for the nurse to implement?

Ask the spouse to step out for a few minutes.

Following a thymectomy, what postoperation care does the nurse provide for a patient with MG

Assist the patient to turn cough and deep breathe every 2 hours, assess for chest pain, dyspnea hypotension, assess for diminished or absent breath sounds

Which component of delegation is defined as the ability to perform duties in a specific role? Correct1 Authority 2 Supervision 3 Responsibility 4 Accountability

Authority is the ability to perform duties in a specific role. Supervision is the provision of guidance and oversight of a delegated task. Responsibility refers to reliability, dependability, and obligation to accomplish work. Accountability involves determining whether the actions are appropriate and providing a detailed explanation of what has occurred.

While caring for a client with asthma, the delegator assigns the client to a registered nurse (RN) and to a licensed practical nurse (LPN). Which component of delegation is transferable to the RN? Select all that apply. Correct1 Authority Incorrect2 Supervision Correct3 Responsibility Correct4 Accountability 5 Communication

Authority, a component of delegation, is transferred to the registered nurse (RN) by the delegator. Responsibility is the component of delegation that is transferable to the RN. Accountability is also a component of delegation that is transferable to the RN. Supervision and communication are rights of delegation.

159. An adult male reports the last time he received penicillin he developed a severe maculopapular rash all over his chest. What information should the nurse provide the client about future antibiotic prescriptions?

Be alert for possible cross-sensitivity to cephalosporin agents.

404. A nurse who is working in the emergency department triage area is presented with four clients at the same time. The client presented with which symptoms requires the most immediate intervention by the nurse?

Chest discomfort one hour after consuming a large, spicy meal

Which health care professional is accountable for establishing systems to assess and communicate competency requirements related to delegation? Incorrect1 Registered nurses Correct2 Chief nursing officers 3 Licensed practical nurses 4 Unlicensed nursing personnel

Chief nursing officers are expected to establish the systems to assess and communicate the competencies required for delegation. Registered nurses are accountable for client care. The licensed practical nurse and unlicensed nursing personnel act as delegatees for various tasks.

287. A preeclamptic client who delivered 24h ago remains in the labor and delivery recovery room. She continues to receive magnesium sulfate at 2 grams per hour. Her total input is limited to 125 ml per hour, and her urinary output for the last hour was 850 ml. What intervention should the nurse implement?

Continue with the plan of care for this client

604. The nurse is assessing the thorax and lungs of a client who is having respiratory difficulty. Which finding is most indicative of respiratory distress?

Contractions of the sternocleidomastoid muscle

484. The nurse is assessing the emotional status of a client with Parkinson's disease. Which client finding is most helpful in planning goals to meet the client's emotional needs?

Cries frequently during the interview

An older adult male is admitted with complications related to COPD. He reports progressive dyspnea that worsens on exertion and his weakness has increased over the past month. The nurse notes that he has dependent edema in both lower legs. Based on these assessment findings, which dietary instruction should the nurse provide? A. Limit the intake of high calorie foods B. Eat meals at the same time daily C. Maintain low protein diet D. Restrict daily fluid intake

D

An older man with a hx of falls at home tells the clinic nurse that his son, who was incarcerated last year for assault and battery, has become abusive since his release from prison. Which intervention is most important for the nurse to implement? A. Tell the client to call Adult Protective Services if his son's abuse continues. B. Refer the client to a program for victims of domestic violence C. Verify the client's report by determining if there is physical evidence of abuse D. Assist the client in developing an emergency safety plan

D

370. A mother runs into the emergency department with s toddler in her arms and tells the nurse that her child got into some cleaning products. The child smells of chemicals on hands, face, and on the front of the child's clothes. After ensuring the airway is patent, what action should the nurse implement first?

Determine type of chemical exposure.

Drugs for bladder dysfunction in MS

Detrusor hyperreflexia (overactiv bladder): tolterodine, oxybutynin, darifenacin, solifenacin Flaccid bladder (urinary retention): bethanechol (urecholine)

470. The nurse reviews the signs of hypoglycemia with the parents of a child with Type I diabetes mellitus. The parents correctly understand signs of hypoglycemia if they include which symptoms?

Diaphoresis

A registered nurse is providing feedback to a delegatee after monitoring the work. Which feedback is the best for shaping the future behavior of the delegatee? 1 "Nice job." Incorrect2 "You could have done it better." 3 "That was better than what I expected." Correct4 "You performed that procedure safely and professionally."

Giving feedback that the performance was safe and professional clearly describes the work performance and helps in shaping the future behavior of the delegatee. Giving feedback that the work was nice is vague and not specific to a behavior. Giving feedback that the work was better than expected is insulting and is not constructive feedback. Giving feedback that the work done was better than expected is vague and does not clearly explain the work performance.

A male client, who has been smoking 1 pack of cigarettes every day for the last 20 years, is scheduled for surgery and will be unable to smoke after surgery. During preoperative teaching, the client asks the nurse what symptoms he may expect after surgery from nicotine withdrawal. Which response is best for the nurse to provide?

Headache and hyperirritability are common.

503. An adult man reports that he recently experienced an episode of chest pressure and breathlessness when he was jogging in the neighborhood. He expresses concern because both of his deceased parents had heart disease and his father was a diabetic. He lives with his male partner, is a vegetarian, and takes atenolol which maintain his blood pressure at 138/74. Which risk factors should the nurse explore further with the client? Select all that apply

History of hypertension. Family heath history.

COMT inhibitors

Inhibit metabolism of Ldopa in the periphery --> increases Ldopa half life in the BBB Entacapone Tolcapone

A client with a suspected dysrhythmia is to wear a Holter monitor for 24 hours at home. What should the nurse instruct the client to do? 1 Keep a record of the day's activities 2 Avoid going through laser-activated doors 3 Record the pulse and blood pressure every four hours 4 Delay taking prescribed medications until the monitor is removed

Keep a record of the days activities

401. A young adult female presents at the emergency center with acute lower abdominal pain. Which assessment finding is most important for the nurse to report to the healthcare provider?

Last menstrual period was 7 weeks ago

373. While changing a client's chest tube dressing, the nurse notes a crackling sensation when gentle pressure is applied to the skin at the insertion site. What is the best action for the nurse to take?

Measure the area of swelling and crackling.

339. While assisting a client who recently had a hip replacement into a bed pan, the nurse notices that there is a small amount of bloody drainage on the surgical dressing, the client's skin is warm to the touch, and there is a strong odor from the urine. Which action should the nurse take?

Measure the client's oral temperature

Which nursing action can the registered nurse (RN) delegate to experienced unlicensed assistive personnel (UAP) working as a telemetry technician on the cardiac care unit?

Observe cardiac rhythms for multiple patients who have telemetry monitoring.

368. The nurse is teaching a male adolescent recently diagnosed with type 1diabetes mellitus (DM) about self-injecting insulin. Which approach is best for the nurse to use to evaluate do you effectiveness of the teaching?

Observe him as he demonstrates self-injection technique in another diabetic adolescent

398. A native-American male client diagnosed with pneumonia, states that in addition to his prescribed medical treatment of IV antibiotics he wishes to have a spiritual cleaning performed. Which outcome statement indicates that the best plan of care was followed?

Participated actively in all treatments regimens

158. In caring for the body of a client who just died, which tasks can be delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)

Place personal religious artifacts on the body. Attach identifying name tags to the body. Follow cultural beliefs in preparing the body.

What nursing delivery of care provides the nurse to plan and direct care of a group of clients over a 24-hour period?

Primary nursing (B) is a model of delivery of care where a nurse is accountable for planning care for clients around the clock. Functional nursing (D) is a care delivery model that provides client care by assignment of functions or tasks. Team nursing (A) is a care delivery model where assignments to a group of clients are provided by a mixed-staff team. Case management (C) is the delivery of care that uses a collaborative process of assessment, planning, facilitation, and advocacy for options and services to meet an individual's health needs and promote quality cost-effective outcomes.

In caring for a pregnant woman with gestational diabetes, the nurse should be alert to which finding? A.A consistent fasting blood sugar level between 80 and 85 mg/dL B.A 2-hour postprandial level greater than 120 mg/dL C.Client reports taking a 30-minute walk after dinner D.Client describes eating pattern of four to six meals daily

Rationale: Two-hour postprandial levels greater than 120 mg/dL may indicate the need for the initiation of insulin to maintain adequate blood glucose levels; consequently, a value greater than 120 mg/dL (B) should be assessed further. Fasting blood sugars between 80 and 85 mg/dL are normal (A). (C and D) are healthy behaviors for a women with gestational diabetes.

The registered nurse (RN) is teaching a newly hired nurse about delegating tasks to the healthcare team. When asked what the rights of delegation are, which right listed by the hired nurse indicates the need for further teaching? Select all that apply. 1 Right task Incorrect2 Right direction 3 Right person Correct4 Right drug name 5 Right circumstance

The 5 rights of delegation are right task, right circumstance, right person, right directions and communication, right supervision and evaluation.

A client underwent angioplasty and is hospitalized for several days for observation. Which task can be delegated by the registered nurse (RN) to a licensed practical nurse (LPN)? Incorrect1 Assisting 2 Assessing 3 Evaluating Correct4 Monitoring

The LPN is eligible to monitor the client who underwent angioplasty. Any change in the condition of the client should be reported to the RN in an emergency. Assistance can be given by unlicensed nursing professional (UPN). Assessment of the client's reports is done by the RN. The LPN and UNP are not eligible for assessing reports. Evaluation of the client's reports can be done only by the physician.

A healthcare team is caring for a 68-year-old client with diabetes insipidus. Which task is most suitable to be delegated to licensed practical nurse (LPN) to provide effective client care? Select all that apply. Incorrect1 Emptying the urinary drainage bag Correct2 Monitoring urine output 3 Feeding the client with food 4 Administration of intravenous fluids Correct5 Administering oral rehydration medication

The LPN scope of practice includes monitoring urine output. Administration of any type of oral medication can also be performed by the LPN. Activities related to a client's hygiene such as emptying the drainage is usually performed by unlicensed assistive personnel (UAP). Feeding the client is usually performed by a UAP. Administration of intravenous fluids is the responsibility of the registered nurse.

42. A client who received multiple antihypertensive medications experiences syncope due to a drop in blood pressure to 70/40. What is the rationale for the nurse's decision to hold the client's scheduled antihypertensive medication?

The additive effect of multiple medications has caused the blood pressure to drop too low

Who functions as a liaison between team leaders and other healthcare providers? Correct1 Charge nurse 2 Registered nurse 3 Nursing manager 4 Chief nursing officer

The charge nurse functions as a liaison between team leaders and other healthcare providers. Registered nurses function as accountable and responsible people for delegated tasks. Nursing managers are responsible for more than one unit and have other managerial responsibilities. Chief nursing officers are accountable for establishing systems to assess, monitor, verify, and communicate competency requirements related to delegation.

The registered nurse delegates a task to the unlicensed assistive personnel (UAP). After the UAP starts the task, the registered nurse (RN) asks for feedback related to the task. Which right of delegation is the RN following? 1 Task Correct2 Supervision 3 Circumstance Incorrect4 Communication

The delegation right of supervision refers to obtaining feedback, monitoring, and evaluating the delegatee appropriately. Right task refers to the delegation of an appropriate task based on institutional policies and procedures. Right circumstance refers to evaluation of the working environment and ensuring adequate supervision of delegatees. To ensure right communication, the RN should communicate properly and accurately to the delegatee and provide clear and concise directions for the task.

Which condition may increase the potential for nursing malpractice? 1 When the client care is satisfactorily provided 2 When the delegatee is unable to perform the specified task 3 When the nursing assistant adapts to the changing situation Correct4 When the delegation task is not within acceptable standards

The delegator is personally responsible for prudent action. A potential for nursing malpractice emerges when the delegation task is not performed within acceptable standards. Satisfactory client care results from successful delegation. The expected outcome of a specified task may be affected when the delegatee is unable to perform the specified task. The nursing assistant usually adapts to the changing situation; if not, a gap in the delivery of client care will be generated.

The nurse is assisting the registered nurse with delegation decisions regarding management of a client with shortness of breath. Which action by the nurse indicates a need for correction? 1 Asking questions about the client's respiratory rate 2 Asking the client to perform breathing exercises regularly 3 Administering oxygen to the client with shortness of breath Correct4 Providing constructive feedback about client care management

The nurse may not provide constructive feedback about the client care management during delegation decisions. The nurse may, however, provide constructive feedback to the delegatee to maximize the efficiency of the client care.

What is the status of the primary healthcare provider as a member of the healthcare team that is in the span of control of a registered nurse (RN)? Incorrect1 Devoid of legal authority 2 Devoid of delegation authority Correct3 Answerable to the nurse manager 4 Answerable to the registered nurse

The primary healthcare provider as a team member is designated to be answerable to a delegator such as the nurse manager. The unit secretary is devoid of legal authority or formal preparation. The primary healthcare provider may delegate tasks to the members of the healthcare team who have dependent status, such as unlicensed assistive personnel (UAP), licensed practical nurses (LPN), or licensed vocational nurses (LVN). Generally, those with dependent status are answerable to the RN.

333. A client with eczema is experiencing severe pruritus. Which PRN prescriptions should the nurse administer? (Select all that apply)

Topical corticosteroid. Oral antihistamine

Prior to a cardiac catheterization, which activity should the nurse have the client practice?

Valsalva's maneuver and coughing.

A patient's QRS complex is becoming increasingly wider. What is occurring within the heart muscle that is reflected on this tracing?

Ventricular depolarization is prolonged.

615. The nurse weighs a 6-month-old infant during a well-baby check-up and determines that the baby's weight has tripled compared to the birth weight of 7 pounds 8 ounces. The mother asks if the baby is gaining enough weight. What response should the nurse offer?

What food does your baby usually eat in a normal day?

The registered nurse (RN) who delegates work to a newly hired licensed practical nurse (LPN) says, "Please tell me how you will go about performing this procedure, and I will share my expectations with you." Which behavior strategy of Hersey's model is being applied? 1 Telling 2 Selling 3 Delegating Correct4 Participating

When the LPN has the willingness and ability to perform a task, but the relationship is new, the RN will share his or her expectations and conditions with the LPN. This is a clinical example of participating. Participating is encouraging the delegatee to perform the task and taking an active part in problem solving, which may occur during the execution of a given task. If the LPN has limited knowledge and ability to perform a task, the RN will provide more guidance, which is an example of telling what is the task to be done and how it is to be performed. If the LPN is delegated a new task, it requires explanation from the RN. This is termed as selling in Hersey's model, which is the process of explaining and persuading; this happens if a situation involves a new task and the relationship is ongoing. If the LPN has an established relationship and experience, he or she requires a little guidance and this is called delegation.

The nurse obtains the pulse rate of 89 beats/minute for an infant before administering digoxin (Lanoxin). Which action should the nurse take?

Withhold the medication and contact the healthcare provider. Bradycardia is an early sign of digoxin toxicity, so if the infant's pulse rate is less than 100 beats/minute, digoxin should be withheld and the healthcare provider should be notified (D). Assessing the respiratory rate (A) is not indicated before administering Lanoxin. (B and C) place the infant at further risk for digoxin toxicity.

Symptoms of cholinergic crisis (DUMB BELS)

diarrea urination miosis bronchorrea bradycardia emesis lacrimation salivation/sweating

negative symptoms

lack of characteristics that should be present: reduced speech, even when encouraged to interact Lack of emotional and facial expression (affective flattening) Diminished ability to begin and sustain activities (avolition) decreased ability to find pleasure in everyday (anhedonia) Social withdrawal (asociality)

Mitoxantrone (immunosuppressant) adverse effects

myelosuppression, cardiotoxicity, fetal harm

421. An adult male is brought to the emergency department by ambulance following a motorcycle accident. He was not wearing a helmet and presents with periorbital bruising and bloody drainage from both ears. Which assessment finding warrants immediate intervention by the nurse?

nausea and projectile vomit

Myasthenia Gravis

neuromuscular disorder (PNS) characterized by fluctuating muscle weakness and rapid fatique

Drugs for BPH (S alpha reductase inhibitors) dutasteride finasteride

reduce dihydrotestosterone (DHT) production delaying BPH progression (takes months to develop) Adverse Effects include decreased ejaculation, bolume and libido teratogenic to male fetus

FGAs therapeutic uses

schizophrenia, bipolar disorder, Tourette's syndrome, prevention of emesis

SSRIs adverse effects

sexual dysfunction, insomnia/agitation, GI toxicity, risk for upper GI bleed, nausea, weight gain, ortho hypoTN, serotonin syndrome, withdrawal syndrome (sysphoria, dizziness, GI distress, fatigue, chills, myalgia), suicide risk

Symptoms of Parkinson's Disease

slow slurred monotonous speech, blank face, rigidity and tremor of extremities and head forward tilt to posture, reduced arm swinging, short shuffling gait

adverse effects: festerodine, toterodine

somnolence, vertigo, dizziness, dry mouth tachycardia mydriasis, blurred vision, dry eyes, dry mouth, urinary retention, constipation

A client with a spinal cord injury at the level of C5 has a weakened respiratory effort and ineffective cough and is using accessory neck muscles in breathing. The nurse carefully monitors the client and suspects the presence of which complication? 1. Altered breathing pattern 2. Increased likelihood of injury 3. Ineffective oxygen consumption 4. Increased susceptibility to aspiration

1 Altered breathing pattern indicates that the respiratory rate, depth, rhythm, timing, or chest wall movements are insufficient for optimal ventilation of the client. This is a risk for clients with spinal cord injury in the lower cervical area. Ineffective oxygen consumption occurs when oxygenation or carbon dioxide elimination is altered at the alveolar-capillary membrane. Increased susceptibility to aspiration and increased likelihood of injury are unrelated to the focus of the question.

A client with postradiation enteritis is to continue receiving total parenteral nutrition (TPN) at home after discharge. What information should the nurse include in the client's teaching plan? A. Showing how to mix the nutritional solutions B. Demonstrating how to test capillary glucose levels C. Identifying the types of infusion pumps that can be used D. Checking for catheter placement by palpating the insertion site

B. Demonstrating how to test capillary glucose levels

Which assessment finding for a client with peritoneal dialysis requires immediate intervention by the nurse? A.The color of the dialysate outflow is opaque yellow. B.The dialysate outflow is greater than the inflow. C.The inflow dialysate feels warm to the touch. D.The inflow dialysate contains potassium chloride.

A Opaque or cloudy dialysate outflow is an early sign of peritonitis. The nurse should obtain a specimen for culture, assess the client, and notify the health care provider (A). (B and C) are desired. (D) is commonly done to prevent hypokalemia.

The nurse is planning care for a client who is having abdominal surgery. To achieve desired postoperative outcomes, the nurse includes interventions that promote progressive mobilization, such as turn, cough, deep breathe, and early ambulation. Which additional intervention should the nurse include?

Administer analgesics prior to encouraging progressive activities and ambulation.

75. A client was admitted to the cardiac observation unit 2 hours ago complaining of chest pain. On admission, the client's EKG showed bradycardia, ST depression, but no ventricular ectopy. The client suddenly reports a sharp increase in pain, telling the nurse, "I feel like an elephant just stepped on my chest" The EKG now shows Q waves and ST segment elevations in the anterior leads. What intervention should the nurse perform?

Administer prescribed morphine sulfate IV and provide oxygen at 2 L/min per nasal cannula.

A healthcare team is caring for a client with dental pain. Which task is most suitable to be delegated to unlicensed assistive personnel (UAP) to provide effective client care? 1 Administering analgesics 2 Administering intravenous antibiotics 3 Administering nerve block anesthesia Correct4 Administering mouth wash for oral hygiene

The UAP scope of practice includes administering mouth wash to the client. Instructing the UAP to administer medications such as antibiotics and anesthetics is inappropriate because the UAP is not eligible to do so and may not have the knowledge to administer medications. Administering nerve block anesthesia should be performed by the anesthesiologist.

Neostigmine Drug-drug interactions

muscarinic antagonists: atropine --> antidote for neostigmine OD; reverses excessive muscarinic stimulation caused by neostigmine neuromuscular blockade (pancuronium) --> reverses muscle relaxation induced by pancuronium

The nurse is preparing to perform suctioning for a client with a tracheostomy tube and gathers the supplies needed for the procedure. What is the initial nursing action? 1. Hyperoxygenate the client. 2. Set the suction pressure range at 150 mm Hg. 3. Place the catheter into the tracheostomy tube. 4. Apply suction on the catheter, and insert it into the tracheostomy tube.

1 The nurse should hyperoxygenate the client both before and after suctioning. This would be the initial nursing action. The safe suction range for an adult client is 80 to 120 mm Hg. When the nurse advances the catheter into the tracheostomy tube, suction is not applied, because applying suction at that time will cause mucosal trauma and aspiration of the client's oxygen.

A nurse who is participating in a client care conference with other members of the health care team is discussing the condition of a client with acute respiratory distress syndrome (ARDS). The health care provider states that as a result of fluid in the alveoli, surfactant production is falling. The nurse understands that which is the natural consequence of insufficient surfactant? 1. Atelectasis and viral infection 2. Bronchoconstriction and stridor 3. Collapse of alveoli and decreased compliance 4. Decreased ciliary action and retained secretions

3 Surfactant is a phospholipid produced in the lungs that decreases surface tension in the lungs. This prevents the alveoli from sticking together and collapsing at the end of exhalation. When alveoli collapse, the lungs become "stiff" because of decreased compliance. Common causes of decreased surfactant production are ARDS and atelectasis. Options 1, 2, and 4 are incorrect.

295. A new member joins the nursing team spreads books on the table, puts items on two chairs, and sits on a third chair. The members of the group are forced to move closer and remove their possessions from the table what action should the nurse leader take?

Ask the new person to move belonging to accommodate others

Drug-drug interaction of Levodopa

Levodopa + MAOI = HTN crisis

395. An adult client with schizophrenia begin treatment three days ago with the Antipsychotic risperidone. The client also received prescription for trazodone as needed for sleep and clonazepam as needed for severe anxiety. When the client reports difficulty with swallowing, what action should the nurse take?

Obtain a prescription for an anticholinergic medication

The nurse is monitoring a patient with GBS undergoing plasmapheresis, the patient reports dizziness and has a heart rate that has dropped to 48 beats per minute, the nurse identifies the primary care provider, which order does the nurse anticipate

atropine IV push

A nurse is interviewing a client in the mental health clinic. Which statement by the client indicates an irreversible adverse response to long-term therapy with an antipsychotic medication? "My mouth is always dry." "I can't seem to sleep at night." "I don't have much of an appetite." "My tongue seems to move by itself."

"My tongue seems to move by itself."

A client is hospitalized with a diagnosis of viral hepatitis. To detect any difficulty in coping with this disease, the nurse should ask which question? 1. "Do you have a fever?" 2. "Are you losing weight?" 3. "Have you enjoyed having visitors?" 4. "Do you rest sometime during the day?"

3 Clients with hepatitis may experience anxiety because of an anticipated change in lifestyle or fear of prognosis. They also may have a disturbance in body image related to the stigma of having a communicable disease or a change in appearance because of jaundice. The correct option relates to the client's possible feelings of not wanting to be seen by others because of altered appearance. Remember that the client with hepatitis is jaundiced.

A client had a seizure 1 hour ago. Family members were present during the episode and reported that the client's jaw was moving as though grinding food. In helping to determine the origin of this seizure, what should the nurse include in the client's assessment? 1. Presence of diaphoresis 2. Loss of consciousness 3. History of prior trauma 4. Rotating eye movements

3 Seizures that originate with specific motor phenomena are considered focal and are indicative of a focal structural lesion in the brain, often caused by trauma, infection, or drug consumption. Options 1, 2, and 4 address signs, rather than an origin of the seizure.

The charge nurse working in the surgical department is making shift assignments. The shift personnel include an RN with 12 years of nursing experience, an RN with 2 years of nursing experience, and an RN with 3 months of nursing experience. Which client should the charge nurse assign to the RN with 3 months of experience? A.A client who is 2 days postoperative with a right total knee replacement B.A client who is scheduled for a sigmoid colostomy surgery today C.A client who has a surgical abdominal wound with dehiscence D.A client who is 1 day postoperative following a right-sided mastectomy

A (A) is the least critical client and should be assigned to the RN with the least experience. A client with a knee replacement is probably ambulating and able to perform self-care, and a physical therapist is likely to be assisting with the client's care. (B) will require a high level of nursing care when returned from surgery. (C) means that there is a separation or rupture of the wound, which requires an experienced nurse to provide care. (D) requires extensive teaching and should be assigned to a more experienced nurse.

A 20-year-old has a mandatory electrocardiogram (ECG) before participating on a college soccer team and is found to have sinus bradycardia, rate 52. Blood pressure (BP) is 114/54, and the student denies any health problems. What action by the nurse is most appropriate?

Allow the student to participate on the soccer team

Which data obtained during a respiratory assessment for a 78-year-old client is most important to report to the primary health care provider? A.Auscultation of vesicular breath sounds B.Pulse oximetry reading of 89% C.Arterial Pao2 of 86% D.Resonance on percussion of the lungs

B Rationale: An oxygen saturation lower than 90% indicates hypoxia (B). (A, C, and D) are all normal findings.

The nurse is planning the care for a client who is admitted with syndrome of inappropriate antidiuretic hormone secretion (SIADH). Which intervention(s) should the nurse include in this client's plan of care? (Select all that apply.) A.Salt-free diet B.Quiet environment C.Deep tendon reflex assessments D.Neurologic checks E.Daily weights

B,C,D,E Rationale: Correct responses are (B, C, D, and E). SAIDH results in water retention and dilutional hyponatremia, which causes neurologic changes when serum sodium levels are less than 115 mEq/L. The nurse should maintain a quiet environment (B) to prevent overstimulation and assess deep tendon reflexes (C) and perform neurologic checks (D) to monitor for neurologic deterioration. Daily weights (E) should be monitored to assess for fluid overload. (A) would contribute to dilutional hyponatremia.

The nursing team is involved in effective pain management. Which task would be performed by a registered nurse (RN) in this case? 1 Performing hygiene tasks 2 Taking and reporting vital signs 3 Administering oral pain medications Correct4 Developing a treatment plan for client's pain

The role of the RN is to develop a treatment plan for the client's pain. All hygienic tasks are performed by unlicensed nursing personnel. Administering oral pain medications is done by the licensed practical nurse. Taking and reporting vital signs is done by the licensed practical nurse.

A nurse is caring for a client with Guillain-Barré syndrome. The nurse should prepare the client for what essential care related to rehabilitation? 1 Physical therapy 2 Speech exercises 3 Fitting with a vertebral brace 4 Follow-up on cataract progression

1. Physical Therapy Rehabilitation needs for a client with Guillain-Barré syndrome focus on physical therapy and exercise for the lower extremities because of muscle weakness and discomfort. A client with Guillain-Barré syndrome does not need speech or swallowing exercises. A client with Guillain-Barré syndrome does not need vertebral support. Problems with cataracts are not associated with Guillain-Barré syndrome

The nurse is developing a teaching plan for a client with viral hepatitis. The nurse should plan to include which information in the teaching session? 1. The diet should be low in calories. 2. Meals should be large to conserve energy. 3. Activity should be limited to prevent fatigue. 4. Alcohol intake should be limited to 2 ounces per day.

3 Rest is necessary for the client with hepatitis, and the client with viral hepatitis should limit activity to avoid fatigue. The diet should be optimal in calories, proteins, and carbohydrates. The client should take in several small meals per d

Staff on a cardiac unit consists of an RN, two practical nurses (PNs), and one UAP. Team 1's assignment includes two clients who are both 1 day postangioplasty and two clients with unstable angina. Team 2's assignment includes all stable clients, but two clients are bedridden and incontinent. Which staffing plan represents the best use of available staff? A.Team 1: RN team leader, PN; team 2, PN team leader, UAP B.Team 1, RN team leader, UAP; team 2, PN team leader, PN C.Team 1, PN team leader, PN; team 2, RN team leader, UAP D.Team 1, PN team leader, UAP; team 2, RN team leader, PN

A Team 1 includes high-risk clients who require a higher level of assessment and decision making, which should be provided by an RN and PN (A). Team 2 has stable clients at lower risk than those on team 1. Although two clients on team 2 require frequent care, the care is routine and predictable in nature and can be managed by the PN and UAP. (B, C, and D) do not use the expertise of the nursing staff for the high-risk clients.

Ten minutes after the initiation of a blood transfusion, a client reports lumbar pain. What is the next nursing action? A. Stop the transfusion. B. Obtain the vital signs. C. Assess the pain further. D. Increase the flow of normal saline.

A. Stop the transfusion.

471. One day following a total knee replacement, a male client tells the nurse that he is unable to transfer because it is too painful. What action should the nurse implement?

Encourage use of analgesics before position change

Which actions in the delegation process represent accountability? Select all that apply. Correct1 Monitoring client care Correct2 Seeking the outcome report 3 Assessing the ability of the delegatee 4 Providing honest feedback to the delegatee Incorrect5 Assisting registered nurses with delegation decisions

Monitoring client care and seeking the outcome report represents accountability of the task in case of conflicts. Assessing the ability of the delegatee and educating about the task indicates responsibility. Providing open and honest feedback to the delegatee improves work performance and client care outcomes. The nurse can assist other registered nurses with delegation decisions regarding safety issues, urgency to intervene, or potential negative client outcomes.

122. Suicide precautions are initiated for a child admitted to the mental health unit following an intentional narcotic overdose. After a visitor leaves, the nurse finds a package of cigarettes in the client's room. Which intervention is most important for the nurse to implement?

Remove cigarettes for the client's room

A client with a spinal cord injury becomes angry and belligerent whenever the nurse tries to administer care. The nurse should perform which action? 1. Ask the family to deliver the care. 2. Leave the client alone until ready to participate. 3. Advise the client that rehabilitation progresses more quickly with cooperation. 4. Acknowledge the client's anger and continue to encourage participation in care.

4 Adjusting to paralysis is physically and psychosocially difficult for the client and family. The nurse recognizes that the client goes through the grieving process in adjusting to the loss and may move back and forth among the stages of grief. The nurse acknowledges the client's feelings while continuing to meet the client's physical needs and encouraging independence. The family also is in crisis and needs the nurse's support and should not be relied on to provide care. The nurse cannot simply neglect the client until the client is ready to participate. Option 3 represents a factual but noncaring approach to the client and is not therapeutic.

An adult female who presents at the mental clinic trembling and crying becomes distressed when the nurse attempts to conduct an assessment. She complains about the number of questions that are being asked, which she is convinced are going to cause her to have a heart attack. What action should the nurse take? A.Take the client's blood pressure and reassure her that questioning will not cause a heart attack. B.Explain that treatment is based on information obtained in the assessment. C.Encourage the client to relax so that she can provide the information requested. D.Empower the client to share her story of why she is here at the mental health clinic.

D Rationale: The client is exhibiting signs of moderate anxiety, which include voice tremors, shakiness, somatic complaints, and selective inattention. (D) is the best method for addressing this client's level of anxiety by creating a shared understanding of the client's concerns. Although assessment of her blood pressure (A) might be a worthwhile intervention, reassuring her that questioning will not cause a heart attack (A) is argumentative. (B) suggests that treatment cannot be provided without the information, which is manipulative. Asking the client to relax (C) is likely to increase her anxiety.

Which statements about MG are accurate

It is an acquired autoimmune disease, it occurs equally in men and women, there is a small familial incidence, it is characterized by remission and exacerbations

550. During a 26-week gestation prenatal exam, a client reports occasional dizziness...What intervention is best for the nurse to recommend to this client?

Lie on the left or right side when sleeping or resting

11. After placing a stethoscope as seen in the picture, the nurse auscultates S1 and S2 heart sounds. To determine if an S3 heart sound is present, what action should the nurse take first?

Listen with the bell at the same location

MAO B

Inactivates DA Inhibitors: anti-Parkinson (giline) Selegiline Rasagiline

A client with terminal cancer is to receive 4 mg of hydromorphone intravenously (IV) every 4 hours as needed for severe breakthrough pain. It is supplied at 10 mg/mL. When the client complains of severe pain, how much solution of hydromorphone should the nurse administer? Record your answer using one decimal place and leading zero if applicable. ___ mL

0.4

A nurse is planning care for a client who is scheduled for a tracheostomy procedure. What equipment should the nurse plan to have at the bedside when the client returns from surgery? 1. Obturator 2. Oral airway 3. Epinephrine (Adrenalin) 4. Tracheostomy set with the next larger size

1 A replacement tube of the same size and an obturator are kept at the bedside at all times in case the tracheostomy tube becomes dislodged. Additionally, a curved hemostat that could be used to hold the trachea open if dislodgement occurs should also be kept at the bedside. An oral airway and epinephrine would not be needed.

The nurse is caring for a client with acute pancreatitis and is monitoring the client for paralytic ileus. Which assessment data would alert the nurse to this occurrence? 1. Inability to pass flatus 2. Loss of anal sphincter control 3. Severe, constant pain with rapid onset 4. Firm, nontender mass palpable at the lower right costal margin

1 An inflammatory reaction such as acute pancreatitis can cause paralytic ileus, the most common form of nonmechanical obstruction. Inability to pass flatus is a clinical manifestation of paralytic ileus. Loss of anal sphincter control is not a sign of paralytic ileus. Pain is associated with paralytic ileus, but the pain usually presents as a more constant generalized discomfort. Pain that is severe, constant, and rapid in onset is more likely caused by strangulation of the bowel. A firm, palpable mass at the right costal margin describes the physical finding of liver enlargement, which is usually associated with cases of cirrhosis or hepatitis. Although this client may have an enlarged liver, this is not a sign of paralytic ileus or intestinal obstruction.

When helping a client with Parkinson disease to ambulate, what instructions should the nurse give the client? 1 Avoid leaning forward. 2 Hesitate between steps. 3 Rest when tremors are experienced. 4 Keep arms close to the center of gravity.

1 The client with Parkinson disease often has a stooped posture [1] [2] [3] because of the tendency of the head and neck to be drawn down; this shift away from the center of gravity causes instability. Hesitation is part of the disease; clients may use a marching rhythm to help maintain a more fluid gait. The tremors of Parkinson disease occur at rest (resting tremors). The client must consciously attempt to maintain a natural arm swing for balance.

A client with chronic pancreatitis needs information on dietary modification to manage the health problem. Which item in the diet should the nurse teach the client to limit? 1. Fat 2. Protein 3. Carbohydrate 4. Water-soluble vitamins

1 The client with chronic pancreatitis should limit fat in the diet and also take in small meals, which will reduce the amount of carbohydrates and protein that the client must digest at any one time. The client does not need to limit water-soluble vitamins in the diet.

A client is admitted to the hospital with a diagnosis of Parkinson disease. Which common signs of Parkinson disease does the nurse expect to identify when completing a nursing admission history and physical? Select all that apply. 1 Muscle rigidity 2 Blank facial expression 3 Leaning toward the affected side 4 Intention tremors with movement 5 Hyperextension of the affected extremity

1, 2 With Parkinson disease muscle rigidity occurs as a result of an imbalance between excitatory and inhibitory messages in the basal ganglia. With Parkinson disease there is a lack of neural control of fine-motor movements, resulting in a characteristic masklike face. Leaning toward an affected side is unrelated to Parkinson disease; this often is associated with a brain attack (CVA). Movement usually abolishes tremors; these are known as nonintention tremors. Hyperextension of the affected extremities does not occur with Parkinson disease; both arms fall rigidly to the sides and do not swing with a regular rhythm when walking, producing a shuffling gait.

The nurse is caring for a client who is mechanically ventilated, and the high-pressure ventilator alarm is sounding. The nurse understands that which complications may cause this alarm? Select all that apply. 1. Water or a kink in the tubing 2. Biting on the endotracheal tube 3. Increased secretions in the airway 4. Disconnection or leak in the system 5. The client stops spontaneous breathing.

1, 2, 3 Causes of high-pressure ventilator alarms include water or a kink in the tubing, biting on the endotracheal tube, increased secretions in the airway, wheezing or bronchospasm, displacement of the endotracheal tube, or the client fighting the ventilator. A disconnection or leak in the system and the client ceasing to spontaneously breathe are causes of a low-pressure ventilator alarm.

The nurse is suctioning an unconscious client who has a tracheostomy. The nurse should perform which actions when performing this procedure? Select all that apply. 1. Keeping a supply of suction catheters at the bedside 2. Auscultating breath sounds to determine the need for suctioning 3. Hyperoxygenating the client before, during, and after suctioning 4. Intermittently suctioning during insertion of the suction catheter 5. Placing suction on the catheter for at least 30 seconds to ensure that all secretions are removed

1, 2, 3 Suction equipment should be kept at the bedside of an unconscious client, regardless of whether an artificial airway is used. The nurse auscultates breath sounds every 2 to 4 hours, or more frequently as needed. The client should be hyperoxygenated before, during, and after suctioning to minimize cerebral hypoxia. Intermittent suction should be applied while the catheter is being withdrawn, not while it is being inserted. Suctioning should not be performed for longer than 10 seconds at one time to prevent cerebral hypoxia and a rise in intracranial pressure.

A nurse is caring for a client with Parkinson disease. Which clinical indicators does the nurse expect to find upon assessment? Select all that apply. 1 Resting tremors 2 Flattened affect 3 Muscle flaccidity 4 Tonic-clonic seizures 5 Slow voluntary movements

1,2,5 Resting (nonintention) tremors, commonly accompanied by pill-rolling movements of the thumb against the fingers, are associated with destruction of the neurons of the basal ganglia and substantia nigra. Destruction of the neurons of the basal ganglia and substantia nigra results in decreased muscle tone. The masklike appearance, unblinking eyes, and monotonous speech patterns can be interpreted as a flat affect. Slow voluntary movements (bradykinesia) are associated with this disorder. Muscle flaccidity is not associated with Parkinson disease. Rigidity is caused by sustained muscle contractions. Movement is jerky in quality (cogwheel rigidity). Tonic-clonic seizures are not associated with Parkinson disease.

A client has a diagnosis of myasthenia gravis. What does the nurse recall are associated clinical manifestations? 1 Blurred vision along with episodes of vertigo 2 Tremors of the hands when attempting to lift objects 3 Partial improvement of muscle strength with mild exercise 4 Involvement of the distal muscles rather than the proximal muscles

1. Blurred vision and episodes of vertigo are symptoms of myasthenia gravis and are aggravated by physical activity. Intentional tremors are associated with multiple sclerosis. Exercise decreases muscle strength. The proximal muscles are more involved than the distal muscles.

A nurse is caring for a hospitalized client who has been diagnosed with pancreatitis. The nurse checks the laboratory results form, anticipating that which enzyme will remain normal in the client? 1. Lipase 2. Lactase 3. Trypsin 4. Amylase

2 Lactase is produced in the small intestine and aids in splitting neutral fats into glycerol and fatty acids. Lipase, trypsin, and amylase are produced in the pancreas and aid in the digestion of fats, starches, and proteins, respectively.

The nurse has assisted a health care provider (HCP) with the insertion of a chest tube. The nurse monitors the client and notes fluctuation of the fluid level in the water-seal chamber after the tube is inserted. Based on this assessment, which action is most appropriate? 1. Inform the HCP. 2. Continue to monitor the client. 3. Reinforce the occlusive dressing. 4. Encourage the client to deep breathe.

2 The presence of fluctuation of the fluid level in the water-seal chamber indicates a patent drainage system. With normal breathing, the water level rises with inspiration and falls with expiration. Fluctuation stops if the tube is obstructed, if a dependent loop exists, the suction is not working properly, or the lung has re-expanded. Because this finding is expected, it is not necessary to notify the HCP. The presence of fluctuation of the fluid level in the water-seal chamber does not indicate that the dressing needs reinforcement. Although it is important for the client to cough and deep breathe, this action is unrelated to the situation presented in the question.

A client is admitted to the hospital with a diagnosis of myasthenia gravis. For which common early clinical finding should the nurse assess the client? 1 Tearing 2 Diplopia 3 Nystagmus 4 Exophthalmos

2 With myasthenia gravis, the sensitivity of the end plates at the postsynaptic junction to acetylcholine is reduced, thus interfering with muscle contraction. Inadequate contraction of the ocular muscles results in double vision (diplopia). Tearing is not a clinical manifestation associated with myasthenia gravis. Nystagmus is not a clinical manifestation associated with myasthenia gravis; it is associated with multiple sclerosis. Exophthalmos is associated with hyperthyroidism.

. A nurse is teaching a client with multiple sclerosis about the disease. Which statement by the client indicates to the nurse that further teaching is needed? 1 "I avoid use of a straw to drink liquids." 2 "I will take a hot bath to help relax my muscles." 3 "I plan to use an incontinence pad when I go out." 4 "I may be having a rough time now, but I hope tomorrow will be better."

2 "I will take a hot bath to help relax my muscles." The nurse needs to address the hot baths to correct this misconception. Hot baths tend to increase symptoms and may result in burns because of decreased sensation. All the rest are correct and do not require teaching. Using a straw gives the client less control of liquid intake, which may lead to aspiration. Although a bladder regimen to maintain control is preferable, the use of pads can avoid embarrassment. The disease does have periods of remission and exacerbation

561. The nurse notes the client receiving heparin infusion labeled, Heparin Na 25,000 Units in 5% Dextrose injection 500 ml at 50ml/hr. What dose of Heparin is the client receiving per hour?

2,500

The nurse is monitoring a client with cirrhosis of the liver for signs of hepatic encephalopathy. Which assessment finding would the nurse note as an early sign of hepatic encephalopathy? 1. Restlessness 2. Complaints of fatigue 3. The presence of asterixis 4. Decreased serum ammonia levels

3 Asterixis is a flapping tremor of the hand that is an early sign of hepatic encephalopathy. The exact cause of this disorder is not known, but abnormal ammonia metabolism may be implicated. Increased serum ammonia levels are thought to interfere with normal cerebral metabolism. Tremors and drowsiness also would be noted.

The nurse is reviewing the record of a client with a diagnosis of cirrhosis and notes that there is documentation of the presence of asterixis. How should the nurse assess for its presence? 1. Dorsiflex the client's foot. 2. Measure the abdominal girth. 3. Ask the client to extend the arms. 4. Instruct the client to lean forward.

3 Asterixis is irregular flapping movements of the fingers and wrists when the hands and arms are outstretched, with the palms down, wrists bent up, and fingers spread. Asterixis is the most common and reliable sign that hepatic encephalopathy is developing. Options 1, 2, and 4 are incorrect

The nurse evaluates that the teaching about myasthenic and cholinergic crises is understood when a client who is diagnosed with myasthenia gravis states that which characteristic is common to both crises? 1 Diarrhea 2 Salivation 3 Difficulty breathing 4 Abdominal cramping

3 Because of the decrease in tone and strength of the respiratory muscles, difficulty breathing is a prominent feature of both crises. Diarrhea occurs in cholinergic crisis; it is an effect of an overdose of the medications (anticholinesterases) used to treat myasthenia gravis. Salivation occurs in cholinergic crisis; it is an effect of an overdose of the medications (anticholinesterases) used to treat myasthenia gravis. Abdominal cramping occurs in cholinergic crisis; it is an effect of an overdose of the medications (anticholinesterases) used to treat myasthenia gravis.

A client has experienced pulmonary embolism. The nurse should assess for which symptom, which is most commonly reported? 1. Hot, flushed feeling 2. Sudden chills and fever 3. Chest pain that occurs suddenly 4. Dyspnea when deep breaths are taken

3 The most common initial symptom in pulmonary embolism is chest pain that is sudden in onset. The next most commonly reported symptom is dyspnea, which is accompanied by an increased respiratory rate. Other typical symptoms of pulmonary embolism include apprehension and restlessness, tachycardia, cough, and cyanosis.

The nurse is preparing to suction a client via a tracheostomy tube. The nurse should plan to limit the suctioning time to a maximum of which time period? 1. 1 minute 2. 5 seconds 3. 10 seconds 4. 30 seconds

3. 10 seconds Hypoxemia can be caused by prolonged suctioning, which stimulates the pacemaker cells in the heart. A vasovagal response may occur, causing bradycardia. The nurse must preoxygenate the client before suctioning and limit the suctioning pass to 10 seconds.

The nurse is providing care for a client with a Sengstaken-Blakemore tube. The nurse suspects which diagnosis for this client? 1. Gastritis 2. Bowel obstruction 3. Small bowel tumor 4. Esophageal varices

4 A Sengstaken-Blakemore tube may be used in a client with a diagnosis of cirrhosis with ruptured esophageal varices if other treatment measures are unsuccessful. The tube has an esophageal and a gastric balloon. The esophageal balloon exerts pressure on the ruptured esophageal varices and stops the bleeding. The gastric balloon holds the tube in the correct position and prevents migration of the esophageal balloon, which could harm the client. This tube is not used in clients with the conditions noted in options 1, 2, or 3.

A client is experiencing diplopia, ptosis, and mild dysphagia. Myasthenia gravis is diagnosed, and an anticholinergic medication is prescribed. The nurse is planning care with the client and spouse. What instruction is the priority? 1 Eat foods that are pureed. 2 Perform range-of-motion exercises. 3 Take a stool softener daily. 4 Take the medication according to a specific schedule.

4 A priority of care for a client with myasthenia gravis [1] [2] is to take medication according to a specific schedule; for example, the anticholinergic medication should be taken before meals because it enhances chewing and swallowing. Dysphagia usually is not an initial problem with myasthenia gravis. A variety of foods in texture and taste should be encouraged. Mechanical soft foods or chopped foods should be eaten until the dysphagia progresses to the point that pureed foods are necessary. Although movement and mobility are important, range-of-motion exercises prevent joint contractures rather than promote muscle strength. Anticholinergic medications taken for myasthenia gravis cause relaxation of smooth muscle, resulting in diarrhea rather than constipation.

A nurse identifies that a client seems to be depressed after a thymectomy for treatment of myasthenia gravis. Which nursing action is most appropriate at this point? 1 Recognize that depression often occurs after surgery 2 Ask the primary healthcare provider to arrange for a psychologic consultation 3 Reassure the client that things will feel better after the discharge date has been set 4 Talk with the client about the prognosis and emphasize activities the client is still able to perform

4 Honest discussion with emphasis on functional and psychologic abilities helps promote adjustment. Postoperative depression is not a characteristic feature of thymectomy. Asking the client's practitioner to arrange for a psychologic consultation is too soon; it may eventually be necessary if the client has difficulty adjusting to the chronicity of this condition. Reassuring the client that things will feel better when the discharge date is set provides false reassurance; there is no guarantee the client will feel better on discharge.

A client has clear fluid leaking from the nose following a basilar skull fracture. Which finding would alert the nurse that cerebrospinal fluid is present? 1. Fluid is clear and tests negative for glucose. 2. Fluid is grossly bloody in appearance and has a pH of 6. 3. Fluid clumps together on the dressing and has a pH of 7. 4. Fluid separates into concentric rings and tests positive for glucose.

4 Leakage of cerebrospinal fluid (CSF) from the ears or nose may accompany basilar skull fracture. CSF can be distinguished from other body fluids because the drainage will separate into bloody and yellow concentric rings on dressing material, called a halo sign. The fluid also tests positive for glucose.

The nurse is teaching a client hospitalized with a seizure disorder and the client's spouse about safety precautions after discharge. The nurse determines that the client needs more information if he or she states an intention to take which action? 1. Refrain from smoking alone. 2. Take all prescribed medications on time. 3. Have the spouse nearby when showering. 4. Drink alcohol in small amounts and only on weekends.

4 The client should avoid the intake of alcohol. Alcohol could interact with the client's seizure medications, or the alcohol could precipitate seizure activity. The client should take all medications on time to avoid decreases in therapeutic drug levels, which could precipitate seizures. The client should not bathe in the shower or tub without someone nearby and should not smoke alone, to minimize the risk of injury if a seizure occurs.

. A client with multiple sclerosis is admitted to the hospital. The client's exacerbations have become more frequent and more severe. One day, the client's partner confides to the nurse, "Life is getting very hard and depressing, and I am upset with myself for thinking about a nursing home." After listening to the partner's concerns, which is the best response by the nurse? 1 "You may be able to lessen your feelings of guilt by seeking counseling." 2 "It would be helpful if you become involved in volunteer work at this time." 3 "I recognize it's hard to deal with this, but try to remember that this too shall pass." 4 "Joining a support group of people who are coping with this problem may be helpful."

4. "Joining a support group of people who are coping with this problem may be helpful." Talking with others in similar circumstances provides support and allows for sharing of experiences. The response "You may be able to lessen your feelings of guilt by seeking counseling" is inappropriate because the feeling of guilt was not expressed directly and is too early for this intervention. The response "It would be helpful if you become involved in volunteer work at this time" avoids the partner's concerns and makes a recommendation for which the partner may not have the energy. Also, it cuts off communication. Although the response "I recognize it's hard to deal with this, but try to remember that this too shall pass" identifies feelings, it offers false reassurance.

A nurse assesses a newly admitted client with renal colic to determine the signs and symptoms that are present. The nurse assesses the client for which primary subjective symptom? 1.Uremia 2.Nausea 3.Voiding at night 4.Flank discomfort

4.Flank discomfort

A patient has a junctional escape rhythm on the monitor. The nurse will expect the patient to have a heart rate of _____ beats/minute.

40 to 60

The healthcare provider prescribes a maintenance dose of norepinephrine bitartrate at 4 mcg/minute for a client with septic shock. The pharmacy provides a solution containing 8 mg in 250 ml of D5W. The nurse should program the infusion pump to deliver how many ml/hr?

7.5

Because of census overload, the charge nurse of an acute care medical unit must select a client who can be transferred back to a residential facility. The client with which symptomology is the most stable? A.A stage 3 sacral pressure ulcer, with colonized methicillin-resistant Staphylococcus aureus (MRSA) B.Pneumonia, with a sputum culture of gram-negative bacteria C.Urinary tract infection, with positive blood cultures D.Culture of a diabetic foot ulcer shows gram-positive cocci

A The client with colonized MRSA (A) is the most stable client, because colonization does not cause symptomatic disease. The gram-negative organisms causing pneumonia are typically resistant to drug therapy (B), which makes recovery very difficult. Positive blood cultures (C) indicate a systemic infection. Poor circulation places the diabetic with an infected ulcer (D) at high risk for poor healing and bone infection.

The nurse is preparing to administer IV fluid to a client with a strict fluid restriction. IV tubing with which feature is most important for the nurse to select?

A Buretrol attachment.

What criteria should the nurse use to determine normal sinus rhythm for a client on a cardiac monitor? Check all that apply. A. The RR intervals are relatively consistent B. One P wave precedes each QRS complex C. Four to eight complexes occur in a 6 second strip D. The ST segment is higher than the PR interval E. The QRS complex ranges from 0.12 to 0.20 second

A and B The consistency of the RR interval indicates regular rhythm. A normal P wave before each complex indicates the impulse originated in the SA node. The number of complexes in a 6 second strip is multiplied by 10 to approximate the heart rate; normal sinus rhythm is 60 to 100. Elevation of the ST segment is a sign of cardiac ischemia and is unrelated to the rhythm. The QRS duration should be less than 0.12 second; the PR interval should be 0.12 to 0.20 second.

Clinical portfolios are being introduced into the performance appraisal process for staff nurses employed at a hospital. What should the nurse-manager request that each staff nurse include in the portfolio?

A self-evaluation that identifies how the nurse has met professional objectives and goals.

The nurse is monitoring a client who is having a third transfusion of packed red blood cells. Which of these may be evident if the client is experiencing a febrile transfusion reaction? Select all that apply. A. Chills B. Urticaria C. Hypotension D. Tachycardia E. Bronchospasm F. Sense of impending doom

A. Chills C. Hypotension D. Tachycardia

A client steps on a rusty nail, and the puncture site becomes swollen and painful. Tetanus immune globulin is prescribed. What does the nurse identify as an action of this drug? A. Provides antibodies B. Stimulates plasma cells C. Produces active immunity D. Facilitates long-lasting immunity

A. Provides antibodies

What does "information salience," a characteristic of communication, refer to according to Anthony and Vidal? Incorrect1 Decay of information Correct2 Clarity of information 3 Change in client's health status 4 Change in client's health information

According to Anthony and Vidal, "information salience" is a characteristic of communication that refers to the clarity of information shared between the delegator and the delegate. Decay of information, change in client's health status, and change in client's health information are described by the term "information decay."

The nurse manager is teaching newly assigned delegators about the limitations of delegation. Which statements made by the delegators indicate effective teaching? Select all that apply. Correct1 "Personal hygiene activities can be delegated to unlicensed assistive personnel (UAP)." Correct2 "Administration of oral medication can be delegated to the licensed practical nurse (LPN)." 3 "Administration of intravenous medication can be delegated to the licensed practical nurse (LPN)." 4 "Tasks related to caring for diabetic clients can be delegated to unlicensed assistive personnel (UAP)." Correct5 "Tasks related to caring for clients in a hospice care setting can be delegated to licensed vocational nurses (LVNs)."

Activities related to client hygiene can be delegated to unlicensed assistive personnel (UAP). Administration of oral medication can be done by the licensed practical nurse (LPN). Licensed vocational nurses (LVNs) can care for the clients in a hospice care setting. Administration of intravenous medication cannot be done by LPNs as they are not eligible. Diabetic clients cannot be cared by UAP as this group does not have sufficient knowledge about how to care for clients with diabetes.

566. A primigravida client is 36 weeks gestation is admitted to labor and delivery unit because her membranes ruptured 30minutes ago. Initial assessment indicates 2cm dilation, 50% effaced, -2 station, vertex presentation greenish colored amniotic fluid, and contractions occurring 3-5 minutes with a low FHR after the last contraction peaks:

Administer Oxygen via face mask

356. A 6 -years-old who has asthma is demonstrating a prolonged expiratory phase and wheezing, and has 35% personal best peak expiratory flow rate (PEFR). Based on these finding, which action should the nurse implement first?

Administer a prescribed bronchodilator.

57. A young adult who is hit with a baseball bat on the temporal area of the left skull is conscious when admitted to the ED and is transferred to the Neurological Unit to be monitored for signs of closed head injury. Which assessment finding is indicative of a developing epidural hematoma?

Altered consciousness within the first 24 hours after injury.

Which among the Five Rights of Delegation is the cornerstone of delegation? 1 "Right person" 2 "Right supervision" 3 "Right circumstance" Correct4 "Right communication and direction"

Among the Five Rights of Delegation, "right communication and direction" is the most important right of delegation. It is the most useful in maintaining the quality and safety outcomes, as it involves communication and direction. "Right person" is useful for understanding which person has the appropriate skills to perform the task. "Right supervision" involves monitoring the tasks that are performed with the goal of improving outcomes. "Right circumstance" seeks to ensure that the appropriate equipment and resources are available for the delegatee.

19. The charge nurse of a critical care unit is informed at the beginning of the shift that less than the optimal number of registered nurses will be working that shift. In planning assignments, which client should receive the most care hours by a registered nurse (RN)?

An 82-year-old client with Alzheimer's disease newly-fractures femur who has a Foley catheter and soft wrist restrains applied

361. In making client care assignment, which client is best to assign to the practical nurse (PN) working on the unit with the nurse?

An immobile client receiving low molecular weight heparin q12 h.

Entacapone

COMT-I combined with levodopa to enhance effects by inhibiting metabolization of levodopa and increasing availability

112. At the end of a preoperative teaching session on pain management techniques, a client starts to cry and states, "I just know I can't handle all the pain." What is the priority nursing diagnosis for this client?

Anxiety

The client is admitted with sinus tachycardia. To treat the dysrhythmia, the nurse would look for potential causes such as: Select all that apply 1 Anxiety. 2 Caffeine. 3 Exercise. 4 Hypothermia. 5 Anemia.

Anxiety, caffeine, exercise & anemia

595. The nurse is teaching a male client with multiple sclerosis how to empty his bladder using the Crede Method. When performing a return demonstration, the client applies pressure to the umbilical areas of his abdomen. What instruction should the nurse provide?

Apply downward manual pressure at the suprapubic regions.

A patient develops sinus bradycardia at a rate of 32 beats/minute, has a blood pressure (BP) of 80/42 mm Hg, and is complaining of feeling faint. Which actions should the nurse take next?

Apply the transcutaneous pacemaker (TCP) pads.

606. A client present at the clinic with blepharitis. What instructions should the nurse provide for home care?

Apply warm moist compresses then gently scrub eyelids with dilute baby shampoo

51. An unlicensed assistive personnel (UAP) assigned to obtain client vital signs reports to the charge nurse that a client has a weak pulse with a rate of 44 beat/ minutes. What action should the charge nurse implement?

Assign a practical nurse (LPN) to determine if an apical radial deficit is present

Non-motor PD symptoms

Autonomic: constipation (fluid, fiber, stool softener, laxative), urinary incontinence (oxybutynin, anticholinergic), ortho HTN (Na and fluids, steroids), erectile dysfunction (PDE5 inhibitor - sildenafil) Insomnia (levodopa/carbidopa) Excessive daytime sleepiness (modafinil) Depression, dementia, psychosis

The charge nurse overhears a staff member asking for a doughnut from a client's meal tray. Which action should the charge nurse implement? A.Advise the client that food from the meal tray should not be shared with others. B.Leave the room and discuss the incident privately with the staff member. C.Objectively document the situation as observed on a variance report. D.Call the nurse-manager to the client's room immediately.

B Discussing the incident privately (B) promotes open communication between the charge nurse and staff member. The client is free to share unwanted food (A) with family or friends, but the employee should not ask for the client's food. (C) is not necessary, and the charge nurse can respond to this situation without implementing (D).

The nurse is caring for a client with an ischemic stroke who has a prescription for tissue plasminogen activator (t-PA) IV. Which action(s) should the nurse expect to implement? (Select all that apply.) A.Administer aspirin with tissue plasminogen activator (t-PA). B.Complete the National Institute of Health Stroke Scale (NIHSS). C.Assess the client for signs of bleeding during and after the infusion. D.Start t-PA within 6 hours after the onset of stroke symptoms. E.Initiate multidisciplinary consult for potential rehabilitation.

B,C,E Rationale: Neurologic assessment, including the NIHSS, is indicated for the client receiving t-PA. This includes close monitoring for bleeding during and after the infusion; if bleeding or other signs of neurologic impairment occur, the infusion should be stopped (B, C, and E). Aspirin is contraindicated with t-PA because it increases the risk for bleeding (A). The administration of t-PA within 6 hours of symptoms is concurrent with a diagnosis of a myocardial infarction and within 4.5 hours of symptoms is concurrent for a stroke (D).

276. The mother of the 12- month-old with cystic fibrosis reports that her child is experiencing increasing congestion despite the use of chest physical therapy (CPT) twice a day, and has also experiences a loss of appetite. What instruction should the nurse provide?

CPT should be performed more frequently, but at least an hour before meals.

When ventricular fibrillation occurs in a CCU, the first person reaching the client should: A. Administer oxygen B. Defibrillate the client C. Initiate CPR D. Administer sodium bicarbonate intravenously

B. Defibrillate the Client Ventricular fibrillation is a death-producing dysrhythmia and, once identified, must be terminated immediately by precordial shock (defibrillation). This is usually a standing physician's order in a CCU.

A health care provider prescribes psyllium 3.5 g twice a day for constipation. What is most important for the nurse to teach this client? A. Urine may be discolored. B. Each dose should be taken with a full glass of water. C. Use only when necessary because it can cause dependence. D. Daily use may inhibit the absorption of some fat-soluble vitamins.

B. Each dose should be taken with a full glass of water.

When administering an intramuscular injection, which factor is most important to ensure the best medication absorption? A.Compress the syringe plunger quickly. B.Select a small-gauge needle. C.Inject the needle at a 90-degree angle. D.Select a small-diameter syringe.

C Rationale: Injecting the needle at a 90-degree angle allows the medication to be injected into the muscle so that appropriate absorption can occur (C). Too rapid injection of the medication (A) may be painful and may cause medication leakage and reduced absorption. (B) will reduce injection discomfort but will not affect absorption. A syringe barrel that is too small (D) increases the pressure during the injection and may traumatize tissue without improving medication absorption.

A client hospitalized for meningitis is demonstrating nuchal rigidity. Which symptom is this client likely to be exhibiting? A.Hyperexcitability of reflexes B.Hyperextension of the head and back C.Inability to flex the chin to the chest D.Lateral facial paralysis

C Nuchal rigidity (neck stiffness) is a characteristic of meningeal irritation and is elicited by attempting to flex the neck and place the chin to the chest (C). Although (A, B, and D) may occur in meningitis, (A) describes exaggerated spinal nerve reflex responses, (B) describes opisthotonus, and (D) may be related to cranial nerve pathology of the trigeminal nerve.

The nurse is monitoring a client who has liver failure and is taking lactulose. which findings indicate that the medication is having a desired effect? (SATA) A. Incrsd urine OP B. Incrsd serum ammonia C. Improved LOC D. Incrsd BMs E. Dec serum potassium

C - D

A client is admitted to the cardiac care unit with a myocardial infarction. The cardiac monitor reveals several runs of ventricular tachycardia. The nurse anticipates that the client will be receiving a prescription for which drug? A. Atropine B. Epinephrine C. Amiodarone D. Sodium bicarbonate

C. Amiodarone

A client who was admitted with a diagnosis of acute lymphoblastic leukemia is receiving chemotherapy. Which assessment findings would alert the nurse to the possible development of thrombocytopenia? Select all that apply. A. Fever B. Diarrhea C. Headache D. Hematuria E. Ecchymosis

C. Headache D. Hematuria E. Ecchymosis

When obtaining a health history, the nurse is informed that a client has been taking digoxin. What therapeutic effect of digoxin does the nurse expect? A. Decreased cardiac output B. Decreased stroke volume of the heart C. Increased contractile force of the myocardium D. Increased electrical conduction through the atrioventricular (AV) node

C. Increased contractile force of the myocardium

A client reports frequently taking calcium carbonate. What effect should the nurse advise the client that this can have? A. Diarrhea B. Water retention C. Rebound hyperacidity D. Bone demineralization

C. Rebound hyperacidity

Anti-Parkinson Drugs

Cannot reverse neuronal damage. Only treats symptoms 2 broad classes of drugs: Dopaminergic agents and anticholinergic agents (anticholinergic = antimuscarinic = parasympathetic)

452. A 12-lead electrocardiogram (ECG) indicates a ST elevations in leads V1 to V4, for a client who reports having chest pain. The healthcare provider prescribe tissue plasminogen activator (t-PA). Prior to initiating the infusion, which interventions is most important for the nurse to implement?

Complete pre-infusion checklist

412. The nurse is changing a client's IV tubing and closes the roller clamp on the new tubing setup when the bag of solution is....which action should the nurse take to ensure adequate filling of the drip chamber?

Compress the drip chamber

630. An adult female client is admitted to the psychiatric unit because of a complex handwashing ritual she performs daily that takes two hours or longer to complete. She worries about staying clean and refuses to sit on any of the chairs in the day area. This client's handwashing is an example of which clinical behavior?

Compulsion

A nurse who has recently completed orientation is beginning work in the labor and delivery unit for the first time. When making assignments, which client should the charge nurse assign to this new nurse? A.A primigravida who is 8 cm dilated after 14 hours of labor B.A client scheduled for a repeat cesarean birth at 38 weeks' gestation C.A client being induced for fetal demise at 20 weeks' gestation D.A multiparous client who is dilated 5 cm and 50% effaced

D The new nurse should be assigned the least complicated client to gain experience and confidence, as well as protect client safety. Of the clients available for assignment, (D) is progressing well and is the least complicated. (A, B and C) have actual or potential complications and should be assigned to a more experienced nurse.

A female client arrives for an annual well-woman checkup and cervical Pap test and tells the nurse that she has been using an over-the-counter (OTC) vaginal cream for the past 2 days to treat an infection. Which initial response should the nurse make? A.Ask the client to describe the symptoms of the vaginal infection. B.Assess if the client has been sexually active recently. C.Tell the client to reschedule the examination in 1 week. D.Inform the client that the scheduled Pap test cannot be done today.

D The over-the-counter (OTC) vaginal cream interferes with obtaining a cervical cellular sample, alters cytology analysis, and masks bacterial or sexually transmitted disease infections, so the Pap test should be postponed (D). Although (A, B, and C) are indicated, the client needs further teaching for the return visit to perform the Pap smear test.

A healthcare provider prescribes simvastatin 20 mg daily for elevated cholesterol and triglyceride levels for a female client. Which is most important for the nurse to teach when the client initially takes the medication? A. Take the medication with breakfast. B. Have liver function tests every 6 months. C. Wear sunscreen to prevent photosensitivity reactions. D. Inform the healthcare provider if the client wishes to become pregnant.

D. Inform the healthcare provider if the client wishes to become pregnant.

The nurse is caring for a client who is experiencing side effects from high doses of methotrexate. Leucovorin calcium is prescribed and is to be administered immediately after the infusion of methotrexate. What is the best indicator that leucovorin calcium is effective? A. Increased energy B. Decreased nausea C. Decreased white blood cell (WBC) level D. Methotrexate level less than 0.05 micromole

D. Methotrexate level less than 0.05 micromole

A client has increased intracranial pressure resulting from a traumatic brain injury. Assessment findings indicate that the client is unconscious with vital signs of pulse 60 beats/min, respirations 16 breaths/min, and blood pressure 142/64 mm Hg. The nurse reviews the treatment plan and questions which prescription? A. Mannitol B. Dexamethasone C. Chlorpromazine D. Morphine

D. Morphine

A client using fentanyl transdermal patches for pain management in late-stage cancer dies. What should the hospice nurse who is caring for this client do about the patch? A. Tell the family to remove and dispose of the patch. B. Leave the patch in place for the mortician to remove. C. Have the family return the patch to the pharmacy for disposal. D. Remove and dispose of the patch in an appropriate receptacle.

D. Remove and dispose of the patch in an appropriate receptacle.

What will the nurse include when developing a teaching plan for a client receiving digoxin for left ventricular failure? A. Sleep flat in bed B. Follow a low-potassium diet C. Take the pulse three times a day D. Rest periodically throughout the day

D. Rest periodically throughout the day

A client with esophageal cancer is to receive total parenteral nutrition. A right subclavian catheter is inserted. What is the primary reason total parenteral nutrition is infused through a central line rather than a peripheral line? A. It prevents the development of infection. B. There is less chance of this infusion infiltrating. C. It is more convenient so clients can use their hands. D. The large amount of blood helps dilute the concentrated solution.

D. The large amount of blood helps dilute the concentrated solution.

A patient with MS is prescribed oral prednisone 60 mg daily for 7 days following a course of IV methylprednisone, which lab abnormality is a side effect of the medication

Decrease in serum potassium

208. The nurse is preparing to administer a histamine 2-receptor antagonist to a client with peptic ulcer disease. What is the primary purpose of this drug classification?

Decreases the amount of HCL secretion by the parietal cells in the stomach

61. A female client reports she has not had a bowel movement for 3 days, but now is defecating frequent small amount of liquid stool. Which action should the nurse implement?

Digitally check the client for a fecal impaction

97. A female client with acute respiratory distress syndrome (ARDS) is chemically paralyzed and sedated while she is on as assist-control ventilator using 50% FIO2. Which assessment finding warrants immediate intervention by the nurse?

Diminished left lower lobe sounds

A patient is admitted for a probably diagnosis of GBS but needs additional diagnostic testing for confirmation, which test does the nurse anticipate will be ordered for this patient

Electrophysiologic studies (EPS), EMG

The parents of a 14-year-old boy express concern about their son's behavior, which ranges from clean-cut and personable to "grungy" and sullen. They have tried talking with him and disciplining him, but he continues to demonstrate confusing behaviors. Which information is best for the nurse to provide?

Early adolescence is a developmental stage of normal experimentation.

110. An elderly female is admitted because of a change in her level of sensorium. During the evening shift, the client attempts to get out bed and falls, breaking her left hip. Buck's skin traction is applied to the left leg while waiting for surgery. Which intervention is most important for the nurse to include in this client's plan care?

Ensure proper alignment of the leg in traction.

The nurse understands that in a first degree atrioventricular (AV) block: 1 Every P wave is conducted to the ventricles. 2 Some P waves are conducted to the ventricles. 3 None of the P waves are conducted to the ventricles. 4 There are no P waves visible on the rhythm strip

Every P wave is conducted to the ventricles

586. A client who is schedule for an elective inguinal hernia repair today in day surgery is seem eating in the waiting area. What action should be taken by the nurse who is preparing to administer the preoperative medications?

Explain that vomiting can occur during surgery Withhold the preoperative medication

171. An adult male is admitted to the emergency department after falling from a ladder. While waiting to have a computed tomography (CT) scan, he requests something for a severe headache. When the nurse offers him a prescribed does of acetaminophen, he asks for something stronger. Which intervention should the nurse implement?

Explain the reason for using only non-narcotics.

16. The nurse is assisting the mother of a child with phenylketonuria (PKU) to select foods that are in keeping with the child's dietary restrictions. Which foods are contraindicated for this child?

Foods sweetened with aspartame

A patient who is on the progressive care unit develops atrial flutter, rate 150, with associated dyspnea and chest pain. Which action that is included in the hospital dysrhythmia protocol should the nurse do first?

Give supplemental O2 at 2 to 3 L/min via nasal cannula.

376. A client with arthritis has been receiving treatment with naproxen and now reports ongoing stomach pain, increasing weakness, and fatigue. Which laboratory test should the nurse monitor?

Hemoglobin

The registered nurse (RN) delegates a task to the licensed practical nurse (LPN). If the LPN fails to perform the task within acceptable standards, what would happen? Select all that apply. Correct1 A potential for nursing malpractice emerges. Correct2 The institution remains legally responsible for the situation. Correct3 The accountability for care remains with the registered nurse (RN). 4 The licensure of the licensed practical nurse (LPN) would be revoked. Incorrect5 The accountability for care remains with the licensed practical nurse (LPN).

If the delegated task is not performed within acceptable standards, a potential for nursing malpractice emerges. Failure to delegate and supervise within acceptable standards may extend to direct corporate liability for the institution. Whenever care is provided by staff other than a registered nurse (RN), the accountability for care remains with the delegator who is an RN. The licensure of the licensed practical nurse (LPN) would not be cancelled because the LPN is not held accountable for the situation. When the work is assigned to the LPN, only responsibility of the task is transferred.

Which element of the healthcare system is the registered nurse (RN) practicing when the delegator shares accountability with the RN? Correct1 Delegation 2 Leadership 3 Supervision 4 Assignment

In delegation, the delegator and delegatee share accountability for certain tasks. In leadership, the delegator, as leader, manages the healthcare team and delegates tasks to members of the team. In supervision, the delegator supervises the delegatee as he or she completes a task. In assignment, both accountability and responsibility are transferred from one person to another on the healthcare team.

8. During shift report, the central electrocardiogram (EKG) monitoring system alarms. Which client alarm should the nurse investigate firs?

Respiratory apnea of 30 seconds

63. The nurse should teach the parents of a 6 year-old recently diagnosed with asthma that the symptom of acute episode of asthma are due to which physiological response?

Inflammation of the mucous membrane & bronchospasm

While caring for a client, the registered nurse (RN) needs the assistance of a licensed practical nurse (LPN). The RN feels that the LPN requires supervision as the LPN has previously only worked in a physician's office. Which action by the RN would help diminish any negative feelings the LPN might have about being supervised? 1 Initiating a conversation about the limited skills of the LPN Incorrect2 Appreciating the performance of the LPN when providing feedback 3 Explaining the policies and procedures of the organization Correct4 Initiating a conversation about the new role and functions of the LPN

Initiating a conversation related to new role and functions of the LPN opens up the lines of communication and provides an opportunity to explain why the supervision is necessary. It also helps eliminate or diminish the negative feelings of the LPN regarding the supervision. The RN can open up the line of communication by briefing the drawbacks of the LPN, but this may not help in diminishing the negative feelings about supervision. Appreciating the LPN's work may be welcome and appropriate, but would not necessarily address the LPN's negative feelings about being supervised. Likewise, an explanation of the organization's policies and procedures is important for a LPN who is new to the organization, but this would not necessarily diminish the LPN's negative feelings about supervision.

349. The nurse is preparing a client who had a below-the-knee (BKA) amputation for discharge to home. Which recommendations should the nurse provide this client? (Select all that apply)

Inspect skin for redness Use a residual limb shrinker Wash the stump with soap and water

577. An adult male who was admitted two days ago following a cerebrovascular accident (CVA) is confused and experiencing left-side weakness. He has tried to get out of bed several times, but is unable to ambulate without assistance. Which intervention is most important for the nurse to implement?

Install a bed exit safety monitoring device

How should a student nurse be trained for implementing delegation in practice? 1 By reinforcing delegation to the student nurse only during academics Correct2 By interacting with highly qualified, clinically experienced nursing mentors 3 By improving didactic content by theoretically educating the student nurse Incorrect4 By considering the student nurse's opinions for the master delegation decisions

Interaction with highly qualified, clinically experienced nursing mentors fosters professional self-confidence in the student nurse. These experiences allow student nurses to build up their ability to be successful delegators. Delegation knowledge should also be reinforced in nursing continuing education programs. Didactic content about delegacy can be improved by pairing the education and the clinical experience from the healthcare practice site. The student nurse does not have enough knowledge to make master delegation decisions without adequate training.

480. The nurse is teaching a client about the antiulcer medications ranitidine which was... statement best describes the action of this drug?

It blocks the effects of histamine, causing decreased secretion of acid

103. The nurse is teaching a client how to perform colostomy irrigations. When observing the client's return demonstration, which action indicated that the client understood the teaching?

Keeps the irrigating container less than 18 inches above the stoma

The primary healthcare provider prescribes a rectal suppository for a client with severe constipation. Which healthcare professional would be delegated the task of administering the suppository? 1 Patient care associate Correct2 Licensed practical nurse 3 Unlicensed assistive personnel 4 Unlicensed nursing personnel

Licensed practical nurses may be delegated the task of administering rectal suppositories to the client. Patient care associates, unlicensed assistive personnel, and unlicensed nursing personnel may do all hygiene tasks and basic care for clients. However, administering suppositories is not in their scope of practice.

76. The nurse is developing a teaching program for the community. What population characteristic is most influential when choosing strategies for implementing a teaching plan?

Literacy level

A male client who lives in an area endemic with Lyme disease asks the nurse what to do if he thinks he may have been exposed. Which response should the nurse provide?

Look for early signs of a lesion that increases in size with a red border, clear center. The client should look for the early signs of localized Lyme disease known as erythema migrans, a skin lesion that slowly expands to form a large round lesion with a bright red border and clear center (B) at the site of the tick bite.

166. A client is admitted with metastatic carcinoma of the liver, ascites, and bilateral 4+ pitting edema of both lower extremities. When the client complains that the antiembolic stocking are too constricting, which intervention should the nurse implement?

Maintain both lower extremities elevated on pillows.

The nurse identifies bright-red drainage, about 6 cm in diameter, on the dressing of a client who is one day post abdominal surgery. Which action should the nurse take next?

Mark the drainage on the dressing and take vital signs. Drainage on a surgical dressing should be described by type, amount, color, consistency, and odor, and the surgeon should be notified of any excessive or abnormal drainage and significant changes in vital signs. To determine that the drainage on an abdominal surgical dressing is usual and not an indication of hemorrhage, marking the 6 cm drainage on the dressing (A) assists in determining an increase in the amount which is supported with any changes in vital signs that indicates possible internal bleeding. (B) is premature. Removing the initial dressing may disturb the surgical site and increase the risk of hemorrhage and infection (C). (D) is compared with the previous amount of drainage marked on the dressing, so (A) is necessary.

A female client reports to the nurse that her sleep was interrupted by "thoughts of anger toward my husband." What type of thoughts is the client having?

Obsessive

152. A client has an intravenous fluid infusing in the right forearm. To determine the client's distal pulse rate most accurately, which action should the nurse implement?

Palpate at the radial pulse site with the pads of two or three fingers.

405. The nurse is planning to assess a client's oxygen saturation to determine if additional oxygen is needed via nasal cannula. The client has a bilateral below-the-knee amputation and pedal pulses that are weak and threaty. What action should the nurse take?

Place the oximeter clip on the ear lobe to obtain the oxygen saturation reading

The nurse notes that a patient has a low serum potassium level. Which phase of the cardiac action potential will be most affected by this blood level?

Phase 3

218. The nurse is teaching a group of clients with rheumatoid arthritis about the need to modify daily activities. Which goal should the nurse emphasize?

Protect joint function

215. The nurse is planning preoperative teaching plan of a 12-years old child who is scheduled for surgery. To help reduce the child anxiety, which action is the best for the nurse to implement?

Provide a family tour of the preoperative unit one week before the surgery is scheduled.

197. A man expresses concern to the nurse about the care his mother is receiving while hospitalized. He believes that her care is not based on any ethical standards and ask what type of care he should expect from a public hospital. What action should the nurse take?

Provide the man and his mother with a copy of the Patient's Bill of Rights

The nurse is assessing a patient with myasthenia gravis, which manifestation can the nurse expect to observe

Ptosis, diploia, incomplete eye closure

74. A male client who is admitted to the mental health unit for treatment of bipolar disorder has a slightly slurred speech pattern and an unsteady gait. Which assessment finding is most important for the nurse to report to the healthcare provider?

Serum lithium level of 1.6 mEq/L or mmol/l (SI)

1. Following discharge teaching, a male client with duodenal ulcer tells the nurse the he will drink plenty of dairy products, such as milk, to help coat and protect his ulcer. What is the best follow-up action by the nurse?

Review with the client the need to avoid foods that are rich in milk and cream

When documenting assessment data, which statement should the nurse record in the narrative nursing notes?

S1 murmur auscultated in supine position.

A female client makes routine visits to a neighborhood community health center. The nurse notes that this client often presents with facial bruising, particularly around the eyes. The nurse discusses prevention of domestic violence with the client even though the client does not admit to being battered. What level of prevention has the nurse applied in this situation?

Secondary prevention (B) attempts to halt the progression of the disease process, in this case, an escalation in the battering, by educating the client about prevention strategies. The nurse has identified client injuries that create a suspicion of battering and domestic violence.

94. For the past 24 hours, an antidiarrheal agent, diphenoxylate, has been administered to a bedridden, older client with infectious gastroenteritis. Which finding requires the nurse to take further action?

Tented skin turgor.

A nursing supervisor sends an unlicensed healthcare worker to help relieve the burden of care on a short-staffed medical-surgical unit. Which tasks can be delegated to the health care worker? Select all that apply. Correct1 Taking routine vital signs 2 Applying a sterile dressing Correct3 Answering clients' call lights 4 Administering saline infusions Correct5 Changing linens on an occupied bed 6 Assessing client responses to ambulation

Taking routine vital signs is a universal activity that all healthcare workers are taught to perform regardless of the setting; it is within the job description for unlicensed health care workers. Answering call lights is a universal activity that all unlicensed healthcare workers are taught to perform regardless of the setting; it is within the job description for unlicensed healthcare workers. Making an occupied bed is a universal activity that all unlicensed healthcare workers are taught to perform regardless of the setting; it is within the job description for unlicensed healthcare workers. Unlicensed health care workers do not have the expertise or credentials to apply sterile dressings. Unlicensed healthcare workers do not have the expertise or credentials to administer intravenous solutions. Registered nurses are not permitted to delegate assessment.

6. A client who recently underwear a tracheostomy is being prepared for discharge to home. Which instructions is most important for the nurse to include in the discharge plan?

Teach tracheal suctioning techniques

A client is hospitalized with pressure ulcers. Which task could be delegated to an unlicensed nursing professional (UNP)? Select all that apply. Correct1 Empty wound drainage containers. Correct2 Report changes in wound appearance. 3 Apply prescribed dressings and medications. 4 Assess and record data about wound appearance. 5 Choose dressings and therapies for wound treatment.

The UAP is eligible to empty wound drainage and report changes in wound appearance. The licensed practical nurse is eligible to apply prescribed dressings and medications to the client. A licensed practical nurse can collect and record data about the appearance of a wound. The registered nurse is eligible to choose dressings and therapies for wound treatment.

The registered nurse is delegating tasks for the care of a vulnerable population. Which healthcare team would be appropriate for the delegation of tasks? 1 Charge nurse (CN), chief nursing officer (CNO), and registered nurse (RN) 2 Licensed practical nurse (LPN), unlicensed nursing professional (UNP), and charge nurse (CN) 3 Chief nursing officer (CNO), Registered nurse (RN), and unlicensed nursing professional (UNP) Correct4 Registered nurse (RN), licensed practical nurse (LPN), and unlicensed nursing professional (UNP)

The appropriate healthcare team for delegation of tasks for the care of vulnerable populations consists of the RN, LPN, and UNP. Proper care and assistance can be provided by this team. The CN, CNO, and RN are all licensed health professionals and there are team members to provide assistance on this team. In the team consisting of the LPN, UNP, and CN, there is no person who can take responsibility and accountability of the client care. In the CNO, RN and UNP team, the UNP may not be eligible to carry all the activities and the CNO and RN are responsible for carrying out delegation.

The nurse is preparing teaching about the coronary arteries for a group of patients scheduled for heart surgery. Which information should the nurse include in this teaching?

The coronary arteries originate in the cusps of the aortic valve.

Which characteristics of the delegatee should be considered to determine that he or she is the "right person"? Select all that apply. Correct1 Experience 2 Supervision Correct3 Willingness Correct4 Competence 5 Communication

The delegatee should be assigned a task if he or she has experience that would allow the delegator to provide minimal guidance. The willingness of the delegatee is also important to consider before assigning the task. The competence of the delegatee must be assessed before assigning the task. The delegator should supervise the tasks performed by the delegatee. The delegatee's communication skills are assessed to ensure right direction and communication.

416. A client with bipolar disorder began taking valproic acid (Depakote) 250 mg PO three times daily two months ago. Which finding provides the best indication that the medication regimen is effective?

The family reports a great reduction in client's maniac behavior

Which condition may lead to delegation failure due to malpractice? 1 Adapting to changing situations by the nursing assistant 2 Educating and monitoring the nursing staff incompetent to perform a task Correct3 Employing more unlicensed nursing personal (UNP) in the emergency department Incorrect4 Assigning the more unlicensed nursing personal (UNP) for long-term care facilities

The greater the stability of a client, the more likely an unlicensed nursing personal (UNP) can provide safe client care. It is not ideal to increase the numbers of UNPs in the emergency department due to client instability. The nursing assistant has to adapt to changing situations to deliver proper client care. The delegator must train and monitor the performance of the nursing staff, who are responsible for completing tasks in a specified time. This helps in improving the performance of any incompetent nursing staff. The intensity and length of the interactions with the client are also significant factors to consider in planning client care. The UNP can provide efficient client care in long-term care facilities because the clients are stable.

What should the nurse include when teaching a client with severe Parkinson disease about carbidopa-levodopa (Sinemet)? Multivitamins should be taken daily Alcohol consumption should be in moderation The medication should be taken with meals A high-protein diet should be followed

The medication should be taken with meals (reduces nausea and vomiting)

A registered nurse (RN) is sent to a rehabilitation center because of chemical impairment issues. Which member of the healthcare team will be asked to provide feedback about the RN's progress? Correct1 Nurse manager 2 Healthcare provider 3 Patient care associate 4 Cross-trained technician

The nurse manager, who is the delegator for the healthcare team, will be asked to provide feedback about the progress of the RN in the rehabilitation center. The healthcare provider will not be asked to provide feedback about the RN's progress. The patient care associate and cross-trained technician also do not provide feedback about the RN because they do not supervise the RN.

The nurse is caring for a client who is unable to void. The plan of care establishes an objective for the client to ingest at least 1000 mL of fluid between 7:00 am and 3:30 pm. Which client response should the nurse document that indicates a successful outcome?

The nurse should evaluate the client's outcome by observing the client's performance of each expected behavior, so drinking 240 mL of fluid five or six times during the shift (D) indicates a fluid intake of 1200 to 1440 mL, which meets the objective of at least 1000 mL during the designated period. (A) uses the term "adequate," which is not quantified. (B) is not the objective, which establishes an intake of at least 1000 mL. (C) is not an evaluation of the specific fluid intake.

Which question does the registered nurse recognize as related to the right of circumstance when delegating? Correct1 "Is the delegation appropriate to the situation?" 2 "Is the task within the delegatee's scope of practice?" 3 "Is the prospective delegate a willing and able employee?" Incorrect4 "Is the delegator able to monitor and evaluate the client appropriately?"

The question, "Is the delegation appropriate to the situation?" is related to right circumstance. The question, "Is the task within the delegatee's scope of practice?" is related to right task. The question, "Is the prospective delegate a willing and able employee?" is related to right person. The question, "Is the delegator able to monitor and evaluate the client appropriately?" is related to right supervision.

While caring for a client with diabetes, the registered nurse delegates the task of administering oral medications to the licensed practitioner nurse (LPN), but the LPN is reluctant to take the assignment. What should be the most appropriate response of the registered nurse in this situation? Correct1 Evaluate the reason for the behavior. 2 Engage more actively in the delegated task. 3 Require the delegatee to complete the task. 4 Report the LPN's reluctance to higher authorities.

The registered nurse (RN) should first evaluate the reason for the behavior of the LPN and try to determine if the LPN has insufficient knowledge, a psychomotor deficit, or any other reason for the reluctance. If the LPN is unwilling to perform in a specific situation, the RN should engage more actively. Requiring the delegatee to complete the task despite reluctance may not be safe. Reporting the issue to higher authorities should not be the initial intervention.

The registered nurse is evaluating the statements of the student nurse after teaching about the span of control in a group of individuals working in a healthcare organization. Which statement made by the student nurse indicates a need for correction? Correct1 "The unit secretary in a healthcare organization has legal recognition." 2 "The nurse manager in a healthcare organization is a designated delegator." 3 "The licensed practical nurse working under a physician has a dependent status." 4 "The registered nurse is designated as being answerable to a designated delegator."

The unit secretary in healthcare organizations has no formal preparation and legal recognition. Therefore, the statement of the student nurse that the unit secretary in healthcare organization has legal recognition is incorrect. The nurse manager in a healthcare organization is a designated delegator. The licensed practical nurse has a dependent status and works under a physician. The registered nurse is designated as being answerable to a designated delegator.

580. A female client with rheumatoid arthritis (RA) comes to the clinic complaining of joint pain and swelling. The client has been taking prednisone (Deltasone) and ibuprofen (Motrin Extra Strength) every day. To assist the client with self-management of her pain, which information should the nurse obtain?

Therapeutic exercise included in daily routine.

343. A client is admitted to a medical unit with the diagnosis of gastritis and chronic heavy alcohol abuse. What should the nurse administered to prevent the development of Wernicke's syndrome?

Thiamine (Vitamin B1)

A patient with MG has been referred to a surgeon for a procedure that may improve the patients symptoms. Which procedure does the nurse anticipate will be recommended for this patient

Thymectomy

A client is to take an antipsychotic drug twice a day. Two thirds of the daily dose is given in the evening and one third in the morning. What should the nurse tell the client is the rationale for this schedule? To facilitate dreaming To maintain the daily sleep rhythm To reduce sedation during the daytime To decrease assaultiveness in the evening

To reduce sedation during the daytime

446. The nurse is explaining the need to reduce salt intake to a client with primary hypertension. What explanation should the nurse provide?

Too much salt can cause the kidneys to retain fluid

547. A client with gestational diabetes is undergoing a non-stress test (NST) at 34-week gestation... is 144 beats/minute. The client is instructed to mark the fetal monitor by pressing a button each time the baby moves. After 20 minutes, the nurse evaluates the fetal monitor strip. What...

Two FHR accelerations of 15 beats/minute x 15 seconds are recorded

The nurse needs to quickly estimate the heart rate for a patient with a regular heart rhythm. Which method will be best to use?

Use the 3-second markers to count the number of QRS complexes in 6 seconds and multiply by 10.

543. A client with HIV and pulmonary coccidioidomycosis is receiving amphotericin B. which assessment finding should the nurse report to the healthcare provider?

Urinary output of 25mL per hour

207. The nurse plans to collect a 24- hour urine specimen for a creatinine clearance test. Which instruction should the nurse provide to the adult male client?

Urinate at specific time, discard the urine, and collect all subsequent urine during the next 24 hours.

An older patient is being evaluated for a cardiac click audible upon auscultation. Which age-related change should the nurse realize might be causing this heart sound?

Valve stenosis

The nurse notes that a patient has bilateral lower extremity edema. For which health problem should the nurse assess further?

Venous insufficiency

145. A client with history of bilateral adrenalectomy is admitted with a week, irregular pulse, and hypotension. Which assessment finding warrants immediate intervention by the nurse?

Ventricular arrhythmias.

The nurse notes that a patient's cardiac monitor shows that every other beat is earlier than expected, has no visible P wave, and has a QRS complex that is wide and bizarre in shape. How will the nurse document the rhythm?

Ventricular bigeminy

A client has an endotracheal tube and is receiving mechanical ventilation. Periodic suctioning is necessary and the nurse follows a specific protocol when performing this procedure. Select in order of priority the nursing actions that should be taken when suctioning. 1. Assess client's vital signs and lung sounds 2. Insert the catheter without applying suction 3. Rotate the catheter while suction is applied 4. Administer oxygen via a ventilation bag

Vital signs, oxygenate the patient, Insert the catheter without applying suction, and then rotate the catheter while suction is applied.

499. When conducting diet teaching for a client who was diagnosed with hypoparathyroidism, which foods should the nurse encourage the client to eat?

Yogurt. Processed cheese.

A young adult female arrives at the emergency center with a black right eye and is bleeding from the left side of her head. She reports that her boyfriend has been abusing her physically. The nurse performs a history and physical examination. How should the nurse document these findings?

Young adult female presents with periorbital ecchymosis on right side, 3 cm laceration on left parietal area, approximately 1 cm deep with tissue bridging. States her boyfriend is abusive

A patient with dilated cardiomyopathy has new onset atrial fibrillation that has been unresponsive to drug therapy for several days. The priority teaching needed for this patient would include information about

anticoagulant therapy.

A client with myasthenia gravis experiences dysphagia, what is the priority risk associated with dysphagia that must be considered when planning nursing care?

aspiration

When a client suffers a complete pneumothorax, there is danger of a mediastinal shift. If such a shift occurs, what potential effect is a cause for concern? a. Rupture of the pericardium b. Infection of the subpleural lining c. Decreased filling of the right heart d. Increased volume of the unaffected lung

c Pressure within the pleural cavity causes a shift of the heart and great vessels to the unaffected side. This not only decreases the capacity of the unaffected lung but also impedes the filling of the right side of the heart and leads to a decreased cardiac output.

A client with emphysema experiences a sudden episode of shortness of breath and is diagnosed with a spontaneous pneumothorax. The client asks, "How could this have happened?" What likely cause of the spontaneous pneumothorax should the nurse's response take into consideration? a. Pleural friction rub b. Tracheoesophageal fistula c. Rupture of a subplueural bleb d. Puncture wound of the chest wall

c The etiology of a spontaneous pneumothorax is commonly the rupture of blebs on the lung surface. Blebs are similar to blisters, but are filled with air.

Cognitive deficits

difficulties with following aspects of cognition can make it heard to live a normal life or earn a living memory attention planning decision making

415. In planning strategies to reduce a client's risk for complications following orthopedic surgery, the nurse recognizes which pathology as the underlying cause of osteomyelitis?

infectious process

An antidepressant is prescribed for a depressed older client. After 1 week the client's son expresses concern that there does not seem to be much improvement. How should the nurse respond? "Antidepressant therapy requires several weeks before it becomes effective." "Antidepressant therapy will be more effective as the physical condition improves." "Additional medications may be required before behavioral changes will be observed." "Additional time is needed for the medication to become effective because of the prolonged depression."

"Antidepressant therapy requires several weeks before it becomes effective."

14. Following a lumbar puncture, a client voices several complaints. What complaint indicated to the nurse that the client is experiencing a complication?

"I have a headache that gets worse when I sit up"

625. The nurse teaches an adolescent male client how to use a metered dose inhaler. Seen in the picture. What instruction should the nurse provide?

.Move the device one to two inches away from the mouth

27. The healthcare provider prescribes celtazidime (Fortax) 35 mg every 8 hours IM for an infant. The 500 mg vial is labeled with the instruction to add 5.3 ml diluent to provide a concentration of 100 mg/ml. How many ml should the nurse administered for each dose? (Enter numeric value only. If rounding is required, round to the nearest tenth)

0.4 ml

The nurse has been caring for a client who required a Sengstaken-Blakemore tube because other treatment measures for esophageal varices were unsuccessful. The health care provider arrives on the nursing unit and deflates the esophageal balloon. After deflation of the balloon, the nurse should monitor the client most closely for which complication? 1. Hematemesis 2. Bloody diarrhea 3. Swelling of the abdomen 4. An elevated temperature and a rise in blood pressure

1 A Sengstaken-Blakemore tube may be inserted in a client with a diagnosis of cirrhosis and ruptured esophageal varices. It has both an esophageal and a gastric balloon. The esophageal balloon exerts pressure on the ruptured esophageal varices and stops the bleeding. The pressure of the esophageal balloon is released at intervals to decrease the risk of trauma to esophageal tissues, including esophageal rupture or necrosis. When the balloon is deflated, the client may begin to bleed again from the esophageal varices, manifested as vomiting of blood (hematemesis). Options 2, 3, and 4 are unrelated to deflating the esophageal balloon.

The nurse has been caring for a client with a Sengstaken-Blakemore tube. The health care provider arrives on the nursing unit and deflates the esophageal balloon. Afterward, the nurse should monitor the client most closely for which sign? 1. Hematemesis 2. Bloody diarrhea 3. Swelling of the abdomen 4. An elevated temperature and a rise in blood pressure

1 A Sengstaken-Blakemore tube may be used in a client with a diagnosis of cirrhosis and ruptured esophageal varices if other interventions are unsuccessful. The tube has an esophageal and a gastric balloon. The esophageal balloon exerts pressure on the ruptured esophageal varices and stops the bleeding. The pressure of the esophageal balloon is released at intervals to decrease the risk of trauma to esophageal tissues, including esophageal rupture or necrosis. When the balloon is deflated, the client may begin to bleed again from the esophageal varices; this would be manifested by vomiting of blood (hematemesis). Options 2, 3, and 4 are not specifically associated with esophageal deflation.

The nurse is caring for a client with an endotracheal tube attached to a mechanical ventilator. The high-pressure alarm sounds, and the nurse assesses the client. The nurse determines that the cause of the alarm is most likely to be due to which complication? 1. A kink in the ventilator circuit 2. A leak in the endotracheal tube cuff 3. Displacement of the endotracheal tube 4. A disconnection of the ventilator tubing

1 A high-pressure alarm occurs if the amount of pressure needed for ventilating a client exceeds the preset amount. Causes of high-pressure alarm activation include excess secretions; mucous plugs; the client biting on the endotracheal tube; kinks in the ventilator tubing; and the client coughing, gagging, or attempting to talk. Options 2, 3, and 4 would trigger the low-pressure alarm.

Discharge planning for an ambulatory client with Parkinson disease (PD) includes recommending equipment for home use that will help with activities of daily living. To foster independence, the nurse should promote the use of which equipment? 1 A raised toilet seat 2 Side rails for the bed 3 A trapeze above the bed 4 Crutches for ambulation

1 A raised toilet seat will reduce strain on the back muscles and make it easier for the client to rise from the seat without injury. The client is not bedridden and will not need side rails for the bed or a trapeze above the bed. Clients with Parkinson disease have poor balance and a propulsive gait, which makes it unsafe to use crutches.

The nurse is providing immediate postprocedure care to a client who had a thoracentesis to relieve a tension pneumothorax that resulted from rib fractures. The goal is that the client will exhibit normal respiratory functioning, and the nurse provides instructions to assist the client toward this goal. Which client statement indicates that further instruction is needed? 1. "I will lie on the affected side for an hour." 2. "I can expect a chest x-ray exam to be done shortly." 3. "I will let you know at once if I have trouble breathing." 4. "I will notify you if I feel a crackling sensation in my chest."

1 After the procedure the client usually is turned onto the unaffected side for 1 hour to facilitate lung expansion. Tachypnea, dyspnea, cyanosis, retractions, or diminished breath sounds, which may indicate pneumothorax, should be reported to the health care provider. A chest x-ray may be performed to evaluate the degree of lung re-expansion or pneumothorax. Subcutaneous emphysema (crepitus) may follow this procedure because air in the pleural cavity leaks into subcutaneous tissues. The involved tissues feel like lumpy paper and crackle when palpated (crepitus). Usually subcutaneous emphysema causes no problems unless it is increasing and constricting vital organs, such as the trachea.

A client with cirrhosis is beginning to show signs of hepatic encephalopathy. The nurse should plan a dietary consultation to limit the amount of which ingredient in the client's diet at this time? 1. Protein 2. Calories 3. Minerals 4. Carbohydrates

1 Ammonia is formed as a product of protein metabolism. Clients with hepatic encephalopathy have a high serum ammonia level, which is responsible for the symptoms of encephalopathy. Limiting protein intake will prevent further elevation in the serum ammonia level and prevent further deterioration of the client's mental status. It is not necessary to limit calories, minerals, or carbohydrates.

The nurse is caring for a client with acute pancreatitis and is monitoring the client for paralytic ileus. Which assessment data should alert the nurse to this occurrence? 1. Inability to pass flatus 2. Loss of anal sphincter control 3. Severe, constant pain with rapid onset 4. Firm, nontender mass palpable at the lower right costal margin

1 An inflammatory reaction such as acute pancreatitis can cause paralytic ileus, the most common form of nonmechanical obstruction. Inability to pass flatus is a clinical manifestation of paralytic ileus. Loss of sphincter control is not a sign of paralytic ileus. Pain is associated with paralytic ileus, but the pain usually manifests as a more constant generalized discomfort. Option 4 is the description of the physical finding of liver enlargement. The liver may be enlarged in cases of cirrhosis or hepatitis. Although this client may have an enlarged liver, an enlarged liver is not a sign of paralytic ileus or intestinal obstruction.

The nurse is caring for a client who sustained a spinal cord injury. During administration of morning care, the client begins to exhibit signs and symptoms of autonomic dysreflexia. Which initial nursing action should the nurse take? 1. Elevate the head of the bed. 2. Examine the rectum digitally. 3. Assess the client's blood pressure. 4. Place the client in the prone position.

1 Autonomic dysreflexia is a serious complication that can occur in the spinal cord-injured client. Once the syndrome is identified, the nurse elevates the head of the client's bed and then examines the client for the source of noxious stimuli. The nurse also assesses the client's blood pressure, but the initial action would be to elevate the head of the bed. The client would not be placed in the prone position.

The nurse is reviewing the laboratory results for a client with cirrhosis and notes that the ammonia level is elevated. Which diet does the nurse anticipate to be prescribed for this client? 1. Low-protein diet 2. High-protein diet 3. Moderate-fat diet 4. High-carbohydrate diet

1 Cirrhosis is a chronic, progressive disease of the liver characterized by diffuse degeneration and destruction of hepatocytes. Most of the ammonia in the body is found in the gastrointestinal tract. Protein provided by the diet is transported to the liver by the portal vein. The liver breaks down protein, which results in the formation of ammonia. If the client has hepatic encephalopathy, a low

A client is admitted to the hospital with acute viral hepatitis. Which sign or symptom should the nurse expect to note based on this diagnosis? 1. Fatigue 2. Pale urine 3. Weight gain 4. Spider angiomas

1 Common manifestations of acute viral hepatitis include weight loss, dark urine, and fatigue. The client is anorexic, possibly from a toxin produced by the diseased liver, and finds food distasteful. The urine darkens because of excess bilirubin being excreted by the kidneys. Fatigue occurs during all phases of hepatitis. Spider angiomas, small, dilated blood vessels, are commonly seen in cirrhosis of the liver.

The nurse caring for a client with a pneumothorax and who has had a chest tube inserted notes continuous gentle bubbling in the suction control chamber. What action is most appropriate? 1. Do nothing, because this is an expected finding. 2. Check for an air leak because the bubbling should be intermittent. 3. Increase the suction pressure so that the bubbling becomes vigorous. 4. Immediately clamp the chest tube and notify the health care provider.

1 Continuous gentle bubbling should be noted in the suction control chamber. Bubbling should be continuous in the suction control chamber and not intermittent. Increasing the suction pressure only increases the rate of evaporation of water in the drainage system; in addition, increasing the suction can be harmful and is not done without a specific prescription to do so. Chest tubes should only be clamped to check for an air leak or when changing drainage devices (according to agency policy).

The nurse is caring for a client after a craniotomy and monitors the client for signs of increased intracranial pressure (ICP). Which finding, if noted in the client, would indicate an early sign of increased ICP? 1. Confusion 2. Bradycardia 3. Sluggish pupils 4. A widened pulse pressure

1 Early manifestations of increased ICP are subtle and often may be transient, lasting for only a few minutes in some cases. These early clinical manifestations include episodes of confusion, drowsiness, and slight pupillary and breathing changes. Later manifestations include a further decrease in the level of consciousness, a widened pulse pressure, and bradycardia. Cheyne-Stokes respiratory pattern, or a hyperventilation respiratory pattern; pupillary sluggishness and dilatation appear in the late stages.

A client has developed hepatitis A after eating contaminated oysters. The nurse assesses the client for which expected assessment finding? 1. Malaise 2. Dark stools 3. Weight gain 4. Left upper quadrant discomfort

1 Hepatitis causes gastrointestinal symptoms such as anorexia, nausea, right upper quadrant discomfort, and weight loss. Fatigue and malaise are common. Stools will be light- or clay-colored if conjugated bilirubin is unable to flow out of the liver because of inflammation or obstruction of the bile ducts.

A health care provider writes a prescription to begin to wean the client from the mechanical ventilator by use of intermittent mandatory ventilation/synchronized intermittent mandatory ventilation (IMV/SIMV). The nurse determines that the process of weaning will occur by which mechanism? 1. Gradually decreasing the respiratory rate until the client can assume the work of breathing without ventilatory assistance 2. Attaching a T-piece to the ventilator and providing supplemental oxygen at a concentration that is 10% higher than the ventilator setting 3. Providing pressure support to decrease the workload of breathing and increase the client's ability to initiate spontaneous breathing efforts 4. Removing the ventilator from the client and closely monitoring the client's ability to breathe spontaneously for a predetermined amount of time

1 IMV/SIMV is one of the methods used for weaning. With this method the respiratory rate is gradually decreased until the client assumes all of the work of breathing on his or her own. This method works exceptionally well in the weaning of clients from short-term mechanical ventilation, such as that used in clients who have undergone surgery. The respiratory rate frequently is decreased in increments on an hourly basis until the client is weaned and is ready for extubation. Therefore options 2, 3, and 4 are incorrect.

A client goes to the primary healthcare provider because of fatigue, double vision, and muscle weakness. A diagnosis of myasthenia gravis is suspected. When collecting a health history, the nurse expects the client to report which information? 1 Muscle weakness improving after a period of rest 2 Symptoms worse in the morning upon awakening 3 Periods of hyperactivity 4 Slow, insidious onset of muscle weakness

1 Increased activity and stress precipitate exacerbation of symptoms because nerve impulses fail to pass to muscles at the myoneural junction with myasthenia gravis; theories include inadequate acetylcholine, excessive cholinesterase, or a nonresponse of the muscle fibers to acetylcholine. Symptoms improve after rest or a good night's sleep. Hyperactivity is not associated with myasthenia gravis. Muscle weakness and fatigue come on quickly and disappear rapidly with rest in the initial stages of myasthenia gravis. Rest promotes a decrease in symptoms associated with myasthenia gravis because the demand for muscle contraction is reduced.

The nurse is reviewing the results of serum laboratory studies for a client admitted for suspected hepatitis. Which laboratory finding is most associated with hepatitis requiring the nurse to contact the health care provider? 1. Elevated serum bilirubin level 2. Below normal hemoglobin concentration 3. Elevated blood urea nitrogen (BUN) level 4. Elevated erythrocyte sedimentation rate (ESR)

1 Laboratory indicators of hepatitis include elevated liver enzymes, serum bilirubin level, and ESR. However, ESR is a nonspecific test that indicates the presence of inflammation somewhere in the body. The hemoglobin concentration is unrelated to this diagnosis. An elevated BUN level may indicate renal dysfunction.

The nurse is reviewing the record of a client admitted to the nursing unit and notes that the client has a history of Laennec's cirrhosis. This type of cirrhosis is most commonly caused by which long-term condition? 1. Alcohol abuse 2. Cardiac disease 3. Exposure to chemicals 4. Obstruction to biliary ducts

1 Laennec's cirrhosis results from long-term alcohol abuse. Cardiac cirrhosis most commonly is caused by long-term right-sided heart failure. Exposure to hepatotoxins, chemicals, or infections, or a metabolic disorder can cause postnecrotic cirrhosis. Biliary cirrhosis results from a decrease in bile flow and is most commonly caused by long-term obstruction of bile ducts.

A client arrives in the hospital emergency department with a closed head injury to the right side of the head caused by an assault with a baseball bat. The nurse assesses the client neurologically, looking primarily for motor response deficits that involve which area? 1. The left side of the body 2. The right side of the body 3. Both sides of the body equally 4. Cranial nerves only, such as speech and pupillary response

1 Motor responses such as weakness and decreased movement will be seen on the side of the body that is opposite an area of head injury. Contralateral deficits result from compression of the cortex of the brain or the pyramidal tracts. Depending on the severity of the injury, the client may have a variety of neurological deficits.

A client has been admitted with chest trauma after a motor vehicle crash and has undergone subsequent intubation. The nurse checks the client when the high-pressure alarm on the ventilator sounds, and notes that the client has absence of breath sounds in the right upper lobe of the lung. The nurse immediately assesses for other signs of which condition? 1. Right pneumothorax 2. Pulmonary embolism 3. Displaced endotracheal tube 4. Acute respiratory distress syndrome

1 Pneumothorax is characterized by restlessness, tachycardia, dyspnea, pain with respiration, asymmetrical chest expansion, and diminished or absent breath sounds on the affected side. Pneumothorax can cause increased airway pressure because of resistance to lung inflation. Acute respiratory distress syndrome and pulmonary embolism are not characterized by absent breath sounds. An endotracheal tube that is inserted too far can cause absent breath sounds, but the lack of breath sounds most likely would be on the left side because of the degree of curvature of the right and left mainstem bronchi.

The nurse determines that a client with a tracheostomy tube needs suctioning if which finding is noted? 1. Rhonchi are auscultated. 2. Pleural friction rub is heard. 3. Fine crackles are auscultated. 4. Pulse oximetry reading is 96%.

1 Presence of rhonchi is an indication that there are secretions in the large airways. The client requires suctioning if he or she cannot expectorate them. A pulse oximetry reading of 96% is an acceptable reading. A pleural friction rub is indicative of inflamed pleural surfaces. Fine crackles are indicative of air moving into previously deflated alveoli.

A Penrose drain is in place on the first postoperative day in a client who has undergone a cholecystectomy procedure. Serosanguineous drainage is noted on the dressing covering the drain. Which nursing intervention is most appropriate? 1. Change the dressing. 2. Continue to monitor the drainage. 3. Notify the health care provider (HCP). 4. Use a pen to circle the amount of drainage on the dressing.

1 Serosanguineous drainage with a small amount of bile is expected from the Penrose drain for the first 24 hours. Drainage then decreases, and the drain is usually removed within 48 hours. A sterile dressing covers the site and should be changed if wet to prevent infection and skin excoriation. Although the nurse would continue to monitor the drainage, the most appropriate intervention is to change the dressing. The HCP does not need to be notified.

A client newly diagnosed with myasthenia gravis is concerned about fluctuations in physical condition and generalized weakness. When caring for this client it is most important for the nurse to plan which intervention? 1 Space activities throughout the day. 2 Restrict activities and encourage bed rest. 3 Teach the client about limitations imposed by the disorder. 4 Have a family member stay at the bedside to give the client support.

1 Spacing activities encourages maximum functioning within the limits of the client's strength and endurance. Bed rest and limited activity may lead to muscle atrophy and calcium depletion. Teaching the limitations imposed by the disorder is necessary for lifelong psychologic adjustment, but does not address the client's concerns at this time. Having a member of the family stay and give the client support should be permitted if requested by the client or family, but does not address the concerns voiced by the client.

Which intervention should the nurse include in a postoperative teaching plan for a client who underwent a spinal fusion and will be wearing a brace? 1. Tell the client to inspect the environment for safety hazards. 2. Inform the client about the importance of sitting as much as possible. 3. Inform the client that lotions and body powders can be used for skin breakdown. 4. Instruct the client to tighten the brace during meals and to loosen it for the first 30 minutes after each meal.

1 The client must inspect the environment for safety hazards. The client is instructed in the importance of avoiding prolonged sitting and standing. Powders and lotions should not be used because they may irritate the skin. The client should be taught to loosen the brace during meals and for 30 minutes after each meal. The client may have difficulty eating if the brace is too tight. Loosening the brace after each meal will allow adequate nutritional intake and promote comfort.

The nursing instructor is observing a nursing student suctioning a client through a tracheostomy tube. Which observation by the nursing instructor indicates an action by the student requiring the need for further instruction? 1. Suctioning the client every hour 2. Applying suction only during withdrawal of the catheter 3. Hyperventilating the client with 100% oxygen before suctioning 4. Applying suction intermittently during withdrawal of the catheter

1 The client should be suctioned as needed. Unnecessary suctioning should be avoided because it can increase secretions and cause mechanical trauma to the tissues. The client should be hyperoxygenated with 100% oxygen before suctioning. Suction is not applied during insertion of the catheter; intermittent suction and a twirling motion of the catheter are used during withdrawal.

A client with viral hepatitis states, "I am so yellow." What is the most appropriate nursing action? 1. Assist the client in expressing feelings. 2. Restrict visitors until the jaundice subsides. 3. Perform most of the activities of daily living for the client. 4. Provide information to the client only when he or she requests it.

1 The client should be supported to explore feelings about the disease process and altered appearance so that appropriate interventions can be planned. Restricting visitors would reinforce the client's negative self-esteem. To assist the client in adapting to changes in appearance, it is important for the nurse to encourage participation in self-care to foster independence and self-esteem. The client should be encouraged to ask questions to clarify misconceptions, to learn ways to prevent the spread of hepatitis, to reduce fear, and to make appropriate decisions.

The nurse is providing instructions to a client with a seizure disorder who will be taking phenytoin (Dilantin). Which statement, if made by the client, would indicate an understanding of the information about this medication? 1. "I need to perform good oral hygiene, including flossing and brushing my teeth." 2. "I should try to avoid alcohol, but if I'm not able to, I can drink alcohol in moderation." 3. "I should take my medication before coming to the laboratory to have a blood level drawn." 4. "I should monitor for side effects and adjust my medication dose depending on how severe the side effects are."

1 The client should perform good oral hygiene, including flossing and brushing the teeth. The client also should see a dentist at regularly scheduled times because gingival hyperplasia is a side effect of this medication. The client should avoid alcohol while taking this medication. The client should also be instructed that follow-up serum blood levels are important and that, on the day of the scheduled laboratory test, the client should avoid taking the medication before the specimen is drawn. The client should not adjust medication dosages.

A nurse is reviewing the health care provider's prescriptions written for a client admitted to the hospital with acute pancreatitis. Which prescription should the nurse confirm? 1. Full liquid diet 2. Morphine sulfate for pain 3. Nasogastric tube insertion 4. An anticholinergic medication

1 The client with acute pancreatitis is placed on an NPO (nothing by mouth) status to decrease the activity of the pancreas, which occurs with oral intake. Pain management for acute pancreatitis typically begins with the administration of opioids by patient-controlled analgesia. Medications such as morphine or hydromorphone (Dilaudid) are typically used. Nasogastric tube insertion is done to provide suction of secretions and administer medications as necessary.

A nurse is providing a simple overview of the anatomy of the liver and gallbladder for a client hospitalized with biliary obstruction. The nurse explains that normally the liver stores bile in the gallbladder and that the liver and gallbladder are connected together by which passageway? 1. Cystic duct 2. Liver canaliculi 3. Common bile duct 4. Right hepatic duct

1 The gallbladder receives bile from the liver through the cystic duct. The liver collects bile in the canaliculi, from which bile flows into the right and left hepatic ducts and then into the common hepatic duct. From there, the bile can be transported for storage in the gallbladder through the cystic duct, or it can flow directly into the duodenum by way of the common bile duct.

A client who had cranial surgery 5 days earlier to remove a brain tumor has a few cognitive deficits and does not seem to be progressing as quickly as the client or family hoped. The nurse plans to implement which approach as most helpful to the client and family at this time? 1. Emphasize progress in a realistic manner. 2. Set high goals to give the client something to "aim for." 3. Tell the family to be extremely optimistic with the client. 4. Inform the client and family of standardized goals of care.

1 The most helpful approach by the nurse is to emphasize progress that is being made in a realistic manner. The nurse does not offer false hope but does provide factual information in a clear and positive manner. The nurse encourages the family to be realistic in their expectations and attitudes. The plan of care should be individualized for each client.

The nurse caring for a client with a head injury is monitoring for signs of increased intracranial pressure. The nurse reviews the record and notes that the intracranial pressure (cerebrospinal fluid) is averaging 8 mm Hg. The nurse plans care, knowing that these results are indicative of which condition? 1. Normal condition 2. Increased pressure 3. Borderline situation 4. Compensating condition

1 The normal intracranial pressure is 5 to 10 mm Hg. A pressure of 8 mm Hg is within normal range.

The nurse is reviewing a discharge teaching plan for a postcraniotomy client that was prepared by a nursing student. The nurse would intervene and provide teaching to the student if the student included which home care instruction? 1. Sounds will not be heard clearly unless they are loud. 2. Obtain assistance with ambulation if client is lightheaded. 3. Tub bath or shower is permitted, but the scalp is kept dry until the sutures are removed. 4. Use a check-off system for administering anticonvulsant medications to avoid missing doses.

1 The postcraniotomy client typically is sensitive to loud noises and can find them excessively irritating. Control of environmental noise by others will be helpful for this client. Seizures are a potential complication that may occur for up to 1 year after surgery. For this reason, the client must diligently take anticonvulsant medications. The client and family are encouraged to keep track of the doses administered. The family should learn seizure precautions and should accompany the client during ambulation if dizziness or seizures tend to occur. The suture line is kept dry until sutures are removed to prevent infection.

A nurse is caring for a client diagnosed with suspected acute pancreatitis. When reviewing the client's laboratory results, the nurse interprets that which finding will support the diagnosis? 1. Elevated serum lipase level 2. Elevated serum bilirubin level 3. Decreased serum trypsin level 4. Decreased serum amylase level

1 The serum lipase level is elevated in the presence of pancreatic cell injury. Serum trypsin and amylase levels are also elevated in pancreatic injury. Although bilirubin can be elevated in the client with pancreatitis, it is secondary to the hepatobiliary obstructive process.

A client with liver dysfunction exhibits low serum levels of thrombin. The nurse provides care, knowing that this client is most at risk for which complication? 1. Bleeding 2. Infection 3. Dehydration 4. Malnutrition

1 Thrombin is produced by the liver and is necessary for normal clotting. The client who has an insufficient level of this substance is at risk for bleeding. Options 2, 3, and 4 are incorrect and not associated with thrombin.

The nurse is teaching a client with paraplegia measures to maintain skin integrity. Which instruction will be most helpful to the client? 1. Shift weight every 2 hours while in a wheelchair. 2. Change bed sheets every other week to maintain cleanliness. 3. Place a pillow on the seat of the wheelchair to provide extra comfort. 4. Use a mirror to inspect for redness and skin breakdown twice a week.

1 To maintain skin integrity, the client should shift weight in the wheelchair every 2 hours and use a pressure relief pad. A pillow is not sufficient to relieve the pressure. While the client is in bed, the bottom sheet should be free of wrinkles and wetness. Sheets should be changed as needed and more frequently than every other week. The client should use a mirror to inspect the skin twice daily (morning and evening) to assess for redness, edema, and breakdown. General additional measures include a nutritious diet and meticulous skin care.

A nurse is caring for a client with a tracheostomy tube attached to a ventilator. The high-pressure alarm sounds on the ventilator. The nurse should plan to perform which action? 1. Suction the client. 2. Evaluate the cuff for a leak. 3. Assess for a disconnection. 4. Notify the respiratory therapist.

1 When the high-pressure alarm sounds on a ventilator, it is most likely because of an obstruction. The obstruction can be caused by the client's biting on the tube, kinking of the tubing, or mucus plugging requiring suctioning. Options 2 and 3 would cause the low-pressure alarm to sound. Option 4 delays necessary treatment.

The nurse has just admitted to the nursing unit a client with a basilar skull fracture who is at risk for increased intracranial pressure. Pending specific health care provider prescriptions, the nurse should safely place the client in which positions? Select all that apply. 1. Head midline 2. Neck in neutral position 3. Head of bed elevated 30 to 45 degrees 4. Head turned to the side when flat in bed 5. Neck and jaw flexed forward when opening the mouth

1, 2, 3 Use of proper positions promotes venous drainage from the cranium to keep intracranial pressure from elevating.The head of the client at risk for or with increased intracranial pressure should be positioned so that the head is in a neutral, midline position. The head of the bed should be raised to 30 to 45 degrees. The nurse should avoid flexing or extending the neck or turning the head from side to side.

A client who is intubated and receiving mechanical ventilation has a problem of risk for infection. The nurse should include which measures in the care of this client? Select all that apply. 1. Monitor the client's temperature. 2. Use sterile technique when suctioning. 3. Use the closed-system method of suctioning. 4. Monitor sputum characteristics and amounts. 5. Drain water from the ventilator tubing into the humidifier bottle.

1, 2, 3, 4 Monitoring temperature and sputum production is indicated in the care of the client. A closed-system method of suctioning and sterile technique decrease the risk of infection associated with suctioning. Water in the ventilator tubing should be emptied, not drained back into the humidifier bottle. This puts the client at risk of acquiring infection, especially Pseudomonas.

The nurse is assessing a client who is experiencing seizure activity. The nurse understands that it is necessary to determine information about which items as part of routine assessment of seizures? Select all that apply. 1. Postictal status 2. Duration of the seizure 3. Changes in pupil size or eye deviation 4. Seizure progression and type of movements 5. What the client ate in the 2 hours preceding seizure activity

1, 2, 3, 4 Typically seizure assessment includes the time the seizure began, parts of the body affected, type of movements and progression of the seizure, change in pupil size or eye deviation or nystagmus, client condition during the seizure, and postictal status. Option 5 is not a component of seizure assessment.

The nurse is developing a plan of care for a client with cirrhosis and ascites. Which nursing actions should be included in the care plan for this client? Select all that apply. 1. Monitor daily weight. 2. Measure abdominal girth. 3. Monitor respiratory status. 4. Place the client in a supine position. 5. Assist the client with care as needed.

1, 2, 3, 5 Ascites is a problem because as more fluid is retained, it pushes up on the diaphragm, thereby impairing the client's breathing patterns. The client should be placed in a semi-Fowler's position with the arms supported on a pillow to allow for free diaphragm movement. The correct options identify appropriate nursing interventions to be included in the plan of care for the client with ascites.

A client with cirrhosis has ascites and excess fluid volume. Which assessment findings does the nurse anticipate to note as a result of increased abdominal pressure? Select all that apply. 1. Orthopnea, dyspnea 2. Petechiae and ecchymosis 3. Inguinal or umbilical hernia 4. Poor body posture and balance 5. Abdominal distention and tenderness

1, 2, 3, 5 Excess fluid volume, related to the accumulation of fluid in the peritoneal cavity and dependent areas of the body, can occur in the client with cirrhosis. Ascites can cause physical problems because of the overdistended abdomen and resultant pressure on internal organs and vessels. These problems include respiratory difficulty, petechiae and ecchymoses, development of hernias, abdominal distention, and tenderness. Option 4 is unrelated to increased abdominal pressure.

The nurse is preparing to wean a client from a ventilator by the use of a T-piece. Which would be a component of the plan of care with this type of weaning process? Select all that apply. 1. Pressure support is added to the oxygen system. 2. The T-piece is connected to the client's artificial airway. 3. The client is removed from the mechanical ventilator for a short period of time. 4. The respiratory rate on the ventilator is gradually decreased until the client can do all of the work of breathing on his or her own. 5. Supplemental oxygen is provided through the T-piece at a fraction of inspired oxygen that is 10% higher than a ventilator setting.

1, 2, 3, 5 The T-piece (or Briggs device) requires that the client be removed from the mechanical ventilation for short periods of time, usually beginning with a 5-minute period. The ventilator is disconnected, and the T-piece is connected to the client's artificial airway. Supplemental oxygen is provided through the device, often at a Fio2 that is 10% higher than the ventilator setting. Option 4 describes intermittent mandatory ventilation/synchronized intermittent mandatory ventilation. Pressure support may be prescribed to open alveoli in some clients on mechanical ventilation.

The nurse is reviewing the prescription for a client admitted to the hospital with a diagnosis of acute pancreatitis. Which interventions would the nurse expect to be prescribed for the client? Select all that apply. 1. Administer antacids as prescribed. 2. Encourage coughing and deep breathing. 3. Administer anticholinergics as prescribed. 4. Give small, frequent high-calorie feedings. 5. Maintain the client in a supine and flat position. 6. Give opioid analgesics as prescribed for pain.

1, 2, 3, 6 The client with acute pancreatitis normally is placed on NPO status to rest the pancreas and suppress gastrointestinal secretions. Because abdominal pain is a prominent symptom of pancreatitis, pain medication is prescribed. Some clients experience lessened pain by assuming positions that flex the trunk, with the knees drawn up to the chest. A side-lying position with the head elevated 45 degrees decreases tension on the abdomen and may help ease the pain. The client is susceptible to respiratory infections because the retroperitoneal fluid raises the diaphragm, which causes the client to take shallow, guarded abdominal breaths. Therefore, measures such as turning, coughing, and deep breathing are instituted. Antacids and anticholinergics may be prescribed to suppress gastrointestinal secretions.

A client who has undergone radical neck dissection for a tumor has a potential problem of obstruction related to postoperative edema, drainage, and secretions. To promote adequate respiratory function in this client, the nurse should implement which activities? Select all that apply. 1. Suctioning the client as needed 2. Encouraging coughing every 2 hours 3. Placing the bed in low Fowler's position 4. Supporting the neck incision when the client coughs 5. Monitoring the respiratory status frequently as prescribed

1, 2, 4, 5 The client's respiratory status is promoted by the use of high Fowler's position after this surgery. Low Fowler's position is avoided because it could result in increased venous pressure on the surgical site and increased risk of regurgitation and aspiration. It also is helpful to encourage the client to cough and deep breathe every 2 hours, to support the neck incision when coughing, to suction periodically as needed, and to monitor the respiratory status frequently as prescribed.

The nurse is planning to institute seizure precautions for a client who is being admitted from the emergency department. Which measures should the nurse include in planning for the client's safety? Select all that apply. 1. Padding the side rails of the bed 2. Placing an airway at the bedside 3. Placing the bed in the high position 4. Putting a padded tongue blade at the head of the bed 5. Placing oxygen and suction equipment at the bedside 6. Having intravenous equipment ready for insertion of an intravenous catheter

1, 2, 5, 6 Seizure precautions may vary from agency to agency, but they generally have some common features. Usually, an airway, oxygen, and suctioning equipment are kept available at the bedside. The side rails of the bed are padded, and the bed is kept in the lowest position. The client has an intravenous access in place to have a readily accessible route if anticonvulsant medications must be administered. The use of padded tongue blades is highly controversial, and they should not be kept at the bedside. Forcing a tongue blade into the mouth during a seizure more likely will harm the client who bites down during seizure activity. Risks include blocking the airway from improper placement, chipping the client's teeth, and subsequent risk of aspirating tooth fragments. If the client has an aura before the seizure, it may give the nurse enough time to place an oral airway before seizure activity begins.

The nurse is teaching the client with viral hepatitis about the stages of the disease. The nurse should explain to the client that the second stage of this disease is characterized by which specific assessment findings? Select all that apply. 1. Jaundice 2. Flu-like symptoms 3. Clay-colored stools 4. Dark or tea-colored urine 5. Elevated bilirubin levels

1, 3, 4, 5 There are three stages associated with viral hepatitis. The first (preicteric) stage includes flulike symptoms only. The second (icteric) stage includes the appearance of jaundice and associated symptoms such as elevated bilirubin levels, dark or tea-colored urine, and clay-colored stools. The third (posticteric) stage occurs when the jaundice decreases and the colors of the urine and stool return to normal.

A nurse is teaching a client with multiple sclerosis (MS) about how to manage urinary retention. Which instructions should the nurse include in the teaching session? Select all that apply. 1 Using Credé maneuver 2 Using an indwelling catheter 3 Using anticholinergic medications 4 Monitoring and restricting fluid intake to 800 mL daily 5 Monitoring for and reporting signs of urinary tract infection

1, 5 Credé maneuver is the use of manual pressure over the suprapubic area to compress the bladder and promote emptying. Urinary retention is a risk factor for urinary tract infection. Physical stressors, such as infections, can trigger exacerbations in clients with multiple sclerosis. Early recognition and treatment of infection is important to decrease the risk of exacerbation in the client with multiple sclerosis. Use of an indwelling urinary catheter puts the client at risk for urinary tract infection. Some clients with urinary retention are taught intermittent self-catheterization. Risk of urinary tract infection is lower with intermittent catheterization than with the use of an indwelling urinary catheter. Acetylcholine is the primary neurotransmitter of the parasympathetic nervous system. Stimulation of the parasympathetic nervous system causes the detrusor muscle to contract, which promotes bladder emptying. Anticholinergic medications inhibit the cholinergic response and lead to urinary retention. Oral fluids should be encouraged in the client with voiding difficulties as concentrated urine increases the risk of urinary tract infection.

A nurse is performing the history and physical examination of a client with Parkinson disease. Which assessments identified by the nurse support this diagnosis? Select all that apply. 1 Nonintention tremors 2 Frequent bouts of diarrhea 3 Masklike facial expression 4 Hyperextension of the neck 5 Rigidity to passive movement

1,3,5 Nonintention tremors associated with Parkinson disease result from degeneration of the dopaminergic pathways and excess cholinergic activity in the feedback circuit. A masklike facial expression results from nigral and basal ganglial depletion of dopamine, an inhibitory neurotransmitter. Cogwheel rigidity is increased resistance to passive motion and is a classic sign of Parkinson. Constipation, not diarrhea, is a common problem because of a weakness of muscles used in defecation. The tendency is for the head and neck to be drawn forward, not hyperextended, because of loss of basal ganglial control.

A nurse assesses a client who is suspected of being in myasthenic crisis. Which assessment finding is most definitive in support of this conclusion? 1 Difficulty breathing 2 Decline in physical mobility 3 Disturbed sensory perception 4 Decreased tolerance to activity

1. Excessive weakness and impaired diaphragmatic innervation result in an ineffective ability to breathe; difficulty breathing, ineffective airway clearance, and ineffective gas exchange support the conclusion that the client is in myasthenic crisis. A decline in physical mobility is not as definitive as respiratory difficulty. A disturbance in sensory perception is not as definitive as respiratory distress; blurred vision and pupillary miosis occur with cholinergic crisis. Deterioration in activity tolerance is not as definitive as respiratory distress; this is a common occurrence in clients with myasthenia gravis.

The nurse is caring for a client immediately after removal of the endotracheal tube. The nurse should report which sign immediately if experienced by the client? 1. Stridor 2. Occasional pink-tinged sputum 3. Respiratory rate of 24 breaths/minute 4. A few basilar lung crackles on the right

1. Stridor Following removal of the endotracheal tube the nurse monitors the client for respiratory distress. The nurse reports stridor to the health care provider (HCP) immediately. This is a high-pitched, coarse sound that is heard with the stethoscope over the trachea. Stridor indicates airway edema and places the client at risk for airway obstruction. Although the findings identified in the remaining options require monitoring, they do not require immediate notification of the health care provider.

A client with myasthenia gravis experiences dysphagia. What is the priority risk associated with dysphagia that must be considered when planning nursing care? 1 Aspiration 2 Dehydration 3 Nutritional imbalance 4 Impaired communication

1. Dysphagia may lead to aspiration, which can cause pneumonia, interfering with gas exchange and posing a threat to life. While nutrition and fluid intake will be adversely affected by dysphagia, dehydration and nutritional imbalance are not the priority. Dysphagia is difficulty swallowing and does not affect communication.

The nurse is assisting a client with myasthenia gravis to bathe. The nurse identifies that the client's arms become weaker with sustained movement. What action should the nurse take? 1 Encourage the client to rest for short periods. 2 Continue the bath while supporting the client's arms. 3 Gradually increase the client's activity level each day. 4 Administer a dose of pyridostigmine bromide.

1. Rest will decrease the demands at the synaptic membrane of the neuromuscular junction, reducing fatigue; activity should be paced to prevent fatigue before it begins. Continuing the bath while supporting the client's arms and gradually increasing the client's activity level each day will aggravate the fatigue; activity and rest should be delicately balanced to prevent fatigue. Administering a dose of pyridostigmine bromide cannot be done without a healthcare provider's prescription; rest usually will alleviate the fatigue.

A client is admitted to the hospital with a tentative diagnosis of Guillain-Barré syndrome. Which question by the nurse will best elicit information that supports this diagnosis? 1 "Have you experienced an infection recently?" 2 "Is there a history of this disorder in your family?" 3 "Did you receive a head injury during the past year?" 4 "What medications have you taken in the last several months?"

1. "Have you experienced an infection recently?" Symptoms usually appear one to three weeks after an acute infection; this syndrome is linked to diseases such as viral hepatitis, the Epstein-Barr virus, and infectious mononucleosis. There is no known familial tendency that exists in the development of Guillain-Barré syndrome. This syndrome is unrelated to head trauma. Drug therapy is not implicated as a contributing factor in Guillain-Barré syndrome.

A client recently diagnosed with multiple sclerosis says, "I had planned to get married before the end of the year. After this diagnosis, I might not be ready. Maybe I should call off the wedding." Which is the best response by the nurse? 1 "You don't feel able to make a decision at this time?" 2 "Have you spoken to your fiancé about your feelings?" 3 "Your fiancé loves you and I'm sure still wants to marry you." 4 "These are your feelings now, but don't decide until you feel better and can cope."

1. "You don't feel able to make a decision at this time?" The response "You don't feel able to make a decision at this time?" reflects the client's concern and provides an opportunity for further verbalization while indicating the nurse's understanding. The response "Have you spoken to your fiancé about your feelings?" changes the emphasis to the fiancé's opinion and asks a direct question, which closes off communication. The response "Your fiancé loves you and I'm sure still wants to marry you" is false reassurance that belittles the client's concerns. The response "These are your feelings now, but don't decide until you feel better and can cope" gives advice and cuts off further exploration of the client's feelings.

98. The development of atherosclerosis is a process of sequential events. Arrange the pathophysiological events in orders of occurrence. (Place the first event on top and the last on the bottom)

1. Arterial endothelium injury causes inflammation 2. Macrophages consume low density lipoprotein (LDL), creating foam cells 3. Foam cells release growth factors for smooth muscle cells 4. Smooth muscle grows over fatty streaks creating fibrous plaques 5. Vessel narrowing results in ischemia

521. The nurse is collecting a sterile urine specimen using a straight catheter tray for culture.... (Arrange from first action to last).

1. Drape the client in a recumbent position for privacy 2. Open the urinary catheterization tray 3. Don sterile gloves using aseptic technique 4. Use forceps and swaps to clean the urinary meatus

365. Which action should the nurse implement with auscultating anterior breath sounds? (Place the first action on top and last action on the bottom)

1. Place stethoscope in suprasternal area to auscultate for bronchial sounds 2. Auscultate bronchovesicular sounds from side to side the first and second intercostal spaces 3. Displace female breast tissue and apply stethoscope directly on chest wall to hear vesicular sounds 4. Document normal breath sounds and location of adventitious breath sounds

212. The nurse is caring for a 4-year-old male child who becomes unresponsive as his heart rate decreases to 40 beats/minute. His blood pressure is 88/70 mmHg, and his oxygen saturation is 70% while receiving 100% oxygen by non-rebreather face mask. In what sequence, from first to last, should the nurse implement these actions? (Place the first action on top and last action on the bottom.)

1. Start chest compressions with assisted manual ventilations 2. Administer epinephrine 0.01 mg/kg intraosseous (IO) 3. Apply pads and prepare for transthoracic pacing 4. Review the possible underlying causes for bradycardia

372. Nurses working on a surgical unit are concerned about the physicians treatment of clients during invasive procedures, such as dressing changes and insertion of IV lines. Clients are often crying during the procedures, and the physician is usually unconcerned or annoyed by the client's response. To resolve this problem, what actions should the nurses take? (Arrange from the first action on the top of the list on the bottom)

1. Talk to the physician as a group in a non-confrontational manner. 2. Document concerns and report them to the charge nurse. 3. Submit a written report to the director of nursing. 4. Contact the hospital's chief of medical services. 5. File a formal complaint with the state medical board.

After a transurethral vaporization of the prostate, the client returns to the unit with an indwelling urinary catheter and a continuous bladder irrigation. The client puts the call light on to report the need to urinate. What should the nurse do first? 1.Assess that the tubing attached to the collection bag is patent 2.Obtain the client's vital signs 3.Explain that the balloon inflated in the bladder causes this feeling 4.Review the client's intake and output

1.Assess that the tubing attached to the collection bag is patent

An obese client who is mildly hypertensive is hospitalized with a diagnosis of ureteral colic and hematuria. What is the immediate focus of nursing care for this client? 1.Pain 2.Weight 3.Hematuria 4.Hypertension

1.Pain

A client is receiving furosemide (Lasix) to relieve edema. The nurse should monitor the client for which responses? (Select all that apply.) 1.Weight loss 2.Negative nitrogen balance 3.Increased urine specific gravity 4.Excessive loss of potassium ions 5.Pronounced retention of sodium ions

1.Weight loss 4.Excessive loss of potassium ions

A client receives a new prescription for guaifenesin (Robitussin) 2 tablespoons PO q6h. The client takes the prescribed dose for 3 days q6h. What is the total number of oz client has taken?

12

310. The healthcare provider prescribes potassium chloride 25 mEq in 500 ml D_5W to infuse over 6 hours. The available 20 ml vial of potassium chloride is labeled, "10 mEq/5ml." how many ml of potassium chloride should the nurse add the IV fluid? (Enter numeric value only. If is rounding is required, round to the nearest tenth.)

12.5

A home care nurse visits a client who was recently diagnosed with cirrhosis. The nurse provides home care management instructions to the client. Which client statement indicates a need for further instruction? 1. "I will obtain adequate rest." 2. "I will take Tylenol if I get a headache." 3. "I should monitor my weight on a regular basis." 4. "I need to include sufficient amounts of carbohydrates in my diet."

2 Acetaminophen is avoided because it can cause fatal liver damage in the client with cirrhosis. Adequate rest and nutrition are important. The client's weight should be monitored on a regular basis. The diet should supply sufficient carbohydrates with a total daily calorie intake of 2000 to 3000.

The nurse has made a judgment that a client who had a craniotomy is experiencing a problem with body image. The nurse develops goals for the client but determines that the client has not met the outcome criteria by discharge if the client performs which action? 1. Wears a turban to cover the incision 2. Indicates that facial puffiness will be a permanent problem 3. Verbalizes that periorbital bruising will disappear over time 4. States an intention to purchase a hairpiece until hair has grown back

2 After craniotomy, clients may experience difficulty with altered personal appearance. The nurse can help by listening to the client's concerns and by clarifying any misconceptions about facial edema, periorbital bruising, and hair loss (all of which are temporary). The nurse can encourage the client to participate in self-grooming and use personal articles of clothing. Finally, the nurse can suggest the use of a turban, followed by a hairpiece, to help the client adapt to the temporary change in appearance.

A nurse is reviewing laboratory test results for a client with liver disease and notes that the client's albumin level is low. The nurse next assesses the client for which physiological effect of decreased circulating albumin? 1. Cerebral edema 2. Peripheral edema 3. Decreased clotting ability 4. Reflexive increase in total protein level

2 Albumin is responsible for maintaining the osmolality of the blood. When the albumin level is low, osmotic pressure is decreased, which in turn can lead to peripheral edema. The client will not experience cerebral edema. Clotting factors produced by the liver (not albumin) are responsible for coagulation. The total protein level may decrease if the albumin level is low.

A client is admitted to the hospital with viral hepatitis, complaining of "no appetite" and "losing my taste for food." What instruction should the nurse give the client to provide adequate nutrition? 1. Select foods high in fat. 2. Increase intake of fluids, including juices. 3. Eat a good supper when anorexia is not as severe. 4. Eat less often, preferably only three large meals daily.

2 Although no special diet is required to treat viral hepatitis, it is generally recommended that clients consume a low-fat diet as fat may be tolerated poorly because of decreased bile production. Small, frequent meals are preferable and may even prevent nausea. Frequently, appetite is better in the morning, so it is easier to eat a good breakfast. An adequate fluid intake of 2500 to 3000 mL/day that includes nutritional juices is also important.

A client admitted to the nursing unit from the hospital emergency department has a C4 spinal cord injury. In conducting the admission assessment, what is the nurse's priority action? 1. Take the temperature. 2. Listen to breath sounds. 3. Observe for dyskinesias. 4. Assess extremity muscle strength.

2 Because compromise of respiration is a leading cause of death in cervical cord injury, respiratory assessment is the highest priority. Assessment of temperature and strength can be done after adequate oxygenation is ensured. Because dyskinesias occur in cerebellar disorders, this is not as important a concern as in cord-injured clients unless head injury is suspected.

The client with a cervical spine injury has cervical tongs applied in the emergency department. What should the nurse avoid when planning care for this client? 1. Using a Roto-Rest bed 2. Removing the weights to reposition the client 3. Assessment of the integrity of the weights and pulleys 4. Comparing the amount of prescribed traction with the amount in use

2 Cervical tongs are applied after drilling holes in the client's skull under local anesthesia. Weights are attached to the tongs, which exert pulling pressure on the longitudinal axis of the cervical spine. Serial x-rays of the cervical spine are taken, with weights being added gradually until the x-ray reveals that the vertebral column is realigned. After that, weights may be reduced gradually to a point that maintains alignment. The client with cervical tongs is placed on a Stryker frame or Roto-Rest bed. The nurse ensures that weights hang freely, and the amount of weight matches the current prescription. The nurse also inspects the integrity and position of the ropes and pulleys. The nurse does not remove the weights to administer care.

The nurse is obtaining a health history for a client with chronic pancreatitis. The health history is most likely to include which as a common causative factor in this client's disorder? 1. Weight gain 2. Use of alcohol 3. Exposure to occupational chemicals 4. Abdominal pain relieved with food or antacids

2 Chronic pancreatitis occurs most often in alcoholics. Abstinence from alcohol is important to prevent the client from developing chronic pancreatitis. Clients usually experience malabsorption with weight loss. Chemical exposure is associated with cancer of the pancreas. Pain will not be relieved with food or antacids.

The home care nurse is making extended follow-up visits to a client discharged from the hospital after a moderately severe head injury. The family states that the client is behaving differently than before the accident. The client is more fatigued and irritable and has some memory problems. The client, who was previously very even-tempered, is prone to outbursts of temper now. The nurse counsels the family on the basis of an understanding that these behaviors are indicative of which condition? 1. Indicate a worsening of the original injury 2. Will probably be a long-term sequela of the injury 3. Will come and go as intracranial pressure changes 4. Are short-term problems that will resolve in about 1 month

2 Clients with moderate to severe head injury usually have residual physical and cognitive disabilities; these include personality changes, increased fatigue and irritability, mood alterations, and memory changes. The client also may require frequent to constant supervision. The nurse assesses the family's ability to cope and makes appropriate referrals to respite services, support groups, and state or local chapters of the National Head Injury Foundation.

A nurse is caring for a client with a chest tube drainage system and notes constant bubbling in the water seal chamber. Which nursing action is appropriate? 1. Reposition the client. 2. Notify the health care provider (HCP). 3. Change the chest tube drainage system. 4. No action is necessary because this is a normal expected finding.

2 Constant bubbling occurring in the water seal chamber may indicate an air leak in the system. Among the options provided, the appropriate action is to notify the HCP. Options 1, 3, and 4 are incorrect.

The nurse in the health care clinic is providing medication instructions to a client with a seizure disorder who will be taking divalproex sodium (Depakote). The nurse should instruct the client about the importance of returning to the clinic for monitoring of which laboratory study? 1. Electrolyte panel 2. Liver function studies 3. Renal function studies 4. Blood glucose level determination

2 Divalproex sodium, an anticonvulsant, can cause fatal hepatotoxicity. The nurse should instruct the client about the importance of monitoring the results of liver function studies and ammonia level determinations. Options 1, 3, and 4 are not studies that are required with the use of this medication.

The nurse is admitting a client to the hospital emergency department from a nursing home. The client is unconscious with an apparent frontal head injury. A medical diagnosis of epidural hematoma is suspected. Which question is of the highest priority for the emergency department nurse to ask of the transferring nurse at the nursing home? 1. "When did the injury occur?" 2. "Was the client awake and talking right after the injury?" 3. "What medications has the client received since the fall?" 4. "What was the client's level of consciousness before the injury?"

2 Epidural hematomas frequently are characterized by a "lucid interval" that lasts for minutes to hours, during which the client is awake and talking. After this lucid interval, signs and symptoms progress rapidly, with potentially catastrophic intracranial pressure increase. Epidural hematomas are medical emergencies. It is important for the nurse to assist in the differentiation between epidural hematoma and other types of head injuries.

A nurse completes an admission assessment on a client who is diagnosed with myasthenia gravis. Which clinical finding is the nurse most likely to identify? 1 Problems with cognition 2 Difficulty swallowing saliva 3 Intention tremors of the hands 4 Nonintention tremors of the extremities

2 Facial muscles innervated by the cranial nerves often are affected; dysphagia, ptosis, and diplopia are present. Myasthenia gravis is a neuromuscular disease with altered neuromuscular junction and receptors, not central nervous system symptoms (problems with cognition). Intention tremors of the hands are associated with multiple sclerosis. Nonintention tremors of the extremities are associated with Parkinson disease.

The nurse is teaching a client with multiple sclerosis methods to reduce fatigue. Which statement indicates an understanding of the education? 1 Take a hot bath. 2 Rest in an air-conditioned room. 3 Increase the dose of muscle relaxants. 4 Avoid naps during the day.

2 Fatigue is a common symptom in clients with multiple sclerosis . Lowering the body temperature by resting in an air-conditioned room may relieve fatigue; however, extreme cold should be avoided. A hot bath or shower can increase body temperature, producing fatigue. Muscle relaxants, prescribed to reduce spasticity, can cause drowsiness and fatigue. Planning for frequent rest periods and naps can relieve fatigue.

A client with viral hepatitis has no appetite, and food makes the client nauseated. Which nursing intervention would be most appropriate? 1. Encourage foods that are high in protein. 2. Monitor for fluid and electrolyte imbalance. 3. Explain that high-fat diets usually are better tolerated. 4. Explain that most daily calories need to be consumed in the evening hours.

2 If nausea occurs and persists, the client will need to be assessed for fluid and electrolyte imbalance. It is important to explain to the client that most calories should be eaten in the morning hours because nausea is most common in the afternoon and evening. Clients should select a diet high in calories because energy is required for healing. Protein increases the workload on the liver. Changes in bilirubin interfere with fat absorption, so low-fat diets are better tolerated.

A registered nurse who is orienting a new nursing graduate to the hospital emergency department instructs the new graduate to monitor a client for one-sided chest movement on the right side while the client is being intubated by the health care provider. This instruction is based on the understanding that the endotracheal tube could enter which respiratory structures? 1. Left main bronchus if inserted too far 2. Right main bronchus if inserted too far 3. Left main bronchus if not inserted far enough 4. Right main bronchus if not inserted far enough

2 If the endotracheal tube is inserted too far into the client's trachea, the tube will enter the right main bronchus. This occurs because the right bronchus is shorter and wider than the left and extends downward in a more vertical plane. If the tube is not inserted far enough, no chest expansion at all will occur. The other options are incorrect.

A client with a tracheostomy tube who is on a ventilator is at risk for impaired gas exchange. The nurse should assess for which finding as the best indicator of adequate ongoing respiratory status? 1. Oxygen saturation of 89% 2. Respiratory rate of 16 breaths per minute 3. Moderate amounts of tracheobronchial secretions 4. Small to moderate amounts of frank blood suctioned from the tube

2 Impaired gas exchange could occur after tracheostomy because of excessive secretions, bleeding into the trachea, restricted lung expansion because of immobility, or concurrent respiratory conditions. An oxygen saturation of 89% is less than optimal. A respiratory rate of 16 breaths per minute is in the normal range.

The nurse is developing a plan of care for a client at risk for acute respiratory distress syndrome (ARDS). As part of the plan, the nurse will check for which item to detect an early sign of this disorder? 1. Edema 2. Dyspnea 3. Frothy sputum 4. Diminished breath sounds

2 In most cases of ARDS, tachypnea and dyspnea are the first clinical manifestations. Blood-tinged frothy sputum would present as a later sign, after the development of pulmonary edema. Breath sounds in the early stages of ARDS usually are clear. Edema is not directly associated with ARDS.

A client is returned to the nursing unit after thoracic surgery with chest tubes in place. During the first few hours postoperatively, what type of drainage should the nurse expect? 1. Serous 2. Bloody 3. Serosanguineous 4. Bloody, with frequent small clots

2 In the first few hours after surgery, the drainage from the chest tube is bloody. After several hours, it becomes serosanguineous. The client should not experience frequent clotting. Proper chest tube function should allow for drainage of blood before it has the chance to clot in the chest or the tubing.

Discharge teaching for a client with chronic pancreatitis should include which instructions? 1. Alcohol should be consumed in moderation. 2. Avoid caffeine, because it may aggravate symptoms. 3. Diet should be high in carbohydrates, fats, and proteins. 4. Frothy fatty stools indicate that enzyme replacement is working.

2 Knowing that caffeinated beverages, such as coffee, tea, and soda, will worsen symptoms, such as pain, will direct you to select the correct option. Alcohol can precipitate an attack of pancreatitis and needs to be avoided. The recommended diet is moderate carbohydrates, low fat, and moderate protein. Frothy fatty stools indicate that the replacement enzyme dose needs to be increased.

Lactulose (Chronulac) is prescribed for a hospitalized client with a diagnosis of hepatic encephalopathy. Which assessment finding indicates that the client is responding to this medication therapy as anticipated? 1. Vomiting occurs. 2. The fecal pH is acidic. 3. The client experiences diarrhea. 4. The client is able to tolerate a full diet.

2 Lactulose is an osmotic laxative used to decrease ammonia levels, which are elevated in hepatic encephalopathy. The desired effect is two or three soft stools per day with an acid fecal pH. Lactulose creates an acid environment in the bowel, resulting in a fall of the colon's pH from 7 to 5. This causes ammonia to leave the circulatory system and move into the colon for excretion. Diarrhea may indicate excessive administration of the medication. Options 1 and 4 do not determine that a desired effect has occurred.

A client is diagnosed with myasthenia gravis. Which response does the nurse expect the client to demonstrate? 1 Partial improvement of muscle strength with mild exercise 2 Fluctuating weakness of muscles innervated by the cranial nerves 3 Little or no change of muscle strength regardless of therapy initiated 4 Dramatic worsening of muscle strength with anticholinesterase drugs

2 Muscle use reduces strength, and rest increases strength; eyelid movement, chewing, swallowing, speech, facial expression, and breathing often are affected [1] [2]. Muscle strength increases with rest and decreases with activity. Anticholinesterase drugs improve muscle strength. Anticholinesterase drugs increase, not decrease, muscle strength.

The nurse is caring for a client who begins to experience seizure activity while in bed. Which action by the nurse is contraindicated? 1. Loosening restrictive clothing 2. Restraining the client's limbs 3. Removing the pillow and raising padded side rails 4. Positioning the client to the side, if possible, with the head flexed forward

2 Nursing actions during a seizure include providing for privacy, loosening restrictive clothing, removing the pillow and raising padded side rails in the bed, and placing the client on one side with the head flexed forward, if possible, to allow the tongue to fall forward and facilitate drainage. The limbs are never restrained because the strong muscle contractions could cause the client harm. If the client is not in bed when seizure activity begins, the nurse lowers the client to the floor, if possible, protects the head from injury, and moves furniture that may injure the client.

A health care provider (HCP) tells the nurse that a client's chest tube is to be removed. The nurse should bring which dressing materials to the bedside for the HCP's use? 1. Telfa dressing and Neosporin ointment 2. Petrolatum gauze and sterile 4 × 4 gauze 3. Benzoin spray and a hydrocolloid dressing 4. Sterile 4 × 4 gauze, Neosporin ointment, and tape

2 On removal of the chest tube, a sterile petrolatum gauze and a sterile 4 × 4 gauze is placed at the insertion site. The entire dressing is securely taped to make sure it is occlusive. The use of Telfa, Neosporin ointment, hydrocolloid dressing, and benzoin spray is not indicated. Elastoplast tape may be used at the discretion of the HCP as the tape of choice to make the dressing occlusive.

The nurse is preparing for removal of an endotracheal (ET) tube from a client. In assisting the health care provider in this procedure, which is the initial nursing action? 1. Deflate the cuff. 2. Suction the ET tube. 3. Turn off the ventilator. 4. Obtain a code cart, and place it at the bedside.

2 Once the client has been weaned successfully and has achieved an acceptable level of consciousness to sustain spontaneous respiration, an ET tube may be removed. The ET tube is suctioned first, and then the cuff is deflated and the tube is removed. Placing a code cart at the bedside is unnecessary and may cause alarm and concern in the client. Additionally, resuscitative equipment should already be available at the client's bedside. Option 3 is not the initial action.

The client with acute pancreatitis is experiencing severe pain from the disorder. Which position taken by the client indicates there is a need for further teaching? 1. Sitting up 2. Lying flat 3. Leaning forward 4. Flexing the left leg

2 Positions such as sitting up, leaning forward, and flexing the legs (especially the left leg) may alleviate some of the pain associated with pancreatitis. The pain is aggravated by lying supine or walking. This is because the pancreas is located retroperitoneally, and the edema and inflammation intensify the irritation of the posterior peritoneal wall with these positions.

A nurse enters the room of a client with myasthenia gravis and identifies that the client is experiencing increased dysphagia. What should the nurse do first? 1 Administer oxygen 2 Raise the head of the bed 3 Perform tracheal suctioning 4 Call the healthcare provide

2 Raising the head of the bed allows gravity to assist in the swallowing of saliva, thus decreasing the risk for aspiration. Oxygen will not assist in the management of dysphagia [1] [2] or the prevention of aspiration. Performing tracheal suctioning may become necessary if the upright position does not allow the client to manage secretions. Alerting the healthcare provider to the problem is necessary, but only after client safety is ensured.

At the beginning of the work shift, the nurse assesses the status of the client wearing a halo device. The nurse determines that which assessment finding requires intervention? 1. Tightened screws 2. Red skin areas under the jacket 3. Clean and dry lamb's wool jacket lining 4. Finger-width space between the jacket and the skin

2 Red skin areas under the jacket indicate that the jacket is too tight. The resulting pressure could lead to altered skin integrity and needs to be relieved by loosening the jacket. The screws all should be properly tightened. A clean, dry lamb's wool lining should be in place underneath the jacket, and there should be a finger-width space between the jacket and the skin. In addition, the client should wear a clean white cotton T-shirt next to the skin to help prevent itching.

A client with myasthenia gravis experiences generalized weakness. What is most important when planning this client's nursing care? 1 Maintaining bed rest 2 Providing frequent rest periods 3 Reassuring the client that there are many tasks that still can be performed 4 Arranging for a relative to be present

2 Spacing activities encourages maximum functioning within the limits of the client's strength and fatigue. Bed rest and limited activity may lead to muscle atrophy and calcium depletion and should be avoided. Although pointing out things the client can do is important, this does not address the client's concerns. Arranging for a relative to be present is unnecessary if the client is observed closely by the nursing staff; however, it should be permitted if requested by the client or family.

A recently hospitalized client with multiple sclerosis is concerned about generalized weakness and fluctuating physical status. What is the priority nursing intervention for this client? 1 Encourage bed rest. 2 Space activities throughout the day. 3 Teach the limitations imposed by the disease. 4 Have one of the client's relatives stay at the bedside

2 Spacing activities will encourage maximum functioning within the limits of strength and fatigue. Bed rest and limited activity may lead to muscle atrophy and calcium depletion. Strengths, rather than limitations, should be stressed. Having one of the client's relatives stay at the bedside is unnecessary. It is the nurse's responsibility to maintain client safety and meet client needs.

The nurse is documenting nursing observations in the record of a client who experienced a tonic-clonic seizure. Which clinical manifestation did the nurse most likely note in the clonic phase of the seizure? 1. Body stiffening 2. Spasms of the entire body 3. Sudden loss of consciousness 4. Brief flexion of the extremities

2 The clonic phase of a seizure is characterized by alternating spasms and momentary muscular relaxation of the entire body, accompanied by strenuous hyperventilation. The face is contorted and the eyes roll. Excessive salivation results in frothing from the mouth. The tongue may be bitten, the client sweats profusely, and the pulse is rapid. The clonic jerking subsides by slowing in frequency and losing strength of contractions over a period of 30 seconds. Options 1, 3, and 4 identify the tonic phase of a seizure.

The nurse has completed discharge instructions for a client with application of a halo device. Which action indicates that the client needs further clarification of the instructions? 1. Uses a straw for drinking 2. Drives only during the daytime 3. Uses caution because the device alters balance 4. Washes the skin daily under the lamb's wool liner of the vest

2 The halo device alters balance and can cause fatigue because of its weight. The client should cleanse the skin daily under the vest to protect the skin from ulceration and should avoid the use of powder or lotions. The liner should be changed if odor becomes a problem. The client should have food cut into small pieces to facilitate chewing and use a straw for drinking. Pin care is done as instructed. The client cannot drive at all because the device impairs the range of vision.

A nurse notes that a client who has suffered a brain injury has an adequate heart rate, blood pressure, fluid balance, and body temperature. The nurse concludes that which area of the client's brain is functioning adequately? 1. Thalamus 2. Hypothalamus 3. Limbic system 4. Reticular activating system

2 The hypothalamus is responsible for autonomic nervous system functions, such as heart rate, blood pressure, temperature, and fluid and electrolyte balance (among others). The thalamus acts as a relay station for sensory and motor information. The limbic system is responsible for emotions. The reticular activating system is responsible for the sleep-wake cycle.

The home care nurse is making a visit to a client who is wheelchair bound after a spinal cord injury sustained 4 months earlier. Just before leaving the home, the nurse ensures that which intervention has been done to prevent an episode of autonomic dysreflexia (hyperreflexia)? 1. Updating the home safety sheet 2. Leaving the client in an unchilled area of the room 3. Noting a bowel movement on the client progress note 4. Recording the amount of urine obtained with catheterization

2 The most common cause of autonomic dysreflexia is visceral stimuli, such as with blockage of urinary drainage or with constipation. Barring these, other causes include noxious mechanical and thermal stimuli, particularly pressure and overchilling. For this reason, the nurse ensures that the client is positioned with no pinching or pressure on paralyzed body parts and that the client will be sufficiently warm.

The nurse is changing the tracheostomy ties on a client with a tracheostomy and is assessing the security of the ties. Which method is used to ensure that the ties are not too tightly placed? 1. The ties leave no marks on the neck. 2. The nurse places two fingers between the tie and the neck. 3. The tracheotomy can be pulled slightly away from the neck. 4. The nurse uses a 12-inch tie that is tightly affixed with hook-and-loop closures.

2 The nurse should assess the tracheostomy ties to ensure that they are not too tight. The nurse ensures that there is room for two fingers to slide comfortably under the ties. Options 1, 3, and 4 are incorrect actions.

A nurse is interviewing a client with a tentative diagnosis of Parkinson disease. What should the nurse expect the client to report about how the onset of symptoms occurred? 1 Suddenly 2 Gradually 3 Overnight 4 Irregularly

2 The onset of this disease is not sudden, but insidious, with a prolonged course and gradual progression. The onset is slow and gradual. The onset is not irregular; there is a gradual, regular progression of symptoms.

A client with acute pancreatitis is experiencing severe pain from the disorder. The nurse determines that the client understands suggestions for positioning to reduce pain if he or she avoids which action? 1. Sitting up 2. Lying flat 3. Leaning forward 4. Drawing the legs up to the chest

2 The pain of pancreatitis is aggravated by lying supine or walking. This is because the pancreas is located retroperitoneally, and the edema and inflammation will intensify the irritation of the posterior peritoneal wall with these positions or movements. Positions such as sitting up, leaning forward, and flexing the legs (especially the left leg) will alleviate some of the pain associated with pancreatitis. The fetal position (with the legs drawn up to the chest) may decrease the abdominal pain of pancreatitis.

A sexually active 20-year-old client has developed viral hepatitis. Which client statement indicates the need for further teaching? 1. "I should avoid drinking alcohol." 2. "I can go back to work right away." 3. "My partner should get the vaccine." 4. "A condom should be used for sexual intercourse."

2 To prevent transmission of hepatitis, vaccination of the partner is advised. In addition, a condom is advised during sexual intercourse. Alcohol should be avoided because it is detoxified in the liver and may interfere with recovery. Rest is especially important until laboratory studies show that liver function has returned to normal. The client's activity is increased gradually, and the client should not return to work right away.

When assessing the progress of a client being treated for myasthenia gravis, the nurse expects what change in muscle strength? 1 Partial improvement of muscle strength with mild exercise 2 Fluctuating weakness of muscles innervated by the cranial nerves 3 Little change regardless of the therapy initiated 4 Dramatic worsening with anticholinesterase drugs

2 Use reduces strength, and rest increases strength; eyelid movement, chewing, swallowing, speech, facial expression, and breathing often are affected, and therefore muscle weakness will fluctuate in relation to activity and rest. Muscle strength decreases, not increases, with activity. Anticholinesterase drugs improve muscle strength.

The nurse is providing instructions to a client being discharged from the hospital following removal of a chest tube that was inserted after thoracic surgery. Which statement, if made by the client, indicates a need for further teaching? 1. "I should avoid heavy lifting for at least 4 to 6 weeks." 2. "I should remove the chest tube site dressing as soon as I get home." 3. "If I have any difficulty in breathing, I should call the health care provider." 4. "If I note any signs of infection, I should contact the health care provider (HCP)."

2 When a chest tube is removed, an occlusive dressing, consisting of petrolatum gauze covered by a dry sterile dressing, usually is placed over the chest tube site. This dressing is maintained in place until the HCP says that it may be removed. The client should avoid heavy lifting for 4 to 6 weeks after discharge to facilitate continued wound healing. The client is taught to monitor and report any signs of respiratory difficulty or any signs of infection or increased temperature.

A nurse identifies that a client exhibits the characteristic gait associated with Parkinson disease. When recording on the client's record, what term does the nurse use to document this gait? 1 Ataxic 2 Shuffling 3 Scissoring 4 Asymmetric

2 With a shuffling gait [1] [2] [3] the steps are short and dragging; this is seen with basal ganglia defects. Ataxia is a staggering gait often associated with cerebellar damage. Scissoring is associated with bilateral spastic paresis of the legs. An asymmetric gait is associated with weakness of or pain in one lower extremity.

The nurse should incorporate which in the dietary plan to ensure optimal nutrition for the client during the acute phase of hepatitis? Select all that apply. 1. Select foods high in protein content. 2. Consume multiple small meals throughout the day. 3. Select foods low in carbohydrates to prevent nausea. 4. Allow the client to select foods that are most appealing. 5. Eliminate fatty foods from the meal trays until nausea subsides. 6. Eat a nutritious dinner because it is typically the best tolerated meal of the day.

2, 4, 5 Because the client with hepatitis experiences general malaise, small, more frequent meals are better tolerated than large meals, with breakfast being the best tolerated meal of the day. Self-selection of foods may enhance appetite over randomly selected foods. Fatty foods can exacerbate nausea and need to be avoided during the acute phase. The diseased liver may be unable to metabolize large amounts of protein at this time. The client should receive a diet high in carbohydrates to assist with meeting increased caloric needs. Anorexia typically increases as the day goes on.

The nurse is monitoring the chest tube drainage system in a client with a chest tube. The nurse notes intermittent bubbling in the water seal chamber. Which is the most appropriate nursing action? 1. Check for an air leak. 2. Document the findings. 3. Notify the health care provider. 4. Change the chest tube drainage system.

2. Bubbling in the water seal chamber is caused by air passing out of the pleural space into the fluid in the chamber. Intermittent (not constant) bubbling is normal. It indicates that the system is accomplishing one of its purposes, removing air from the pleural space. Continuous bubbling during inspiration and expiration indicates that an air leak exists. If this occurs, it must be corrected. Notifying the health care provider and changing the chest tube drainage system are not indicated at this time.

The nurse is performing an assessment on a client with the diagnosis of Brown-Séquard syndrome. The nurse would expect to note which assessment finding? 1. Bilateral loss of pain and temperature sensation 2. Ipsilateral paralysis and loss of touch and vibration 3. Contralateral paralysis and loss of touch, pressure, and vibration 4. Complete paraplegia or quadriplegia, depending on the level of injury

2. Ipsilateral paralysis and loss of touch and vibration Brown-Séquard syndrome results from hemisection of the spinal cord, resulting in ipsilateral paralysis and loss of touch, pressure, vibration, and proprioception. Contralaterally, pain and temperature sensation are lost because these fibers decussate after entering the cord. Options 1, 3, and 4 are not assessment findings in this syndrome.

The nurse assesses for one-sided chest movement on the right while a client is being intubated by the health care provider. The nurse's action is based on the possibility that which could occur with the endotracheal tube? 1. It could enter the left main bronchus if inserted too far. 2. It could enter the right main bronchus if inserted too far. 3. It could enter the left main bronchus if not inserted far enough. 4. It could enter the right main bronchus if not inserted far enough.

2. It could enter the right main bronchus if inserted too far. If the endotracheal tube is inserted too far, the tube will travel past the trachea and enter the right main bronchus. This occurs because the right bronchus is shorter and wider than the left and extends downward in a more vertical plane. The other options are incorrect.

The nurse caring for a client with a chest tube turns the client to the side and the chest tube accidentally disconnects from the water seal chamber. Which initial nursing action should the nurse take? 1. Call the health care provider (HCP). 2. Place the tube in a bottle of sterile water. 3. Replace the chest tube system. 4. Place a sterile dressing over the disconnection site.

2. Place the tube in a bottle of sterile water. If the chest drainage system is disconnected, the end of the tube is placed in a bottle of sterile water held below the level of the chest. The HCP may need to be notified, but this is not the initial action. The system is replaced if it breaks or cracks or if the collection chamber is full. Placing a sterile dressing over the disconnection site will not prevent complications resulting from the disconnection.

A client with multiple sclerosis is in remission. Which diversional activity should the nurse encourage that best meets the client's needs while in remission? 1 Hiking 2 Swimming 3 Sewing classes 4 Watching television

2. Swimming helps keep the muscles supple, without requiring fine-motor activity. Hiking might prove too rigorous for the client. Sewing requires fine-motor activity and will be difficult for the client. Sedentary activities are not helpful in maintaining muscle tone.

During the neurologic assessment of a client with a tentative diagnosis of Guillain-Barré syndrome, what does the nurse expect the client to manifest? 1 Diminished visual acuity 2 Increased muscular weakness 3 Pronounced muscular atrophy 4 Impairment in cognitive reasoning

2. Increased muscular weakness Muscular weakness with paralysis results from impaired nerve conduction because the motor nerves become demyelinated. Diminished visual acuity usually is not a problem; motor loss is greater than sensory loss, with paresthesia of the extremities being the most frequent sensory loss. Demyelination occurs rapidly early in the disease, and the muscles will not have had time to atrophy; this can occur later if rehabilitation is delayed. Only the peripheral nerves are involved; the central nervous system is unaffected.

What nursing intervention is anticipated for a client with Guillain-Barré syndrome? 1 Providing a straw to stimulate the facial muscles 2 Maintaining ventilator settings to support respiration 3 Encouraging aerobic exercises to avoid muscle atrophy 4 Administering antibiotic medication to prevent pneumonia

2. Maintaining ventilator settings to support respiration Guillain-Barré syndrome is a progressive paralysis beginning with the lower extremities and moving upward; mechanical ventilation may be required when respiratory muscles are affected. The use of a straw would not be an effective stimulant for the facial muscles; oral intake may be contraindicated, depending on the extent of the paralysis, because of the risk for aspiration. With progressive paralysis, the client will not be able to perform aerobic exercises. Antibiotics are not given prophylactically; antibiotics will not help if pneumonia is caused by etiologies that are not bacterial.

A nurse is caring for a client newly diagnosed with Guillain-Barré syndrome. The nurse expects which procedure will be considered as a treatment option? 1 Hemodialysis 2 Plasmapheresis 3 Thrombolytic therapy 4 Immunosuppression therapy

2. Plasmapheresis A client diagnosed with Guillain-Barré syndrome may have plasmapheresis as part of treatment. Plasmapheresis is the removal of plasma from withdrawn blood followed by the reconstitution of its cellular components in an isotonic solution and the reinfusion of this solution. A client with Guillain-Barré syndrome, in the absence of kidney disease, does not need hemodialysis. Guillain-Barré syndrome is not a hematological disorder; thrombolytic therapy is not required. Guillain-Barré syndrome is not an autoimmune disorder; immunosuppressive therapy is not required.

A nurse is caring for a client with the diagnosis of Guillain-Barré syndrome with nasal cannula oxygen. The nurse identifies that the client is having difficulty expectorating respiratory secretions. What should be the nurse's first intervention? 1 Auscultate for breath sounds. 2 Suction the client's oropharynx. 3 Administer and continue to monitor oxygen via nasal cannula. 4 Place the client in the orthopneic position.

2. Suction the client's oropharynx A patent airway is the priority. The client does not have the ability to deep breathe and cough. Auscultating for breath sounds takes time and delays an intervention that will maintain an open airway. Administering oxygen via nasal cannula will take time and delay an intervention that will maintain an open airway. Oxygen administration will be useless if the airway is not patent. Placing the client in the orthopneic position is unsafe for a client with Guillain-Barré syndrome. The client will be unable to maintain this position. Muscle weakness involves the lower extremities, progressing to the upper extremities and diaphragm.

A nurse is preparing to administer insulin to a client with diabetes. In which order should the nurse perform the actions associated with insulin administration? 1. Wipe the top of the insulin vial with an alcohol swab. 2. Wash hands with soap and water. 3. Rotate the vial of insulin between the palms of the hands. 4. Withdraw the correct amount of insulin from the inverted vial. 5. Instill air into the vial of insulin equal to the desired dose.

2. Wash hands with soap and water. 3. Rotate the vial of insulin between the palms of the hands. 1. Wipe the top of the insulin vial with an alcohol swab. 5. Instill air into the vial of insulin equal to the desired dose. 4. Withdraw the correct amount of insulin from the inverted vial.

The nurse is providing postoperative care eight hours after a client had a total cystectomy and the formation of an ileal conduit. What assessment finding should be reported immediately? 1.Edematous stoma 2.Dusky-colored stoma 3.Absence of bowel sounds 4.Pink-tinged urinary drainage

2.Dusky-colored stoma

A nurse is caring for a client who just had surgery to repair an inguinal hernia. To limit a common complication associated with this surgery, the nurse should: 1.Apply an abdominal binder 2.Place a support under the scrotum 3.Teach the client to cough several times an hour 4.Encourage the client to eat a high carbohydrate diet

2.Place a support under the scrotum

Levofloxacin 750 mg intravenous piggyback (IVPB) is prescribed for a client with pneumonia. The dose is available in 150 mL of 5% dextrose and is to infuse over 90 minutes. The administration set has a drop factor of 15 drops per mL. At how many drops per minute should the nurse regulate the IVPB to infuse? Record your answer using a whole number. ___ gtt/minute

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A client seen in the ambulatory care clinic has ascites and slight jaundice. The nurse should assess the client for a history of chronic use of which medication? 1. Ibuprofen (Advil) 2. Ranitidine (Zantac) 3. Acetaminophen (Tylenol) 4. Acetylsalicylic acid (aspirin)

3 Acetaminophen is a potentially hepatotoxic medication. Use of this medication and other hepatotoxic agents should be investigated whenever a client presents with signs and symptoms compatible with liver disease (such as ascites and jaundice). Hepatotoxicity is not an adverse effect of the medications identified in options 1, 2, and 4.

The nurse is caring for a client who has undergone a craniotomy and has a supratentorial incision. The nurse should place the client in which position postoperatively? 1. Head of bed flat, head and neck midline 2. Head of bed flat, head turned to the nonoperative side 3. Head of bed elevated 30 to 45 degrees, head and neck midline 4. Head of bed elevated 30 to 45 degrees, head turned to the operative side

3 After supratentorial surgery, the head is kept at a 30- to 45-degree angle. The head and neck should not be angled either anteriorly or laterally, but rather should be kept in a neutral (midline) position. This promotes venous return through the jugular veins, which will help prevent a rise in intracranial pressure.

The nurse in the neurological unit is caring for a client who was in a motor vehicle crash and sustained a blunt head injury. On assessment of the client, the nurse notes the presence of bloody drainage from the nose. Which nursing action is most appropriate? 1. Insert nasal packing. 2. Document the findings. 3. Contact the health care provider (HCP). 4. Monitor the client's blood pressure and check for signs of increased intracranial pressure.

3 Bloody or clear drainage from either the nasal or the auditory canal after head trauma could indicate a cerebrospinal fluid leak. The appropriate nursing action is to notify the HCP, because this finding requires immediate intervention. Options 1, 2, and 4 are inappropriate nursing actions in this situation.

The nurse caring for a client who is mechanically ventilated is monitoring for complications of mechanical ventilation. Which assessment finding, if noted by the nurse, indicates the need for follow-up? 1. Muscle weakness in the arms and legs 2. A temperature of 98.6° F decreased from 99.0° F 3. A blood pressure of 90/60 mm Hg decreased from 112/78 mm Hg 4. A heart rate of 80 beats per minute decreased from 85 beats per minute

3 Complications of mechanical ventilation include the following: (1) hypotension caused by application of positive pressure, which increases intrathoracic pressure and inhibits blood return to the heart; (2) pneumothorax or subcutaneous emphysema as a result of positive pressure; (3) gastrointestinal alterations such as stress ulcers; (4) malnutrition if nutrition is not maintained; (5) infections; (6) muscular deconditioning; and (7) ventilator-dependence or inability to wean. Some muscle weakness is expected. Options 1, 2, and 4 present normal assessment findings.

A nurse is caring for two clients. One has Parkinson disease, and the other has myasthenia gravis. For which common complication associated with both disorders should the nurse assess these clients? 1 Cogwheel gait 2 Impaired cognition 3 Difficulty swallowing 4 Nonintention tremors

3 Difficulty swallowing (dysphagia) is a manifestation of both neurologic disorders. With Parkinson disease there is a progressive loss of spontaneity of movement, including swallowing, related to degeneration of the dopamine-producing neurons in the substantia nigra of the midbrain. With myasthenia gravis there is a decreased number of acetylcholine (Ach) receptor sites at the neuromuscular junction, which interferes with muscle contraction, impairing muscles involved in chewing, swallowing, speaking, and breathing. A cogwheel gait is associated with Parkinson disease, not myasthenia gravis. Impaired cognition is associated with Parkinson disease, not myasthenia gravis. Nonintention tremors are associated with Parkinson disease, not myasthenia gravis. The nonintention tremors associated with Parkinson disease result from the loss of the inhibitory influence of dopamine in the basal ganglia, which interferes with the feedback circuit within the cerebral cortex.

A client with liver dysfunction is having difficulty with protein metabolism. The nurse checks the laboratory results, expecting that the results of which serum laboratory values will be elevated? 1. Lactase 2. Albumin 3. Ammonia 4. Lactic acid

3 During deamination of proteins in the liver, the amino group splits from the carbon-containing compound, which results in formation of ammonia and a carbon residue. The liver then converts the toxic ammonia substance into urea, which can be excreted by the kidneys. Clients with liver dysfunction may have high serum ammonia levels as a result. Options 1, 2, and 4 are incorrect.

A client with a chest injury has suffered flail chest. The nurse assesses the client for which most distinctive sign of flail chest? 1. Cyanosis 2. Hypotension 3. Paradoxical chest movement 4. Dyspnea, especially on exhalation

3 Flail chest results from multiple rib fractures. This results in a "floating" section of ribs. Because this section is unattached to the rest of the bony rib cage, this segment results in paradoxical chest movement. This means that the force of inspiration pulls the fractured segment inward, while the rest of the chest expands. Similarly, during exhalation, the segment balloons outward while the rest of the chest moves inward. This is a characteristic sign of flail chest.

The nurse is monitoring the respiratory status of a client after creation of a tracheostomy. The nurse understands that oxygen saturation measurements obtained by pulse oximetry may be inaccurate if the client has which coexisting problem? 1. Fever 2. Epilepsy 3. Hypotension 4. Respiratory failure

3 Hypotension, shock, or the use of peripheral vasoconstricting medications may result in inaccurate pulse oximetry readings as a result of impaired peripheral perfusion. Fever and epilepsy would not affect the accuracy of measurement. Respiratory failure also would not affect the accuracy of measurement, although the readings may be abnormally low.

The nurse is assisting the neurologist in performing an assessment on a client who is unconscious after sustaining a head injury. The nurse understands that the neurologist would avoid performing the oculocephalic response (doll's-eyes maneuver) if which condition is present in the client? 1. Dilated pupils 2. Lumbar trauma 3. A cervical cord injury 4. Altered level of consciousness

3 In an unconscious client, eye movements are an indication of brainstem activity and are tested by the oculocephalic response. When the doll's-eyes maneuver is intact, the eyes move in the opposite direction when the head is turned. Abnormal responses include movement of the eyes in the same direction as that for the head and maintenance of a midline position of the eyes when the head is turned. An abnormal response indicates a disruption in the processing of information through the brainstem. Contraindications to performing this test include cervical-level spinal cord injuries and severely increased intracranial pressure.

A nurse manager is providing an educational session to nursing staff members about the phases of viral hepatitis. The nurse manager tells the staff that which clinical manifestation(s) is/are primarily characteristic of the preicteric phase? 1. Pruritus 2. Right upper quadrant pain 3. Fatigue, anorexia, and nausea 4. Jaundice, dark-colored urine, and clay-colored stools

3 In the preicteric phase the client has nonspecific complaints of fatigue, anorexia, nausea, cough, and joint pain. The remaining options are clinical manifestations that occur in the icteric phase. In the posticteric phase, jaundice decreases, the color of urine and stool returns to normal, and the client's appetite improves.

A nursing student is developing a plan of care for a client with a chest tube that is attached to a Pleur-Evac drainage system. Which intervention in the care plan indicates the need for further teaching for the student? 1. Position the client in semi-Fowler's position. 2. Add water to the suction chamber as it evaporates. 3. Instruct the client to avoid coughing and deep breathing. 4. Tape the connection sites between the chest tube and the drainage system.

3 It is important to encourage the client to cough and deep breathe when a chest tube drainage system is in place. This will assist in facilitating appropriate lung re-expansion. The client is positioned in semi-Fowler's position to facilitate ease in breathing. Water is added to the suction chamber as it evaporates to maintain the full suction level prescribed. Connections between the chest tube and the drainage system are taped to prevent accidental disconnection.

A client has experienced an episode of myasthenic crisis. Upon review of the client history by the nurse, which finding will most likely be a precipitating factor of the myasthenic crisis? 1 Getting too little exercise 2 Taking excess medication 3 Omitting doses of medication 4 Increasing intake of fatty foods

3 Myasthenic crisis often is caused by undermedication and responds to the administration of cholinergic medications, such as neostigmine and pyridostigmine. Too little exercise is not a factor. Cholinergic crisis (the opposite problem) is caused by excess medication and responds to withholding of medications. Fatty food intake is incorrect.

The nurse is caring for a client with a tracheostomy tube who is receiving mechanical ventilation. The nurse is monitoring for complications related to the tracheostomy and suspects tracheoesophageal fistula when which occurs? 1. Suctioning is required frequently. 2. The client's skin and mucous membranes are light pink. 3. Aspiration of gastric contents occurs during suctioning. 4. Excessive secretions are suctioned from the tube and stoma.

3 Necrosis of the tracheal wall can lead to formation of an abnormal opening between the posterior trachea and the esophagus. The opening, called a tracheoesophageal fistula, allows air to escape into the stomach, causing abdominal distention. It also causes aspiration of gastric contents. Options 1, 2, and 4 are not signs of this complication.

A client is admitted to the hospital with a diagnosis of acute pancreatitis. Which would the nurse expect the client to report about the pain? 1. The pain is mostly around the umbilicus and comes and goes. 2. The pain increases when the client sits up and bends forward. 3. The pain usually increases after vomiting. 4. Eating helps to decrease the pain.

3 Pain with acute pancreatitis usually increases after vomiting because of an increase in intraductal pressure caused by retching, which leads to further obstruction of the outflow of pancreatic secretions. The pain is a steady and intense epigastric pain that radiates to the client's back and flank. The pain may lessen when the client sits up or bends forward. Eating exacerbates the pain by stimulating the secretion of enzymes.

The nurse is evaluating the neurological signs of a client in spinal shock following spinal cord injury. Which observation indicates that spinal shock persists? 1. Hyperreflexia 2. Positive reflexes 3. Flaccid paralysis 4. Reflex emptying of the bladder

3 Resolution of spinal shock is occurring when there is return of reflexes (especially flexors to noxious cutaneous stimuli), a state of hyperreflexia rather than flaccidity, and reflex emptying of the bladder.

A client is suspected of having myasthenia gravis. What are the most significant initial nursing assessments that should be performed? 1 Ability to chew and speak distinctly 2 Capacity to smile and close the eyelids 3 Effectiveness of respiratory exchange and ability to swallow 4 Degree of anxiety and concern about the suspected diagnosis

3 Respiratory failure will require emergency intervention, and inability to swallow may lead to aspiration. Difficulty with chewing and speaking are signs of myasthenia gravis that may occur but are not life threatening. Ocular palsies and an inability to smile are signs of myasthenia gravis that may occur but are not life threatening. Although the client's level of anxiety and concerns about the diagnosis are important, they are not the most significant assessments.

During a routine clinic visit of a client who has myasthenia gravis, the nurse reinforces previous teaching about the disease and self-care. The nurse evaluates that the teaching is effective when the client states which information? 1 Plan activities for later in the day. 2 Eat meals in a semirecumbent position. 3 Avoid people with respiratory infections. 4 Take muscle relaxants when under stress.

3 Respiratory infections place people with myasthenia gravis at high risk because they do not cough effectively and may develop pneumonia or airway obstruction. Activity should be conducted earlier in the day before the energy reserve is depleted; periods of activity should be alternated with periods of rest. The client should eat sitting in a chair to prevent aspiration. Taking muscle relaxants when under stress is contraindicated; these potentiate weakness because of their effect on the myoneural junction.

A client is scheduled to have a series of diagnostic studies for myasthenia gravis, including a Tensilon test. The nurse explains to the client that the diagnosis of myasthenia gravis is confirmed if the administration of Tensilon produces which response? 1 Brief exaggeration of symptoms 2 Prolonged symptomatic improvement 3 Rapid but brief symptomatic improvement 4 Symptomatic improvement of only the ptosis

3 Tensilon acts systemically to increase muscle strength; it lasts several minutes. Tensilon produces a brief increase in muscle strength; with a negative response the client will demonstrate no change in symptoms. Tensilon may intensify muscle weakness in a cholinergic crisis. Tensilon does not cause lasting effects. Tensilon acts systemically on all muscles, rather than selectively on the eyelids.

A client has a diagnosis of multiple sclerosis and is currently in remission. The client is a parent of two active preschoolers. What should the nurse encourage the client to do? 1 Plan a schedule of specific times each day that will be set aside for playtime with the children. 2 While in remission, provide support to other people with multiple sclerosis who also have young children. 3 Develop a flexible schedule for completion of routine daily activities. 4 Meet with a self-help group for people with the diagnosis of multiple sclerosis.

3 The client must be flexible and adjust activities to provide for rest when necessary; activity should cease before the point of fatigue. Although quality time with children is important, it must be done on a flexible schedule to prevent fatigue. Although laudable, providing support to other people with multiple sclerosis who also have young children cannot be done if the client is in need of support or if it overtaxes physical resources. Meeting with a self-help group for people with the diagnosis of multiple sclerosis may not be a need at this time; prevention of fatigue always is important.

The nurse has just admitted to the nursing unit a client with a basilar skull fracture who is at risk for increased intracranial pressure (ICP). Pending specific health care provider prescriptions, the nurse should avoid placing the client in which positions? 1. Head midline 2. Neck in neutral position 3. Flat, with head turned to the side 4. Head of bed elevated 30 to 45 degrees

3 The client who is at risk for or with increased ICP should be positioned so that the head is in a neutral, midline position. The nurse should avoid flexing or extending the client's neck or turning the head from side to side. The head of the bed should be raised to 30 to 45 degrees. Use of proper positions promotes venous drainage from the cranium to keep ICP down.

The nurse has given instructions to a client with hepatitis about post-discharge management during convalescence. The nurse determines that further teaching is needed if the client makes which statement? 1. "I need to avoid alcohol and aspirin." 2. "I should eat a high-carbohydrate, low-fat diet." 3. "I can resume a full activity level within 1 week." 4. "I need to take the prescribed amounts of vitamin K."

3 The client with hepatitis is easily fatigued and may require several weeks to resume a full activity level. It is important for the client to get adequate rest so that the liver can heal. The client should avoid hepatotoxic substances such as aspirin and alcohol. The client should take in a high-carbohydrate and low-fat diet. Vitamin K may be prescribed for prolonged clotting times.

A nurse is caring for a client on a mechanical ventilator. The high-pressure alarm on the ventilator sounds. The nurse suspects that the most likely cause of the alarm is which finding? 1. A disconnection of the ventilator tubing 2. An exaggerated client inspiratory effort 3. Accumulation of respiratory secretions 4. Generation of extreme negative pressure by the client

3 The high pressure alarm sounds when the preset peak inspiratory pressure limit is reached by the ventilator before it has delivered a set tidal volume. Causes include tubing obstruction or kinks, breathing "out of phase" or "bucking the ventilator," accumulation of secretions, condensation of water in the ventilator tubing, coughing or Valsalva maneuvers, increased airway resistance, bronchospasms, decreased pulmonary compliance, and pneumothorax. Options 1, 2, and 4 identify causes for triggering the low-pressure alarm

The nurse has assisted the health care provider and the anesthesiologist with placement of an endotracheal (ET) tube for a client in respiratory distress. What is the initial nursing action to evaluate proper ET tube placement? 1. Tape the ET tube in place, and note the centimeter marking at the lip line. 2. Ask the radiology department to obtain a stat portable radiograph at the client's bedside. 3. Use an Ambu (resuscitation) bag to ventilate the client and assess for bilateral breath sounds. 4. Attach the ET tube to the ventilator and determine whether the client is able to tolerate the tidal volume prescribed.

3 The nurse verifies the placement of an ET tube immediately by ventilating the client using an Ambu bag and by auscultating for breath sounds bilaterally, which ensures ventilation of both lungs. After this initial assessment, placement is checked radiographically. The nurse marks the ET tube at the point where it enters the nose or mouth for ongoing monitoring of correct placement, but this will not determine initial adequate placement of the ET tube. Noting the tidal volume and the client's toleration of the tidal volume prescribed is not a measure of appropriate ET tube placement.

A client newly diagnosed with multiple sclerosis asks the nurse if it will be painful. Which response should the nurse give the client first? 1 "Tell me more about your fears regarding pain." 2 "Medications will be prescribed to help control pain." 3 "Pain is a common symptom of this condition." 4 "Let's list your questions for the healthcare provider."

3 The response "Pain is a common symptom of this condition" is a truthful answer for the client. Reassuring the client that "medications will be prescribed to help control pain" when the client experiences it is the next helpful response from the nurse. After being truthful about pain and reassuring the client about its medical management, asking the client to "tell more about...fears regarding pain" opens the conversation to discuss it and offers an opportunity for emotional release, which can decrease anxiety. The response "Let's list your questions for the healthcare provider" is a helpful final conversation during this encounter because it teaches the client how to make the most of their visit with the healthcare provider.

A client with multiple sclerosis is informed that this is a chronic, progressive neurologic condition. The client asks the nurse, "Will I experience unbearable pain?" What is the nurse's best response? 1 "Tell me about your fears regarding pain." 2 "Analgesics will be prescribed to control the pain." 3 "Some clients report feeling a tingling or burning sensation but not unbearable pain." 4 "Let's make a list of the things you need to ask your healthcare provider."

3 The response, "Some clients report feeling a tingling or burning sensation , but not unbearable pain," is a truthful answer that provides hope for the client. Although neuropathic pain may sometimes occur, it does not occur in all clients. These clients more typically have diminished sensitivity to pain and paresthesias (e.g., tingling, burning, crawling sensations). The response, "Tell me about your fears regarding pain," avoids the client's question and may increase anxiety. Analgesics are not commonly prescribed unless pain results from some other condition. The response, "Let's make a list of the things you need to ask your healthcare provider," avoids the client's question and abdicates the nurse's responsibility.

A healthcare provider prescribes a diagnostic workup for a client who may have myasthenia gravis. What is the initial nursing objective for the client during the diagnostic phase? 1 "The client will adhere to the teaching plan." 2 "The client will achieve psychologic adjustment." 3 "The client will maintain present muscle strength." 4 "The client will prepare for a possible myasthenic crisis."

3 Until the diagnosis has been confirmed, the primary goal should be to maintain appropriate activity and prevent muscle atrophy. It is too early to develop a teaching plan; the diagnosis has not yet been established. The response "achieve psychologic adjustment" is too early; the client cannot adjust if a diagnosis has not yet been confirmed. The response "prepare for a possible myasthenic crisis" is an intervention, not an objective.

To what does the nurse attribute the increased risk of respiratory complications in clients with myasthenia gravis? 1 Narrowed airways 2 Impaired immunity 3 Ineffective coughing 4 Viscosity of secretions

3 Weakened muscles result in ineffective coughing; secretions are retained and provide a medium for bacterial growth. The airways are not narrowed. Immune mechanisms are not impaired directly. Viscosity of secretions depends on fluid intake and humidity.

A client is diagnosed with stage 3 of Parkinson disease. Which clinical manifestations are found in the client? Select all that apply. 1 Akinesia 2 Masklike face 3 Postural instability 4 Unilateral limb involvement 5 Increased gait disturbances

3, 5 Parkinson disease is a progressive neurodegenerative disease that is one of the most common neurologic disorders of older adults. Stage 3 of Parkinson disease is characterized by postural instability and increased gait disturbances. Akinesia is manifested in stage 4 of the disease. Clinical manifestation of stage 2 is "masklike" face. Unilateral limb involvement is seen in stage 1 of Parkinson disease.

The nurse is assessing the functioning of a chest tube drainage system in a client who has just returned from the recovery room following a thoracotomy with wedge resection. Which are the expected assessment findings? Select all that apply. 1. Excessive bubbling in the water seal chamber 2. Vigorous bubbling in the suction control chamber 3. Drainage system maintained below the client's chest 4. 50 mL of drainage in the drainage collection chamber 5. Occlusive dressing in place over the chest tube insertion site 6. Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation

3. Drainage system maintained below the client's chest 4. 50 mL of drainage in the drainage collection chamber 5. Occlusive dressing in place over the chest tube insertion site 6. Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation The bubbling of water in the water seal chamber indicates air drainage from the client and usually is seen when intrathoracic pressure is higher than atmospheric pressure, and may occur during exhalation, coughing, or sneezing. Excessive bubbling in the water seal chamber may indicate an air leak, an unexpected finding. Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation is expected. An absence of fluctuation may indicate that the chest tube is obstructed or that the lung has reexpanded and that no more air is leaking into the pleural space. Gentle (not vigorous) bubbling should be noted in the suction control chamber. A total of 50 mL of drainage is not excessive in a client returning to the nursing unit from the recovery room. Drainage that is more than 70 to 100 mL/hour is considered excessive and requires health care provider notification. The chest tube insertion site is covered with an occlusive (airtight) dressing to prevent air from entering the pleural space. Positioning the drainage system below the client's chest allows gravity to drain the pleural space.

A client with myasthenia gravis asks the nurse why the disease has occurred. Which pathology underlies the nurse's reply? 1 A genetic defect in the production of acetylcholine (ACh) 2 An inefficient use of the neurotransmitter acetylcholine 3 A decreased number of functioning acetylcholine receptor (AChR) sites 4 An inhibition of the enzyme acetylcholinesterase (AChE), leaving the end plates folded

3. One of the pathologic changes is fewer AChR sites; also, antibodies cause destruction and blockade at the AChR sites. There is no genetic defect in the production of ACh; rather than a genetic cause, it is thought that myasthenia gravis has an autoimmune etiology. Although the defect is at the neuromuscular junction, it is not an inefficiency in the use of ACh but a decrease in the number of receptor sites for ACh. AChE is inhibited by anticholinesterase drugs used to treat myasthenia gravis, leaving more ACh available to the damaged or decreased ACh receptors.

Arrange the order of tests chronologically to be performed to determine the neurologic status of a client. 1. Speak in loud voice 2. Apply painful stimuli 3. Speak in normal voice 4. Shake the client gently

3. Speak in a normal voice 1. Speak in a loud voice 4. Shake client gently 2. Apply painful stimuli The assessment of neurologic status should start with speaking to the client in a normal voice. If the client does not respond, the nurse should speak loudly. If the client does not respond to this, the nurse should gently shake the client. The degree of shaking should be similar to that used in waking a child. If the client does not respond to this, painful stimuli can be applied.

A nurse plans to teach the signs of rejection to a client who just had a transplanted kidney. What sign of rejection should the nurse include? 1.Weight loss 2.Subnormal temperature 3.Elevated blood pressure 4.Increased urinary output

3.Elevated blood pressure

A nurse teaches the signs of organ rejection to a client who had a kidney transplant. What should be included in the education? 1.Weight loss 2.Subnormal temperature 3.Elevated blood pressure 4.Increased urinary output

3.Elevated blood pressure

A client with acute glomerulonephritis complains of thirst. The most appropriate item that the nurse can offer to relieve the client's thirst is: 1.Ginger ale 2.Milkshake 3.Hard candy 4.Cup of broth

3.Hard candy

A nurse is caring for a client receiving hemodialysis for chronic kidney disease. The nurse should monitor the client for what complication? 1.Peritonitis 2.Renal calculi 3.Hepatitis B 4.Bladder infection

3.Hepatitis B

A client who is to begin continuous ambulatory peritoneal dialysis (CAPD) asks the nurse what this treatment entails. What information should the nurse include in the explanation? 1.Peritoneal dialysis is done in an ambulatory care clinic. 2.Hemodialysis and peritoneal dialysis are provided continuously. 3.The peritoneal membrane allows passage of toxins into the dialysate. 4.A quarter of a liter of dialysate is maintained inter- and intraperitoneally

3.The peritoneal membrane allows passage of toxins into the dialysate.

A nurse is caring for a client with acute kidney failure who is receiving a protein-restricted diet. The client asks why this diet is necessary. What information should the nurse include in a response to the client's questions? 1.A high-protein intake ensures an adequate daily supply of amino acids to compensate for losses. 2.Essential and nonessential amino acids are necessary in the diet to supply materials for tissue protein synthesis. 3.This supplies only essential amino acids, reducing the amount of metabolic waste products, thus decreasing stress on the kidneys. 4.Urea nitrogen cannot be used to synthesize amino acids in the body, so the nitrogen for amino acid synthesis must come from the dietary protein

3.This supplies only essential amino acids, reducing the amount of metabolic waste products, thus decreasing stress on the kidneys.

A client recovering from a head injury is participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure if the nurse observes the client doing which activity? 1. Blowing the nose 2. Isometric exercises 3. Coughing vigorously 4. Exhaling during repositioning

4 Activities that increase intrathoracic and intraabdominal pressures cause an indirect elevation of the intracranial pressure. Some of these activities include isometric exercises, Valsalva's maneuver, coughing, sneezing, and blowing the nose. Exhaling during activities such as repositioning or pulling up in bed, opens the glottis, which prevents intrathoracic pressure from rising.

The nurse is assessing fluid balance in a client who has undergone a craniotomy. The nurse should assess for which finding as a sign of overhydration, which would aggravate cerebral edema? 1. Unchanged weight 2. Shift intake 950 mL, output 900 mL 3. Blood urea nitrogen (BUN) 10 mg/dL 4. Serum osmolality 280 mOsm/kg H2O

4 After craniotomy the goal is to keep the serum osmolality on the high side of normal to minimize excess body water and control cerebral edema. The normal serum osmolality is 285 to 295 mOsm/kg H2O. A higher value indicates dehydration; a lower value indicates overhydration. Stable weight indicates that there is neither fluid excess nor fluid deficit. A difference of 50 mL in intake and output for an 8-hour shift is insignificant. The BUN of 10 mg/dL is within normal range and does not indicate overhydration or underhydration.

The nurse is preparing to care for a client who had a supratentorial craniotomy. The nurse should plan to place the client in which position? 1. Prone 2. Supine 3. Side-lying 4. Semi-Fowler's

4 After supratentorial surgery (surgery above the tentorium of the brain), the head of the client's bed usually is elevated 30 degrees to promote venous outflow through the jugular veins. Options 1, 2, and 3 denote incorrect positions after this surgery and these positions could result in edema at the surgical site and increased intracranial pressure.

A client who has a spinal cord injury that resulted in paraplegia experiences a sudden onset of severe headache and nausea. The client is diaphoretic with piloerection and has flushing of the skin. The client's systolic blood pressure (BP) is 210 mm Hg. What should the nurse immediately suspect? 1. Return of spinal shock 2. Malignant hypertension 3. Impending brain attack (stroke) 4. Autonomic dysreflexia (hyperreflexia)

4 Autonomic dysreflexia (hyperreflexia) results from sudden strong discharge of the sympathetic nervous system in response to a noxious stimulus. Signs and symptoms include pounding headache, nausea, nasal stuffiness, flushed skin, piloerection, and diaphoresis. Severe hypertension can occur, with a systolic BP rising potentially as high as 300 mm Hg. It often is triggered by thermal or mechanical events such as a kinking of catheter tubing, constipation, urinary tract infection, or any variety of cutaneous stimuli. The nurse must recognize this situation immediately and take corrective action to remove the stimulus. If untreated, this medical emergency could result in stroke, status epilepticus, or possibly death.

A postoperative craniotomy client who sustained a severe head injury is admitted to the neurological unit. What important nursing intervention is necessary for this client? 1. Take and record vital signs every 4 to 8 hours. 2. Prophylactically hyperventilate during the first 20 hours. 3. Treat a central fever with the administration of antipyretic medications such as acetaminophen (Tylenol). 4. Keep the head of the bed elevated at least 30 degrees, and position the client to avoid extreme flexion or extension of the neck and head.

4 Avoiding extreme flexion and extension of the neck can enhance venous drainage and help prevent increased intracranial pressure. As a general rule, hyperventilation is avoided during the first 20 hours postoperatively because it may produce ischemia caused by cerebral vasoconstriction. Vital signs need to be taken and recorded at least every 1 to 2 hours. Central fevers caused by hypothalamic damage respond better to cooling (hypothermia blankets, sponge baths) than to the administration of antipyretic medications.

A client with a 5-year history of myasthenia gravis is admitted to the hospital because of an exacerbation. When assessing the client, the nurse identifies ptosis, dysarthria, dysphagia, and muscle weakness. Which assessment finding should the nurse expect the client to report? 1 Weakness decreases after hot baths 2 Weakness improves with muscle use 3 Strength improves immediately after meals 4 Strength decreases with repeated muscle use

4 Because of the myoneural junction defect, repeated muscle contraction depletes acetylcholine, elevates cholinesterase, or exhausts acetylcholine receptor sites, resulting in decreased muscle strength as the day progresses. Hot baths tend to increase, not decrease, muscle weakness. Muscle weakness decreases, not improves, with muscle use. There is no evidence that eating meals will bring about improvement.

The nurse who is caring for a client with a diagnosis of cirrhosis is monitoring the client for signs of portal hypertension. Which initial sign, if noted in the client, indicates the presence of portal hypertension? 1. Weak pulse 2. Hypotension 3. Flat neck veins 4. Crackles on auscultation of the lungs

4 Clinical signs and symptoms of portal hypertension are similar to those of heart failure and include jugular vein distention, lung crackles, and decreased perfusion to all organs. Initially the client may have hypertension, flushed skin, and a bounding pulse.

The nurse determines the client with a chest tube to a closed drainage system is experiencing an air leak. Which finding is indicative of this? 1. Tidaling is absent. 2. Gentle bubbling is observed in the suction control chamber. 3. Vacillation of water in the water seal chamber occurs during respiration. 4. Continuous bubbling is observed in the water seal during inspiration and expiration.

4 Continuous bubbling in the water seal chamber during inspiration and expiration indicates that air is leaking into the drainage system or pleural cavity. Bubbling is an expected finding in the suction control chamber when the device is connected to suction. Tidaling is a normal phenomenon. Absence of tidaling can be indicative of re-expansion of the lung or obstruction or kinking of the chest tube.

A client with a spinal cord injury expresses little interest in food and is very particular about the choice of meals that are actually eaten. How should the nurse interpret this information? 1. Anorexia is a sign of clinical depression, and a referral to a psychologist is needed. 2. The client has compulsive habits that should be ignored so long as they are not harmful. 3. The client probably has a naturally slow metabolism, and the decreased nutritional intake will not matter. 4. Meal choices represent an area of client control and should be encouraged as much as is nutritionally reasonable.

4 Depression frequently may be seen in the client with spinal cord injury and may be exhibited as a loss of appetite. However, the client should be allowed to choose the types of food eaten and when they are eaten as much as is feasible because it is one of the few areas of control that the client has left. There is no information in the query of the question that would indicate that the client is anorexic, obsessive-compulsive, or has a slow metabolism.

A client with myasthenia gravis has increased difficulty swallowing. Which action will the nurse take to prevent the aspiration of food? 1 Offer three large meals a day. 2 Assess the client's respiratory status before and after meals. 3 Seek a change in the diet prescription from soft foods to clear liquids. 4 Schedule meals with the peak effect of an anticholinesterase muscle stimulant.

4 Dysphagia should be minimized during the peak effect of an anticholinesterase muscle stimulant such as pyridostigmine, thereby decreasing the probability of aspiration. Three large meals a day will tire the client with myasthenia gravis. Assessing the client's respiratory status before and after meals will not prevent aspiration, although it is vital that respiratory function be monitored. Data are insufficient to determine whether changing the diet to clear liquids is appropriate because liquids also may be aspirated; liquids are more difficult to manage than are foods with the consistency of pudding.

The nurse caring for a client with a closed chest drainage system notes that the fluctuation (tidaling) in the water-seal compartment has stopped. On the basis of this assessment finding, the nurse would suspect which occurrence? 1. The system needs changing. 2. Suction needs to be increased. 3. Suction needs to be decreased. 4. The chest tubes are obstructed.

4 Fluid in the water-seal compartment should rise with inspiration and fall with expiration (tidaling). When tidaling occurs, the drainage tubes are patent and the apparatus is functioning properly. Tidaling stops when the lung has reexpanded or if the chest drainage tubes are kinked or obstructed. Options 1, 2, and 3 are incorrect interpretations.

The nurse is caring for a client on a mechanical ventilator. The high-pressure alarm sounds. The nurse assesses the client and attempts to determine the cause of the alarm. Which initial nursing action would be appropriate if the nurse is unable to determine the cause of ventilator alarm? 1. Shut the alarm off and call for help. 2. Call the respiratory therapy department to fix the problem. 3. Call the health care provider (HCP) for further instructions. 4. Disconnect the client from the ventilator and manually ventilate the client with a resuscitation device.

4 If the nurse is unable to troubleshoot an alarm or suspects equipment failure in a mechanical ventilator, the nurse should manually ventilate the client with a resuscitation device. The nurse should never shut off the alarm. It is not necessary to contact the HCP, although the respiratory therapist may be notified to assist in troubleshooting the cause of the problem. However, the initial nursing action would be to manually ventilate the client.

A nurse provides education to a client with myasthenia gravis about how to prevent myasthenic crisis. The nurse evaluates that the teaching is effective when the client makes which statement? 1 "I'll take an antihistamine at the first sign of a cold." 2 "I should skip a dose of pyridostigmine bromide (Mestinon) if it upsets my stomach." 3 "We've told our daughter to wait to visit until her cold is better." 4 "The healthcare provider may need to adjust the dosage of my medication if I'm more active."

4 Increased activity without an increase in medication can precipitate a myasthenic crisis [1] [2]. Self-medication may result in drug interactions; a change in medical therapy can have serious consequences. A dose should not be skipped because doing so may result in severe respiratory distress. People with myasthenia gravis should avoid crowds and others with colds; they are more prone to respiratory infections because of an ineffective cough and a potential for aspiration.

A client being mechanically ventilated after experiencing a fat embolism is visibly anxious. What is the best nursing action? 1. Ask a family member to stay with the client at all times. 2. Ask the health care provider for a prescription for succinylcholine. 3. Encourage the client to sleep until arterial blood gas results improve. 4. Provide reassurance to the client and give small doses of morphine sulfate intravenously as prescribed.

4 Morphine sulfate often is prescribed for pain and anxiety in the client receiving mechanical ventilation. The nurse should speak to the client calmly and provide reassurance to the anxious client. Family members also are stressed, not just because of the complication but because of the original injury. It is not beneficial to ask the family to take on the burden of remaining with the client at all times. Succinylcholine is a neuromuscular blocker but has no antianxiety properties. Encouraging the client to sleep until arterial blood gas results improve does nothing to reassure or help the client.

A client with parkinsonism is taking an anticholinergic medication for morning stiffness and tremors in the right arm. During a visit to the clinic, the client complains of some numbness in the left hand. What is the nurse's priority intervention? 1 Refer the client to the primary healthcare provider only if other neurologic deficits are present. 2 Ask the primary healthcare provider to increase the client's dosage of the anticholinergic medication. 3 Stress the importance of having the client call the primary healthcare provider as soon as possible. 4 Make arrangements immediately for further medical evaluation by the client's primary healthcare provider.

4 Numbness, a sensory deficit, is inconsistent with parkinsonism; further medical evaluation is necessary. Numbness, even in the absence of other problems, may be indicative of an impending brain attack (cerebrovascular accident, CVA). This symptom is not caused by parkinsonism; increasing the dosage of the anticholinergic medication will not be helpful. Stressing the importance of having the client call the primary healthcare provider as soon as possible can cause a delay in the client's receiving immediate medical attention.

A client with the diagnosis of multiple sclerosis experiences a sudden loss of vision and asks the nurse what caused it to happen. The nurse considers the common clinical findings associated with multiple sclerosis before responding. Which is the most probable cause of the client's sudden loss of vision? 1 Virus-induced iritis 2 Intracranial pressure 3 Closed-angle glaucoma 4 Optic nerve inflammation

4 Optic nerve inflammation is a common early effect of multiple sclerosis caused by lesions in the optic nerves or their connections (demyelization). This effect may resolve during periods of remission. At present there is no evidence of viral infection of the eyes in multiple sclerosis. Tumors of the brain and cerebral edema, not multiple sclerosis, cause increased intracranial pressure because the skull cannot expand. Closed-angle glaucoma causes blindness as a result of increased intraocular pressure, not inflammation of the optic nerve, which is commonly associated with multiple sclerosis. Closed-angle glaucoma is unrelated to multiple sclerosis.

A client with a history of parkinsonism recently developed rigidity, tremors, and signs of pneumonia. The client is hospitalized for treatment. What should the nursing plan of care include? 1 Gait training in the physical therapy department daily 2 Isometric exercises every two hours while awake 3 Active range-of-motion exercises at least every four hours 4 Passive range-of-motion exercises at least every eight hours

4 Passive range-of-motion exercises at least every eight hours maintain the range of joint movement with a minimum of energy expenditure by the client. Ambulation may fatigue the client and does not provide sufficient movement of the upper extremities. Isometric exercises do not provide the joint movement necessary to prevent contractures. Active range-of-motion exercises at least every four hours increase the client's metabolic rate and need for oxygen; the client's ability to meet increased oxygen demand is decreased in the presence of pneumonia.

The nurse is caring for a client who is brought to the hospital emergency department with a spinal cord injury. The nurse minimizes the risk of compounding the injury most effectively by performing which action? 1. Keeping the client on a stretcher 2. Logrolling the client onto a soft mattress 3. Logrolling the client onto a firm mattress 4. Placing the client on a bed that provides spinal immobilization

4 Spinal immobilization is necessary after spinal cord injury to prevent further damage and insult to the spinal cord. Whenever possible, the client is placed on a special bed, such as a Stryker frame, which allows the nurse to turn the client to prevent complications of immobility while maintaining alignment of the spine. If a Stryker frame is not available, a firm mattress with a bed board under it should be used. Options 1, 2, and 3 are incorrect and potentially harmful interventions.

A client with an endotracheal tube attached to mechanical ventilation begins to cough, and his face appears flushed. Which action should the nurse take first? 1. Call respiratory therapy. 2. Contact the health care provider. 3. Check the client's blood pressure. 4. Suction the client through the endotracheal tube.

4 The client is choking on his secretions, which should be removed by suctioning of the endotracheal tube. There is no need at this time to contact the health care provider or call for respiratory therapy. The nurse should check the client's blood pressure, but suctioning is the priority.

A client with cirrhosis complicated by ascites is admitted to the hospital. The client reports a 10-lb weight gain over the last 1½ weeks. The client has edema of the feet and ankles, and his abdomen is distended, taut, and shiny with striae. Which client problem is most appropriate at this time? 1. Difficulty with breathing 2. Risk for skin breakdown 3. Difficulty with sleeping 4. Excessive body fluid volume

4 The client with weight gain who also has cirrhosis complicated by ascites most often is retaining fluid. This is especially true when the client has not demonstrated an appreciable increase in food intake or when the weight gain is massive in relation to the time frame given. Therefore, excessive body fluid volume is the most appropriate problem. No data are given to support difficulty with breathing, although in some clients upward pressure on the diaphragm from ascites does impair respiration. Risk for skin breakdown assumes a lower priority because it is a risk rather than an actual problem. There is no data in the question that indicates that the client is having difficulty with sleep.

The nurse is assessing a client with multiple trauma who is at risk for developing acute respiratory distress syndrome. The nurse should assess for which earliest sign of acute respiratory distress syndrome? 1. Bilateral wheezing 2. Inspiratory crackles 3. Intercostal retractions 4. Increased respiratory rate

4 The earliest detectable sign of acute respiratory distress syndrome is an increased respiratory rate, which can begin from 1 to 96 hours after the initial insult to the body. This is followed by increasing dyspnea, air hunger, retraction of accessory muscles, and cyanosis. Breath sounds may be clear or consist of fine inspiratory crackles or diffuse coarse crackles.

The low-exhaled volume alarm sounds on a mechanical ventilator of a client with an endotracheal tube. The nurse determines that the cause for alarm activation may be which complication? 1. Excessive secretions 2. Kinks in the ventilator tubing 3. The presence of a mucous plug 4. Displacement of the endotracheal tube

4 The low-exhaled volume alarm will sound if the client does not receive the preset tidal volume. Possible causes of inadequate tidal volume include disconnection of the ventilator tubing from the artificial airway, a leak in the endotracheal or tracheostomy cuff, displacement of the endotracheal tube or tracheostomy tube, and disconnection at any location of the ventilator parts. Options 1, 2, and 3 would cause the high-pressure alarm to sound.

A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse should avoid which measure to minimize the risk of occurrence? 1. Strict adherence to a bowel retraining program 2. Keeping the linen wrinkle-free under the client 3. Preventing unnecessary pressure on the lower limbs 4. Limiting bladder catheterization to once every 12 hours

4 The most frequent cause of autonomic dysreflexia is a distended bladder. Straight catheterization should be done every 4 to 6 hours (catheterization every 12 hours is too infrequent), and Foley catheters should be checked frequently to prevent kinks in the tubing. Constipation and fecal impaction are other causes, so maintaining bowel regularity is important. Other causes include stimulation of the skin from tactile, thermal, or painful stimuli. The nurse administers care to minimize risk in these areas.

A client has a chest tube attached to a water seal drainage system. As part of routine nursing care, the nurse should ensure that which intervention is implemented? 1. The water seal chamber has continuous bubbling, and assessment for crepitus is done once a shift. 2. The amount of drainage into the chest tube is noted and recorded every 24 hours in the client's record. 3. The suction control chamber has sterile water added every shift, and the system is kept below waist level. 4. The connection between the chest tube and the drainage system is taped, and an occlusive dressing is maintained at the insertion site.

4 The nurse ensures that all system connections are securely taped to prevent accidental disconnection and that an occlusive dressing is maintained at the chest tube insertion site. Continuous bubbling in the water seal chamber indicates an air leak in the system and requires immediate investigation and correction. Drainage is noted and recorded every hour during the first 24 hours after insertion and every 8 hours thereafter. The system is kept below the level of the waist. Assessment for crepitus is done once every 8 hours. Sterile water is added to the suction control chamber only as needed to replace evaporation losses.

The clinical trainer is reviewing the renin-angiotensin-aldosterone system with graduate nurses during orientation to the telemetry unit. In which order should the trainer discuss this system? (Enter the number of each step in the proper sequence

4) Kidneys release renin in response to a drop in blood pressure 2) Renin reacts with angiotensin to create angiotensin 1 3) Angiotensin I is converted to angiotensin II in the lungs 5) Angiotensin II influences adrenal glands to release aldosterone 1) Sodium and water reabsorbed in the kidneys

A client with liver dysfunction has low serum levels of fibrinogen and a prolonged prothrombin time (PT). Based on these findings, which actions should the nurse plan to promote the client's safety? Select all that apply. 1. Monitor serum potassium levels. 2. Weigh client daily, and monitor trends. 3. Monitor for symptoms of fluid retention. 4. Provide the client with a soft toothbrush. 5. Instruct the client to use an electric razor. 6. Monitor all secretions for frank or occult blood.

4, 5, 6 Fibrinogen is produced by the liver and is necessary for normal clotting. A client who has insufficient levels is at risk for bleeding. The prothrombin time is prolonged when one or more of the clotting factors (II, V, VII, or X) is deficient, so the client's risk for bleeding is also increased. Options 4, 5, and 6 are measures that provide for client safety and monitor for bleeding.

A client with Guillain-Barré syndrome has been hospitalized for three days. Which assessment finding would the nurse expect and need to monitor frequently in this client? 1 Localized seizures 2 Skin desquamation 3 Hyperactive reflexes 4 Ascending weakness

4. Ascending weakness The classic feature of Guillain-Barré syndrome is ascending weakness, beginning in the lower extremities and progressing to the trunk, upper extremities, and face; more frequent assessment, especially of respiratory status, is needed. Localized seizures are not a characteristic of Guillain-Barré syndrome. Skin desquamation is not a characteristic of Guillain-Barré syndrome. Deep tendon reflexes are absent with Guillain-Barré syndrome.

The nurse provides education to a client about the side effects of furosemide (Lasix). Which client statements indicate that the teaching is understood? (Select all that apply.) 1."I must not eat citrus fruits." 2."I should wear dark glasses." 3."I should avoid lying flat in bed." 4."I should change my position slowly." 5."I must eat a food that contains potassium every day."

4."I should change my position slowly." 5."I must eat a food that contains potassium every day."

A nurse is developing a discharge plan for a client who was hospitalized with severe cirrhosis of the liver. The plan should include the: 1.Need for a high protein diet 2.Use of a sedative for relaxation 3.Need to increase fluids 4.Importance of reporting personality changes to the health care provider

4.Importance of reporting personality changes to the health care provider

The nurse providing postoperative care for a client who had kidney surgery reviews the client's urinalysis results. The nurse concludes that the presence of what substance in the urine needs to be reported to the health care provider? 1.Sodium 2.Potassium 3.Urea nitrogen 4.Large proteins

4.Large proteins

A nurse is caring for a client who is experiencing urinary incontinence. The client has an involuntary loss of small amounts (25 to 35 mL) of urine from an overdistended bladder. This should be documented in the medical record as: 1.Urge incontinence 2.Stress incontinence 3.Reflex incontinence 4.Overflow incontinence

4.Overflow incontinence

The nurse should ask the client with secondary syphilis about sexual contacts during the past: 1.21 days 2.30 days 3.Three months 4.Six months

4.Six months

A client is scheduled for an intravenous pyelogram (IVP). The nurse explains that on the day before the IVP the client must: 1.Avoid fats and proteins 2.Drink a large amount of fluids 3.Omit dinner and limit beverages 4.Take a laxative before going to bed

4.Take a laxative before going to bed

A lithotripsy to break up renal calculi is unsuccessful, and a nephrolithotomy is performed. Which postoperative clinical indicator should the nurse report to the health care provider? 1.Passage of pink-tinged urine 2.Pink drainage on the dressing 3.Intake of 1750 mL in 24 hours 4.Urine output of 20 to 30 mL/hr

4.Urine output of 20 to 30 mL/hr

607. Dopamine protocol is prescribed for a male client who weigh 198 pounds to maintain the mean arterial pressure (MAP) greater than 65 mmHg. His current MAP is 50 mmHg, so the nurse increases the infusion to 7 mcg/kg/minute. The infusion is labeled dextrose 5% in water (D5W) 500 ml with dopamine 400 mg. The nurse should program the infusion pump to deliver how many ml/hour?

47

A child is receiving maintainance intravenous (IV) fluids at the rate of 1000 mL for the first 10 kg of body weight, plus 50 mL/kg per day for each kilogram between 10 and 20. How many milliliters per hour should the nurse program the infusion pump for a child who weighs 19.5 kg? (Enter numeric value only. If rounding is required, round to the nearest whole number.)

61 The formula for calculating daily fluid requirements is: 0 to 10 kg, 100 mL/kg per day; or 10 to 20 kg, 1000 mL for the first 10 kg of body weight plus 50 mL/kg per day for each kilogram between 10 and 20. To determine an hourly rate, divide the total milliliters per day by 24. 19.5 kg x 50 mL/kg = 475 mL + 1000 mL = 1475 mL / 24 hours = 61 mL/hour

A client who weighs 176 pounds (80 kg) is being immunosuppressed by daily maintenance doses of cyclosporine to prevent organ transplant rejection. The dose prescribed is 8 mg/kg each day. How many milligrams should the nurse plan to administer each day? Record your answer using a whole number. ___ mg

640

297. The nurse is preparing a heparin bolus dose of 80 units/kg for a client who weighs 220 pounds. Heparin sodium injection, USP is available in a 3o ml multidose vial with the concentration of 1,000 USP units/ml. how many ml of heparin should the nurse administer? (Enter numeric value only)

8

A postmenopausal obese female client who smokes has developed an intolerance to fatty foods and believes she is at risk for developing gallbladder problems. What instruction should the nurse provide to help reduce the client's risk for gallbladder disease? A. Join a group weight loss program B. Begin a smoking cessation class C. Schedule rest periods after eating D. Consider hormone replacement therapy

A

An older male client who fainted while working in the garden is admitted to the ED with sudden onset of difficulty speaking, right hemiplegia, and atrial fibrillation. Which pathophysiological mechanism explains these findings? A. Ischemic damage to the left cerebral hemisphere B. Transient loss of cerebral activity due to head injury C. Decreased cerebral blood flow caused by hypotension D. Increased intracranial pressure r/t hemorrhage

A

The nurse is performing an assessment of a client during the early period of Acute Respiratory Distress Syndrome (ARDS). What signs and symptoms should the nurse expect to find? A. Agitation, confusion, and using abdominal muscles to breathe. B. Drowsiness, stupor, and inability to arouse C. Dyspnea, and uneven movements of the chest wall D. Shallow breathing, accompanied by a productive cough

A

Prior to administering an oral suspension, which intervention is most important for the nurse to implement? A.Assess the client's ability to swallow liquids. B.Obtain applesauce in which to mix the medication. C.Determine the client's food likes and dislikes. D.Auscultate the client's breath sounds.

A An oral suspension is a liquid, so the nurse needs to assess the client's ability to swallow liquids (A) to ensure that the client will not choke. If the client has difficulty swallowing liquids, a thickening substance may be used (B). If a food product is used to thicken the liquid, (C) would be beneficial. (D) may also be warranted, but only if the client is at risk for aspiration, determined by (A).

The nurse plans to evaluate the effectiveness of a bronchodilator. Which assessment datum indicates that the desired effect of a bronchodilator has been achieved? A.Increased oxygen saturation B.Increased urinary output C.Decreased apical pulse rate D.Decreased blood pressure

A Bronchodilators increase the diameter of the bronchioles, resulting in improved oxygenation, reflected by an increase in oxygen saturation (A). (B, C, and D) do not indicate the desired effect of a bronchodilator

Which physiologic finding in an older adult contributes to an adverse drug reaction? A.Reduced renal excretion B.Reduced gastrointestinal motility C.Increased hepatic metabolism D.Increased risk of autoimmune disorders

A During the aging process, reduced renal function (A) is common and contributes to drug accumulation that contributes to adverse reactions. Reduced hepatic function, not (C), predisposes an older adult to an increase in adverse drug reactions. (B) may occur frequently in an older client but does not impact the bioavailability of drugs. Although an older adult may have a decreased immune response, the aging client's risk for autoimmune disorders (D) is not increased nor does it affect drug pharmacotherapeutics.

A client with glomerulonephritis is scheduled for a creatinine clearance test to determine the need for dialysis. Which information should the nurse provide the client prior to the test? A.Failure to collect all urine specimens during the period of the study will invalidate the test. B.Blood is collected to measure the amount of creatinine and determine the glomerular filtration rate (GFR). C.Dialysis is started when the GFR is lower than 5 mL/min. D.Discard the first voiding, and record the time and amount of urine of each voiding for 24 hours.

A Glomerulonephritis damages the renal glomeruli and affects the kidney's ability to clear serum creatinine into the urine. Creatinine clearance is a 24-hour urine specimen test, so all urine should be collected during the period of the study or the results are inaccurate (A). As renal function decreases, the creatinine level will decrease in the urine (B). Dialysis is usually started when the GFR is 12 mL/min (C). There is no need to record the frequency and amount of each voiding (D) during the time span of urine collection.

A client with human immunodeficiency virus (HIV) infection has white lesions in the oral cavity that resemble milk curds. Nystatin (Mycostatin) preparation is prescribed as a swish and swallow. Which information is most important for the nurse to provide the client? A.Oral hygiene should be performed before the medication. B.Antifungal medications are available in tablet, suppository, and liquid forms. C.Candida albicans is the organism that causes the white lesions in the mouth. D.The dietary intake of dairy and spicy foods should be limited.

A HIV infection causes depression of cell-mediated immunity that allows an overgrowth of Candida albicans (oral moniliasis), which appears as white, cheesy plaque or lesions that resemble milk curds. To ensure effective contact of the medication with the oral lesions, oral liquids should be consumed and oral hygiene performed before swishing the liquid Mycostatin (A). (B and C) provide the client with additional information about the pathogenesis and treatment of opportunistic infections, but (A) allows the client to participate in self-care of the oral infection. Dietary restriction of spicy foods reduces discomfort associated with stomatitis, but restriction of dairy products is not indicated (D).

After administration of an 0730 dose of Humalog 50/50 insulin to a client with diabetes mellitus, which nursing action has the highest priority? A.Ensure that the client receives breakfast within 30 minutes. B.Remind the client to have a midmorning snack at 1000. C.Discuss the importance of a midafternoon snack with the client. D.Explain that the client's capillary glucose will be checked at 1130.

A Insulin 50/50 contains 50% regular and 50% NPH insulin. Therefore, the onset of action is within 30 minutes and the nurse's priority action is to ensure that the client receives a breakfast tray to avoid a hypoglycemic reaction (A). (B, C, and D) are also important nursing actions but are of less immediacy than (A).

The nurse is correct in withholding an older adult client's dose of nifedipine (Procardia) if which assessment finding is obtained? A.Blood pressure of 90/56 mm Hg B.Apical pulse rate of 68 beats/min C.Potassium level of 3.3 mEq/L D.Urine output of 200 mL in 4 hours

A Nifedipine (Procardia) is a calcium channel blocker that causes a decrease in blood pressure. It should be withheld if the blood pressure is lowered, and 90/56 mm Hg is a low blood pressure for an adult male (A). A pulse rate less than 60 beats/min is an indication to withhold the drug (B). A potassium level of 3.3 mEq/L is low (normal, 3.5 to 5.0 mEq/L), but this finding does not affect the administration of Procardia (C). Urine output of more than 30 mL/hr, or 120 mL in 4 hours, is normal. Although a 200- mL output in 4 hours is slightly less than normal and warrants follow-up, it is not an indication to withhold a nifedipine (Procardia) dose (D).

A very busy hospital unit has had several discharges and the census is unusually low. What is the best way for the charge nurse to use the time of the nursing staff? A.Encourage staff to participate in online in-service education. B.Assign staff to make sure that all equipment is thoroughly cleaned. C.Ask which staff members would like to go home for the remainder of the day. D.Notify the supervisor that the staff needs additional assignments.

A Online educational programs are available around the clock, so staff can engage in continuing education programs when the opportunity arises, such as during periods of low census (A). (B) is not the responsibility of the nursing staff. (C) is not the best use of staff and does not use the extra time provided by the low census. The charge nurse should use the time to improve the unit, and requesting additional assignments is not necessary (D)

Which question is most relevant to ask the parents when obtaining the history of a 2-year-old child recently diagnosed with osteomyelitis? A."Has your child had an ear infection recently?" B."Does your child seem resistant to toilet training?" C."Is your child a picky eater?" D."Do you have a family history of bone disorders?"

A Osteomyelitis can be caused by internal infections, such as otitis media (A). (B and C) are normal developmental findings for a 2-year-old. Osteomyelitis is caused by a bacterial infection, so (D) is not relevant.

A client with type 2 diabetes has a plantar foot ulcer. When developing a teaching plan regarding foot care, what information should the nurse obtain first from the client? A.How the client examines her feet B.Which hypoglycemic medication she takes C.Who lives in the home with her D.How long she has had diabetes mellitus

A Rationale: (A) specifically relates to foot care. (B, C, and D) provide worthwhile information to obtain but do not have the importance of (A).

After assessing a 26-year-old client with type 1 diabetes mellitus, which data may indicate that the client is experiencing chronic complications of diabetes? A.Blood pressure, 159/98 mm Hg B.Hemoglobin A1c (HbA1c), 6% C.Creatinine level, 1.0 mg/dL D.Chronic sciatica

A Rationale: A blood pressure of 159/98 mm Hg is hypertensive and increases the client's risk for acute coronary syndrome and/or stroke (A). (B and C) are within defined parameters, and (D) is not a recognized chronic complication of diabetes.

A primipara presents to the perinatal unit describing rupture of the membranes (ROM), which occurred 12 hours prior to coming to the hospital. An oxytocin (Pitocin) infusion is begun, and 8 hours later the client's contractions are irregular and mild. What vital sign should the nurse monitor with greater frequency than the typical unit protocol? A.Maternal temperature B.Fetal blood pressure C.Maternal respiratory rate D.Fetal heart rate

A Rationale: Maternal temperature (A) should be monitored frequently as a primary indicator of infection. This client's rupture of membranes (ROM) occurred at least 20 hours ago (12 hours before coming to the hospital, in addition to 8 hours since hospital admission). Delivery is not imminent, and there is an increased risk of the development of infection 24 hours after ROM. (B) cannot be established with standard bedside monitoring. (C) is not specifically related to ROM. (D) is always monitored during labor; this situation would not prompt the nurse to increase FHR monitoring.

A client with bipolar disorder is seen in the mental health clinic for evaluation of a new medication regimen that includes risperidone (Risperdal). The nurse notes that the client has gained 30 lb in the past 3 months. Which assessment is most important for the nurse to obtain? A.Compliance with medication regimen B.Current thyroid-stimulating hormone (TSH) level C.Occurrence of mania or depression D.A 24-hour diet and exercise recall

A Rationale: Medication compliance (A) is most important for the treatment of psychotic disorders and, because Risperdal is associated with weight gain, it is probable that the client is complying with the treatment plan. The TSH level (B) indicates thyroid function, which regulates basal metabolic rate and influences weight. It is important to obtain information about occurrences of mania and depression (C) since the last visit, but if the client is compliant with the medication regimen, these symptoms are likely to have been controlled. Diet and exercise (D) should also be assessed, but weight gain is a likely indicator of medication compliance.

The nurse is caring for a hospitalized client with myasthenia gravis. Which finding requires the most immediate action by the nurse? A.O2 saturation, 89% B.Reports diplopia C.Ptosis to left eye D.Difficulty speaking

A Rationale: Respiratory failure is a life-threatening complication that can occur with myasthenia gravis (A). (B, C, and D) are signs of the disease but are not as life threatening as decreased oxygen saturation.

A client who is prescribed chlorpromazine HCl (Thorazine) for schizophrenia develops rigidity, a shuffling gait, and tremors. Which action by the nurse is most important?A.Administer a dose of benztropine mesylate (Cogentin) PRN. B.Determine if the client has increased photosensitivity. C.Provide comfort measures for sore muscles. D.Assess the client for visual and auditory hallucinations.

A Rationale: Rigidity, shuffling gait, pill-rolling hand movements, tremors, dyskinesia, and masklike face are extrapyramidal side effects associated with Thorazine. It is most important for the nurse to administer an anticholinergic such as Cogentin to reverse these effects (A). The others (B, C, D) may be appropriate interventions but are not as urgent as (A).

Which vaccination should the nurse administer to a newborn? A.Hepatitis B B.Human papilloma virus (HPV) C.Varicella D.Meningococcal vaccine

A Rationale: The hepatitis B vaccination should be given to all newborns before hospital discharge (A). HPV is not recommended until adolescence (B). Varicella immunization begins at 12 months (C). Meningococcal vaccine is administered beginning at 2 years (D).

The charge nurse is making assignments for the upcoming shift. Which client is most appropriate to assign to the licensed practical nurse (LPN)? A.A client with nausea who needs a nasogastric tube inserted B.A client in hypertensive crisis who needs titration of IV nitroglycerin C. A newly admitted client who needs to have a plan of care established D.A client who is ready for discharge who needs discharge teaching

A Rationale: This client has a need for a skill that is within the scope of practice for the LPN (A). Titration of an IV drip, establishing care plans, and discharge teaching are within the scope of practice of a registered nurse (RN) and are not delegated (B, C, and D).

The antigout medication allopurinol (Zyloprim) is prescribed for a client newly diagnosed with gout. Which comment by the client warrants intervention by the nurse? A."I take aspirin for my pain." B."I frequently eat fruit and drink fruit juices." C."I drink a great deal of water, so I have to get up at night to urinate." D."I observe my skin daily to see if I have an allergic rash to the medication."

A The client should be taught to avoid aspirin (A) because the ingestion of aspirin or diuretics can precipitate an attack of gout. (B, C, and D) are all appropriate for the treatment of gout. The client's urinary pH can be increased by the intake of alkaline ash foods, such as citrus fruits and juices, which will help reduce stone formation (B). Increasing fluids helps prevent urinary calculi (stone) formation and should be encouraged, even if the client must get up at night to urinate (C). Allopurinol has a rare but potentially fatal hypersensitivity syndrome, which is characterized by a rash and fever. The medication should be discontinued immediately if this occurs (D).

A male client with arterial peripheral vascular disease (PVD) complains of pain in his feet. Which instruction should the nurse give to the UAP to relieve the client's pain quickly? A.Help the client dangle his legs. B.Apply compression stockings. C.Assist with passive leg exercises. D.Ambulate three times a day.

A The client who has arterial PVD may benefit from dependent positioning, and this can be achieved with bedside dangling (A), which will promote gravitation of blood to the feet, improve blood flow, and relieve pain. (B) is indicated for venous insufficiency (C) and indicated for bed rest. Ambulation (D) is indicated to facilitate collateral circulation and may improve long-term complaints of pain.

A client tells the nurse that he is suffering from insomnia. Which information is most important for the nurse to obtain? A.The client's usual sleeping pattern B.Whether the client smokes C.How much liquid the client consumes before bedtime D.The amount of caffeine that the client consumes during the day

A The first thing to determine is the client's usual sleeping pattern and how it has changed to become what the client describes as insomnia (A). (B, C, and D) provide additional information after (A) is ascertained.

The client with which fasting plasma glucose level needs the most immediate intervention by the nurse? A.50 mg/dL B.80 mg/dL C.110 mg/dL D.140 mg/dL

A The normal fasting plasma glucose level ranges from 70 to 105 mg/dL. A client with a low level, such as 50 mg/dL (A), requires the most immediate intervention to prevent loss of consciousness. Normal (B) and slightly elevated levels, such as 110 or 140 mg/dL (C and D), do not require immediate intervention.

A client reports experiencing dysuria and urinary frequency. Which client teaching should the nurse provide? A.Save the next urine sample. B.Restrict oral fluid intake. C.Strain all voided urine. D.Reduce physical activity.

A The nurse should instruct the client to save the next urine sample (A) for observation of its appearance and for possible urinalysis. The client is reporting symptoms that may indicate the onset of a urinary tract infection. Increased fluid intake should be encouraged, unless contraindicated (B). (C) is only necessary if a calculus (stone) is suspected. (D) is not indicated by this client's symptoms.

The nurse meets resistance while flushing a central venous catheter (CVC) at the subclavian site. Which action should the nurse perform? A.Examine for clamp closures. B.Irrigate with a larger syringe. C.Assess for signs of infection. D.Flush the line with heparin.

A Thrombus formation, closed clamp, or crystallized medication can cause resistance while flushing a central line, so the line should be assessed for closed clamps (A) first. Irrigation with a larger syringe (B) will not alleviate the cause for the resistance and can rupture the line. A central line infection (C) should not cause resistance while flushing the line. The CVC should be flushed with normal saline (D) or a diluted solution of heparin (10-100 U/mL) after (A) is completed, if necessary.

457. The nurse is assigned to care for clients on a medical unit. Based on the notes taken during the shift report, which client situation warrants the nurse's immediate attention?

A 10-year-old who is receiving chemotherapy and the infusion pump is beeping

123. A family member of a frail elderly adult asks the nurse about eligibility requirements for hospice care. What information should the nurse provide? (Select all that apply.)

A client must be willing to accept palliative care, not curative care. The healthcare provider must project that the client has 6 months or less to live.

381. A nurse working on an endocrine unit should see which client first?

A client taking corticosteroids who has become disoriented in the last two hours.

A nurse manager delegates the task of phlebotomy to the members of a healthcare team who are caring for a client with diabetes. Which individual on the team can be delegated to perform the task of phlebotomy? Incorrect1 Registered nurse Correct2 Cross-trained technician 3 Licensed vocational nurse 4 Unlicensed assistive personnel

A cross-trained technician can safely perform the task of phlebotomy when paired with a registered nurse (RN). The RN delegates tasks to other assistive personnel. A licensed vocational nurse is assigned to administer oral and intramuscular medications to clients. Unlicensed assistive personnel are delegated to perform basic hygiene for clients.

The nurse is managing a client who underwent cardiac bypass surgery. Which healthcare member can be safely delegated the task of monitoring electrocardiography? 1 Nurse aide 2 Certified technician Correct3 Cross-trained technician Incorrect4 Licensed vocational nurse (LVN)

A cross-trained technician is suitable for monitoring electrocardiography in a client who underwent bypass surgery. A nurse aide is an unlicensed individual who can assist the client with basic hygiene; this aide cannot monitor electrocardiography. A certified technician is also an unlicensed member who can only record the vital signs or provide basic hygiene to the client. A licensed vocational nurse (LVN) can administer oral and intramuscular medications and record the vital signs.

Which of these clients is most appropriate for delegation to a cross-trained technician? Correct1 Client A 2 Client B Incorrect3 Client C 4 Client D

A cross-trained technician, when paired with a registered nurse (RN), may perform respiratory therapy, phlebotomy, and electrocardiography. Care of client A can be safely delegated to a cross-trained technician. Though the cross-trained technician can record the ECG, he or she may not monitor the continuous ECG. Monitoring of vital signs is also the role of the RN. Leg exercises may be taught by the RN or by a physician. The other licensed assistive personnel may be delegated the task of reinforcing the teaching, but this is not an appropriate role for the cross-trained technician.

Which delegatee requires little guidance from the delegator? Correct1 Delegatee who is familiar with the task but not the client 2 Delegatee who has experience but is unfamiliar with the task 3 Delegatee who has little experience but has willingness to do the task 4 Delegatee who is very familiar with the client but has a lack of ability to do the task

A delegatee who has experience and is familiar with the task requires less guidance and support from the delegator as he or she has the ability to accomplish the task. A delegatee who has work experience may have ability but requires guidance as he or she is new to the delegated task. A delegatee who shows willingness to do the task but has little experience requires supervision. A delegatee who is familiar with the client but has a lack of ability to do the task requires supervision or guidance.

While caring for a post-operative client, the delegator has assigned a task to a delegatee. Which statements made by the delegator indicates that the delegatee has the experience to perform the task? Select all that apply. Correct1 "I am available to you at any time for report." Correct2 "I am aware of your technical competencies." 3 "I will tell you what is necessary to perform the task." Incorrect4 "I will share my expectations about your performance." Incorrect5 "I will tell you what conditions are important to notify each other."

A delegatee with good experience may need little guidance. He or she knows what to do and when to report. As the delegatee has experience, he or she should just remember that the delegator is available at all times; the delegate can report at any time. The delegator should also make it known that the delegatee's competencies are known. The delegator tells a delegatee who is new to a task what is necessary to perform that task. The delegator will share expectations about the delegatee's performance when that delegatee can do the work and when he or she is new in assisting the registered nurse (RN). When the delegatee can do the work and is new in assisting the RN, the delegator tells the delegatee the appropriate conditions for notifying one another.

A delegator working in a rural setting has to handle a task of managing care for clients in that area. Which crucial step should the delegator take to develop a productive strategy in delegating tasks to a delegatee? 1 Assigning the task to the delegatee 2 Providing feedback to the delegatee 3 Supervising the task at regular intervals Correct4 Understanding the capabilities of the delegatee

A delegator, before handling a task, should understand the specific capabilities and skill set of the delegatee. Selecting a delegatee who has the specific skill set for the particular task is a more productive strategy than just selecting a competent individual. The delegator has to assess the delegatee and then assign the task on the basis of the competitive skills. Providing feedback during and after the task may enhance the working capabilities of the delegatee. Supervising a task is an ultimate essential element for the delegator, because the delegator is responsible for the accountability of completing the task.

The nurse has received change-of-shift report about the following patients on the progressive care unit. Which patient should the nurse see first?

A patient whose implantable cardioverter-defibrillator (ICD) fired two times today who has a dose of amiodarone (Cordarone) due

464. After teaching a male client with chronic kidney disease (CKD) about therapeutic diet...which menu of foods indicates that the teaching was effective? Select all that apply

A slice of whole grain toast A bowl of cream of wheat

The nurse assesses a woman in the emergency room who is in her third trimester of pregnancy. Which finding(s) is(are) indicative of abruptio placentae? (Select all that apply.) A.Dark red vaginal bleeding B.Rigid boardlike abdomen C.Soft abdomen on palpation D.Complaints of severe abdominal pain E.Painless bright red vaginal bleeding

A,B,D Rationale: These are all signs of abruptio placentae (A, B, and D). The others are signs of placenta previa (C and E).

The nurse anticipates administering Rho(D) immune globulin (RhoGAM) to which individual(s)? (Select all that apply.) A.An Rh-negative woman who has had a miscarriage at 24 weeks B.The father of a baby of an Rh-positive fetus C.An Rh-negative mother after delivery of an Rh-positive infant with a negative direct Coombs' test D.An Rh-positive infant within 72 hours after birth E.An Rh-negative mother with a negative antibody titer at 28 weeks

A,C,E Rationale: (A, C, and E) are all candidates for RhoGAM. RhoGAM should never be given to an infant or father (B and D).

The nurse is preparing a client for dc to home who had a BKA amputation. Which recommendations should the nurse provide this client? (SATA) A. Inspect skin for redness B. Use a residual limb shrinker C. Apply ETOH after bathing D. Wash with soap and water E. Avoid range of motion exercises

A-B-D

A client with rapid rate atrial fibrillation asks a nurse why the physician is going to perform carotid massage. The nurse responds that this procedure may stimulate the: A. Vagus nerve to slow the heart rate B. Vagus nerve to increase the heart rate; over driving the rhythm C. Diaphragmatic nerve to slow the heart rate D. Diaphragmatic nerve to overdrive the rhythm

A. Carotid sinus massage is one of the maneuvers used for vagal stimulation to decrease a rapid heart rate and possibly terminate a tachydysrhythmia. The others include inducing the gag reflex and asking the client to strain or bear down. Medication therapy often is needed as an adjunct to keep the rate down or maintain the normal rhythm.

A client is having frequent premature ventricular contractions. A nurse would place priority on assessment of which of the following items? A. Blood pressure and peripheral perfusion B. Sensation of palpitations C. Causative factors such as caffeine D. Precipitating factors such as infection

A. Premature ventricular contractions can cause hemodynamic compromise. The shortened ventricular filling time with the ectopic beats leads to decreased stroke volume and, if frequent enough, to decreased cardiac output. The client may be asymptomatic or may feel palpitations. PVCs can be caused by cardiac disorders or by any number of physiological stressors, such as infection, illness, surgery, or trauma, and by the intake of caffeine, alcohol, or nicotine.

A client has developed atrial fibrillation, which a ventricular rate of 150 beats per minute. A nurse assesses the client for: A. Hypotension and dizziness B. Nausea and vomiting C. Hypertension and headache D. Flat neck veins

A. The client with uncontrolled atrial fibrillation with a ventricular rate more than 150 beats a minute is at risk for low cardiac output because of loss of atrial kick. The nurse assesses the client for palpitations, chest pain or discomfort, hypotension, pulse deficit, fatigue, weakness, dizziness, syncope, shortness of breath, and distended neck veins.

A client is diagnosed with acute kidney failure secondary to dehydration. An intravenous (IV) infusion of 50% glucose with regular insulin is prescribed. What does the nurse recognize as the primary purpose of the IV insulin for this client? A. Correct hyperkalemia B. Increase urinary output C. Prevent respiratory acidosis D. Increase serum calcium levels

A. Correct hyperkalemia

A client diagnosed with asthma has received a prescription for an inhaler. The nurse teaches the client how to determine when the inhaler is empty, instructing the client to do what? A. Count the number of doses taken. B. Taste the medication when sprayed into the air. C. Shake the canister. D. Place the canister in water to see if it floats.

A. Count the number of doses taken.

A nurse is assessing an electrocardiogram rhythm strip. The P waves and QRS complexes are regular. The PR interval is 0.16 second, and QRS complexes measure 0.06 second. The overall heart rate is 64 beats per minute. The nurse assesses the cardiac rhythm as: A. Normal Sinus Rhythm B. Sinus Bradycardia C. Sick Sinus Syndrome D. First-degree heart block

A. Normal Sinus Rhythm measurements are normal, measuring 0.12 to 0.20 second and 0.4 to 0.10 second, respectively.

A client is admitted to the emergency department in the midst of persistent tonic-clonic seizures (status epilepticus). Diazepam is to be administered immediately. In addition to decreasing central neuronal activity, what other effect does the nurse anticipate? A. Relaxing peripheral muscles B. Slowing cardiac contractions C. Dilating tracheobronchial structures D. Providing amnesia of the convulsive episode

A. Relaxing peripheral muscles

Hydrocortisone is prescribed for a client with Addison disease. Before discharge, the nurse teaches the client about this medication. What did the nurse include as a therapeutic effect of the drug? A. Supports a better response to stress B. Promotes a decrease in blood pressure C. Decreases episodes of shortness of breath D. Controls an excessive loss of potassium from the body

A. Supports a better response to stress

A client with bleeding esophageal varices is to be treated via infusion of medication through an intravenous line. Which medication should the nurse anticipate will be prescribed? A. Vasopressin B. Neostigmine C. Lansoprazole D. Phytonadione

A. Vasopressin

The nurse is preparing a client for surgical stabilization of a fractured lumbar vertebrae. Which indication(s) best supports the client's need for insertion of an indwelling urinary catheter? (Select all that apply.) A.Hourly urine output B.Bladder distention C.Urinary incontinence D.Intraoperative bladder decompression E.Urine sample for culture

ABD Continuous bladder drainage using an indwelling catheter is indicated for monitoring hourly urinary output (A), bladder distention (B), and bladder decompression (D) related to urinary retention under anesthesia. Less invasive measures, such as a condom catheter or bladder training for urinary incontinence (C) or midstream collection of urine for culture (E) are not indicated based on the client's description.

The nurse assists the health care provider with an amniocentesis during the third trimester of pregnancy. Which intervention(s) would the nurse expect to implement after the procedure? (Select all that apply.) A.Monitor maternal vital signs for hemorrhage. B.Instruct the woman to report any contractions. C.Ensure that the woman has a full bladder prior to beginning. D.Monitor fetal heart rate for 1 hour after the procedure. E.Place the client in a side-lying position.

ABD These are safe measures to implement during an amniocentesis to monitor for and prevent complications (A, B, and D). During late pregnancy the bladder should be emptied so that it will not be punctured, but during early pregnancy the bladder must be full to push the uterus upward (C). The woman should be placed in a supine position with her hands across her chest (E).

The nurse administers levothyroxine (Synthroid) to a client with hypothyroidism. Which data indicate(s) that the drug is effective? (Select all that apply.) A.Increase in T3 and T4 B.Decrease in heart rate C.Increase in TSH D.Decrease in urine output E.Decrease in periorbital edema

ABE Levothyroxine is a thyroid replacement drug that increases thyroid hormone levels (T3 [triiodothyronine] and T4 [thyroxine]) and decreases periorbital edema, a symptom of hypothyroidism (A and E). Decrease in heart rate and an increased level of thyroid-stimulating hormone (TSH) are not therapeutic results from taking levothyroxine (Synthroid) (B and C). Levothyroxine does not affect urine output (D).

Which intervention(s) is(are) most helpful in evaluating the effectiveness of nursing and medical treatments for dehydration in a 36-month-old child? (Select all that apply.) A.Record wet diapers. B.Assess for sunken fontanels. C.Examine skin turgor. D.Observe mucous membranes.

ACD All these interventions can be used to evaluate fluid status in children and are helpful assessment functions (A, C, and D), but the age of the child makes a fontanel check impractical (B). The posterior fontanel closes at 2 months and the anterior fontanel closes at 18 months of age.

The nurse performs an assessment on a client with heart failure. Which finding(s) is(are) consistent with the diagnosis of left-sided heart failure? (Select all that apply.) A.Confusion B.Peripheral edema C.Crackles in the lungs D.Dyspnea E.Distended neck veins

ACD Left-sided heart failure results in pulmonary congestion caused by the left ventricle's inability to pump blood to the periphery. Confusion, crackles in the lungs, and dyspnea are all signs of pulmonary congestion (A, C, and D). (B and E) are associated with right-sided heart failure.

What instruction(s) related to foot care is(are) appropriate for the client with type 1 diabetes mellitus? (Select all that apply.) A.Use lanolin to moisturize the tops and bottoms of the feet. B.Soak the feet in warm water for at least 1 hour daily. C.Wash feet daily and dry well, particularly between the toes. D.Use over-the-counter products to remove corns and calluses. E.Wear leather shoes that fit properly.

ACE (A, C, and E) are therapeutic interventions for foot care in the diabetic patient. (B and D) are contraindicated and could cause foot infection or injury.

Transcutaneous electrical nerve stimulation (TENS) is prescribed for a client with chronic back pain. Which action(s) should the nurse take when preparing the client for this type of pain relief? (Select all that apply.) A.Shave the area where the TENS will be placed. B.Obtain small needles for insertion. C.Place the TENS unit directly over or near the site of pain. D.Explain to the client that drowsiness may occur immediately after using TENS. E.Describe the use of TENS for postoperative procedures such as dressing changes.

ACE The correct choices are (A, C, and E). The TENS unit consists of a battery-operated transmitter, lead wires, and electrodes. The electrodes are placed directly over or near the site of pain (C), and hair or skin preparations should be removed before attaching the electrodes (A). The TENS unit is useful for managing postoperative pain or pain associated with postoperative procedures, such as removing drains or changing dressings (E). Electrodes are used, not needles (B) and, unlike with opioids, pain relief is achieved without drowsiness (D).

Which nursing intervention(s) should be implemented when caring for a client with bipolar disorder in the manic phase? (Select all that apply.) A.Report lithium level of 2.0 mEq/L to the primary health care provider. B.Encourage competitive physical activities as part of the client's therapy. C.Provide an environment with increased stimuli to engage the client. D.Maintain consistent salt levels in the diet when client is taking lithium. E.Assess the client's nutritional and hydration status.

ADE A therapeutic level for serum lithium is 0.5 to 1.5 mEq/L, and the client with 2.0 mEq/L is experiencing toxicity (A). Consistent salt levels are important when taking lithium to maintain a therapeutic level (D). Because of the client's manic state, the client is at risk for impaired nutrition and dehydration; therefore, they should be assessed (E). Noncompetitive physical activities should be encouraged because of the risk for agitation (B), and decreased environmental stimuli is therapeutic for the manic phase (C).

The nurse is assessing the level of readiness before delegating tasks to unlicensed assistive personnel (UAP). According to Hersey's model of situational leadership, what specific factors reflect the level of readiness? Select all that apply. Correct1 Ability 2 Honesty Incorrect3 Reliability Correct4 Willingness Incorrect5 Conscientiousness

Ability and willingness are two factors that determine the level of readiness according to the Hersey's model. Honesty and reliability may not determine the readiness of the UAP to perform a delegated task. Conscientiousness is the desire to complete a task, which may not determine readiness if the UAP does not have sufficient knowledge to perform the task.

A nurse delegator assigns work to a delegatee who has the ability and willingness to do the work but the relationship between the delegator and delegatee is relatively new. How is the delegator's behavior described according to Hersey's Model? 1 Selling 2 Telling 3 Delegating Correct4 Participating

According to Hersey's Model, if the delegatee has the ability and willingness, but the relationship between the delegator and delegatee is relatively new, they need to establish mutual expectations and conditions of performance. Hersey's model describes this behavior of the leader as participating. If a situation involves a new task and the relationship is ongoing, Hersey's model describes this behavior of the leader as selling. If the delegatee has limited knowledge and ability to perform a task, the delegator needs to provide more guidance. Hersey's model describes this behavior of the leader as telling. If the delegatee has the ability and willingness, the expertise to accomplish the work, and an established relationship, Hersey's model describes this behavior of the leader as delegating.

Which behavior does the delegator adopt when communicating with the delegatee if the relationship between them is new, the delegatee has limited knowledge, and the delegator does not expect the relationship to be ongoing? Correct1 Telling 2 Selling 3 Delegating 4 Participating

According to Hersey's Situational Leadership Model, if the relationship between a delegator and a delegatee with limited knowledge is new and is not going to be ongoing, the delegator's behavior is characterized as "telling." Delegator's behavior is characterized as "selling" if the delegatee and delegator have an ongoing relationship and a new task is being delegated. The delegator's behavior is characterized as "delegating" when the delegatee has expertise and an established relationship with the delegator. If the delegatee has willingness and ability, but the relationship with the delegator is new, then the delegator's behavior is characterized as "participating."

The registered nurse is delegating work to four delegatees. Which delegatee has an established relationship with the delegator? 1 Delegatee A Correct2 Delegatee B 3 Delegatee C 4 Delegatee D

According to Hersey's model, if the relationship between the delegator and delegatee is established, the behavior of the delegator is "observing or monitoring." Telling delegate B that his or her method is correct and to continue doing it in the same way indicates that the delegator is monitoring the delegatee's actions, which indicates an established relationship.

The registered nurse is delegating work to four delegatees. Which delegatee has an established relationship with the delegator? 1 Delegatee A Correct2 Delegatee B 3 Delegatee C Incorrect4 Delegatee D

According to Hersey's model, if the relationship between the delegator and delegatee is established, the behavior of the delegator is "observing or monitoring." Telling delegate B that his or her method is correct and to continue doing it in the same way indicates that the delegator is monitoring the delegatee's actions, which indicates an established relationship. Recommending delegatee A do the procedure because it can easily be done indicates a persuading behavior, which is done when the relationship between the delegator and delegate is developing. According to Hersey's model, if the relationship between the delegator and delegate is limited, the behavior of the delegator is "telling." The delegator is simply telling delegatee C to check the client's blood sugar level every morning for 5 days, which indicates a limited relationship between them. Participating in the work of delegatee D by demonstration indicates a new relationship.

The registered nurse is assigning work to four delegatees. Which delegatee most likely has a limited relationship with the delegator? Incorrect1 Delegatee A Correct2 Delegatee B 3 Delegatee C 4 Delegatee D

According to Hersey's model, if the relationship between the delegator and delegatee is limited, the behavior of the delegator is "telling." The delegator is telling Delegatee B to check the client's blood pressure every morning, which indicates a limited relationship between them. Participating in the delegatee's work by helping to complete the task early indicates a new relationship, which may be ongoing. Monitoring the delegatee by saying he or she is right indicates an established relationship between the delegator and delegatee. Recommending that the delegatee use a digital sphygmomanometer for ease and accuracy indicates selling behavior; this is done when the relationship between the delegator and delegatee is ongoing.

Which factors should be assessed to determine the level of followers' readiness according to Hersey's model? Select all that apply. Correct1 Ability Correct2 Willingness 3 Family history Incorrect4 Work experience Incorrect5 Educational qualifications

According to Hersey's model, the delegator should check the ability and willingness of the delegatee before delegating any task. Information about family history may not be required for delegating a task. According to Hersey's model, work experience and educational qualifications are not considered as factors required to determine followers' readiness.

The registered nurse is evaluating the statements made by a student nurse after teaching Hersey's situational leadership model regarding core competencies of a situational leader. Which statement made by the student nurse indicates a need for correction? 1 "A situational leader partners for performance." Correct2 "A situational leader is inflexible towards the work." 3 "A situational leader is able to identify the commitment of delegatee." 4 "A situational leader is able to diagnose the performance of a delegatee."

According to Hersey's situational leadership model, a situational leader is flexible towards work and adapts to the given situation. A situational leader collaborates with others to achieve the goals. A situational leader is able to identify the commitment of a delegatee. A situational leader is able to diagnose the performance of a delegate.

A client with cancer has a history of alcohol abuse and is taking acetaminophen (Tylenol) for pain. Which organ function is most important for the nurse to monitor?

Acetaminophen and alcohol are both metabolized in the liver. This places the client at risk for hepatotoxicity, so monitoring liver (A) function is the most important assessment because the combination of acetaminophen and alcohol, even in moderate amounts, can cause potentially fatal liver damage. Other non-narcotic analgesics, such as n onsteroidal anti-inflammatory drugs (NSAIDs), are more likely to promote adverse renal effects (B). Acetaminophen does not place the client at risk for toxic reactions related to (C or D).

590. A female client comes to the clinic complaining of fatigue and inability to sleep because she is the full-time caretaker for 22-year-old son who was paralyzed by a motor vehicle collision. She adds that her husband left her because he says he can't take her behavior any more since all she does is care for their son. What intervention should the nurse implement?

Acknowledge the client's stress and suggest that she consider respite care.

Treatment for EPS

Acute Dystonia: antiCHOLinergic drugs (eg, benztropine) IM or IV Parkinsonism: antiCHOLinergic drugs (eg, benztropine, diphenhydramine), amantadine, or both Akathisia: Benzodiazepine, beta blockers, antiCHOLinergic Tardive Dyskinesia (TD): No reliable treatment

314. An older adult resident of a long-term care facility has a 5-year history of hypertension. The client has a headache and rate the pain 5 on a pain scale 0 to 10. The client's blood pressure is currently 142/89. Which interventions should the nurse implement? (Select all that apply)

Administer a daily dose of lisinopril as scheduled. Provide a PRN dose of acetaminophen for headache

A nurse whose tuberculosis (TB ) skin test result reveals an 8 mm induration obtains a negative chest radiograph, which indicates latent tuberculosis. The employee-health nurse should implement which intervention for this nurse?

Administer isoniazid (INH) daily for 6 to 9 months.

139. A client with a history of chronic pain requests a nonopioid analgesic. The client is alert but has difficulty describing the exact nature and location of the pain to the nurse. Which action should the nurse implement next?

Administer the analgesic as requested

The nurse obtains a heart rate of 92 and a blood pressure of 110/76 prior to administering a scheduled dose of verapamil (Calan) for a client with atrial flutter. Which action should the nurse implement?

Administer the dose as prescribed. Verapamil slows sinoatrial (SA) nodal automaticity, delays atrioventricular (AV) nodal conduction, which slows the ventricular rate, and is used to treat atrial flutter, so (A) should be implemented, based on the client's heart rate and blood pressure. (B and C) are not indicated. (D) delays the administration of the scheduled dose.

192. The healthcare provider changes a client's medication prescription from IV to PO administration and double the dose. The nurse notes in the drug guide that the prescribed medication, when given orally, has a high first-pass effect and reduce bioavailability. What action should the nurse implement?

Administer the medication via the oral route as prescribed

The registered nurse (RN) is caring for a pregnant client with malnutrition due to morning sickness. Which task can be safely performed by the licensed practical nurse (LPN) in this condition? 1 Assessing hemoglobin levels 2 Evaluating nutritional status Correct3 Administering oral antiemetics 4 Administering intravenous fluids

Administering oral antiemetics is a task that can be safely performed by the licensed practical nurse (LPN). Assessing the hemoglobin levels is the role of the RN; this task may not be delegated to the LPN. Evaluating the nutritional status is also the role of the RN. Intravenous fluids are only administered by a registered nurse (RN).

434. The nurse makes a supervisory home visit to observe an unlicensed assistive personnel (UAP) who is providing personal care for a client with Alzheimer's disease. The nurse observes that whenever the client gets upset, the UAP changes the subject. What action should the nurse take in response to this observation?

Affirm that the UAP is using and effective strategy to reduce the client's anxiety.

A patient's blood pressure is 174/98 mm Hg. Which aspect of cardiac output is most affected by this elevated reading?

Afterload

532. The nurse observes a newly hired unlicensed assistive personnel (UAP) performing a fingestick to obtain a client's blood glucose. Prior to sticking the client's finger, the UAP explains the procedure and tell the client that it I painless. What action should the nurse take?

Allow the UAP to complete the procedure, then discuss the painless comment privately with the UAP.

536. A nurse is preparing to feed a 2-month-old male infant with heart failure who was born with congenital heart defect. Which intervention should the nurse implement?

Allow the infant to rest before feeding

A client is admitted to the intensive care unit with a diagnosis of acute respiratory distress syndrome. When assessing the client, the nurse expects to identify: 1 Hypertension 2 Tenacious sputum 3 Altered mental status 4 Slow rate of breathing

Altered mental status

After one month of short-term corticosteroid therapy, a client with an acute exacerbation of rheumatoid arthritis returns to the clinic for a follow-up visit. Which laboratory finding should the nurse review for a therapeutic response?

An elevated erythrocyte sedimentation rate (ESR) is indicative of active inflammation, so the nurse should determine if the ESR has normalized (D)

378. After receiving the Braden scale findings of residents at a long-term facility, the charge nurse should to tell the unlicensed assistive personnel (UAP) to prioritize the skin care for which client?

An older man whose sheets are damped each time he is turned.

150. A 16-year-old adolescent with meningococcal meningitis is receiving a continuous IV infusion of penicillin G, which is prescribed as 20 million units in a total volume of 2 liters of normal saline every 24 hr. The pharmacy delivers 10 million units/ liters of normal saline. How many ml/hr should the nurse program the infusion pump? (Enter numeric value only. If rounding is required, round to the nearest whole number.)

Answer 83

More adverse effects of FGAs

Anticholinergic effects, orthostatic hypoTN, sedation, neuroendocrine effects (increase levels of prolactin which leas to gynecomastia and galactorrhea), seizures Sexual dysfunction, agranulocytosis (check and monitor WBCs), severe dysrhythmias

A male client who had abdominal surgery has a nasogastric tube to suction, oxygen per nasal cannula, and complains of dry mouth. Which action should the nurse implement?

Apply a water soluble lubricant to the lips, oral mucosa and nares. To ease the client's discomfort, a water soluble lubricant to the lips and nares assists to keep the mucous membranes moist (D). (A) is a petroleum-based product and should not be used because it is flammable. (B and C) should not be given to the client with a nasogastric tube to suction because it can cause further distension and interfere with fluid and electrolyte balance.

A practitioner prescribes an antidepressant for a hospitalized client who has been severely depressed. Eight days later the nurse notes that the client is neatly dressed and well groomed. The client smiles at the nurse and says, "Things sure look better today." What nursing response is appropriate in light of the client's statement? Complimenting the client's appearance Starting preparations for the client's discharge Arranging for constant supervision of the client Adding privileges to the client's plan of care as a reward

Arranging for constant supervision of the client

406. A young adult male who is being seen at the employee health care clinic for an annual assessment tell the nurse that his mother was diagnosed with schizophrenia when she was his age and that life with a schizophrenic mother was difficulty indeed. Which response is best for the nurse to provide?

Ask the client if he is worried about becoming schizophrenic at the age his mother was diagnosed.

29. A female client is admitted with end stage pulmonary disease is alert, oriented, and complaining of shortness of breath. The client tells the nurse that she wants "no heroic measures" taken if she stops breathing, and she asks the nurse to document this in her medical record. What action should the nurse implement?

Ask the client to discuss "do not resuscitate" with her healthcare provider

128. While teaching a young male adult to use an inhaler for his newly diagnosed asthma, the client stares into the distance and appears to be concentrating on something other than the lesson the nurse is presenting. What action should the nurse take?

Ask the client what he is thinking about at his time.

465. When five family members arrive at the hospital, they all begin asking the nurse questions regarding the prognosis of their critically ill mother. What intervention should the nurse implement first?

Ask the family to identify a specific spokesperson

462. On a busy day, one hour after the shift report is completed, the charge nurse learns that a female staff nurse who lives one hour away from the hospital forgot her prescription eye glasses at home. What action should the charge nurse take?

Ask the nurse to return home and get her prescription eyeglasses for work.

154. A preschool-aged boy is admitted to the pediatric unit following successful resuscitation from a near-drowning incident. While providing care to child, the nurse begins talking with his preadolescent brother who rescued the child from the swimming pool and initiated resuscitation. The nurse notices the older boy becomes withdrawn when asked about what happened. What action should the nurse take?

Ask the older brother how he felt during the incident.

A 19-year-old student comes to the student health center at the end of the semester complaining that, "My heart is skipping beats." An electrocardiogram (ECG) shows occasional premature ventricular contractions (PVCs). What action should the nurse take next?

Ask the patient about current stress level and caffeine use.

A nurse is caring for several clients in the intensive care unit. Which is the greatest risk factor for a client to develop acute respiratory distress syndrome (ARDS)? 1 Aspirating gastric contents 2 Getting an opioid overdose 3 Experiencing an anaphylactic reaction 4 Receiving multiple blood transfusions

Aspirating gastric contents

A client with acute respiratory distress syndrome is intubated and placed on a ventilator. What should the nurse do when caring for this client and the mechanical ventilator? 1 Regulate the positive end-expiratory pressure (PEEP) according to the rate and depth of the client's respirations. 2 Deflate the cuff on the endotracheal tube for a few minutes every one to two hours. 3 Assess the need for suctioning when the high-pressure alarm of the ventilator is activated. 4 Adjust the temperature of fluid in the humidification chamber depending on the volume of gas delivered.

Assess the need for suctioning when the high-pressure alarm of the ventilator is activated.

Prior to the discharge of a healthy 4-day-old newborn, the nurse is collecting the blood specimens to screen for phenylketonuria (PKU), the Guthrie inhibition assay blood test. What action should the nurse implement to ensure the validity of the test?

Assess the newborn's feeding patterns of formula or breast milk which has "come in."

443. The nurse who works in labor and delivery is reassigned to the cardiac care unit for the day because of a low census in labor and delivery. Which assignments is best for the nurse to give this nurse?

Assist cardiac nurses with their assignments

86. Several months after a foot injury, and adult woman is diagnosed with neuropathic pain. The client describes the pain as severe and burning and is unable to put weight on her foot. She asks the nurse when the pain will "finally go away." How should the nurse respond?

Assist the client in developing a goal of managing the pain

597. A client with gestational diabetes, at 39 weeks of gestation, is in the second stage of labor. After delivering of the fetal head, the nurse recognizes that shoulder dystocia is occurring. What intervention should the nurse implement first?

Assist the client to sharply flex her thighs up again the abdomen.

The registered nurse (RN) is teaching a novice RN about delegating tasks to licensed practical nurses (LPN) and unlicensed assistive personnel (UAP). Which statement made by the novice RN indicates a need for further teaching? 1 "I will delegate the task of reinforcing client teaching to the LPN." Correct2 "I will delegate the task of assisting the client with bathing to the LPN." 3 "I will delegate the task of recording vital signs of the client to the UAP." Incorrect4 "I will delegate the task of administering intramuscular injections to the LPN."

Assisting the client with bathing is related to providing basic care, comfort, and hygiene and is a task better suited to unlicensed assistive personnel. The scope of practice of an LPN includes reinforcing the client teaching. Recording vital signs is within the scope of practice of UAP. Administering intramuscular injections is within the scope of practice of an LPN, not UAP.

A client is receiving atenolol (Tenormin) 25 mg PO after a myocardial infarction. The nurse determines the client's apical pulse is 65 beats per minute. What action should the nurse implement next?

Atenolol, a beta-blocker, blocks the beta receptors of the sinoatrial node to reduce the heart rate, so the medication should be administered (C) because the client's apical pulse is greater than 60. (A, B, and D) are not indicated at this time.

While a pacemaker catheter is being inserted, the client's heart rate drops to 38 beats/min. What medication should the nurse expect the health care provider to prescribe? 1 Digoxin (Lanoxin) 2 Lidocaine (Xylocaine) 3 Amiodarone (Cordarone) 4 Atropine sulfate (Atropine)

Atropine sulfate (Atropine)

450. A client who had an open cholecystectomy two weeks ago comes to the emergency department with complaints of nausea, abdominal distention, and pain. Which assessment should the nurse implement?

Auscultate all quadrant of the abdomen.

384. The nurse identifies an electrolyte imbalance, an elevated pulse rate, and elevated BP for a client with chronic kidney disease. Which is the most important action for the nurse to take?

Auscultate for irregular heart rate.

433. A client in the intensive care unit is being mechanically ventilated, has an indwelling urinary catheter in place, and is exhibiting signs of restlessness. Which action should the nurse take first?

Auscultated bilateral breath sounds

Which component of delegation is suitable to all the members on the healthcare team? Correct1 Authority 2 Supervision 3 Accountability 4 Communication

Authority is the component of delegation that is suitable for all the members on the healthcare team. Supervision is a right of delegation in which the delegator supervises the other assistive personnel to perform the task. Accountability is the component of delegation that is suitable for delegators such as registered nurses (RNs). Communication is the right of delegation in which the delegator gives the directions to perform the task.

A health care provider prescribes tolterodine (Detrol) for a client with an overactive bladder. What is most important for the nurse to teach the client to do? Maintain a strict record of fluid intake and urinary output. Chew the extended release capsule thoroughly before swallowing. Report episodes of diarrhea or any increase in respiratory secretions. Avoid activities requiring alertness until the response to medication is known.

Avoid activities requiring alertness until the response to medication is known. Because tolterodine an antispasmatic may cause dizziness and blurred vision which increases risk for injury

305. The nurse is preparing a discharge teaching plan for a client who had a liver transplant. Which instruction is most important to include in this plan?

Avoid crowds for first two months after surgery.

608. The nurse is teaching a client with atrial fibrillation about a newly prescribed medication, dronedarone. Which information should the nurse include in client interactions? (Select all that apply)

Avoid eating grapefruit or drinking grapefruit juice. Report changes in the use of daily supplements Notify you heal care provider if your skin looks yellow

104. The nurse should teach the client to observe which precaution while taking dronedarone?

Avoid grapefruits and its juice

Which information should the nurse give a client with chronic kidney disease (CKD)?

Avoid salt substitutes. A client with CKD should restrict sodium and potassium dietary intake, and salt substitutes usually contain potassium, so (C) should be taught. Hypocalcemia is a complication of CKD and calcium supplements are often needed, not (A). Anemia related to CKD is treated with iron, folic acid, and erythropoietin, not (B). Although (D) is a common dietary recommendation, it not an essential part of client teaching for CKD.

A child with bacterial conjunctivitis receives a prescription for erythromycin eye drops. Which information is most important for the nurse to include in the teaching plan?

Avoid sharing towels and washcloths with siblings.

124. A client with atrial fibrillation receives a new prescription for dabigatran. What instruction should the nurse include in this client's teaching plan?

Avoid use of nonsteroidal ant-inflammatory drugs (NSAID).

A client diagnosed with a seizure disorder is receiving Dilantin. Which instruction should the nurse provide this client? A. Take the medication on an empty stomach B. Contact your healthcare provider before trying to get pregnant. C. Stop taking the medication if hirsutism occurs D. Decrease fluid intake when taking this medication

B

The charge nurse of a 16-bed medical unit is making 0700 to 1900 shift assignments. The team consists of two RNs, two PNs, and two UAP. Which assignment is the most effective use of the available team members? A.Assign the PNs to perform am care and assist with feeding the clients. B.Assign the UAPs to take vital signs and obtain daily weights. C.Assign the RNs to answer the call lights and administer all medications. D.Assign the PNs to assist health care providers on rounds and perform glucometer checks.

B A UAP can take vital signs and daily weights on stable clients (B). UAPs can perform am care and feed clients, which is a better use of personnel than assigning the task to the PN (A). All team members can answer call lights and PNs can administer some of the medications, so assigning the RN (C) these tasks is not an effective use of the available personnel. The RN is the best team member to assist on rounds (D), and the UAP can perform glucometer checks, so assigning the PN these tasks is not an effective use of available personnel.

A client with hemiparesis needs assistance transferring from the bed to the wheelchair. The nurse assists the client to a sitting position on the side of the bed. Which action should the nurse implement next? A.Flex the hips and knees and align the knees with the client's knees for safety. B.Allow the client to sit on the side of the bed for a few minutes before transferring. C.Place the client's weight-bearing or strong leg forward and the weak foot back. D.Grasp the transfer belt at the client's sides to provide movement of the client.

B A client who has been immobile may be weak and dizzy and develop orthostatic hypotension (a drop in blood pressure on rising), so allowing the client to sit for a few minutes (B) before transferring from the bedside to the wheelchair provides time for the client to gain equilibrium and allows dependent blood in the lower extremities to return to the heart. Next, positioning the legs under the client's center of gravity (A and C) reduces back strain and stabilizes the client to stand. To ensure a safe transfer for a client with hemiparesis (unilateral muscle weakness), a transfer belt (D) provides a secure hold to prevent sudden falls.

An older client is admitted to the hospital with abdominal pain and watery, incontinent diarrhea following a course of antibiotic therapy for pneumonia. Stool cultures reveal the presence of Clostridium difficile. While planning care, which nursing goal should the nurse establish as the priority? A.Fluid and electrolyte balance is maintained. B.Health care-associated infection (HAI) transmission of infectious diarrhea is prevented. C.Abdominal pain is relieved and perianal skin integrity is maintained. D.Normal bowel patterns are reestablished.

B A priority goal for the client with infectious diarrhea caused by Clostridium difficile is infection control precautions and the prevention of health care-associated infection (HAI) transmission (B). (A and C) are goals dependent on the return of the client's normal bowel pattern (D).

The health care provider performs a bone marrow aspiration from the posterior iliac crest for a client with pancytopenia. Which action should the nurse implement first? A.Inspect the dressing over the puncture site and under the client for bleeding. B.Take the vital signs to determine the client's response for a potential blood loss. C.Use caution when changing the dressing to avoid dislodging a clot at the puncture site. D.Assess the client's pain level to determine the need for analgesic medication.

B After bone marrow aspiration, pressure is applied at the aspiration site, which is critical for a client with pancytopenia because of a decrease in the platelet count. The client's baseline vital signs should be obtained first to determine changes indicating bleeding caused by the procedure (B). Although (A, C, and D) should be implemented after the procedure, the first action is to obtain a baseline assessment.

The nurse is teaching a client newly diagnosed with diabetes mellitus about the subcutaneous administration of Regular and NPH insulin. Which statement indicates that the client needs further instruction? A."I should balance my daily exercise with my dietary intake and insulin dosages." B."When I give myself an injection, I should aspirate to make sure that I am not in a blood vessel." C."I should inject my insulin into a different site to reduce the development of scar tissue." D."I should remove the dose of clear insulin first and then the dose of cloudy insulin from the vials."

B Aspiration (B) is not necessary when giving insulin because it could increase tissue trauma and affect the absorption rate. (C) helps minimize tissue atrophy, which can affect the absorption of the insulin. (A and D) are correct procedures. The client should balance an active physical lifestyle with diet, insulin, and blood glucose monitoring to ensure good serum glucose control. When mixing insulins in the same syringe, the clear (Regular) insulin is withdrawn first to avoid contamination of the clear vial with cloudy NPH insulin, which will alter the absorption rate of the remaining Regular insulin.

A client with acute renal failure (ARF) starts to void 4 L/day 2 weeks after treatment is initiated. Which complication is important for the nurse to monitor the client for at this time? A.Diabetes insipidus B.Hypotension C.Hyperkalemia D.Uremia

B During the transition from oliguria to the diuretic phase of acute renal failure, the tubule's inability to concentrate the urine causes osmotic diuresis, which places the client at risk for hypovolemia and hypotension (B). (A) is related to the secretion of antidiuretic hormone (ADH) and not specifically to the kidney function. Because of the excessive fluid loss, the client is at risk for potassium loss, not (C). (D) is characteristic of chronic renal failure with multiple body system involvement.

When the administration at a large urban medical center decides to establish a unit to care for clients with infectious diseases, such as severe acute respiratory syndrome (SARS) and the avian flu, several employees express fear related to caring for these clients. When choosing staff to work on this unit, which action is best for the nurse-manager to take? A.Make it clear that no one who is afraid to care for clients with rare disorders will be permitted to work on the unit. B.Conduct an education program about infectious diseases and then assess the staff's willingness to work with these clients. C.Introduce the staff to the family of a client who has been treated for SARS and ask the staff to share their fears with this family. D.Assign staff based on the needs of the unit, providing peer counseling for those staff members who express fear.

B Fear is often related to a lack of knowledge and an education program about the relevant disorders would be appropriate, but after the education program, the nursing staff should be reassessed regarding their willingness to work with these clients (B). (A) is too authoritarian and does not permit education to play a role in reducing fears. (C) is likely to be intrusive to the family member. Arbitrary staffing (D) without education does not reduce staff fears, even with the provision of peer counseling.

The nurse is preparing to administer dalteparin (Fragmin) subcutaneously to an immobile client who has been receiving the medication for 5 days. Which finding indicates that the nurse should hold the prescribed dose? A.Tachypnea B.Guaiac-positive stool C.Multiple small abdominal bruises D.Dependent pitting edema

B Fragmin is an anticoagulant used to prevent deep vein thrombosis (DVT) in the at-risk client. If the client develops overt signs of bleeding, such as guaiac-positive stool (B) while receiving an anticoagulant, the medication should be held and coagulation studies completed. (A) is not an indication to hold the medication unless accompanied by signs of bleeding. (C) is an expected result. (D) is related to fluid volume, rather than anticoagulant therapy.

The nurse is obtaining a client's sexual history. Which finding requires additional follow-up regarding the client's self-image? A.Sexual intercourse with the spouse occurs four times a week. B.The spouse has never seen the client naked. C.The client has had surgery for permanent birth control. D.A history of a 20-lb weight loss occurred in the past year.

B It is usual for spouses to see each other without clothing, so a follow-up question about (B) should provide additional information about the client's self-concept and body image. (A and C) are choices within the continuum of normal and acceptable sexual needs based on each couple's preferences. Body image is a perception of one's physical self and weight gain or loss normally affects one's self-image (D).

When caring for a client hospitalized with Guillain-Barré syndrome, which information is most important for the nurse to report to the primary health care provider? A.Ascending numbness from the feet to the knees B.Decrease in cognitive status of the client C.Blurred vision and sensation changesD. Persistent unilateral headache

B Rationale: A decline in cognitive status in a client is indicative of symptoms of hypoxia and a possible need to assist the client with mechanical ventilation. A primary health care provider will need to be contacted immediately (B). (A, C, and D) are findings associated with Guillain-Barré syndrome that should also be reported, but are not as critical as the client's hypoxic status.

When caring for a client in labor, which finding is most important to report to the primary health care provider? A.Maternal heart rate, 90 beats/min. B.Fetal heart rate, 100 beats/min C.Maternal blood pressure, 140/86 mm Hg D.Maternal temperature, 100.0° F

B Rationale: A fetal heart rate (FHR) of 100 beats/min may indicate fetal distress (B) because the average FHR at term is 140 beats/min and the normal range is 110 to beats/min 160. The others (A, C, and D) are normal findings for a woman in labor.

A client in the psychiatric setting with an anxiety disorder reports chest pain. Which action should the nurse take first? A.Administer an antianxiety medication PRN. B.Assess the client's vital signs. C.Notify the primary health care provider. D.Determine coping mechanisms used in the past.

B Rationale: Although increased heart rate, palpitations, and chest pain may be caused by anxiety, it is important that the nurse assess the patient and rule out physiologic causes (B). Nonpharmacologic measures should be taken first (A). (C and D) may be considered but are not as high priority as the initial physiologic assessment.

The nurse empties a client's urinary drainage from an indwelling Foley catheter. Which finding should be reported to the primary health care provider? A.Ammonia odor is noted when the catheter is emptied. B.240 mL of urinary output is produced in 12 hours. C.A 16-French catheter was used for an adult female. D.Drainage system is hanging below the level of the bladder.

B Rationale: An expected finding is between 400 and 750 mL in 12 hours = average of 30 mL/hr (B). Ammonia odor is an expected finding (A). Size 14- to 18-French catheters are common sizes used in the adult female (C). Below the level of the bladder is the correct position for the drainage bag (D).

A nurse is interviewing a mother during a well-child visit. Which finding would alert the nurse to continue further assessment of the infant? A.Two-month-old who is unable to roll from back to abdomen B.Ten-month-old who cannot sit without support C.Nine-month-old who cries when his mother leaves the room D.Eight-month-old who has not yet begun to speak words

B Rationale: As a developmental milestone, infants should sit unsupported by 8 months (B). The milestone of rolling over is achieved at 5 to 6 months for most infants (A). Stranger anxiety is common from 7 to 9 months (C). Speaking a few words is expected at about 12 months (D).

The nurse plans to teach blood glucose self-monitoring to a client who is newly diagnosed with diabetes mellitus type 1, and the health care provider has given the client a schedule for testing. In addition to the prescribed schedule, the nurse should also instruct the client to check the blood glucose level in which circumstance? A.Any time the client awakens during the night B.Whenever the client has feelings of dizziness C.Right after meals if insulin is not administered 30 minutes before the meal D.Only at scheduled times; additional testing harmful to fingertips

B Rationale: Clients should be instructed to always check their blood glucose level whenever they feel faint or dizzy (B). There is great variability in recommendations for the frequency of blood glucose testing. When first diagnosed, clients are often advised to test before and after meals and at bedtime, and then after meals and at bedtime for a short period. Once they are stable, clients may be advised to test four times a day or as little as once each week, depending on the consistency of their diet and exercise and stability of their blood sugar level. (A, C, and D) provide inaccurate information.

The nurse is caring for a client who develops ventricular fibrillation. Which action should the nurse take first? A.Administer epinephrine. B.Defibrillate immediately. C.Bolus with isotonic fluid. D.Notify the health care provider.

B Rationale: Defibrillation is the first and most effective emergency treatment for ventricular fibrillation (B). The others may follow the first action (A, C, and D).

A nurse working in the emergency department admits a client with full-thickness burns to 50% of the body. Assessment findings indicate high-pitched wheezing, heart rate of 120 beats/min, and disorientation. Which action should the nurse take first? A.Insert a large-bore IV for fluid resuscitation. B.Prepare to assist with maintaining the airway. C.Cleanse the wounds using sterile technique. D.Administer an analgesic for pain.

B Rationale: High-pitched wheezing indicates laryngeal stridor, a sign of laryngeal edema associated with lung injury. Airway management is the first priority of care (B). (A, C, and D) are all appropriate interventions in managing the client with a burn but are not as critical as establishing an airway.

A client at 32 weeks of gestation is hospitalized with preeclampsia, and magnesium sulfate is prescribed to control the symptoms. Before the next dose of MgSO4 is given, which assessment finding indicates that the patient is at risk for toxicity? A.Deep tendon reflexes—decrease to 2+ B.100 mL of urine output in 4 hours C.Respiratory rate decreases to 16 breaths/min D.Serum magnesium level, 7.5 mg/dL

B Rationale: Magnesium sulfate, a central nervous system (CNS) depressant, helps prevent seizures, so (A) is a positive sign that the medication is having a desired effect. The minimum urine output expected for a repeat dose of magnesium sulfate is 30 mL/hr, so 100 mL of urine in 4 hours can lead to poor excretion of magnesium, with a possible cumulative effect (B). A decreased respiratory rate (C) indicates that the drug is effective. A respiratory rate below 12 breaths/min indicates toxic effects. The therapeutic level of magnesium sulfate for a PIH client is 4 to 8 mg/dL (D).

When caring for a postsurgical client who has undergone multiple blood transfusions, which serum laboratory finding is of most concern to the nurse? A.Sodium level, 137 mEq/L B.Potassium level, 5.5 mEq/L C.Blood urea nitrogen (BUN) level, 18 mg/dL D.Calcium level, 10 mEq/L

B Rationale: Multiple blood transfusions are a risk factor for hyperkalemia. A serum potassium level higher than 5.0 mEq/L indicates hyperkalemia (B). The others are normal findings (A, C, and D).

The nurse is caring for a client on the medical unit. Which task can be delegated to unlicensed assistive personnel (UAP)? A.Assess the need to change a central line dressing. B.Obtain a fingerstick blood glucose level. C.Answer a family member's questions about the client's plan of care. D.Teach the client side effects to report related to the current medication regimen.

B Rationale: Obtaining a fingerstick blood glucose level is a simple treatment and is an appropriate skill for UAP to perform (B). (A, C, and D) are skills that cannot be delegated to UAP.

A client with human immunodeficiency virus (HIV) develops a painful blistering skin rash on the right lateral abdominal area. Which drug should the nurse expect to administer to treat this condition? A.Levofloxacin (Levaquin) B.Acyclovir sodium (Zovirax) C.Fluconazole (Diflucan) D.Esomeprazole (Nexium)

B Rationale: The clinical manifestations listed are consistent with herpes zoster (shingles). Acyclovir sodium is an antiviral used to treat herpes zoster or shingles (B). Levofloxacin is an antibiotic and may be used to treat pneumonia or other infections in the HIV client (A). Fluconazole is an antifungal and is used to treat candidiasis in the HIV client (C). Esomeprazole is a protein pump inhibitor used for gastroesophageal reflux disease (D).

Which nursing intervention should be implemented postoperatively in an infant with spina bifida after repair of a meningocele? A.Limit fluids to prevent infection to the surgical site. B.Place the infant in the prone position. C.Provide a low-residue diet to limit bowel movements. D.Cover sac with a moist sterile dressing.

B Rationale: The infant should be placed in the prone position to alleviate pressure on the surgical site, which is in the sacrum (B). Fluids should be increased postoperatively to prevent dehydration (A). A high-fiber diet should be implemented to prevent constipation (C). After the repair, the sac is no longer exposed, so (D) does not apply.

When caring for a client with a tracheostomy, which intervention should the nurse delegate to the unlicensed assistive personnel (UAP)? A.Teach the family about signs and symptoms of hypoxia. B.Take the vital signs and obtain an O2 saturation level. C.Evaluate the need for tracheal suctioning. D.Revise the plan of care to include tracheostomy care.

B Rationale: The nurse may delegate obtaining vital signs and O2 saturation; however, the nurse is responsible for following up on any reported data (B). (A, C, and D) are all part of the nursing process and should not be delegated under the nurse's scope of practice.

A couple expresses concern and fear prior to having an amniocentesis to determine fetal lung maturity. To assist them in coping with this situation, which intervention is best for the nurse to implement? A.Explain that harm to the fetus is highly unlikely. B.Answer all their questions regarding the procedure. C.Encourage them to verbalize their feelings. D.Show them a video about the procedure.

B Rationale: The nurse should allay their concerns by providing information about the procedure and answering questions (B). This action assists the couple in coping with the situation. (A) may offer false reassurance. (C) alone does not resolve the couple's fears. Although (D) may be helpful, it is a passive activity, and the nurse's availability to answer questions is likely to be most helpful in calming their fears.

A client who is first day postoperative after a mastectomy becomes increasingly restless and agitated. Vital signs are temperature, 100° F; pulse, 98 beats/min; respirations, 24/breaths/min; and blood pressure, 120/80 mm Hg. Which intervention should the nurse implement first? A.Administer a PRN dose of a prescribed analgesic. B.Assess the incision for any drainage or redness C.Instruct the UAP to take vital signs hourly. D.Assist the client to a more comfortable position.

B Rationale: The nurse's priority is to observe for possible hemorrhage (B). The client is at high risk for hypovolemic shock and is exhibiting early symptoms of shock. Remember, in early shock the blood pressure may be stable or increase slightly as a compensatory mechanism. If there is no obvious indication of bleeding, the client should then be assessed for the need of an analgesic (A, C, and D) should be implemented.

The nurse in the emergency department is caring for a client with type 1 diabetes mellitus in diabetic ketoacidosis (DKA). Which action should the nurse take first? A.Administer regular insulin IV. B.Start an IV infusion of normal saline. C.Check serum electrolyte levels. D.Give a potassium supplement.

B Rationale: The patient in DKA experiences severe dehydration and must be rehydrated before insulin is administered (B). The other actions will follow rehydration (A, C, and D).

The nurse prepares to administer 3 units of regular insulin and 20 units of NPH insulin subcutaneously to a client with an elevated blood glucose level. Which procedure is correct? A.Using one syringe, first insert air into the regular vial and then insert air into the NPH vial. B.Using one syringe, add the regular insulin into the syringe and then add the NPH insulin. C.Avoid combining the two insulins because incompatibility could cause an adverse reaction. D.Administer the regular insulin subcutaneously and then give the NPH IV to prevent a separate stick.

B Rationale: The regular or "clear" insulin should be withdrawn into the syringe first, followed by the NPH (B). Air should first be injected into the NPH vial and then air should be inserted into the regular vial (A). NPH and regular insulin are compatible, and combining will reduce the number of injections (C). The insulin is ordered subcutaneously and NPH cannot be given IV (D).

The charge nurse observes a student nurse enter the room of a client who is prescribed airborne precautions. The application of which personal protective equipment by the student indicates a correct understanding of this precaution? A.Surgical mask, clean gloves, and gown B.Properly fitted N95 respirator or mask C.Sterile gloves and gown D.Goggles, clean gloves, and gown

B Rationale: The use of personal protective equipment (PPE) for airborne precautions includes a properly prefitted N95 respirator or mask (B). (A, C and D) do not provide the appropriate respiratory equipment for airborne precautions. A surgical mask is used for preventing transmission of droplet precautions.

The nurse prepares to administer ophthalmic drops to a client prior to cataract surgery. List the steps in the order that they should be implemented from first step to final step. A. Drop prescribed number of drops into conjunctival sac. B. Wash hands and apply clean gloves. C. Place dominant hand on the client's forehead. D. Ask the client to close the eye gently. A. C, B, A, D B. B, C, A, D C. A, B, D, C D. A, C, B, D

B Rationale: Washing hands and applying gloves prior to procedure initiation prevents the spread of infection (B). Placing the dominant hand on the client's forehead (C) stabilizes the hand so the nurse can hold the dropper 1 to 2 cm above the conjunctival sac and drop the prescribed number of drops (A); asking the client to close the eye gently helps distribute the medication (D).

A client with rhabdomyolysis tells the nurse about falling while going to the bathroom and lying on the floor for 24 hours before being found. Which current client finding is indicative of renal complications? A.3+ protein in the urine B.Blood urea nitrogen >25 mg/dL C.Blood pH >7.45 D.Urine output, 2500 mL/day

B Rhabdomyolysis is characterized by destruction of muscles that release myoglobin, causing myoglobinuria, which places the client at risk for acute renal failure, so an increased blood urea nitrogen (BUN) level (B) indicates a decrease in renal function. Blood in the urine from the accompanying breakdown of red blood cells contributes to proteinuria (A), an expected finding. Metabolic acidosis is the potential complication, not alkalosis (C). During the diuretic phase of acute renal failure, there can be a normal output volume (D) (approximately 2000 mL/day), which can result from IV fluid hydration.

The nurse calls the primary health care provider to report the status of a postsurgical client. Place the statements in the correct SBAR communication format. A. "Mr. Jones is experiencing pain of a 7 on a scale of 1 to 10. Vital signs are B/P 150/88, HR 90, and RR 26, with an O2 sat of 95%." B. "This is Mary Smith, RN, calling about Mr. Jones in room 325 at Memorial Hospital." C. "Mr. Jones had an open cholecystectomy yesterday and reports inadequate pain control with his current medication regimen since the surgery." D. "Would you like to make a change in his pharmacologic regimen?" A. C, B, A, D B. B, C, A, D C. A, B, C, D D. A, C, D, B

B SBAR: S = Situation and includes introduction of the nurse and client/setting (B). B = Background and includes the presenting complaint and relevant history (C). A = Assessment and includes current vital signs and other information (A). R = Recommendations and includes an explanation of why you are calling or a suggestion about which action should be taken (D).

The nurse is developing a health risk assessment protocol for use in a well-baby clinic in a low-income neighborhood. Which information is most important for the nurse to include in the assessment? A.Hearing acuity B.Immunization history C.Weight and length D.Head circumference

B The Centers for Disease Control and Prevention indicate that vaccines are among the most widely used, effective, and safe medical products in use today. Assessing the infant immunization histories in clients from disadvantaged socioeconomic groups (B) is the most effective method for determining these infants' susceptibilities to vaccine-preventable diseases. Assessment of (A, C, and D) provides valuable information but does not supply information about infants' susceptibilities to vaccine-preventable diseases, which are major causes of infant mortality and morbidity.

The RN is caring for a client who is in skeletal traction. Which activity should the RN assign to the PN? A.Assess skeletal pins for infection. B.Assist the client with toileting. C.Establish thrombus prevention care. D.Evaluate pain management plan.

B The PN can implement nursing care, such as (B). The PN assists the RN in the development of a teaching plan and reinforces information to the client according to the plan. (A, C, and D) are outside the scope of PN practice, but the PN can assist the RN in gathering data, implementing nursing care, and contributing to the plan of care under the supervision of the RN.

A client who is on the outpatient surgical unit is preparing for discharge after a myringotomy with placement of ventilating tubes. Which response by the client indicates that further teaching is necessary? A."I will avoid coughing, sneezing, and forceful nose blowing." B."Swimming can begin on the tenth postoperative day." C."Any mild discomfort can be managed with acetaminophen." D."Drainage from my ears is expected after the surgery."

B The purpose of the ventilating tubes in the tympanic membrane is to equalize pressure and drain fluid collection from the middle ear. The tube's patency allows air and water to enter the middle ear, so the client should be reeducated if the client swims (B) or allows water to enter the external ear. (A, C, and D) reflect correct responses.

Six hours following thoracic surgery, a client has the following arterial blood gas (ABG) findings: pH, 7.50; Paco2, 30 mm Hg; HCO3, 25 mEq/L; Pao2, 96 mm Hg. Which intervention should the nurse implement based on these results? A.Increase the oxygen flow rate from 4 to 10 L/min per nasal cannula. B.Assess the client for pain and administer pain medication as prescribed. C.Encourage the client to take short shallow breaths for 5 minutes. D.Prepare to administer sodium bicarbonate IV over 30 minutes.

B These ABGs reveal respiratory alkalosis (B), and treatment depends on the underlying cause. Because the client is only 6 hours postoperative, he or she should be assessed for pain because treating the pain will correct the underlying problem. A Pao2 of 96 mm Hg does not indicate the need for an increase in oxygen administration (A). The Paco2 indicates mild hyperventilation, so (C) is not indicated. In addition, it is very difficult to change one's breathing pattern. The use of sodium bicarbonate (D) is indicated for the treatment of metabolic acidosis, not respiratory alkalosis.

The health care provider prescribes 1000 mL of Ringer's lactate solution with 30 units of oxytocin (Pitocin) to infuse over 4 hours for a client who has just delivered a 10-lb infant by cesarean section. The tubing has been changed to a 20 gtt/mL administration set. The nurse should set the flow rate at how many gtt/min? A.42 B.83 C.125 D.250

B Use the following calculation (B): 20 gtt/mL × (1000 mL/4 hr) × (1 hr/60 min) = 83 gtt/min

Which instruction(s) should the nurse include in the discharge teaching plan of a male client who has had a myocardial infarction and who has a new prescription for nitroglycerin (NTG)? (Select all that apply.) A.Keep the medication in your pocket so that it can be accessed quickly. B.Call 911 if chest pain is not relieved after one nitroglycerin. C.Store the medication in its original container and protect it from light. D.Activate the emergency medical system after three doses of medication. E.Do not use within 1 hour of taking sildenafil citrate (Viagra).

B,C Rationale: Emergency action should be taken if chest pain is not relieved after one nitroglycerin tablet (B). The medication should be kept in the original container to protect from light (C). Keeping the medication in the shirt pocket provides an environment that is too warm (A). The newest guidelines recommend calling 911 after one nitroglycerin tablet if chest pain is not relieved (D). Nitroglycerin and other nitrates should never be taken with Viagra (E).

Which intervention(s) should the nurse implement when administering a new prescription of amitriptyline HCl (Elavil) to a client with a depressive disorder? (Select all that apply.) A.Explain that therapeutic effects should be achieved within 1 to 3 days. B.Administer at bedtime to minimize sedative effects. C.Give 1 hour after the administration of isocarboxazid (Marplan). D.Take blood pressure prior to and after administration. E.Assess for adverse reactions such as dry mouth and blurred vision.

B,D,E Rationale: The drug causes sedation, so it should be given at bedtime (B). Cardiovascular adverse reactions include orthostatic hypotension; therefore, the blood pressure should be assessed (D). This drug can cause anticholinergic effects such as dry mouth, blurred vision, constipation, and urinary retention (E). The drug takes 2 to 6 weeks to achieve therapeutic effects (A). All monoamine oxidase (MAO) inhibitors such as isocarboxazid should be discontinued 1 to 3 weeks prior to the administration of Elavil (C).

Which intervention(s) should be performed by the nurse when caring for a woman in the fourth stage of labor? (Select all that apply.) A.Maintain bed rest for the first 6 hours after delivery. B.Palpate and massage the fundus to maintain firmness. C.Have client empty bladder if fundus is above umbilicus. D.Check perineal pad for color and consistency of lochia. E.Apply ice pack or witch hazel compresses to the perineum.

B,D,E Rationale: The fundus should be palpated and massaged frequently to prevent hemorrhage (B). The lochia should be assessed to detect for hemorrhage (D) and ice packs and witch hazel can decrease edema and discomfort (E). Bed rest is only recommended for the first 2 hours (A). A full bladder is suspected if the fundus is deviated to the right or left of the umbilicus (C).

A client who is admitted to the emergency room following a motorcyle accident is having difficulty breathing. While assessing the client's chest and lungs, the nurse notes that there are no breath sounds over the left fields. Which actions should the nurse implement? (SATA) A. Place client in Trendelenburg position B. Apply a high-flow oxygen face mask C. Elevate the head of the bed 45 degrees D. Withhold narcotic pain medication E. Obtain a chest tube insertion kit

B-C-E

While caring for a client who has sustained an MI, the nurse notes eight PVCs in one minute on the cardiac monitor. The client is receiving an IV infusion of D5W and oxygen at 2 L/minute. The nurse's first course of action should be to: A. Increase the IV infusion rate B. Notify the physician promptly C. Increase the oxygen concentration D. Administer a prescribed analgesic

B. PVCs are often a precursor of life-threatening dysrhythmias, including ventricular tachycardia and ventricular fibrillation. An occasional PVC is not considered dangerous, but if PVCs occur at a rate greater than 5 or 6 per minute in the post MI client, the physician should be notified immediately. More than 6 PVCs per minute is considered serious and usually calls for decreasing ventricular irritability by administering medications such as lidocaine. Increasing the IV infusion rate would not decrease the number of PVCs. Increasing the oxygen concentration should not be the nurse's first course of action; rather, the nurse should notify the physician promptly. Administering a prescribed analgesic would not decrease ventricular irritability.

A client with arthritis is taking large doses of aspirin. What symptom does the nurse include when teaching the client about the clinical manifestations of aspirin toxicity? A. Feelings of drowsiness B. Disturbances in hearing C. Intermittent constipation D. Metallic taste in the mouth

B. Disturbances in hearing

The nurse is caring for a client with type 1 diabetes. For which signs or symptoms of insulin-induced hypoglycemia should the nurse particularly be observant? Select all that apply. A. Excessive hunger B. Headache C. Diaphoresis D. Excessive thirst E. Deep respirations

B. Headache C. Diaphoresis

A healthcare provider informs a client that midazolam will be administered preoperatively. Later, the client asks the nurse why this medication is given. What primary reason should the nurse consider when formulating a response? A. Reduces pain B. Induces sedation C. Produces amnesia D. Limits oral secretions

B. Induces sedation

What are the desired outcomes that the nurse expects when administering ibuprofen? Select all that apply A. Diuresis B. Pain relief C. Antipyresis D. Bronchodilation E. Anticoagulation F. Reduced inflammation

B. Pain relief C. Antipyresis F. Reduced inflammation

Dexamethasone has been prescribed for a client after a craniotomy for a brain tumor. When evaluating the effectiveness of the medication, the nurse expects what physiologic response? A. Reduced cell growth B. Reduced cerebral edema C. Increased renal reabsorption D. Increased response to sedation

B. Reduced cerebral edema

What should the nurse include in a teaching plan for a client taking calcium channel blockers such as nifedipine? Select all that apply. A. Reduce calcium intake. B. Report peripheral edema. C. Expect temporary hair loss. D. Avoid drinking grapefruit juice. E. Change to a standing position slowly.

B. Report peripheral edema. D. Avoid drinking grapefruit juice. E. Change to a standing position slowly.

A nurse notices frequent artifact on the ECG monitor for a client whose leads are connected by cable to a console at the bedside. The nurse examines the client to determine the cause. Which of the following items is unlikely to be responsible for the artifact? A.Frequent movement of the client B. Tightly secured cable connections C. Leads applied over hairy areas D. Leads applied to the limbs

B. Tightly Secured Cable Connections Motion artifact, or "noise," can be caused by frequent client movement, electrode placement on limbs, and insufficient adhesion to the skin, such as placing electrodes over hairy areas of the skin. Electrode placement over bony prominences also should be avoided. Signal interference can also occur with electrode removal and cable disconnection.

49. A client receiving chemotherapy has severe neutropenia. Which snack is best for the nurse to recommend to the client?

Baked apples topped with dried raisins

After receiving report, the nurse prioritizes the client care assignment. Which client should the nurse assess first?

Based on Maslow's hierarchy of needs and the need to address airway, breathing, and circulation (ABCs), the client with a new onset of difficulty breathing (A) should be assessed first. (B, C and D) do not have the priority of (A).

The registered nurse is evaluating the statements of the student nurse after teaching about delegation. Which statement made by the student nurse indicates a need for correction? 1 "Delegation is merely sharing a set of functions." 2 "Delegation ensures quality client care outcomes." Correct3 "Professional aspects of care can also be delegated." 4 "The final accountability of a task remains with the delegator."

Basic activities of daily living and personal hygiene can be delegated but professional aspects of care cannot be delegated and should be performed by the registered nurse only. Delegation is a process of merely sharing a set of functions in which the delegator shares functions with the delegatee. Because delegation involves sharing of functions, it ensures quality client-care outcomes. Though the delegator assigns work, the final accountability of a task remains with the delegator.

A healthcare team is delegated the task of assisting a client with bathing. Which member of the healthcare team is responsible and accountable for this aspect of client care? Incorrect1 Nursing aide Correct2 Registered nurse (RN) 3 Patient care associate (PCA) 4 Licensed vocational nurse (LVN)

Bathing is often delegated to a patient care associate (PCA) on the healthcare team. The registered nurse (RN) is accountable for the client care, but is not delegated the task of basic hygiene care such as bathing. Though the nursing aide is responsible for client care, he or she is not accountable for the client care. Similarly, a PCA may be responsible but not accountable for client care. As bathing is not generally delegated to a licensed vocational nurse (LVN), the LVN is neither responsible nor accountable for client care.

514. A male client has received a prescription for orlistat for weight and nutrition management. In addition to the medication, the client states he plans to take a multivitamin. What teaching should the nurse provide?

Be sure to take the multivitamin and the medication at least two hours apart for best absorption and effectiveness.

288. The nurse is planning care for a client who admits having suicidal thoughts. Which client behavior indicates the highest risk for the client acting on these suicidal thoughts?

Begin to show signs of improvement in affect

FGAs

Blocks dopamine (causes EPS and prolactin release), histamine (weight gain, sedation), cholinergic receptors (dry mouth, blurred vision, urinary retention, constipation), and alpha1 receptors (otho hypoTN, reflex tachycardia)

488. A client has a prescription for lorazepam 2mg for alcohol withdrawal symptoms. Which finding... the client?

Blood pressure 149/101

582. A client admitted to the emergency center had inspiratory and expiratory wheezing, nasal flaring, and thick, tenacious sputum secretions observed during the physical examination. Based on these assessment findings, what classification of pharmacologic agents should the nurse anticipate administering?

Bronchodilators

A 6-week-old infant diagnosed with pyloric stenosis has recently devlpd projectile vomiting. Which assessment finding indicates to the nurse that the infant is becoming dehydrated? A. Palpable mass in the right upper quadrant B. Bulging fontanel C. Visible peristaltic wave D. Weak cry without any tears

C

A 62-year-old male client who has been diagnosed with emphysema, asks the nurse to tell him about the symptoms of his disease. Which statement should be included in the nurse's description of emphysema to this client. A. Breathing through pursed lips causes lung expansion and decreased physical exertion. B. Tolerance for oxygen deprivation results in an increased ability to carry out daily activities. C. A barrel chest results because of using a hyperventilating breathing pattern D. Oxygen requirements decreased because of the overexpansion of alveoli.

C

An elderly female resident of a long-term care facility makes a regular appearance during the change of shift report to inform the nurses of her new arthritic aches and to provide the staff with a detailed description of her daily BM. What nursing action is most effective in meeting this client's needs? A. Thank the client for the information and take her to the activity room. B. Offer a PRN prescription for muscle stiffness and discomfort. C. Before the report, interact with the client and ask how she is feeling D. Document the client's symptoms for shift report.

C

An older male with type 2 DM presents to the ED with a respiratory infection. The nurse recognizes that the client is at risk for hyperosmolar hyperglycemic nonketotic syndrome (HHNS) as a result of what process? A. Elevated WBC count? B. Fever greater than 103 F C. Stress-induced release of hormones D. Adverse reaction to IV antibiotics

C

At 20-weeks gestation, a client who has gained 20 lbs during this pregnancy tells the nurse that she is feeling fetal movemnt. Fundal height measurement is 20cm, and the client's only complaint is that her breasts are leaking clear fluid. Which assessment finding warrants further evaluation? A. Presence of fetal movement B. Leakage from breasts C. Gestational weight gain D. Fundal height measurement

C

The nurse is counseling a family whose 5-year-old daughter was killed by a hit and run driver. The 10-year old daughter child tells the nurse that she should have been watching her sister better. After the nurse tells the child that she did not cause the accident, which response is best for the nurse to provide? A. Explain to the child that the accident was the fault of the person driving. B. Inquire if the parents or others were watching when the accident occurred. C. Ask the child to share what could have been done to stop this from happening. D. Question the parents if the child had the duty to watch her sister often

C

The nurse plans to assist a male client out of bed for the first time since his surgery yesterday. His wife objects and tells the nurse to get out of the room because her husband is too ill to get out of bed. What actions should the take? A. Check the client's blood pressure and pulse deficit B. Quickly pivot the client to the chair and elevate the legs C. Help the client to lie back down in the bed D. Administer nasal O2 at the rate of 5 L/min

C

The nurse is preparing assignments for the day shift. Which client should be assigned to the staff RN rather than a PN? A.A client with an admitting diagnosis of menorrhagia who is now 24 hours post-vaginal hysterectomy B.A client admitted with a myocardial infarction 4 days ago who was transferred from the intensive care unit (ICU) the previous day C.A client admitted during the night with depression following a suicide attempt with an overdose of acetaminophen (Tylenol) D.A 4-year-old admitted the previous evening with gastrointestinal rotavirus who is receiving IV fluids and a clear liquid diet

C (C) requires communication skills and assessment skills beyond the educational level of a PN or UAP. Establishing a therapeutic, one on one relationship with a depressed client is beyond the scope of practice for a PN. In addition, Tylenol is extremely hepatotoxic and careful assessment is essential. (A, B, and D) could all be cared for by a PN under the supervision of the RN.

When caring for a postpartum client, which intervention is best for the nurse to implement to promote increased peripheral vascular activity? A.Encourage the client to turn from side to side every 2 hours. B.Elevate the foot of the client's bed at least 6 inches. C.Encourage the client to ambulate every 3 hours. D.Teach the client how to perform leg exercises while in bed.

C Ambulation is the best way to increase peripheral vascular activity (C). (A, B, and D) will increase peripheral vascular activity but are not as effective as ambulation.

A comatose client is admitted to the critical care unit and a central venous catheter is inserted by the health care provider. What is the priority nursing assessment before initiating IV fluids? A.Pain scale B.Vital signs C.Breath sounds D.Level of consciousness

C Before administering IV fluids through a central line, the nurse must first ensure that the catheter did not puncture the vessel or lungs. A chest radiograph should be obtained STAT, and the nurse should auscultate the client's breath sounds (C). (A, B, and D) are important assessment data but are not specifically related to insertion of a central venous catheter.

Which instruction should the nurse provide to a client whose vision is being tested with a Snellen chart? A.Stand on a line drawn 10 feet from the chart. B.Read each sentence slowly and carefully. C.Cover one eye while reading the chart with the other. D.Begin by identifying the first line that is hard to read.

C Each eye should be tested separately (C) because visual acuity can vary from one eye to the other. A Snellen chart scores vision in comparison with what a person with normal vision can read at a distance of 20 feet (A). The Snellen chart is comprised of letters, not sentences (B). The client should be instructed to begin at or near the top of the chart with the line that can be easily read, moving down until a line is reached that cannot be read (D)

The nurse is teaching the parents of a 10-year-old child with rheumatoid arthritis measures to help reduce the pain associated with the disease. Which instruction should the nurse provide to these parents? A.Administer a nonsteroidal antiinflammatory drug (NSAID) to the child prior to getting the child out of bed in the morning. B.Apply ice packs to edematous or tender joints to reduce pain and swelling. C.Warm the child with an electric blanket prior to getting the child out of bed. D.Immobilize swollen joints during acute exacerbations until function returns.

C Early morning stiffness and pain are common symptoms of rheumatoid arthritis. Warming the child (C) in the morning helps reduce these symptoms. Although moist heat is best, an electric blanket could also be used to help relieve early morning discomfort. (A) on an empty stomach is likely to cause gastric discomfort. Warm (not cold) packs or baths are used to minimize joint inflammation and stiffness (B). (D) is contraindicated, because joints should be exercised, not immobilized.

The nurse is planning a community teaching program regarding the use of folic acid to prevent neural tube birth defects. Which community group is likely to benefit most from this program? A.Parents of children with spina bifida B.High school girls in a health class C.Individuals interested in having children D.Postpartum women attending a baby care class

C Folic acid is needed early in pregnancy to prevent neural tube defects; the group most likely to be considering pregnancy is (C). Parents with children who already have a neural tube defect such as spina bifida (A) are not as invested in the content as (C). High school age students (B) may have interest in the topic but as a group are less likely to anticipate the likelihood that problems could occur in their lives than (C). (D) may be interested if planning future pregnancies, but have higher learning priorities during the postpartum period.

A client with acquired immunodeficiency syndrome (AIDS) is hospitalized after a recent discharge. Which nursing intervention is most important in reducing the client's stress associated with repeated hospitalization? A.Allow the client to discuss the seriousness of the illness. B.Ensure that the client is provided with information about medications. C.Encourage as much independence in decision making as possible. D.Include the client in planning the course of treatment.

C Hospitalization compromises an individual's sense of control and independence, which contributes to stress, so allowing the client as much independence in decisions as possible (C) helps reduce stress experienced with repeated hospitalization. (A, B, and D) are important components in stress reduction, but the isolation and dependence associated with hospitalization alter the client's sense of control and affect the client's cognitive ability to understand (B) and participate (D) in the hospitalized plan of care.

The nurse would be correct in withholding a dose of digoxin in a client with congestive heart failure without specific instruction from the health care provider if which finding was documented? A.Serum digoxin level is 1.5 ng/mL B.Blood pressure is 104/68 mm Hg C.Serum potassium level is 2.5 mEq/L D.Apical pulse is 68/min

C Hypokalemia (C) can precipitate digitalis toxicity in persons receiving digoxin, which will increase the chance of dangerous dysrhythmias (normal potassium level is 3.5 to 5.5 mEq/L). The therapeutic range for digoxin is 0.8 to 2 ng/mL (toxic levels ≥2 ng/mL); (A) is within this range. (B) would not warrant the nurse withholding the digoxin. The nurse should withhold the digoxin if the apical pulse is less than 60/min (D).

A client has been receiving levofloxacin (Levaquin), 500 mg IV piggyback q24h for 7 days. The UAP reports to the nurse that the client has had three loose foul-smelling stools this morning. Which intervention is most important for the nurse to implement? A.Perform a digital evaluation for fecal impaction. B.Administer a PRN dose of psyllium (Metamucil). C.Obtain a stool specimen for culture and sensitivity. D.Instruct the UAP to obtain incontinent pads for the client.

C Long-term use of levofloxacin (Levaquin) can cause foul-smelling diarrhea because of Clostridium difficile infection or associated colitis, so it is most important to obtain a stool specimen (C). Impaction is unlikely, so (A) is of less priority and may not be necessary. (B) is a bulk-forming agent that may be used for constipation or diarrhea. Treatment of the diarrhea and client comfort (D) are important interventions but of less priority than determining the cause of the client's diarrhea.

Which assessment is most important for the nurse to implement when seeing a client with multiple myeloma? A.Inspection of the skin B.Breath sound auscultation C.Pain scale measurement D.Mobility limitations

C Multiple myeloma is a tumor that causes bone marrow changes, which most commonly manifest as pain, so measurement of the client's pain is the highest priority (C). (A, B, and D) are part of the complete assessment but do not have the priority of (C) for this client.

Which assessment finding indicates that nystatin (Mycostatin) swish and swallow, prescribed for a client with oral candidiasis, has been effective? A.The client denies dysphagia. B.The client is afebrile with warm and dry skin. C.The oral mucosa is pink and intact. D.There is no reflux following food intake.

C Mycostatin swish and swallow is prescribed for its local effect on the oral mucosa, reducing the white curdlike lesions in the mouth and larynx (C). The ability to swallow (A) does not indicate that the medication has been effective. (B and D) do not reflect effectiveness of the local medication.

A male client is admitted for observation after being hit on the head with a baseball bat. Six hours after admission, the client attempts to crawl out of bed and asks the nurse why there are so many bugs in his bed. His vital signs are stable, and the pulse oximeter reading is 98% on room air. Which intervention should the nurse perform first? A.Administer oxygen per nasal cannula at 2 L/min. B.Plan to check his vital signs again in 30 minutes. C.Notify the health care provider of the change in mental status. D.Ask the client why he thinks there are bugs in the bed.

C One of the earliest signs of increased intracranial pressure (ICP) is a change in mental status (C). It is important to act early and quickly when symptoms of increased ICP occur. Because his oxygen saturation is normal, the administration of oxygen (A) is not the top priority. Vital signs should be monitored frequently (B), but the client's confusion should be reported immediately. (D) is not a useful intervention.

A 50-year-old man arrives at the clinic with complaints of pain on ejaculation. Which action should the nurse implement? A.Teach the client testicular self-examination (TSE). B.Assess for the presence of blood in the urine. C.Ask about scrotal pain or blood in the semen. D.Inquire about a history of kidney stones.

C Orchitis is an acute testicular inflammation resulting from recurrent urinary tract infection, recurrent sexually transmitted disease (STD), or an indwelling urethral urinary catheter causing pain on ejaculation, scrotal pain, blood in the semen, and penile discharge, so the nurse should determine the presence of other symptoms (C). Although all men should practice TSE, the client's symptoms are suggestive of an inflammatory syndrome rather than testicular cancer (A). Although hematuria (B) is associated with renal disease or calculi (D), the client's pain is associated with ejaculate, not urine.

The nurse should encourage a laboring client to begin pushing at which point? A.When the cervix is completely effaced B.When the client describes the need to have a bowel movement C.When the cervix is completely dilated D.When the anterior or posterior lip of the cervix is palpable

C Pushing begins with the second stage of labor, when the cervix is completely dilated at 10 cm (C). If pushing begins before the cervix is completely dilated (A, B, and D), the cervix can become edematous and may never dilate completely, necessitating an operative delivery. The most effective pushing occurs when the cervix is completely dilated and the woman feels the urge to push (Ferguson's reflex).

A 45-year-old female client is admitted to the psychiatric unit for evaluation. Her husband states that she has been reluctant to leave home for the last 6 months. The client has not gone to work for a month, has been terminated from her job, and has not left the house since that time. This client is displaying symptoms of which disorder? A.Claustrophobia B.Acrophobia C.Agoraphobia D.Necrophobia

C Rationale: Agoraphobia (C) is the fear of crowds or of being in an open place. (A) is the fear of being in closed places. (B) is the fear of high places. (D) is an abnormal fear of death or bodies after death. A phobia is an unrealistic fear associated with severe anxiety.

An adult client with a medical diagnosis of substance abuse and schizophrenia was recently switched from oral fluphenazine HCl (Prolixin) to IM fluphenazine decanoate (Prolixin Decanoate) because of medication noncompliance. What should the nurse teach the client and family about this change in medication regimen? A.Long-acting medication is more effective than daily medication. B.A client with substance abuse must not take any oral medications. C.There will continue to be a risk of alcohol and drug interaction. D.Support groups are only helpful for substance abuse treatment.

C Rationale: Alcohol enhances the side effects of Prolixin. The half-life of Prolixin PO is 8 hours, whereas the half-life of the Prolixin Decanoate IM is 2 to 4 weeks. Therefore, the side effects of drinking alcohol are far more severe when the client drinks alcohol after taking the long-acting Prolixin Decanoate IM (C). (A, B, and D) provide incorrect information.

While assessing a client with recurring chest pain, the unit secretary notifies the nurse that the client's health care provider is on the telephone. What action should the nurse instruct the unit secretary to implement? A.Transfer the call into the room of the client. B.Instruct the secretary to explain reason for the call. C.Ask another nurse to take the phone call. D.Ask the health care provider to see the client on the unit.

C Rationale: Another nurse should be asked to take the phone call (C), which allows the nurse to stay at the bedside to complete the assessment of the client's chest pain. (A and B) should not be done during an acute change in the client's condition. Requesting the health care provider (D) to come to the unit is premature until the nurse completes assessment of the client's status.

The charge nurse reviews the charting of a graduate nurse. Which indicates a need for further education on documentation? A.Uses descriptive words such as "gurgling" to describe breath sounds B.Records temperature 30 minutes before and after giving acetaminophen C.Charts some actions in advance of performing them D.Includes the client's response to an intervention

C Rationale: Charting actions prior to implementing them is an example of fraudulent charting and the graduate nurse should receive further education (C). (A, B, and D) are appropriate charting examples.

When caring for a hospitalized child with type 1 diabetes mellitus, which intervention can the nurse delegate to the unlicensed assistive personnel (UAP)? A.Teach the signs and symptoms of hypoglycemia. B.Assess for polydipsia, polyphasia, and polyuria. C.Check the blood glucose level every 4 hours. D.Evaluate the need for a snack between meals.

C Rationale: Checking the blood glucose level is a low-risk task that can be safely delegated to the UAP in most circumstances (C). Teaching, assessment, and evaluation are all within the scope of practice of the RN and should not be delegated to the UAP (A, B, and D).

A client exhibits symptoms of alcohol intoxication. The blood alcohol level is 200 mg (0.2%). Which measurement tool is best for the nurse to use during the initial assessment of this client? A.CAGE questionnaire for alcoholism B.Addiction Severity Index C.Glasgow Coma Scale D.DSM multiaxial evaluation

C Rationale: Evaluation of level of consciousness, which is the purpose of the Glasgow Coma Scale (C), has the highest priority. (A) is useful in helping clients recognize their alcoholism. (B and D) are comprehensive assessments that should be completed after the acute phase is resolved.

A 12-year-old boy complains to the nurse that he is "short" (4'5" [53 inches]). His twin sister is 5 inches taller than he is (4'10" [58 inches]). Based on these findings, what conclusion should the nurse reach? A.The boy is not growing as normally expected. B.The girl is experiencing a period of unexpected growth. C.A normal growth spurt occurs in girls 1 to 2 years earlier than boys. D.Male-female twins are not identical; therefore, their growth cannot be compared.

C Rationale: Girls experience a growth spurt at 9.5 to 14.5 years of age and boys at 10.5 to 16 years of age (C). There are insufficient data to support (A); growth trends must be assessed to reach such a conclusion. (B) is not unexpected. The fact that the children are twins has less to do with their growth than the fact that they are male and female (D).

A client is admitted with a diagnosis of leukemia. This condition is manifested by which of the following? A.Fever, elevated white blood count, elevated platelets B.Fatigue, weight loss and anorexia, elevated red blood cells C.Hyperplasia of the gums, elevated white blood count, weakness D.Hypocellular bone marrow aspirate, fever, decreased hemoglobin level

C Rationale: Hyperplastic gums, weakness, and elevated white blood count are classic signs of leukemia (C). (A, B, and D) state incorrect information for symptoms of leukemia.

A client is admitted to a mental health unit because of mild depression. When asked, he denies suicidal ideation, but the nurse reads in the psychosocial assessment that there were attempts to overdose on aspirin 5 years earlier. Which intervention is most important for the nurse to implement? A.Orient the client to activities on the unit. B.Document suicide precautions on the shift report. C.Assign the client to a semiprivate room. D.Obtain a verbal no-suicide contract with the client.

C Rationale: It is most important to prevent the risk of self-harm from social isolation, so the client should be assigned to a semiprivate room (C). (A) does not have the priority of (C). (B and D) can be implemented if the client admits suicidal ideation. However, based on the fact that this client is mildly depressed and that he attempted suicide 5 years ago using a method that is usually nonlethal (aspirin overdose), it is most important to prevent social isolation.

Which disaster management intervention by the nurse is an example of primary prevention? A.Emergency department triage B.Follow-up care for psychological problems C.Education of rescue workers in first aid D.Treatment of clients who are injured

C Rationale: Primary prevention is aimed at preventing disease or injury. Training rescue workers prior to a disaster is an example of minimizing or preventing injury (C). (A) is an example of secondary prevention. (B) is an example of tertiary prevention. (D) is an example of secondary prevention.

The nurse prepares to administer digoxin, 0.125 mg IV, to an adult client with atrial fibrillation. Which client datum requires the nurse to withhold the medication? A.The apical heart rate is 64 beats/min. B.The serum digoxin level is 1.5 ng/mL. C.The client reports seeing yellow-green halos. D.The potassium level is 4.0 mEq/L.

C Rationale: Reports of yellow-green halos and blurred vision are a sign of digoxin toxicity (C). The others are normal findings (A, B, and C).

When assessing the laboratory findings of a 38-year-old client with tuberculosis who is taking rifampin (Rifadin), which laboratory finding would be most important to report to the primary health care provider immediately? A.Orange-colored urine B.Potassium level, 4.9 mEq/L C.Elevated liver enzyme levels D.Blood urea nitrogen (BUN) level, 12 mg/dL

C Rationale: Rifampin can cause hepatoxicity, so elevated liver enzyme levels need to be closely monitored and reported to the health care provider (C). Orange discoloration of the urine is an expected side effect of this medication (A). The potassium level (B) is normal. A BUN level of 12 mg/dL is within defined parameters (D).

A client in an acute psychiatric setting asks the nurse if their conversations will remain confidential. How should the nurse respond? A."The Health Insurance Portability and Accountability Act (HIPAA) prevents me from repeating what you say." B."You can be assured that I will keep all of our conversations confidential because it is important that you can trust me." C."For your safety and well-being, it may be necessary to share some of our conversations with the health care team." D."I am legally required to document all of our conversations in the electronic medical record."

C Rationale: Some information, such as a suicide plan, must be shared with other team members for the client's safety and optimal therapy (C). HIPAA does not prevent a member of the health care team from repeating all conversations, particularly if safety is an issue (A). Ensuring a client that a conversation will remain confidential puts the nurse at risk, particularly if safety is an issue (B). Although pertinent information should be documented, the nurse is not legally required to document all conversations with a client (D).

A client is receiving substitution therapy during withdrawal from benzodiazepines. Which expected outcome statement has the highest priority when planning nursing care? A.Client will not demonstrate cross addiction. B.Codependent behaviors will be decreased. C.Excessive CNS stimulation will be reduced. D.The client will demonstrate an increased level of consciousness.

C Rationale: Substitution therapy with another CNS depressant is intended to decrease the excessive CNS stimulation that can occur during benzodiazepine withdrawal (C). (A, B, and D) are all appropriate outcome statements for the client described but do not have the priority of (C).

Which vital sign in a pediatric client is most important to report to the primary health care provider? A.Newborn with a heart rate of 140 beats/min B.Three-year-old with a respiratory rate of 28 breaths/min C.Six-year-old with a heart rate of 130 beats/min D.Twelve-year-old with a respiratory rate of 16 breaths/min

C Rationale: The normal heart rate for a 6- to 10-year-old is 70 to 110 beats/min (C). The others are all within normal range for those ages (A, B, and D).

The nurse assesses a pressure ulcer on a client's heel and notes full-thickness tissue loss, with some visible subcutaneous fat. How should the nurse stage this pressure ulcer? A.Stage I B.Stage II C.Stage III D.Stage IV

C Rationale: The statement above describes a stage III ulcer which is defined as full-thickness tissue loss in which subcutaneous fat may be exposed but without exposure of bone, tendon, or muscle (C). A stage I ulcer includes intact skin with nonblanchable redness of a localized area (A). A stage II ulcer is described by partial-thickness loss of dermis, including a shallow open ulcer with a pinkish red wound bed (B). Full-thickness tissue loss with exposed bone, tendon, or muscle and slough or eschar is indicative of a stage IV ulcer (D).

The nurse hears a series of long-duration, discontinuous, low-pitched sounds on auscultation of a client's lower lung fields. Which documentation of this finding is correct? A.Fine crackles B.Wheezes C.Course crackles D.Stridor

C Rationale: This sound is caused by air passing through airways that are intermittently occluded by mucus (C). Fine crackles are a series of short-duration, discontinuous, high-pitched sounds (A). Wheezes are continuous, high-pitched, musical or squeaking-type sounds (B). Stridor is a continuous croupy sound of constant pitch and indicates partial obstruction of the airway (D).

Which information is most concerning to the nurse when caring for an older client with bilateral cataracts? A.States having difficulty with color perception B.Presents with opacity of the lens upon assessment C.Complains of seeing a cobweb-type structure in the visual field D.Reports the need to use a magnifying glass to see small print

C Rationale: Visualization of a cobweb- or hairnet-type structure is a sign of a retinal detachment, which constitutes a medical emergency. Clients with cataracts are at increased risk for retinal detachment (C). Distorted color perception (A), opacity of the lens (B), and gradual vision loss (D) are expected signs and symptom of cataracts, but do not need immediate attention.

The nurse formulates a nursing diagnosis of pain related to muscle spasms for a client with extreme lower back pain associated with acute lumbosacral strain. Which is the best intervention for the nurse to implement? A.Perform range-of-motion exercises on the lower extremities every 4 hours. B.Place a small firm pillow under the upper back to flex the lumbar spine gently. C.Rest in bed with the head of the bed elevated 20 degrees and flex the knees. D.Position in reverse Trendelenburg with the feet firmly against the foot of the bed.

C Resting in bed with the head of the bed elevated 20 degrees and flexing the knees reduces stress on the lower back muscles (C). Range-of-motion exercises can result in paravertebral muscle spasms and increased pain (A). Bending the knees, rather than (B), reduces stress on the lower back. (D) places stress on the lower back and increases the client's pain.

A registered nurse (RN) delivers telehealth services to clients via electronic communication. Which nursing action creates the greatest risk for professional liability and has the potential for a malpractice lawsuit? A.Participating in telephone consultations with clients B.Identifying oneself by name and title to clients in telehealth communications C.Sending medical records to health care providers via the Internet D.Answering a client-initiated health question via electronic mail

C Sending medical records over the Internet, even with the latest security protection, creates the greatest risk for liability because of the high potential of breaching client confidentiality and the amount of information being transferred (C). Client confidentiality is protected by federal wiretapping laws making telephone consultation (A) a private and protected form of communication. By stating one's name and credentials in telehealth communication (B), one is taking responsibility for the encounter. E-mail initiated by the client (D) poses less risk than sending records via the Internet.

The only RN on a surgical unit is performing an admission assessment on a client scheduled for surgery in 2 hours. The UAP reports to the RN that an unresponsive male client with a continuous feeding tube has just vomited. Which action should the RN delegate to the UAP? A.Obtain the remainder of the preoperative admission information. B.Check the vomiting client for signs of tube feeding aspiration. C.Position the client who has vomited on his side and obtain vital signs. D.Teach the preoperative client coughing and deep breathing exercises.

C The UAP can be assigned to perform tasks that do not require the judgment of the nurse, such as positioning the client and obtaining vital signs (C). (A and B) involve assessment, which should be performed by a nurse. (D) involves initial client teaching, which should be performed by the nurse.

Until the census on the obstetrics (OB) unit increases, an unlicensed assistive personnel (UAP) who usually works in labor and delivery and the newborn nursery is assigned to work on the postoperative unit. Which client would be best for the charge nurse to assign to this UAP? A.An adolescent who was readmitted to the hospital because of a postoperative infection B.A woman with a new colostomy who requires discharge teaching C.A woman who had a hip replacement and may be transferred to the home care unit D.A man who had a cholecystectomy and currently has a nasogastric tube set to intermittent suction

C The charge nurse will be responsible for providing a report to the home care unit if the transfer occurs (A). The client is infected and an employee who works on an OB unit should be assigned to clean cases in case the employee is required to return to the OB unit (B). This requires the skills of a registered nurse (RN) to do discharge teaching and provide emotional support (D). This may require skills beyond the level of this UAP.

A client with chronic renal insufficiency (CRI) is taking 25 mg of hydrochlorothiazide (HCTZ) PO and 40 mg of furosemide (Lasix) PO daily. Today, at a routine clinic visit, the client's serum potassium level is 4 mEq/L. What is the most likely cause of this client's potassium level? A.The client is noncompliant with his medications. B.The client recently consumed large quantities of pears or nuts. C.The client's renal function has affected his potassium level. D.The client needs to be started on a potassium supplement.

C The client has a normalized potassium level despite diuretic use (C). The kidney automatically secretes 90% of potassium consumed, but in chronic renal insufficiency (CRI), less potassium is excreted than normal. Therefore, the two potassium-wasting drugs, a thiazide diuretic and loop diuretic, are not likely to affect potassium levels. The normal potassium level is 3.5 to 5 mEq/L, and with a potassium level of 4 mEq/L, there is no reason to believe that the client is noncompliant with his treatment (A). Pears and nuts do not affect the serum potassium level (B). There is no need for a potassium supplement (D) because the client's potassium level is within the normal range.

The nurse is assessing a client using the Snellen chart and determines that the client's visual acuity is the same as in a previous examination, which was recorded as 20/100. When the client asks the meaning of this, which information should the nurse provide? A.This visual acuity result is five times worse that of a normal finding. B.This line should be seen clearly when the client wears corrective lenses. C.A client with normal vision can read at 100 feet what this client reads at 20 feet. D.This client can see at 100 feet what a client with normal vision can see at 20 feet.

C The interpretation of the client's visual acuity is compared to the Snellen scale of 20/20, which indicates that the letter size on the Snellen chart is seen clearly and read by a client with normal vision at 20 feet. A finding of 20/100 means that this client can read at 20 feet what a person with normal vision can read at 100 feet (C). (A, B, and D) are inaccurate.

Which action by the nurse is consistent with culturally competent care? A.Treating each client the same regardless of race or religion B.Ensuring that all Native American clients have access to a shaman C.Understanding one's own world view in addition to the client's D.Including the family in the plan of care for older clients

C The nurse should understand his or her own values and views to prevent those values from being imparted to others, in addition to understanding the client's cultural views (C). Treating every client the same or assuming that all clients share the same values does not exhibit cultural competence or sensitivity (A, B, and D).

A nurse-manager of a long-term care facility learns that the nursing administrator plans to remove the television from the residents' day room because night shift staff members are sitting around watching television. How should the nurse-manager respond to this situation? A.Advocate for the rights of the staff to watch television once their assignments are complete. B.Confront the administrator about making a decision that will negatively affect the residents. C.Offer to develop an alternate solution so that the residents can continue to watch television. D.Remind the administrator that watching television helps the night shift staff remain awake.

C The role of the nurse-manager in the mediation process is to assess the problem, analyze the information, and reframe it in a manner that might provide compromise (C). The staff do not have the right to watch television (A) while being paid to work. (B) challenges the administrator and is likely to alienate the administrator, causing anger and shutting off further communication. (D) is not a sound rationale for the use of the television.

A 77-year-old female client states that she has never been so large around the waist and that she has frequent periods of constipation. Colon disease has been ruled out with a flexible sigmoidoscopy. Which information should the nurse provide to this client? A.As women age, they often become rounder in the middle because they do not exercise properly. B.Further assessment is indicated because loss of abdominal muscle tone and constipation do not occur with aging. C.With age, more fatty tissue develops in the abdomen and decreased intestinal movement can cause constipation. D.Because there is no evidence of a diseased colon, there is no need to worry about abdominal size

C With aging, the abdominal muscles weaken as fatty tissue is deposited around the trunk and waist. Slowing peristalsis also affects the emptying of the colon, resulting in constipation (C). (A) is not the primary reason for the changes in body structure. (B) is not indicated because loss of muscle tone and constipation are age-related changes. (D) dismisses the client's concerns and does not help her understand the changes that she is experiencing.

When auscultating the apical pulse of a client who has atrial fibrillation, the nurse would expect to hear a rhythm that is characterized by: A. The presence of occasional coupled beats B. Long pauses in an otherwise regular rhythm C. A continuous and totally unpredictable irregularity D. Slow but Strong and regular Beats

C. A continuous and totally unpredictable irregularity In atrial fibrillation, multiple ectopic foci stimulate the atria to contract. The AV node is unable to transmit all of these impulses to the ventricles, resulting in a pattern of highly irregular ventricular contractions.

A client is scheduled to receive phenytoin 100 mg orally at 6 PM but is having difficulty swallowing capsules. What method should the nurse use to help the client take the medication? A. Sprinkle the powder from the capsule into a cup of water. B. Insert a rectal suppository containing 100 mg of phenytoin. C. Administer 4 mL of phenytoin suspension containing 125 mg/5 mL. D. Obtain a change in the administration route to allow an intramuscular injection.

C. Administer 4 mL of phenytoin suspension containing 125 mg/5 mL.

A nurse is viewing the cardiac monitor in a client's room and notes that the client has just gone into ventricular tachycardia. The client is awake and alert and has good skin color. The nurse would prepare to do which of the following? A. Immediately defibrillate B. Prepare for pacemaker insertion C. Administer amiodarone (Cordarone) intravenously D. Administer epinephrine (Adrenaline) intravenously

C. Administer amiodarone (Cordarone) intravenously First-line treatment of ventricular tachycardia in a client who is hemodynamically stable is the use of anti-dysrhythmics such as amiodarone (Cordarone), lidocaine (Xylocaine), and procainamide (Pronestyl). Cardioversion also may be needed to correct the rhythm (cardioversion is recommended for stable ventricular tachycardia). Defibrillation is used with pulseless ventricular tachycardia. Epinephrine would stimulate and already excitable ventricle and is contraindicated

The nurse administers 2 units of salt-poor albumin to a client with portal hypertension and ascites. What does the nurse explain to the client regarding the purpose of the albumin? A. It provides nutrients. B. It increases protein stores. C. Albumin elevates the circulating blood volume. D. Albumin temporarily diverts blood flow away from the liver.

C. Albumin elevates the circulating blood volume.

A client has an anaphylactic reaction after receiving intravenous penicillin. What does the nurse conclude is the cause of this reaction? A. An acquired atopic sensitization occurred. B. There was passive immunity to the penicillin allergen. C. Antibodies to penicillin developed after a previous exposure. D. Potent antibodies were produced when the infusion was instituted.

C. Antibodies to penicillin developed after a previous exposure.

The nurse is caring for a client who is scheduled for an electrophysiology study (EPS) because of persistent ventricular tachycardia. Before the procedure the client is to receive a beta-blocker. What client's response during the procedure best indicates that the beta-blocker is working effectively? A. Decreased anxiety B. Reduced chest pain C. Decreased heart rate D. Increased blood pressure

C. Decreased heart rate

The health care provider prescribes propylthiouracil (PTU) for a client with hyperthyroidism. What is an action of PTU that the nurse will include in teaching? A. Increases the uptake of iodine B. Causes the thyroid gland to atrophy C. Interferes with the synthesis of thyroid hormone D. Decreases the secretion of thyroid-stimulating hormone (TSH)

C. Interferes with the synthesis of thyroid hormone

A client has severe diarrhea, and the health care provider prescribes intravenous fluids, sodium bicarbonate, and an antidiarrheal medication. Which drug does the nurse expect the health care provider to prescribe? A. Psyllium B. Bisacodyl C. Loperamide D. Docusate sodium

C. Loperamide

A client with Addison disease is receiving cortisone therapy. What complications does the nurse expect if the client abruptly stops the medication? Select all that apply. A. Diplopia B. Dysphagia C. Tachypnea D. Bradycardia E. Hypotension

C. Tachypnea E. Hypotension

A nurse in the surgical intensive care unit is caring for a client with a large surgical incision. The nurse reviews a list of vitamins and expects that which medication may be prescribed because of its major role in wound healing? A. Vitamin A (retinol) B. Vitamin K (phytonadione) C. Vitamin C (ascorbic acid) D. Vitamin B12 (cyanocobalamin)

C. Vitamin C (ascorbic acid)

Two days after swallowing 30 tablets of alprazolam (Xanax), a client with a history of depression is hemodynamically stable but wants to leave the hospital against medical advice. Which nursing action(s) is(are) most likely to maintain client safety? (Select all that apply.) A.Direct the client to sign a liability release form. B.Restrict the client's ability to leave the unit. C.Explain the benefits of remaining in the hospital. D.Instruct the client to take medications as prescribed. E.Provide the client with names of local support groups. F.Notify the health care provider of the client's intention.

CDF Correct responses are (C, D, and F). To maintain safety and to provide information, the nurse should explain the potential benefits of continuing treatment in the hospital (C) and the need to take prescribed medications (D). This client, who is very likely self-destructive, should remain on the unit and the health care provider should be notified (F). Signing a release form (A) before leaving the hospital does not contribute to safety. The nurse may ask the client not to leave the hospital (B), but pressuring clients is unethical behavior. (E) may be helpful at a later time in this client's treatment program.

A patient's cardiac monitor shows sinus rhythm, rate 64. The P-R interval is 0.18 seconds at 1:00 AM, 0.22 seconds at 2:30 PM, and 0.28 seconds at 4:00 PM. Which action should the nurse take next?

Call the health care provider before giving the next dose of metoprolol (Lopressor).

574. Which statement is accurate regarding the pathological changes in the pulmonary system associated with acute (adult) respiratory distress syndrome (ARDS)?

Capillary hydrostatic pressure exceeds colloid osmotic pressure, producing interstitial edema

32. After a third hospitalization 6 months ago, a client is admitted to the hospital with ascites and malnutrition. The client is drowsy but responding to verbal stimuli and reports recently spitting up blood. What assessment finding warrants immediate intervention by the nurse?

Capillary refill of 8 seconds

Which client's care can the registered nurse (RN) safely delegate to unlicensed nursing personnel (UNP) based on the given data? Correct1 Client A, with chronic hypertension and stable vitals 2 Client B, with drainage from diabetic foot 3 Client C, with myocardial infarction due to atherosclerosis 4 Client D, with foot ulcers from peripheral vascular disease

Care of client A can be safely delegated because the chronic hypertension with stable vitals is not generally associated with any complications. Client B with drainage from diabetic foot is at a risk of aggravating foot issues, so this client's care cannot be safely delegated. Client C with myocardial infarction due to atherosclerosis is at a risk of cardiovascular instability and care should not be delegated. Client D has a risk of foot ulcers due to peripheral heart disease so this client's care also cannot be safely delegated to the UNP.

The nurse is monitoring neurological vital signs for a male client who lost consciousness after falling and hitting his head. Which assessment finding is the earliest and most sensitive indication of altered cerebral function?

Change in level of consciousness. Neurological vital signs include serial assessments of TPR, blood pressure, and components of the Glasgow coma scale (GCS), which includes verbal, musculoskeletal, and pupillary responses. A change in the client's level of consciousness (D), as indicated by responses to commands during the GCS, is the first and the most sensitive sign of change in cerebral function. (A, B, and C) are late signs of altered cerebral function.

A client, residing in an assisted living facility, is diagnosed with Parkinson disease and the health care provider prescribes selegiline (Eldepryl). What precaution should the nurse teach the client? Change positions slowly. Take the medication between meals. Perform self-blood glucose monitoring. Withhold the next dose if nausea occurs.

Change positions slowly.

In a health care setting, there are a limited number of unlicensed nursing personnel. Who would take up the responsibility of delegation in place of the registered nurse? Correct1 Charge nurse 2 Chief nursing officer 3 Patient care associate 4 Licensed practical nurse

Charge nurses act as delegators as they also have knowledge and expertise in the clinical setting. In cases where there are a limited number of unlicensed nursing personnel, the registered nurse does not delegate tasks. In this instance the charge nurse usually becomes a delegator and delegates the tasks. The chief nursing officer is not the immediate person to delegate the tasks in such instances. Patient care associates and licensed practical nurses act as delegatees.

459. The nurse is preparing to administer an infusion of amino acid-dextrose total parenteral nutrition (TPN) through a central venous catheter (CVC) line. Which action should the nurse implement first?

Check the TPN solution for cloudiness

224. The charge nurse in a critical care unit is reviewing clients' conditions to determine who is stable enough to be transferred. Which client status report indicates readiness for transfer from the critical care unit to a medical unit?

Chronic liver failure with a hemoglobin of 10.1 and slight bilirubin elevation

20. A mother brings her 6-year-old child, who has just stepped on a rusty nail, to the pediatrician's office. Upon inspection, the nurse notes that the nail went through the shoe and pierced the bottom of the child's foot. Which action should the nurse implement first?

Cleanse the foot with soap and water and apply an antibiotic ointment

88. The nurse is completing a head to be assessment for a client admitted for observation after falling out of a tree. Which finding warrants immediate intervention by the nurse?

Clear fluid leaking from the nose.

Which client care can be safely delegated to the unlicensed nursing personnel (UNP) to provide oral hygiene? Correct1 Client A 2 Client B 3 Client C Incorrect4 Client D

Client A with dental caries is least likely to have any complications during oral hygiene. Oral care in clients with oral cancer has associated risks; therefore, it should be performed by a registered nurse (RN). Since client C with a jaw fracture has limited ability to open the mouth, care cannot be safely delegated to the UNP. In client D with thrombocytopenia, small bruises that could occur during oral care may result in persistent bleeding. This complication prevents delegation of oral hygiene for client D to UNPs.

The nurse manager has delegated tasks to a registered nurse (RN) and unlicensed assistive personnel (UAP) who are paired to provide care for a client with substance abuse. Which hospital care setting uses this model to deliver care to the clients? 1 Hospice care 2 Extended care 3 Long term care Correct4 Rehabilitative care

Clients with substance abuse require rehabilitative care. Rehabilitative care uses the partnership model to deliver care to the clients. In this model, the RN and UAP are paired to deliver the care. Hospice care is indicated for end-of-life care in clients. Extended care is provided for older clients. Long-term care is provided for clients with chronic diseases. Hospice care, extended care, and long-term care setting may not require the partnership model to deliver the care to the clients.

Which task can be safely delegated by a registered nurse (RN) to unlicensed nursing personnel (UNP) for a client with thrombocytopenia? 1 Shaving the client Correct2 Positioning the client 3 Maintaining oral hygiene 4 Giving intravenous platelet infusions

Clients with thrombocytopenia are at risk of bleeding with slight bruising. Therefore tasks that do not risk bruising the client may be delegated to the UNP. The RN should shave the client and maintain oral hygiene. Intravenous infusions should not be administered by a UNP to any client.

623. A 7-year-old boy is brought to the clinic because of facial edema. He reports that he has been voiding small amounts of dark, cloudy, tea-colored urine. The parents state that their son had a sore throat 2 weeks earlier, but it has resolved. After assessing the child's vital signs and weight, what intervention should the nurse implement next?

Collect a urine specimen for routine urinalysis

Adverse effects of SGAs

Common: sedation, weight gain, ortho hypoTN, dry mouth, blurred vision, urinary retention, constipation, tachycardia Rare: neuroendocrine effects, EPS and TD

A registered nurse is teaching a group of newly hired licensed registered nurses, licensed practical nurses, and unlicensed nursing professionals. Which teaching strategies would be appropriate to develop competencies? Select all that apply. Correct1 Case studies Correct2 Online learning 3 Teaching experience Correct4 Clinical nursing practice Incorrect5 Demographics of learning group

Competencies can be developed through different teaching strategies such as case studies, online learning, and clinical nursing practice. These strategies can help in improving the learning ability of the student nurses, licensed practical nurses, and unlicensed nursing professionals. Teaching experience and demographics may not be required to develop competencies.

221. An older male client with type 2 diabetes mellitus reports that has experiences legs pain when walking short distances, and that the pain is relieved by rest. Which client behavior indicates an understanding of healthcare teaching to promote more effective arterial circulation?

Completely stop cigarette/ cigar smoking.

106. The nurse is caring for a client receiving continuous IV fluids through a single lumen central venous catheter (CVC). Based on the CVC care bundle, which action should be completed daily to reduce the risk for infection?

Confirm the necessity for continued use of the CVC.

105. A client who sustained a head injury following an automobile collision is admitted to the hospital. The nurse include the client's risk for developing increased intracranial pressure (ICP) in the plan of care. Which signs indicate to the nurse that ICP has increased?

Confusion and papilledema

A client with schizophrenia who is receiving an antipsychotic medication begins to exhibit a shuffling gait and tremors. The practitioner prescribes the anticholinergic medication benztropine (Cogentin) 2 mg daily. What should the nurse assess the client for daily when administering these medications together? Constipation Hypertension Increased salivation Excessive perspiration

Constipation

489. A client with end-stage liver failure is declared brain dead. The family wants to discontinue feeding and donate any viable organs. Which action should the nurse take?

Contact the regional organ procurement agency

359. A primigravida a 40-weeks gestation with preeclampsia is admitted after having a seizure in the hot tub at a midwife's birthing center. Based on documentation in the medical record, which action should the nurse implement? (Click on each chart tab for additional information. Please be sure to scroll to the bottom right corner of each tab to view all information contained in the client's medical record.)

Continue to monitor the client's blood pressure hourly

81. Based on the information provided in this client's medical record during labor, which should the nurse implement? (Click on each chart tab for additional information. Please be sure to scroll to the bottom right corner of each tab to view all information contained in the client's medical record.)

Continue to monitor the progress of labor.

175. The nurse is caring for a client who is entering the second stage of labor. Which action should the nurse implement first?

Convey to the client that birth is imminent.

When meeting with the client and the family, which nursing intervention demonstrates the nurse's role as collaborator of care?

Coordinating and educating about multidisciplinary services.

The registered nurse is delegating tasks for nursing assistants caring for a client who requires more attention. Which element should be considered when selecting the suitable nursing assistant for delegation of a task? 1 Time Incorrect2 Safety 3 Stability Correct4 Critical thinking

Critical thinking is of utmost importance for selecting a suitable nursing assistant for delegation of a task in a situation where a client requires more attention, as the delegatee should be able to perform the task effectively. Time, safety, and stability are also the elements for effective delegation, but these are suitable depending on the situation for assigning a task and delegation.

496. A client is admitted with a wound on the right hand and associated cellulitis. In assessing the client's hand, which finding required most immediate follow-up by the nurse?

Cyanotic nailbeds

The mother of an infant born with hypospadias is concerned because she has been told that her child cannot be circumcised according to her Jewish faith tradition. Which response is best for the nurse to provide? A. I understand your conver. Would you like to talk to the pediatrician B. Circumcising the penis now may contribute to frequent urinary infections C. Your faith is important, but correcting this program is priority for your son D. During the surgery part of the foreskin is used to repair the meatus.

D

Which problem, reported to the nurse by a 70-year-old male client, requires the most immediate intervention by the nurse? A. Urinary hesitancy B. Slow urinary stream C. Frequent nocturia D. Painless hematuria

D

A child with nephrotic syndrome is receiving prednisone (Deltasone). Which choice of breakfast foods at a fast food restaurant indicates that the mother understands the dietary guidelines necessary for her child? A.French toast sticks and orange juice B.Sausage egg muffin and grape juice C.Canadian bacon slices and hot chocolate D.Toasted oat cereal and low-fat milk

D A child receiving a corticosteroid for nephrotic syndrome should follow a low-sodium, low-fat, and low-sugar diet. Based on these guidelines, the best breakfast choice is (D). (A) is high in fat and sugar. (B and C) are high in fat and sodium.

A client with schizophrenia tells the nurse, "The world is coming to an end. All the violence in the Middle East is soon going to destroy the entire world!" How should the nurse respond? A."Let's play some dominoes for a few minutes." B."I don't think the violence means the world is ending." C."The news makes you have upsetting thoughts." D."Listening to the news seems to be frightening you."

D A client's delusional statements are best addressed by identifying the feeling associated with the delusion (D). Distraction (A) may be helpful but ignores the feelings that the client is experiencing. Delusional clients often argue with statements that contradict their belief system (B). The client is unlikely to understand the relationship between the news and the thoughts experienced (C).

An older client who resides in a long-term care facility is hearing-impaired. How should the nurse modify interventions for this client? A.Turn off the client's television and speak very loudly. B.Communicate in writing whenever it is possible. C.Speak very slowly while exaggerating each word. D.Face the client and speak in a normal tone of voice.

D A hearing-impaired client frequently relies on lip reading and body language to determine what is being said, so (D) should be implemented. (A and C) may distort the sounds and facial expressions, which alters the client's ability to interpret the verbal message. Communicating in writing is another option that could be used if verbal or body language is ineffective (B).

A client with hepatic failure tells the nurse about recent use of acetaminophen (Tylenol). How should the nurse respond to this client's statement? A.Bleeding precautions should be implemented. B.Tylenol is indicated for minor aches and pains. C.Acetaminophen reduces inflammation. D.The drug is hepatotoxic and contraindicated.

D Acetaminophen is hepatotoxic and can cause further complications for a client with impaired liver function, so its use is contraindicated (D). Although bleeding (A) is a risk in clients with liver disease caused by decreased production of clotting components, this drug significantly increases this risk and is contraindicated. Although (B) is an indicated use for this drug, it remains contraindicated in patients with hepatic failure. (C) is inaccurate.

A client who is admitted with emphysema is having difficulty breathing. In which position should the nurse place the client? A.High Fowler's position without a pillow behind the head B.Semi-Fowler's position with a single pillow behind the head C.Right side-lying position with the head of the bed elevated 45 degrees D.Sitting upright and forward with both arms supported on an over the bed table

D Adequate lung expansion is dependent on deep breaths that allow the respiratory muscles to increase the longitudinal and anterior-posterior size of the thoracic cage. Sitting upright and leaning forward with the arms supported on an over the bed table (D) allows the thoracic cage to expand in all four directions and reduces dyspnea. A high Fowler's position does not allow maximum expansion of the posterior lobes of the lungs (A). A semi-Fowler's position restricts expansion of the anterior-posterior diameter of the thoracic cage (B). Positioning a client on the right side with the head of the bed elevated (C) does not facilitate lung expansion.

The nurse administers atropine sulfate ophthalmic drops preoperatively to the right eye of a client scheduled for cataract surgery. Which response by the client indicates that the drug was effective? A.The pupils become equal and reactive to light. B.The right pupil constricts within 30 minutes. C.Bilateral visual accommodation is restored. D.The right pupil dilates after drop installation.

D Atropine (Isopto Atropine) is a mydriatic drug, which causes pupil dilation and paralysis in preparation for surgery or examination (D). (A, B, and C) do not describe the therapeutic effects of atropine sulfate ophthalmic drops prior to cataract surgery.

The nurse is preparing a client for surgery scheduled in 2 hours. A UAP is helping the nurse. Which task is important for the nurse to perform, rather than the UAP? A.Remove the client's nail polish and dentures. B.Assist the client to the restroom to void. C.Obtain the client's height and weight. D.Offer the client emotional support.

D By using therapeutic techniques to offer support (D), the nurse can determine any client concerns that need to be addressed. (A, B, and C) are all actions that can be performed by the UAP under the supervision of the nurse.

A mother of a 12-year-old boy states that her son is short and she fears that he will always be shorter than his peers. She tells the nurse that her grown daughter only grew 2 inches after she was 12 years of age. To provide health teaching, which question is most important for the nurse to ask this mother? A."Is your son's short stature a social embarrassment to him or the family?" B."What types of foods do both your children eat now and what did they eat when they were infants?" C."Did any significant trauma occur with the birth of your son?" D."Did your daughter also start her menstrual period at 12 years of age?"

D Girls are expected to mature sexually and grow physically sooner than boys. Furthermore, girls only grow an average of 2 inches after menses begins (D). (A) is not appropriate at this time. The mother is worried that something is wrong with her son physically. (B) has less to do with stature than growth and development. (C) is not related to growth hormone deficiencies, which are idiopathic (without known causes).

In conducting a routine assessment, which question should the nurse ask to determine a client's risk for open-angle glaucoma? A."Have you ever been told that you have hardening of the arteries?" B."Do you frequently experience eye pain?" C."Do you have high blood pressure or kidney problems?" D."Does anyone in your family have glaucoma?"

D Glaucoma has a definite genetic link, so clients should be screened for a positive family history, especially an immediate family member (D). (A and C) are not related to glaucoma. Glaucoma rarely causes pain (B), which is why screening is so important.

The nurse is assisting a father to change the diaper of his 2-day-old infant. The father notices several bluish-black pigmented areas on the infant's buttocks and asks the nurse, "What did you do to my baby?" Which response is best for the nurse to provide? A."What makes you think we did anything to your baby?" B."Are you or any of your blood relatives of Asian descent?" C."Those are stork bites and will go away in about 2 years." D."Those are Mongolian spots and will gradually fade in 1 or 2 years."

D Mongolian spots (D) are areas of bluish-black or gray-blue pigmentation seen primarily on the dorsal area and buttocks of infants of Asian or African decent or dark-skinned babies. (A) is a defensive answer. Although Mongolian spots occur more frequently in those of Asian and African decent, (B) does not respond to the father's concern. Telangiectatic nevi, frequently referred to as stork bites (C), appear reddish-purple or red and are usually on the face or head and neck area.

Which situation demonstrates proper application of client confidentiality requirements for the Health Insurance Portability and Accountability Act (HIPAA)? A.Clients' names are not used while they are in a public waiting room. B.Nurses should not recommend any community self-help groups by specific name, such as Alcoholics Anonymous. C.Clients must pick up their filled prescriptions from a pharmacy in person with a photo identification card. D.Old medical records are kept in a locked file cabinet in the department.

D Past medical records must be "secured" and "reasonably protected" from inadvertent viewing (D). A locked room or file cabinet can serve this purpose, and when any protected health information (PHI) is discarded, it must be shredded. A person's name only (without their diagnosis or treatment) is not considered confidential or PHI (A). Nurses may suggest categories of community resources, with examples, such as Alcoholics Anonymous (B), but cannot market a specific program in which they have a financial interest. Others can pick up a client's filled prescriptions (C).

The nurse is caring for a client with respiratory distress whose arterial blood gas (ABG) results are as follows: pH, 7.33; Pco2,50 mm Hg; Po2, 70 mm Hg; HCO3, 26 mEq/L. How should the nurse interpret these results? A.Metabolic acidosis B.Respiratory alkalosis C.Metabolic alkalosis D.Respiratory acidosis

D Rationale: A pH <7.25 and Pco2 >45 mm Hg with a normal HCO3 indicates respiratory acidosis (D). The others are incorrect analyses of the ABGs (A, B, and C).

A client comes to the obstetric clinic for her first prenatal visit and complains of feeling nauseated every morning. The client tells the nurse, "I'm having second thoughts about wanting to have this baby." Which response is best for the nurse to make? A."It's normal to feel ambivalent about a pregnancy when you are not feeling well." B."I think you should discuss these feelings with your health care provider." C."How does the father of your child feel about your having this baby?" D."Tell me about these second thoughts you are having about this pregnancy."

D Rationale: Although ambivalence is normal during the first trimester, (D) is the best nursing response at this time. It is reflective and keeps the lines of communication open. (A) is not the best response because it offers false reassurance. (B) dismisses the client's feelings. The nurse should use communication skills that encourage this type of discussion, not shift responsibility to the care provider. (C) may eventually be discussed, but it is not the most important information to obtain at this time.

The nurse is caring for a client with deep vein thrombosis who is on a continuous IV heparin infusion. The activated partial prothrombin time (aPTT) is 120 seconds. Which action should the nurse take? A.Increase the rate of the heparin infusion using a nomogram. B.Decrease the heparin infusion rate and give vitamin K IM. C.Continue the heparin infusion at the current prescribed rate. D.Stop the heparin drip and prepare to administer protamine sulfate.

D Rationale: An aPTT more than 100 seconds is a critically high value; therefore, the heparin should be stopped. The antidote for heparin is protamine sulfate (D). Increasing the rate would increase the risk for hemorrhage (A). The infusion should be stopped, and vitamin K is the antidote for warfarin (Coumadin) (B). Keeping the infusion at the current rate would increase the risk for hemorrhage (C).

The nurse is caring for a client with chronic renal failure (CRF) who is receiving dialysis therapy. Which nursing intervention has the greatest priority when planning this client's care? A.Palpate for pitting edema. B.Provide meticulous skin care. C.Administer phosphate binders. D.Monitor serum potassium levels.

D Rationale: Clients with CRF are at risk for electrolyte imbalances, and imbalances in potassium can be life threatening (D). One sign of fluid retention is pitting edema (A), but it is an expected symptom of renal failure and is not as high a priority as (D). (B and C) are common nursing interventions for CRF but not as high a priority as (D).

Which monitored pattern of fetal heart rate alerts the nurse to seek immediate intervention by the health care provider? A.Accelerations in response to fetal movement B.Early decelerations in the second stage of labor C.Fetal heart rate of 130 beats/min between contractions D.Late decelerations with absent variability and tachycardia

D Rationale: Late decelerations indicate uteroplacental insufficiency and can be indicative of complications. When occurring with absent variability and tachycardia, the situation is ominous (D). 130 beats/min is an expected heart rate (C). The others are not as critical (A and B).

The nurse walks into the room and observes the client experiencing a tonic-clonic seizure. Which intervention should the nurse implement first? A.Restrain the client to protect from injury. B.Flex the neck to ensure stabilization. C.Use a tongue blade to open the airway. D.Turn client on the side to aid ventilation.

D Rationale: Maintaining airway during a seizure is priority for safety (D). (A, B, and C) are contraindicated during a seizure and may cause further injury to the client.

A client is receiving propylthiouracil (PTU) prior to thyroid surgery. Which diagnostic test results indicate that the medication is producing the desired effect? A.Increased hemoglobin and hematocrit levels B.Increased serum calcium level C.Decreased white blood cell (WBC) count D.Decreased triiodothyronine (T3) and thyroxine (T4) levels

D Rationale: Propylthiouracil (PTU) is an adjunct therapy used to control hyperthyroidism by inhibiting the production of thyroid hormones (D). It is often prescribed in preparation for thyroidectomy or radioactive iodine therapy. It is does not affect (A). (B) must be monitored after surgery in case the parathyroid glands were removed, but preoperative PTU does not increase the serum calcium level. If the client has an infection preoperatively, antibiotics will be given and (C) monitored.

An older client calls the clinic and complains of feeling very weak and dizzy. Further assessment by the nurse indicates that the client self-administered an enema of 3 L of tap water because of constipation. What is the most likely cause of the client's symptoms? A.Mucosal bleeding B.Sodium retention C.Fluid volume depletion D.Water intoxication

D Rationale: Tap water is a hypotonic fluid that can leave the intestine and enter the interstitial fluid by osmosis, ultimately causing systemic water intoxication (D). This is manifested by weakness, dizziness, pallor, diaphoresis, and respiratory distress. Excessive use of enemas can cause mucosal irritation, which might result in some bleeding (A), but the client would not experience weakness and dizziness unless she was hemorrhaging. (B and C) can occur with the use of a hypertonic rather than hypotonic solution.

Which intervention is most important when caring for a client immediately after electroconvulsive therapy (ECT)?A.Reorient the client to surroundings. B.Assess blood pressure every 15 minutes. C.Determine if muscle soreness is present. D.Maintain a patent airway.

D Rationale: The client is typically unconscious immediately following ECT, and nausea is a common side effect. The nurse should take measures to prevent aspiration and maintain a patent airway (D). Patients may be confused after ECT (A), but reorientation is not as high a priority as the airway. Although vital signs should be assessed, the airway is a higher priority (B). Muscle soreness is an expected finding after ECT (C).

The nurse enters the examination room of a client who has been told by her health care provider that she has advanced ovarian cancer. Which response by the nurse is likely to be most supportive for the client? A."I know many women who have survived ovarian cancer." B."Let's talk about the treatments of ovarian cancer." C."In my opinion I would suggest getting a second opinion." D."Tell me about what you are feeling right now."

D Rationale: The most therapeutic action for the nurse is to be an active listener and to encourage the client to explore her feelings (D). Giving false reassurance or personal suggestions are not therapeutic communication for the client (A, B, and C).

The outpatient clinic nurse is reviewing phone messages from last night. Which client should the nurse call back first? A.An 18-year-old woman who had a positive pregnancy test and wants advice on how to tell her parents B.A woman with type 1 diabetes who has just discovered she is pregnant and is worried about her fingerstick glucose C.A women at 24 weeks of gestation crying about painful genital lesions on the vulva and urinary frequency D.A women at 30 weeks of gestation who has been diagnosed with mild preeclampsia and is unable to relieve her heartburn

D Rationale: The women with epigastric pain should be called first (D). One of the cardinal signs of eclampsia, a life-threatening complication of pregnancy, is epigastric pain. (A, B, and C) are less serious and should be called after (D).

The nurse prepares to administer amoxicillin clavulanate potassium (Augmentin) to a child weighing 15 kg. The prescription is for 15 mg/kg every 12 hours by mouth. How many milliliters should the nurse administer when supplied as below? A.0.5 B.1.8 C.5 D.9

D Rationale:15 mg/kg × 15 kg = 225 mg to be administered Supply = 125 mg/5 mL (5 mL/125 mg) × 225 mg = 9 mL or (225 mg/125 mg) × 5 ml = 9 mL

A client with small cell carcinoma of the lung has also developed syndrome of inappropriate antidiuretic hormone (SIADH). Which outcome finding is the priority for this client? A.Reduced peripheral edema B.Urinary output of at least 70 mL/hr C.Decrease in urine osmolarity D.Serum sodium level of 137 mEq/L

D Syndrome of inappropriate antidiuretic hormone (SIADH) results from an abnormal production or sustained secretion of antidiuretic hormone, causing fluid retention, hyponatremia, and central nervous system (CNS) fluid shifts. The client's normalization of the serum sodium level (normal is 135 to 145 mEq/L) (D) is the most important outcome because sudden and severe hyponatremia caused by fluid overload can result in heart failure. Fluid retention of SIADH contributes to daily weight gain, which can predispose to peripheral edema (A), but the higher priority outcome is the effect on serum electrolyte levels. Although (B and C) are findings associated with resolving SIADH, they do not have the priority of (D).

A nurse is planning patient care and wants to verify the steps for a specific client procedure. Which action should the nurse take? A.Review the plan and the steps in performing the procedure with another nurse. B.Look up the specific procedure in a medical surgical nursing text on the unit. C.Discuss the client's prescribed procedure with an available health care provider. D.Consult the agency's policies and procedures manual and follow the guidelines.

D The agency's policies and procedures manual (D) should be consulted to verify the agency's approved protocol for the client's procedure, which is adapted to follow current standards of care. (A and B) may be resources, but client care should be implemented according to the agency's published policies and procedures. (C) is not practical.

Which client is best to assign to a graduate PN who is being oriented to a renal unit? A.A client who is 1 day postoperative after placement of an arteriovenous (AV) shunt B.A client who is receiving continuous ambulatory peritoneal dialysis C.A client with continuous bladder irrigation for hematuria D.A client with renal calculi whose urine needs to be strained

D The client with renal calculi (kidney stones) (D) is the most stable client for a PN who is being oriented. Straining urine and the administration of pain medication are tasks that can be safely performed with minimal risk of problems. (A, B, and C) require careful assessment from an experienced nurse because of the potential for significant complications.

The nurse is monitoring a client who is receiving bedside conscious sedation with midazolam hydrochloride (Versed). In assessing the client, the nurse determines that the client has slurred speech with diplopia. Based on this finding, what action should the nurse take? A.Open the airway with a chin lift-head tilt maneuver. B.Obtain a fingerstick glucose reading. C.Administer flumazenil (Romazicon). D.Continue to monitor the client.

D The desired level III in conscious sedation includes slurred speech, glazed eyes, and marked diplopia. Because this is the desired outcome of the medication regimen, no action is needed but continuing to monitor the client (D). The airway is open if the client is able to talk (A). There are no signs of hypoglycemia (B). No reversal is necessary for the benzodiazepine (Versed) without signs of oversedation, such as respiratory depression (C).

A client has been on a mechanical ventilator for several days. What should the nurse use to document and record this client's respirations? A.The respiratory settings on the ventilator B.Only the client's spontaneous respirations C.The ventilator-assisted respirations minus the client's independent breaths D.The ventilator setting for respiratory rate and the client-initiated respirations

D The nurse should count the client's respirations, and document both the respiratory rate set by the ventilator and the client's independent respiratory rate (D). Never rely strictly on (A). Although the client's spontaneous breaths will be shallow and machine-assisted breaths will be deep, it is important to record machine-assisted breaths as well as the client's spontaneous breaths to get an overall respiratory picture of the client (B and C).

According to Erikson, which client should the nurse identify as having difficulty completing the developmental stage of older adults? A.A 60-year-old man who tells the nurse that he is feeling fine and really does not need any help from anyone B.A 78-year-old widower who has come to the mental health clinic for counseling after the recent death of his wife C.An 81-year-old woman who states that she enjoys having her grandchildren visit but is usually glad when they go home D.A 75-year-old woman who wishes her friends were still alive so she could change some of the choices she made over the years

D The older woman who wishes she could change the choices she has made in her lifetime is expressing despair and is still searching for integrity (D). The nurse uses Erikson stages of development over the life span to assess an older client's adjustment to aging and plans teaching strategies to assist the clients attain integrity versus despair. (A, B, and C) are normal developmental tasks of older adults.

A client who is receiving multiple antihypertensive medications has a serum K level of 6.2 mEq/L. Which of the client's prescribed meds can the nurse administer? A. Valsartan B. Lisinopril C. Aldactone D. Hydrochlorothiazide

D - K wasting diuretic

The nurse expects a clinical finding of cyanosis in an infant with which condition(s)? (Select all that apply.) A.Ventricular septal defect (VSD) B.Patent ductus arteriosis (PDA) C.Coarctation of the aorta D.Tetralogy of Fallot E.Transposition of the great vessels

D,E Rationale: Both tetralogy of Fallot and transposition of the great vessels are classified as cyanotic heart disease, in which unoxygenated blood is pumped into the systemic circulation, causing cyanosis (D and E). The others are all abnormal cardiac conditions, but are classified as acyanotic and involve left-to-right shunts, increased pulmonary blood flow, or obstructive defects. (A, B, and C).

A client with a bundle branch block is on a cardiac monitor. The nurse should expect to observe: A. Sagging ST segments B. Absence of P wave configurations C. Inverted T waves following each QRS complex D. Widening of QRS complexes to 0.12 second or greater

D. Bundle branch block interferes with the conduction of impulses from the AV node to the ventricle supplied by the affected bundle. Conduction through the ventricles is delayed, as evidenced by a widened QRS complex.

The adaptations of a client with complete heart block would most likely include: A. Nausea and vertigo B. Flushing and slurred speech C. Cephalalgia and blurred vision D. Syncope and slow ventricular rate

D. In complete atrioventricular block, the ventricles take over the pacemaker function in the heart but at a much slower rate than that of the SA node. As a result there is decreased cerebral circulation, causing syncope.

A client is admitted to the hospital for medical management of acute pancreatitis. Which nursing action is most likely to reduce the pancreatic and gastric secretions of a client with pancreatitis? A. Encouraging clear liquids B. Obtaining a prescription for morphine C. Assisting the client into a semi-Fowler position D. Administering prescribed anticholinergic medication

D. Administering prescribed anticholinergic medication

A nurse is caring for a client who is receiving serum albumin. What indicates that the albumin is effective? A. Improved clotting of blood B. Formation of red blood cells C. Activation of white blood cells (WBCs) D. Effective cardiac output

D. Effective cardiac output

A client who has a long leg cast for a fractured bone is to be discharged from the emergency department. When discussing pain management, when does the nurse advise the client to take the prescribed as-needed oxycodone? A. Just as a last resort B. Before going to sleep C. As the pain becomes intense D. When the discomfort begins

D. When the discomfort begins

Drug therapy for MS

DZ modifiers: immunomodulators and immunosupresants Tx of acute relapse: high dose IV glucocorticoids and IV gamma globulin Symptom management: bladder dysfunction, bowel dysfunction, fatiqgue, depression, sexual dysfunction, neuropathic pain

476. The nurse is triaging victims of a tornado at an emergency shelter. An adult woman who has been wandering and crying comes to the nurse. What action should the nurse take?

Delegate care of the crying client to an unlicensed assistant

Which healthcare professional does the nurse know is authorized to delegate work to other healthcare members? Correct1 Registered nurse (RN) 2 Licensed practical nurse (LPN) 3 Unlicensed nursing personnel (UNP) 4 Unlicensed assistive personnel (UAP)

Delegating work is the most effective professional management strategy that an RN can implement in clinical practice to improve the safety and quality of client care. RNs can delegate work to LPNs, UNP, or UAP.

What would the nurse describe as the challenges of delegation? Select all that apply. Correct1 Limited resources 2 More staff availability Correct3 Larger geographic area Correct4 Care for vulnerable populations 5 Deciding if delegating is time-saving

Delegation can be more challenging when the resources are limited, when the geographic area is greater, and when care is given for vulnerable populations. Availability of more staff is a benefit of delegation. Decisions for delegation should not be solely based on time-saving considerations; they should also be based on the abilities of the nursing staff to complete the tasks effectively and safely.

The registered nurse (RN) is caring for a client who underwent brain surgery. The registered nurse delegated the task of reinforcing ambulation to the licensed practical nurse (LPN). Who is accountable for the client' scare? 1 Charge nurse Correct2 Registered nurse 3 Licensed practical nurse 4 Primary healthcare provider

Delegation involves sharing the responsibility of client care while the delegator retains the accountability. In this scenario, the RN is the delegator who retains the accountability by transferring tasks to the LPN. A charge nurse is accountable in the absence of the RN or if the charge nurse is delegating the task. The LPN is under dependent status and is transferred the responsibility but the accountability is retained by the delegator. The primary healthcare provider may not be accountable for the client's care because the primary healthcare provider is not the delegator.

Which statement is correct regarding delegation? Select all that apply. Correct1 It involves transfer of authority. Correct2 The delegator retains accountability for the outcome. Incorrect3 The delegatee retains accountability for the outcome. 4 It is the transfer of both responsibility and accountability. Correct5 Principles of delegation outline what nurses need to know about the task.

Delegation involves two people—delegator and delegatee—with the transfer of authority to perform the task. The delegator retains accountability for the outcome of the task delegated. The delegatee holds responsibility but not accountability for the task. Assignment involves the transfer of both responsibility and accountability of the work to the delegatee. Principles of delegation outline what nurses need to know and do in relation to completing the task.

After assigning a specific task, the registered nurse observes that the delegatee is unable to perform the task accurately. What will be the appropriate statement of the registered nurse in this situation? 1 "It's better if I do the work myself." 2 "We will do the task some other time." 3 "You can't do even this work properly." Correct4 "Just follow my steps and you can do it."

Delegation is a complex process of sharing activities among team members. If a team member is not competent to perform a given task, the registered nurse lowers expectations and helps the delegatee accomplish the task. Therefore the appropriate statement of the registered nurse in this situation is to follow his or her example to do the work, because this provides encouragement. If the registered nurse says that it is better for him or her to do the work, it increases time and affects the process of delegation. If the registered nurse says to accomplish the task some other time, it affects the quality of client care. If the registered nurse says to the delegate that he or she cannot do the work properly, it is a verbal attack, which may undermine their relationship.

What are some challenges faced in the process of delegation? Select all that apply. Correct1 Limited resources Correct2 Large geographic area 3 Time-saving considerations Correct4 Vulnerable populations receiving care 5 Provision of assistance with activities of daily living

Delegation is a complex process. Delegating a task when resources are limited is a great challenge. Delegation is also more challenging the larger the geographic area is where the task should be performed. The process of delegation also becomes more challenging when care is being delivered to vulnerable populations. Time conservation is a benefit of the delegation process even if the decision to delegate may not be based on time-saving considerations. Providing assistance with the client's activities of daily living is a benefit rather than a challenge of delegation.

Which conditions make a delegation more challenging for the registered nurses, delegatees, and clients? Select all that apply. Correct1 Limited resources 2 More staff availability 3 More client care time Correct4 Greater geographical area Correct5 Vulnerable populations receiving care

Delegation is a multifaceted decision-making process which involves a nurse directing another person to perform nursing tasks and activities. Delegation is more challenging when other resources are limited because it is difficult to care for all clients when resources are limited. Delegation is more challenging when the geographic area is greater because of more population. Delegation is more challenging when vulnerable populations are receiving care because they are economically uninsured. Delegation is better when more staff is available and when more time is allotted to care for clients.

The unlicensed nursing personnel (UNP) is delegated tasks related to client care. What is the correct order of steps the registered nurse (RN) should follow when deciding to delegate the work to the UNP? Incorrect 1. Determining the knowledge and skills of the UNP Incorrect 2. Assigning the client-specific tasks to the UNP Incorrect 3. Monitoring the assignments allotted to the UNP Incorrect 4. Assessing the client's health status Correct 5. Reporting deviations in the client's response Correct 6. Providing feedback about the UNP performance

Delegation is a process of the RN assigning work to other health care personnel who are capable. First, the RN should assess the client's health needs and the knowledge and skills of the UNP for performing the care. Assignment of tasks to the UNP is based on the client's health needs after assessing the skills of UNP. The RN then monitors the client's responses to the care provided by the UNP, which is also useful to assess the performance of UNP. Any deviated client responses or any other client-specific issues are reported in order to evaluate the client's response to the care. Finally, the RN provides feedback to the UNP to help the UNP improve care.

The registered nurse (RN) is getting ready to leave the client care unit for a lunch break. The RN asks the LPN to take care of a client during the lunch break. Which concept is emphasized in this situation? 1 Leadership Correct2 Delegation 3 Supervision 4 Assignment

Delegation is the concept of a transfer of authority between two people to perform some type of task, e.g., between an RN and licensed staff. Leadership is the action of leading a group or an organization. Supervision is defined as the active process of directing, guiding, and influencing the outcome of an individual's performance. Assignment is the transfer of both accountability and responsibility.

The registered nurse assigns a task to a licensed practical nurse (LPN) to check the blood pressure and temperature of a client. Which factor is transferred to the LPN for the performance of the task? 1 Liability 2 Authority Correct3 Responsibility 4 Accountability

Delegation is the transfer of responsibility for the performance of the task. So, the LPN is responsible until the task is completed. Liability is the person's responsibility and accountability for individual actions. Authority is the ability to perform duties in a specific role. Accountability is transferred when the work of one individual is performed by the other.

The registered nurse is teaching the student nurse about the concepts of delegation. Which response given by the student nurse indicates the need for further teaching? 1 Delegation always involves two individuals. Correct2 Delegation is the transfer of accountability while retaining responsibility. 3 Delegation is an important strategy for client safety and quality of client care. 4 Delegation has five rights that should be followed in the process of delegation.

Delegation is the transfer of the responsibility for the task, while the final accountability is always retained with the delegator. Delegation involves the delegator and the delegatee. Delegation is an important strategy for ensuring client safety and quality of client care. Delegation has five rights that are to be followed throughout the delegation process: right task, right person, right circumstance, right direction/communication, and right supervision.

What does appropriate delegation do to a healthcare organization? Select all that apply. Correct1 Reduces stress 2 Decreases trust 3 Reduces client care Incorrect4 Decrease time efficiency Correct5 Improves treatment outcomes

Delegation requires empowerment of the delegatee to accomplish the task and, therefore, sharing functions reduces stress. As functions are distributed, it improves treatment outcomes. Appropriate delegation increases trust between the delegator and the delegates, increases client care, and increases time efficiency.

A client assigned to a female practical nurse (PN) needs total morning care and sterile wound packing with a wet to dry dressing. The PN tells the nurse that she has never performed a wound packing. Which intervention should the charge nurse implement?

Demonstrate the wound care procedure to the PN while the PN assists

135. A client with hyperthyroidism is being treated with radioactive iodine (I-131). Which explanation should be included in preparing this client for this treatment?

Describe radioactive iodine as a tasteless, colorless medication administered by the healthcare provider

4. An adolescent with major depressive disorder has been taking duloxetine (Cymbalta) for the past 12 days. Which assessment finding requires immediate follow-up?

Describes life without purpose

Which assessment finding should make the nurse suspect that a 21-year-old male client is taking anabolic steroids?

Describes working hard to develop muscles.

TCAs (block NE)

Desipramine (Norpramin) Maprotiline Nortriptyline (Pamelor) Protriptyline (Vivacti

431. A young couple who has been unsuccessful in conceiving a child for over a year is seen in the family planning clinic. During an initial visit, which intervention is most important for the nurse to implement?

Determine current sexual practice

375. The nurse is preparing an intravenous (IV) fluid infusion using an IV pump. Within 30 seconds of turning on the machine, the pump's alarm beeps "occlusion". What action should the nurse implement first?

Determine if the clamp on the IV tubing is released

385. A client with persistent low back pain has received a prescription for electronic stimulator (TENS) unit. After the nurse applies the electrodes and turns on the power, the client reports feeling a tingling sensation. How should the nurse respond?

Determine if the sensation feels uncomfortable.

426. A male client was transferred yesterday from the emergency department to the telemetry unit because he had ST depression and resolved chest pain. When his EKG monitor alarms for ventricular tachycardia (VT), what action should the nurse take first?

Determine the client's responsiveness and respirations

319. A young boy who is in a chronic vegetative state and living at home is readmitted to the hospital with pneumonia and pressure ulcers. The mother insists that she is capable of caring for her son and which action should the nurse implement next?

Determine the mother's basic skill level in providing care.

66. The nurse is preparing to administer an oral antibiotic to a client with unilateral weakness, ptosis, mouth drooping and, aspiration pneumonia. What is the priority nursing assessment that should be done before administering this medication?

Determine which side of the body is weak.

A patient with MG experienced a cholinergic crisis and is currently being maintained on a ventilator, the patient received several 1 mg doses of atropine, what does the nurse closely monitor this patient for

Development of mucus plugs

487. The nurse is presenting information about fetal development to a group of parents with...when discussing cephalocaudal fetal development, which information should the nurse gives the parents?

Development progress from head to rump

581. The charge nurse of the Intensive Care Unit is making assignments for the permanent staff and one RN who was floated from a medical unit. The client with which condition is the best to assign to the float nurse?

Diabetic ketoacidosis and titrated IV insulin infusion

Prenatal diagnostic testing is recommended for a couple expecting their first child who have a family history of congenital disorders. The couple tells the nurse that they are opposed to abortion for religious reasons. Which concept should the nurse consider when responding to this couple?

Diagnostic testing may indicate a fetal problem that could be treated prior to delivery.

527. A female client reports she has not had a bowel movement for 3 days, but now is defecating frequent small amount of liquid stool. Which action should the nurse implement?

Digitally check the client for a fecal impaction

328. During a routine clinic visit, an older female adult tells the nurse that she is concerned that the flu season is coming soon, but is reluctant to obtain the vaccination. What action should the nurse take first?

Discuss the concerns expressed by the client about the vaccination.

461. A client diagnosed with bipolar disorder is going home on a week-end pass. Which suggestions should give the client's family to help them prepare for the visit?

Discuss the importance of continuing the usual at-home activities

73. A client in the emergency center demonstrates rapid speech, flight of ideas, and reports sleeping only three hours during the past 48h. Based on these finding, it is most important for the nurse to review the laboratory value for which medication?

Divalproex.

292. The nurse is preparing to administer 1.6 ml of medication IM to a 4 month old infant. Which action should the nurse include?

Divide the medication into two injection with volumes under 1ml

567. A woman just received the Rubella vaccine after a delivery of a normal new born, has two children at home, ages 13 months and 3 years. Which instruction is most important to provide to the client?

Do not get pregnant for at least 3 months

7. In assessing an adult client with a partial rebreather mask, the nurse notes that the oxygen reservoir bag does not deflate completely during inspiration and the client's respiratory rate is 14 breaths / minute. What action should the nurse implement?

Document the assessment data

Which characteristic of the nurse as a delegator is reflected in the statement, "Let me show you how this procedure is done; then you can do it yourself"? Correct1 Doing 2 Asking Incorrect3 Offering 4 Delegating

Doing occurs by demonstrating the specific task or behavior to improve client care. The statement, "Let me show you how this procedure is done; then you can do it yourself," indicates doing. Asking begins with questions related to the problem or issue regarding client care and can open lines of communication between the delegator and the delegatee. Offering involves making a suggestion to facilitate the achievement of a desirable outcome. Delegating refers to transferring responsibility for the performance of a task nurse or delegator to the delegatee while retaining the accountability for the outcome.

Treatment managements of antidepressants

Dose should be low Drugs should be continued for 4-8 wks to assess efficacy Tx should continue at least 4 - 9 months to prevent relapse ADHERENCE IS CRITICAL discontinuation done SLOWLY

A client is on mechanical ventilation. When condensation collects in the ventilator tubing, the nurse should: 1 Notify a respiratory therapist 2 Drain the fluid from the tubing 3 Decrease the amount of humidity 4 Record the amount of fluid removed from the tubing

Drain the fluid from the tubing

578. A client in her first trimester of pregnancy complains of nausea. Which complementary therapy should the nurse recommend?

Drink chamomile tea at breakfast and in the evening.

An 80-year-old client is given morphine sulphate for postoperative pain. Which concomitant medication should the nurse question that poses a potential development of urinary retention in this geriatric client?

Drugs with anticholinergic properties, such as tricyclic antidepressants (C), can exacerbate urinary retention associated with opioids in the older client. Although tricyclic antidepressants and antihistamines with opioids can exacerbate urinary retention, the concurrent use of (A and B) with opioids do not. Nonsteroidal antiinflammatory agents (D) can increase the risk for bleeding, but do not increase urinary retention with opioids (D).

366. A client with chronic alcoholism is admitted with a decreased serum magnesium level. Which snack option should the nurse recommend to this client?

Dry roasted almonds.

The nurse is caring for a patient receiving anticholinesterase drugs for MG, which symptoms does the nurse immediately report to the physician

Dyspnea and difficulty swallowing

Adverse effects of FGAs (EPS)

EPS -> movement disorders -> too little DA and too much ACh Early reactions (hrs to days) - acute dystonia (abnormal muscle tone), parkinsonism, akathisia (restlessness) Late reaction (months to yrs) - tardive dyskinesia

59. Which instruction should the nurse provide a pregnant client who is complaining of heartburn?

Eat small meal throughout the day to avoid a full stomach.

556. In preparing a diabetes education program, which goal should the nurse identify as the primary emphasis for a class on diabetes self-management?

Enable clients to become active participants in controlling the disease process

290. A 12 year old client who had an appendectomy two days ago is receiving 0.9% normal saline at 50 ml/hour. The client's urine specific gravity is 1.035. What action should the nurse implement?

Encourage popsicles and fluids of choice

517. An adult woman who is seen in the clinic with possible neuropathic pain of the right leg rates her pain as a 7 on a 10 point scale. What action should the nurse take?

Encourage the client to describe the pain.

147. A resident of a long-term care facility, who has moderate dementia, is having difficulty eating in the dining room. The client becomes frustrated when dropping utensils on the floor and then refuses to eat. What action should the nurse implement?

Encourage the client to eat finger foods.

Which strategies should be incorporated in the plan of care to provide emotional support for a patient with GBS who has ascending paralysis

Encourage the patient to verbalize feelings, teach the patient and family about the condition, explain all procedures and tasks, assess previous coping skills

Following major abdominal surgery, a male client's arterial blood gas analysis reveals Pa02 95 mmHg and PaC02 50 mmHg. He is receiving oxygen by nasal cannula at 4 liters/minute and is reluctant to move in bed or deep breathe. Based on this information, what action should the nurse implement at this time?

Encourage the use of an incentive spirometer.

134. After administering an antipyretic medication. Which intervention should the nurse implement?

Encouraging liberal fluid intake

How can registered nurses develop delegation and supervisory strategies to adapt to their changing roles? Select all that apply. Correct1 Engage a nurse mentor for guidance. 2 Practice the nursing care process in various clinical settings. Correct3 Reinforce delegation knowledge through continuing education. 4 Become familiar with the hierarchy of authority in the health care organization. Correct5 Seek high-quality clinical delegation experience early in their career.

Engaging a nurse mentor helps provide guidance and facilitate problem-solving related to delegation and supervision. Reinforcing delegation knowledge through continuing education helps nurses become familiar with the changing trends in health care delivery in context of delegation. Seeking high-quality clinical delegation experience early in a nurse's career helps nurses gain confidence in delegation skills. Practicing the nursing care process in various clinical settings helps the nurses to improve patient outcomes, but would not specifically help develop delegation and supervisory strategies. Becoming familiar with the hierarchy of authority in the health care organization may help nurses understand management-related issues. However, this knowledge would not directly help nurses develop delegation and supervisory strategies.

181. In assessing a client twelve hours following transurethral resection of the prostate (TURP), the nurse observes that the urinary drainage tubing contains a large amount of clear pale pink urine and the continuous bladder irrigation is infusing slowly. What action should the nurse implement?

Ensure that no dependent loops are present in the tubing.

531. The nurse plans to use an electronic digital scale to weight a client who is able to stand. Which intervention should the nurse implement to ensure that measurement of the client's weight is accurate?

Ensure that the scale is calibrated before a weight is obtained

205. A vacuum-assistive closure (VAC) device is being use to provide wound care for a client who has stage III pressure ulcer on a below-the- knee (BKA) residual limb. Which intervention should the nurse implement to ensure maximum effectiveness of the device?

Ensure the transparent dressing has no tears that might create vacuum leaks

After assigning a task, the delegator makes sure that the instructions are clear to provide feedback related to the task. Which delegation right is referred in this situation? 1 Task 2 Person 3 Direction Correct4 Supervision

Ensuring that the delegatee is clear to provide feedback related to the task refers to the right supervision. Knowing whether the task is appropriate to delegatee based on institutional policies and procedures refers to the right task. Knowing whether the delegatee has the knowledge and experience to perform the specific task safely refers to the right person. Knowing whether the delegatee understands the assignment and directions of the task refers to the delegation right direction.

Before assigning a task, the registered nurse makes sure that the prospective delegatee is willing to complete the task. Which delegation right does this situation reference? Correct1 Person 2 Supervision 3 Circumstance Incorrect4 Communication

Ensuring that the prospective delegatee is willing to complete the task refers to the delegation right person. Knowing whether the delegator is able to monitor and evaluate the client appropriately refers to the delegation right supervision. Ensuring whether the equipment and resources are available to complete the delegation process refers to circumstance. Ensuring whether the delegator and delegatee understand a common work-related language refers to the delegation right communication.

144. A client admitted to the psychiatric unit diagnosed with major depression wants to sleep during the day, refuses to take a bath, and refuses to eat. Which nursing intervention should the nurse implement first?

Establish a structured routine for the client to follow.

298. In monitoring tissue perfusion in a client following an above the knee amputation (aka), which action should the nurse include in the plan of care?

Evaluate closet proximal pulse.

352. A client who is admitted to the intensive care unit with syndrome of inappropriate antidiuretic hormone (SIADH) has developed osmotic demyelination. Which intervention should the nurse implement first?

Evaluate swallow

512. A young adult male was admitted 36 hours ago for a head injury that occurred as the result of a motorcycle accident. In the last 4 hours, his urine output has increased to over 200 ml/H. Before reporting the finding to the healthcare provider, which intervention should the nurse implement?

Evaluate the urine osmolality and the serum osmolality values.

335. An adult male was diagnosed with stage IV lung cancer three weeks ago. His wife approaches the nurse and asks how she will know that her husband's death is imminent because their two adult children want to be there when he dies. What is the best response by the nurse?

Explain that the client will start to lose consciousness and his body system will slow down

Which care settings are more suitable for unlicensed nursing personnel (UNP)? Select all that apply. 1 Acute care 2 Surgical care Correct3 Extended care Correct4 Long-term care 5 Emergency care

Extended care and long-term care settings are more suitable for unlicensed nursing personnel (UNP). Acute care, surgical care, and emergency care settings require highly qualified and licensed nursing professionals. Acute care, surgical care, and emergency care are not suitable for UNPs because the clients are less stable compared to those in extended care and long-term care. Since acute care, surgical care, and emergency care settings require highly qualified and licensed nursing professionals, the UNP's role is very limited.

Drug therapy for Schizophrenia

FGAs and SGAs are equally effective (except clozapine is the most effective of all) FGAs = increased risk of EPS SGAs = greater risk of metabolic effects FGAs are cheaper Routes: oral (preferred) or IM (for severe, acute schizo and long term therapy) 12 months maintenance therapy; 102 days symptoms resolve (full response takes several wks to months) TAPER to discontinue

177. Diagnostic studies indicate that the elderly client has decreased bone density. In providing client teaching, which area of instruction is most important for the nurse to include?

Fall prevention measures.

568. Following a motor vehicle collision (MCV), a male adult in severe pain is brought to the emergency department via ambulance. His injured left leg is edematous, ecchymotic around the impact of injury on the thigh, and shorter than his right leg. Based on these findings, the client is at greatest risk for which complication?

Fat embolism

A registered nurse delegated a task to the unlicensed nursing personnel (UNP) and is supervising the UNP. Which statements made by the nurse after the UNP completes the task can yield a positive outcome from the UNP? Select all that apply. Correct1 "Nice job." 2 "What is wrong with you?" Correct3 "You performed that task safely and professionally." 4 "Did the client respond positively to the nursing care?" Correct5 "The task was well done, but there is room for improvement."

Feedback, when given clearly and honestly, will yield a positive outcome from the UNP. When the nurse says, "You performed that task safely and professionally," or "The task was well done, but there is room for improvement," it shows that the UNP's work is recognized. Statements such as, "Nice job," are vague and ineffective. Statements such as, "What is wrong with you?" will be perceived as a verbal attack and will not have any positive effect. Questions should be open-ended, in order to encourage the UNP to share experiences with the RN. "Did the client respond positively to the nursing care?" is a closed-ended question that cannot be described further.

MAO B Inhibitors

First line (modest result) Reduces "wear off" effect of Ldopa Increases DA by inhibiting MAO-B enzymes Selegiline Rasagiline

DA Agonists

First line for PD Pramipexole (Mirapex) Ropinirole (Requip) Bromocriptine (Parlodel)

25. The pathophysiological mechanism are responsible for ascites related to liver failure? (Select all that apply)

Fluid shifts from intravascular to interstitial area due to decreased serum protein Increased hydrostatic pressure in portal circulation increases fluid shifts into abdomen Increased circulating aldosterone levels that increase sodium and water retention

364. The nurse discovers that an elderly client with no history of cardiac or renal disease has an elevated serum magnesium level. To further investigate the cause of this electrolyte imbalance, what information is most important for the nurse to obtain from the client's medical history?

Frequency of laxative use for chronic constipation

211. A neonate with a congenital heart defect (CHD) is demonstrating symptoms of heart failure (HF). Which interventions should the nurse include in the infant's plan of care?

Give O2 at 6 L/nasal cannula for 3 repeated oximetry screens below 90% Evaluate heart rate for effectiveness of cardio tonic medications Use high energy formula 30 calories/ounce at Q3 hours feeding via soft nipples Ensure Interrupted and frequent rest periods between procedures.

Which action should the nurse implement when administering a prescription drug that should be given on an empty stomach?

Give one hour before or two hours after a meal.

A patient has been newly diagnosed with GBS, the nurse is teaching the patient and family about the condition, which statement by the family indicates a need for additional teaching

He will never be able to walk again

The nurse suspects that a patient is experiencing a release of norepinephrine from the adrenal medulla. Which assessment finding did the nurse use to make this clinical decision?

Heart rate 120 beats per minute

The behavior of four nurses in different situations is given below. Which nurse exhibits a behavior that can be characterized as delegation according to Hersey's model? 1 Nurse A Correct2 Nurse B 3 Nurse C 4 Nurse D

Hersey's model describes "delegation" as the leader's behavior of observing or monitoring if the delegatee has the ability, willingness, and expertise to accomplish the work and there is an established relationship, as with nurse B. Nurse A exhibits guiding or directing, described as "telling," in which the delegator simply tells the individual what is the task to be done and how to perform the task. This happens if the relationship is limited. "Selling" is exhibited by nurse C and is the process of explaining and persuading, which happens if a situation involves a new task and the relationship is ongoing. "Participating" is exhibited by nurse D and is the ability of encouraging the delegatee to perform the task and taking an active part in problem solving, which may occur during the execution of a given task.

518. A client has both primary IV infusion and a secondary infusion of medication. An infusion pump is not available. The nurse needs to determine the current rate of infusion of the primary IV. Where should the nurse observe to determine the rate of infusion?

Hot Spot

A client who is taking clonidine (Catapres, Duraclon) reports drowsiness. Which additional assessment should the nurse make?

How long has the client been taking the medication? Drowsiness can occur in the early weeks of treatment with clonidine and with continued use becomes less intense, so the length of time the client has been on the medication (A) provides information to direct additional instruction. (B, C, and D) are not relevant.

202. A group of nurse-managers is asked to engage in a needs assessment for a piece of equipment that will be expensed to the organization's budget. Which question is most important to consider when analyzing the cost-benefit for this piece of equipment?

How many departments can use this equipment?

Which finding should the nurse identify as an early clinical manifestation of neonatal encephalopathy related to hyperbilirubinemia?

Hyperbilirubinemia causes severe brain damage, encephalopathy (kernicterus), that results from the deposition of unconjugated bilirubin in brain cells. Prodromal clinical manifestations of central nervous system involvement include decreased activity, a loss of interest in feeding, and lethargy or irritability (C).

490. A male client who was hit by a car while dodging through traffic is admitted to the emergency department with intracranial pressure (ICP). A computerized tomography (CT) scan reveals an intracranial bleed. After evacuation of hematoma, postoperative prescription include: intubation with controlled mechanical ventilation to PaCO2...what is the pathophysiological basis for this ventilator settings?

Hypocapnea reduces ICP

572. A male client arrives at the clinic with a severe sunburn and explains that he did not use sun screen because it was an overcast day. Large blisters are noted over his back and chest and his shirt is soaked with serosanguinous fluid. Which assessment finding warrants immediate intervention by the nurse?

Hypotension.

Which statement by a client with multiple sclerosis indicates to the nurse that the client needs further teaching?

I will take a hot bath to help relax my muscles

A patient has ST segment changes that support an acute inferior wall myocardial infarction. Which lead would be best for monitoring the patient?

II

Which interventions are appropriate for pain management in an older adult with GBS

IV opiates, gabapentin, massage, music therapy

164. When implementing a disaster intervention plan, which intervention should the nurse implement first?

Identify a command center where activities are coordinated

179. An older male client with history of diabetes mellitus, chronic gout, and osteoarthritis comes to the clinic with a bag of medication bottles. Which intervention should the nurse implement first?

Identify pills in the bag.

During a client assessment, the client says, "I can't walk very well." Which action should the nurse implement first?

Identify the problem.

327. The nurse walks into a client's room and notices bright red blood on the sheets and on the floor by the IV pole. Which action should the nurse take first?

Identify the source and amount of bleeding.

A patient care associate (PCA) is delegated a task that can be completed in 2 hours. The PCA has limited knowledge and willingness regarding that particular task. Which leadership style should be implemented by the delegator in this situation? 1 Selling Correct2 Telling Incorrect3 Monitoring 4 Participating

If the ability and willingness of the delegatee is low and the work assigned to the delegatee can be completed in 2 hours, it means the nature of relationship between delegator and delegatee is limited. In such situation, the leadership style of the delegator should be telling, because it provides a fair amount of guidance and also limits the time spent on the interactions. The selling style of leadership should be used when the relationship is ongoing; that is, individuals who usually work together continue to work together. The monitoring style should be used when the delegatee has the ability and willingness, and has an established relationship with the delegator. The participating style can be implemented when the delegatee is willing to perform the task.

A registered nurse (RN) delegates the task of foot care for a client to an unlicensed nursing personnel (UNP). The UNP is skillful and willing to perform the given task, but was recently hired and is unfamiliar with the client's condition. What should the RN do in this situation? 1 Provide guidance to the UNP. 2 Observe and motivate the UNP. Correct3 Establish mutual expectations and conditions. Incorrect4 Explain what to do and how to perform the task.

If the delegatee is new to the workplace, but has the ability and willingness to perform a task, the RN should establish mutual expectations and conditions of performance to establish a good relationship. If the delegatee has limited knowledge and ability to perform a task, the delegator is expected to guide the UNP. The RN is expected to observe and monitor the task performed by the delegate to ensure the delegatee has the ability and willingness to establish a relationship and accomplish the work. The RN can also explain the task and how to execute it if the situation involves a new task and relationship is ongoing.

A client underwent extraction of a tooth due to an underlying tumor one day ago. Which healthcare professional is appropriately involved in caring for the postoperative oral hygiene needs of this client? Correct1 Registered nurse (RN) 2 Licensed practical nurse (LPN) 3 Licensed vocational nurse (LVN) Incorrect4 Unlicensed nursing practitioner (UNP)

If there is any anticipated risk in client care, the task should not be delegated but should be carried out by the RN. Because there is a risk of infection and oral bleeding, the RN should not delegate the task of postoperative oral hygiene to the LPN, LVN, or UNP.

570. The nurse prepares to insert an oral airway by first measuring for the correct sized airway. Which picture shows the correct approach to airway size measurement?

Image

304. An adult client is exhibit the maniac stage of bipolar disorder is admitted to the psychiatric unit. The client has lost 10 pounds in the last two weeks and has no bathed in a week "I'm trying to start a new business and "I'm too busy to eat". The client is oriented to time, place, person but not situation. Which nursing problem has the greatest priority?

Imbalance nutrition

Which nursing intervention is an example of a competent performance criterion for an occupational and environmental health nurse?

Implements health programs for construction workers.

In a long-term care facility, the care tasks for a client who is suffering with liver disease are being delegated. Which statement made by the delegator indicates the responsibility for the tasks is with the registered nurse? Select all that apply. 1 "You will be responsible for the whole nursing unit." 2 "You will provide the treatment that is prescribed." Correct3 "You will assess alleviation of the client's symptoms." Correct4 "You will be monitoring the client care on an hourly basis." Correct5 "You will admit the client to the intensive care unit (ICU) if her condition deteriorates."

In a long-term care facility, the registered nurse will be responsible for supervising the licensed nursing professionals who will be the performing the delegated tasks. The registered nurse takes the responsibility of assessing alleviation of symptoms and monitoring the client on an hourly basis. Admission of the client to the ICU is the responsibility of the registered nurse. The licensed practical nurse (LPN) or the licensed vocational nurse (LVN) is responsible for taking the responsibility for the whole nursing unit. The LPN or LVN will be delegated the task of providing the treatments that are prescribed by the primary healthcare provider.

The registered nurse (RN) is caring for a client who has severe abdominal pain. The RN plans to work with the assistance of an unlicensed nursing personnel (UNP). The RN starts the client care. What should the RN consider during the process of active delegation? Select all that apply. Correct1 Assessing the level of the client's abdominal pain Correct2 Directing the UNP to assist the client while toileting 3 Advising the client to take pain medication when needed Correct4 Ensuring that the UNP is accountable for successful completion of the task 5 Explaining to the client about the reason and cause of abdominal pain

In active delegation the RN assesses the client's situation to ensure the client is stable enough to be handed over to the UNP. The RN can then delegate specific basic tasks to the UNP such as oral care and toileting. The RN then holds the UNP accountable for successful completion of the task. It is within the scope of practice of the RN to advise the client to take pain medication in accordance with the primary health care provider's prescription. Likewise, the RN can explain the reason and cause of the condition diagnosed by the primary health care provider. These tasks are considered passive delegation.

The registered nurse is caring for a client admitted with sudden paralysis in the legs and an inability to walk. Which interventions made by the registered nurse (RN) indicates correct active delegation? Select all that apply. 1 The RN assessing the client's diagnostic and laboratory findings 2 The RN administering an intravenous (IV) calcium gluconate injection Correct3 Instructing the licensed practical nurse (LPN) to report client's vital signs Correct4 Instructing the licensed practical nurse (LPN) to administer vitamin B12 injection 5 Instructing the unlicensed nursing personnel (UNP) to administer oral vitamin D3

In active delegation, the RN assesses the situation, determines what is appropriate for client care, directs assistive personnel to perform certain tasks, and holds the individual accountable. Instructing the LPN to report the client's vital signs is an active delegation that includes directing the assistive personnel to perform the task. Instructing the unlicensed nursing personnel to administer oral vitamin D3 is beyond their scope of practice. The RN assessing the client's diagnostic and laboratory findings does not involve delegation. The RN administering an intravenous calcium gluconate injection does not involve delegation. Instructing the LPN to administer a vitamin B12 injection is within the scope of practice for the LPN.

The registered nurse is teaching a newly hired nurse about active delegation. Which statement made by the newly hired nurse indicates the need for further teaching? 1 "I will evaluate the client's pain status." 2 "I will assess the client's laboratory findings." 3 "I will instruct the unlicensed assistive personnel (UAP) to wash the client." Correct4 "I will instruct the licensed vocational nurse (LVN) to administer intravenous (IV) medications."

In active delegation, the registered nurse (RN) assesses the client's situation, determines what is appropriate for client care, directs assistive personnel to perform certain tasks, and holds the individuals accountable. Instructing the LVN to administer intravenous (IV) medications is beyond the practice scope for an LVN. Evaluating the client's pain status is a part of active delegation. Assessing the client's laboratory findings is active delegation. Instructing the UAP to wash the client is an active delegation as the RN is directing a task that is to be performed by the UAP for the client.

The nurse manager is assisting a nurse with improving organizational skills and time management. Which nursing activity is the priority in pre-planning a schedule for selected nursing activities in the daily assignment?

In developing organizational skills, medication administration is based on a prescribed schedule that is time-sensitive in the delivery of nursing care and should be the priority in scheduling nursing activities in a daily assignment. Although suctioning a client's tracheostomy takes precedence in providing care, the client's PRN need is less amenable to a preselected schedule. (B and C) can be scheduled around time-sensitive delivery of care.

A client with postural hypotension requires nursing care. Which task can be safely delegated by the registered nurse to unlicensed nursing personnel (UNP)? Select all that apply. Incorrect1 Mobilizing the client 2 Assessing the pulse rate 3 Assessing the blood pressure Correct4 Managing foot care of the client Correct5 Maintaining oral hygiene of the client

In postural hypotension, any sudden change in posture will lower the blood pressure. Therefore, the client should be carefully evaluated before delegation. Managing foot care and maintaining oral hygiene can be done by the UNP because there is no foreseeable risk associated with the condition. Mobilizing the client and assessing vital signs such as pulse rate and blood pressure should be carefully monitored and performed by the registered nurse.

Which nursing model includes a registered nurse (RN) paired with technical assistance? 1 Team nursing model Correct2 Co-primary nursing model 3 Patient-focused care model 4 Functional model of nursing

In the co-primary nursing model or practice partnership model, the registered nurse (RN) is paired with technical assistance. The team nursing model is a modification of the functional nursing model. The focused care model is the care delivered in patient-focused care. The functional model of nursing is a method of providing care by each licensed and unlicensed staff member who performs specific tasks for a large group of clients.

Monoamine Oxidase A

Inactivates NE and S-HT Inhibitors: antidepressants: PANAMA PAmate NArdil MArplan

318. Assessment by the home health nurse of an older client who lives alone indicates that client has chronic constipations. Daily medications include furosemide for hypertension and heart failure and laxatives. To manage the client's constipation, which suggestions should the nurse provide? (Select all that apply)

Include oatmeal with stewed pruned for breakfast as often as possible. Increase fluid intake by keeping water glass next to recliner. Recommend seeking help with regular shopping and meal preparation.

206. The nurse is developing the plan of care for a client with pneumonia and includes the nursing diagnosis of "Ineffective airway clearance related to thick pulmonary secretions." Which intervention is most important for the nurse to include in the client's plan of care?

Increase fluid intake to 3,000 ml/daily

A nurse is educating a client who is taking clozapine (Clozaril) for paranoid schizophrenia. What should the nurse emphasize about the side effects of clozapine? Risk for falls Inability to sit still Increase in temperature Dizziness upon standing

Increase in temperature

472. The nurse is caring for a client with hypovolemic shock who is receiving two units of packed red blood cells (RBCs) through a large bore peripheral IV. What action promotes maintenance of the client's cardiopulmonary stability during the blood transfusion?

Increase the oxygen flow via nasal cannula if dyspnea is present.

What does the nurse understand that clients with myasthenia gravis, Guillain-Barré syndrome and amyotrophic lateral sclerosis share in common?

Increased risk for respiratory complications

In planning the care of a 3-year-old child with diabetes insipidus, it is most important for the nurse to caution the parents to be alert for which condition?

Increased thirst. (A) is a primary factor in monitoring effectiveness of treatment for diabetes insipidus. A child with diabetes insipidus does not want to eat, and only wants to drink; in fact he or she may even drink water from toilets and vases. The anterior fontanel usually closes at about 18 months of age; therefore, (B) is not an appropriate measure of dehydration for a 3-year-old. The skin of a child with diabetes insipidus is usually warm and dry, not (C). (D) is not characteristic of diabetes insipidus, but is characteristic of hypothyroidism, Cushing syndrome, or nephrotic syndrome.

The registered nurse (RN) has delegated a task to an unlicensed nursing personnel (UNP). After performing the task, the UNP reports to the RN for appraisal. Which statement by the UNP is related to individual accountability? Select all that apply. Correct1 "I take full responsibility for the action performed." Correct2 "I have ensured that the action has achieved the desired outcome." 3 "I have ensured that there is a ventilator placed in every intensive care unit." 4 "I have established systems for assessing and monitoring the tasks assigned." Incorrect5 "I have evaluated whether the work environment is conducive to work or not."

Individual accountability is a component of delegation. It refers to the individual's ability to take responsibility for the actions performed and outcomes related to the task, which are obtained after the action. Ensuring that there is a ventilator placed in the intensive care unit, establishing systems for assessing and monitoring the competencies, and evaluation of the work environment are all related to organizational accountability, not individual accountability.

The nurse is planning a teaching program about prenatal care for a diverse ethnic group of clients. Which factor is most influential for the acceptance of the healthcare practices?

Individual beliefs.

387. The psychiatric nurse is talking to a newly admitted client when a male client diagnosed with antisocial behavior intrudes on the conversation and tells the nurse, "I have to talk to you right now! It is very important!" how should the nurse respond to this client?

Inform him that the nurse is busy admitting a new client and will talk to him later.

10. At 0600 while admitting a woman for a schedule repeat cesarean section (C-Section), the client tells the nurse that she drank a cup a coffee at 0400 because she wanted to avoid getting a headache. Which action should the nurse take first?

Inform the anesthesia care provider

The registered nurse (RN) delegates the collection of respiratory rate data to a licensed practical nurse (LPN) for a client who is experiencing severe dehydration and whose condition is unstable. The LPN reports the data to the RN. The RN rechecks the data and finds that the report no longer reflects the patient's current condition. Which characteristic of communication has interfered with the delegation process? Correct1 Information decay 2 Information salience 3 Confidence in abilities 4 Synergy between team members

Information decay can occur in a rapidly changing situation when reported information is no longer relevant to a patient's condition. Information salience describes the different ways individuals from different backgrounds might assess the quality, meaning, and clarity of certain information. Trust is developed when there is confidence in the abilities and capabilities of the team members. Healthy relationships among members of the health care team promote synergy between the team members.

The registered nurse finds information decay during the process of delegation. What possible causes may have contributed to this? Select all that apply. Correct1 Frequent changes in the heart rate of the client Correct2 Rapid change in the blood pressure of the client Correct3 Frequent changes in the client's perception of pain Incorrect4 Diverse cultural background of the delegator and delegatee Incorrect5 Different educational background of the delegator and delegatee

Information decay is a characteristic of communication that occurs when the client's health status changes rapidly and specific information loses its value or becomes irrelevant to the client's condition. Rapid change in the blood pressure, frequent changes in the heart rate, and frequent changes in the client's perception to pain can all cause rapid changes in information and lead to information decay. Diverse cultural backgrounds of the delegator and delegatee refer to another characteristic of communication, "information salience." Different educational backgrounds of the delegator and delegatee refer to another characteristic of communication, "information salience."

The registered nurse (RN) delegates obtaining and recording a client's pulse every 30 minutes. During the last hour, the licensed practical nurse (LPN) fails to report the client's elevated heart rate to the RN. Which factor best explains the situation? 1 Limited delegation 2 Information salience Correct3 Decayed information 4 Ineffective supervision

Information decay is the characteristic feature of communication that occurs when the client's health status changes rapidly; this might include a change in the client's vital signs such as the heartbeat. Nursing when performed with limited delegation leads to misusing valuable resources. Information salience is a characteristic feature of communication in which the information provided by the delegator is monitored and evaluated. Supervision is mainly provided to the new delegatees.

The direct care nurse is delegated the task of reviewing the informed consent form after being completed by the client. Who should the direct care nurse consult regarding queries related to client rights? Incorrect1 Charge nurse Correct2 Nurse manager 3 Licensed practical nurse 4 Primary healthcare provider

Informed consent is the authorization by the client or client's representative to perform some therapeutic intervention. Informed consent is an important concept for nurse managers, and the nurse manager is the person who can clarify queries regarding informed consent. The charge nurse is the registered nurse who has the responsibility of coordinating and assigning client care and supervises the delegatees. A licensed practical nurse is a licensed nursing professional whose scope of practice is limited. It is not the responsibility of the primary healthcare provider to explain the concepts of informed consent of the client to the direct care nurses.

Which action by a new registered nurse (RN) who is orienting to the progressive care unit indicates a good understanding of the treatment of cardiac dysrhythmias?

Injects IV adenosine (Adenocard) over 2 seconds to a patient with supraventricular tachycardia

301. If the nurse is initiating IV fluid replacement for a child who has dry, sticky mucous membranes, flushed skin, and fever of 103.6 F. Laboratory finding indicate that the child has a sodium concentration of 156 mEq/L. What physiologic mechanism contributes to this finding?

Insensible loss of body fluids contributes to the hemoconcentration of serum solutes

3. The nurse observes an unlicensed assistive personnel (UAP) positioning a newly admitted client who has a seizure disorder. The client is supine and the UAP is placing soft pillows along the side rails. What action should the nurse implement?

Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows.

542. During a left femoral artery aortogram, the healthcare provider inserts an arterial sheath and initiate...through the sheath to dissolve an occluded artery. Which interventions should the nurse implement?

Instruct the client to keep the left leg straight Observe the insertion site for a hematoma Circle first noted drainage on the dressing

A patient with MG is experiencing impaired communication related to weakness of the facial muscles, which interventions are best in assisting the patient to communicate with the family and staff

Instruct the patient to speak slowly, ask yes or no questions, have the patient use a picture, letter or word board.

576. During the intraoperative phase of care, the circulating nurse observes that the client is not adequately client's privacy. What is the best initial nursing action for the nurse to implement?

Instruct the scrub nurse to re-drape the client

337. A child newly diagnosed with sickle cell anemia (SCA) is being discharged from the hospital. Which information is most important for the nurse to provide the parents prior to discharge?

Instructions about how much fluid the child should drink daily

545. An infant born to a heroin-addicted mother is admitted to the neonatal care unit. What behaviors can...to exhibit?

Irritability and a high-pitched cry

A client who is one week postoperative after an aortic valve replacement suddenly develops severe pain in the left leg. On assessment, the nurse determines that the client's leg is pale and cool, and no pulses are palpable in the left leg. After notifying the healthcare provider, which action should the nurse take?

Keep the client in bed in the supine position.

The registered nurse is caring for a client suffering from skin infections. The nurse delegates the client care tasks to the health care team. Which task delegated is correct as per guidelines? 1 Daily changing of wet dressings by the unlicensed assistive personnel (UAP) Correct2 Topical administration of medication by the licensed practical nurse (LPN) 3 Administering intravenous antibiotics by the licensed practical nurse (LPN) 4 Teaching the client to minimize sun exposure by the unlicensed assistive personnel (UAP)

LPN scope of practice is limited to administering oral, topical, and parenteral medications except intravenous. The LPN can be delegated the task of administering topical medication to the client. The scope of practice for an unlicensed assistive personnel involves maintaining the client's hygiene and daily changing of wet dressings is delegated to a certified technician. Administering intravenous antibiotics to a client with infection is an inappropriate task to be delegated to an LPN. Teaching the client to minimize sun exposure cannot be delegated to the UAP. UAP can only reinforce the teaching provided by the registered nurse.

419. A client with Alzheimer's disease falls in the bathroom. The nurse notifies the charge nurse and completes a fall follow-up assessment. What assessment finding warrants immediate intervention by the nurse?

Left forearm hematoma

Which task can be delegated to the licensed vocational nurse (LVN)? Select all that apply. 1 Analyzing vital signs 2 Maintaining oral hygiene 3 Administering intravenous drugs Correct4 Administering oral hypoglycemic agents Correct5 Administering intramuscular medications

Licensed vocational nurses and licensed practical nurses are authorized to administer drugs through oral and intramuscular routes. Analyzing vital signs should be performed by the registered nurse. Hygiene maintenance can be delegated to unlicensed nursing practitioners (UNP). Administering intravenous drugs should be done by the registered nurse.

500. The nurse is assessing a middle-aged adult who is diagnosed with osteoarthritis. Which factor in this client's history is a contributor to the osteoarthritis?

Long distance runner since high school.

Drugs for sexual dysfunction in MS

Lubricants (vaginal dryness) PDE-5 inhibitors (Sildenafil (Viagra), vardenafil (Levitra) for erectile dysfunction

78. A client who had a small bowel resection acquired methicillin resistant staphylococcus aureus (MRSA) while hospitalized. He treated and released, but is readmitted today because of diarrhea and dehydration. It is most important for the nurse to implement which intervention.

Maintain contact transmission precaution

444. A client who had an emergency appendectomy is being mechanically ventilated, and soft wrist restrain are in place to prevent self extubation. Which outcome is most important for the nurse to include in the client's plan of care?

Maintain effective breathing patterns

610. A 16-year-old male is admitted to the pediatric intensive care unit after being involved in a house fire. He has full thickness burns to his lower torso and extremities. Before a dressing change to his legs, which intervention is most important for the nurse to implement?

Maintain strict aseptic technique.

A client on a telemetry unit develops paroxysmal atrial fibrillation. When planning care for this client, the nurse considers that it: 1 Rarely occurs. 2 Frequently is transient. 3 Requires cardioversion. 4 May be life threatening.

May be life threatening.

345. A client with type 2 diabetes mellitus is admitted for antibiotic treatment for a leg ulcer. To monitor the client for the onset of hyperosmolar hyperglycemic nonketotic syndrome (HHNS), what actions should the nurse take? (Select all that apply)

Measure blood glucose Monitor vital signs Assessed level of consciousness

68. The nurse is caring for a client who had gastric bypass surgery yesterday. Which intervention is most important for the nurse to implement during the first 24 postoperative hours?

Measure hourly urinary output.

121. Which intervention should the nurse include in the plan of care for a child with tetanus?

Minimize the amount of stimuli in the room

The legal authority has delegated the tasks according to the model of analysis type of care. Which statements are true regarding the model analysis? Select all that apply. Correct1 Model analysis improves client satisfaction. Correct2 Model analysis is a cost-effective idea for client care. 3 Quality control is better in the model analysis type of care. Correct4 Model analysis promotes organizational decision-making at lower levels. 5 Model analysis promotes adequate communication among the staff members.

Model analysis is a type of care that benefits clients in terms of satisfaction of care being provided. In model analysis, the team nursing method is followed. It is a cost-effective system because it works with an expected ratio of unlicensed to licensed personnel. Organizational decision making occurs at lower levels in model analysis. Control of quality is lower in model analysis. There may be inadequate communication among staff members due to the higher potential for fragmentation of care.

564. The nurse is assessing a first day postpartum client. Which finding is most indicative of a postpartum infection?

Moderate amount of foul-smelling lochia.

A client is admitted to the hospital for alcohol dependency. What is the priority nursing intervention during the first 48 hours following admission?

Monitor for increased blood pressure and pulse.

612. A client with acute pancreatitis is complaining of pain and nausea. Which interventions should the nurse implement (Select all that apply)

Monitor heart, lung, and kidney function. Notify healthcare provider of serum amylase and lipase levels. Review client's abdominal ultrasound findings.

605. After receiving lactulose, a client with hepatic encephalopathy has several loose stools. What action should the nurse implement?

Monitor mental status.

After an anterior fossa craniotomy, a client is placed on controlled mechanical ventilation. To ensure adequate cerebral blood flow the nurse should: 1 Clear the ear of draining fluid 2 Discontinue anticonvulsant therapy 3 Elevate the head of the bed 30 degrees 4 Monitor serum carbon dioxide levels routinely

Monitor serum carbon dioxide levels routinely

562. A male client is returned to the surgical unit following a left nephrectomy and is medicated with morphine. His dressing has a small amount of bloody drainage, and a Jackson-Pratt bulb surgical drainage device is in place. Which interventions is most important for the nurse to include in this clients plan of care?

Monitor urine output hourly.

Which action in the delegation process represents accountability? 1 Providing open and honest feedback to the delegatee 2 Assisting other registered nurses with delegation decisions Correct3 Monitoring the client care given and determining outcomes 4 Assessing the ability of the delegatee and educating him or her about the task

Monitoring client care and determining outcomes represents accountability of the task in case of conflicts. Providing open and honest feedback to the delegatee improves work performance and client care outcomes. The nurse can assist other registered nurses with delegation decisions when there are safety issues, an urgent need to intervene, or potential negative client outcomes. Assessing the ability of the delegatee and educating him or her about the task indicates responsibility.

435. An older female who ambulate with a quad-cane prefer to use a wheel chair because she has a halting and unsteady gait at times. Which interventions should the nurse implement? (Select all that apply)

Move personal items within client's reach Lower bed to the lower possible position Give directions to call for assistance Assist client to the bathroom in 2 hours.

481. A client with superficial burns to the face, neck, and hands resulting from a house fire...which assessment finding indicates to the nurse that the client should be monitored for carbon monoxide...?

Mucous membranes cherry red color

196. An older client is admitted to the intensive care unit with severe abdominal pain, abdominal distention, and absent bowel sound. The client has a history of smoking 2 packs of cigarettes daily for 50 years and is currently restless and confused. Vital signs are: temperature 96`F, heart rate 122 beats/minute, respiratory rate 36 breaths/minute, mean arterial pressure(MAP) 64 mmHg and central venous pressure (CVP) 7 mmHg. Serum laboratory findings include: hemoglobin 6.5 grams/dl, platelets 6o, 000, and white blood cell count (WBC) 3,000/mm3. Based on these findings this client is at greatest risk for which pathophysiological condition?

Multiple organ dysfunction syndrome (MODS)

592. A client who developed syndrome of inappropriate antidiuretic hormone (SIADH) associated with small carcinoma of the lung is preparing for discharge. When teaching the client about self-management with demeclocycline (Declomycin), the nurse should instruct the client to report which condition to the health care provider?

Muscle cramping

The nurse explains to the family of a client suspected of having myasthenia gravis that edrophonium (Enlon) is used to establish the diagnosis. An increase in which factor will confirm the diagnosis? Symptoms Consciousness Blood pressure Muscle strength

Muscle strength

Adverse affects of DA agonists

Nausea, postural hypoTN (dizziness), hallucinations, daytime sleepiness, "sleep attack", fetal injury, impulse control disorders

87. One day following an open reduction and internal fixation of a compound fracture of the leg, a male client complains of "a tingly sensation" in his left foot. The nurse determines the client's left pedal pulses are diminished. Based on these finding, what is the client's greatest risk?

Neurovascular and circulation compromise related to compartment syndrome.

188. A client is admitted to the emergency department with a respiratory rate of 34 breaths per minute and high pitched wheezing on inspiration and expiration, the medical diagnosis is severe exacerbation of asthma. Which assessment finding, obtained 10 min after the admission assessment, should the nurse report immediately to the emergency department healthcare provider?

No wheezing upon auscultation of the chest.

522. The nurse is caring for a toddler with a severe birth anomaly that is dying. The parents... holding the child as death approaches. Which intervention is most important for the nurse?

Notify nursing supervisor and hospital chaplain of the child's impending death.

537. While removing an IV infusion from the hand of a client who has AIDS, the nurse is struck with the needle. After washing the puncture site with soap & water, which action should the nurse take?

Notify the employee health nurse.

132. Two days after admission a male client remembers that he is allergic to eggs, and informs the nurse of the allergy. Which actions should the nurse implement? (Select all that apply)

Notify the food services department of the allergy. Enter the allergy information in the client's record. Add egg allergy to the client's allergy arm band.

118. An older male adult resident of long-term care facility is hospitalized for a cardiac catheterization that occurred yesterday. Since the procedure was conducted, the client has become increasingly disoriented. The night shift nurse reports that he attempted to remove the sandbag from his femoral artery multiple times during the night. What actions should the nurse take? (Select all that apply.)

Notify the healthcare provider of the client's change in mental status. Include q2 hour's reorientation in the client's plan of care.

A nursing assistant is working with a delegator. Which action of the nursing assistant may negatively affect client care management? 1 Addressing challenges together Correct2 Performing the same tasks as the delegator 3 Initiating conversation about the new roles and functions Incorrect4 Communicating the cultural perspectives with the delegator

Nursing assistants who have similar strengths as the delegator should adapt to changing situations. A nursing assistant performing the same tasks as the delegator may create a gap in the delivery of client care. Building on the strengths and minimizing the challenges of the team proves to be an effective strategy. Initiating a conversation about the new roles and functions in the organization can open lines of communication to explain why supervision is necessary. It also helps to eliminate or diminish any negative feelings about being supervised. The lines of communication between the delegator and the nursing client can be improved by appreciating and valuing cultural perspectives.

436. In evaluating the effectiveness of a postoperative client's intermittent pneumatic compression devices, which assessment is most important for the nurse to complete?

Observe both lower extremities for redness and swelling

274. A male client with a long history of alcoholism is admitted because of mild confusion and fine motor tremors. He reports that he quit drinking alcohol and stopped smoking cigarettes one month ago after his brother died of lung cancer. Which intervention is most important for the nurses to include in the client's plan of care?

Observe for changes in level of consciousness.

400. A client with myasthenia Gravis (MG) is receiving immunosuppressive therapy. Review recent laboratory test results show that the client's serum magnesium level has decreased below the normal range. In addition to contacting the healthcare provider, what nursing action is most important?

Observe rhythm on telemetry monitor

53. A client with a peripherally inserted central catheter (PICC) line has a fever. What client assessment is most important for the nurse to perform?

Observe the antecubital fossa for inflammation.

During the process of delegation, the delegator's behavior is noted to be observing and monitoring. How is the relationship between the delegator and delagatee in this situation? 1 Limited Correct2 Established 3 New or developing Incorrect4 Developing or ongoing

Observing and monitoring behavior of the delegator indicates delegating, which is done when the relationship between the delegator and delegatee is established. The delegator's behavior is guiding or directing when the relationship between the delegator and delegatee is limited. The delegator's behavior is encouraging or problem solving when the relationship between the delegator and delegatee is new or developing. The delegator's behavior is explaining or persuading when the relationship between the delegator and delegatee is developing or ongoing.

509. The father of 4-year-old has been battling metastatic lung cancer for the past 2 years. After discussing the remaining options with his healthcare provider, the client requests that all treatment stop and that no heroic measures be taken to save his life. When the client is transferred to the palliative care unit, which action is most important for the nurse working on the palliative care unit to take in facilitating continuity of care?

Obtain a detailed report from the nurse transferring the client.

466. An older male who is admitted for end stage of chronic obstructive pulmonary disease (COPD) tells the nurse .... The client provides the nurse with a living will and DNR. What action should the nurse implement?

Obtain a prescription for DNR

463. A client with pneumonia has an IV of lactated ringer's solution infusing at 30ml/hr current labor....sodium level of 155 mEq/L, a serum potassium level of 4mEq/L.... what nursing intervention is most important?

Obtain a prescription to increase the IV rate

A patient who is complaining of a "racing" heart and feeling "anxious" comes to the emergency department. The nurse places the patient on a heart monitor and obtains the following electrocardiographic (ECG) tracing. Which action should the nurse take next?

Obtain the patient's vital signs including oxygen saturation.

353. A client with possible acute kidney injury (AKI) is admitted to the hospital and mannitol is prescribed as a fluid challenge. Prior to carrying out this prescription, what intervention should the nurse implement?

Obtain vital signs and breath sounds.

348. The nurse instructs an unlicensed assistive personnel (UAP) to turn an immobilized elderly client with an indwelling urinary catheter every two hours. What additional action should the nurse instruct the UAP to take each time the client is turned?

Offer the client oral fluids

563. The family of a client who just died arrives on the nursing unit after receiving telephone notification of the death. Several family members state they would like to view the body. How should the nurse respond?

Offer to go with the family members to view the body.

332. A young adult female college student visits the health clinic in early winter to obtain birth control pills. The clinic nurse asks if the student has received an influenza vaccination. The student stated she did not receive vaccination because she has asthma. How should the nurse respond?

Offer to provide the influenza vaccination to the student while she is at the clinic

A nurse is assisting another registered nurse in the intensive care unit who is caring for a client with uncontrolled blood pressure. Which action on the part of the nurse indicates "offering" during delegation decisions? 1 "Did you check the client's blood pressure this morning?" Correct2 "You can use this stethoscope and sphygmomanometer to take the blood pressure." 3 "Would you fetch me the client's laboratory reports? I'll record the blood pressure." 4 "How is the client doing this morning? Let me look at yesterday's blood pressure report."

Offering involves making a suggestion to facilitate the achievement of a desirable client care outcome. The statement, "You can use this stethoscope and sphygmomanometer to take the blood pressure," is an example of offering. Asking begins with questions related to the problem or issue regarding client care. "Did you check the client's blood pressure this morning?" is an example of asking. Doing involves demonstrating the specific task or behavior needed to improve client care. "Would you fetch me the client's laboratory reports? I'll record the blood pressure," is an example of doing. "How is the client doing this morning? Let me look at yesterday's blood pressure report," is an example of supervision.

Which statement is true regarding delegation? Select all that apply. 1 The delegatees are accountable for effective client care. Correct2 Open lines of communication must occur between delegator and delegatee. Correct3 Delegation occurs only when at least two people are involved in a mutual work situation. Incorrect4 The delegation potentials are significantly lower when caregivers such as UNPs are partnered. Correct5 Delegation involves sharing activities with other appropriate authority to accomplish the work.

Open lines of communication between delegator and delegatee helps to eliminate any misunderstanding regarding delegated tasks. Delegation occurs only when at least two people are involved in a mutual work situation; one who has the authority to perform specific tasks and other who holds accountability for the task being performed. Delegation involves sharing activities with other appropriate authority to accomplish the work. When delegating a task to delegatee, the delegator retains accountability for effective client care by ensuring that the task is completed by the right person and that the person is supervised appropriately. The delegation potentials are significantly higher when caregivers such as UNPs are partnered.

494. The nurse prepares an intravenous solution and tubing for a client with a saline lock, as seen in the video. Which nurse takes next

Open the roller clamp on the tubing.

Implementation: administration

Oral route Assist with administration if needed Involve family in medicating outpatients Inform patients that levodopa ma be taken with food to reduce n/jv but high-protein should be avoided Inform patients that benefits of levodopa may be delayed for weeks to months

To determine whether there is a delay in impulse conduction through the atria, the nurse will measure the duration of the patient's

P wave.

The registered nurse (RN) is caring for a client with epilepsy. Which tasks delegated by the registered nurse (RN) to the assistive personnel indicates active delegation? Select all that apply. 1 Instructing the licensed practical nurse (LPN) to administer diazepam Correct2 Instructing the licensed practical nurse (LPN) to monitor the vital signs 3 Instructing the licensed vocational nurse (LVN) to administer sedatives Correct4 Instructing the unlicensed assistive personnel (UAP) to reposition the client Correct5 Instructing the unlicensed assistive personnel (UAP) to place the oxygen mask

Passive delegation includes performing the tasks based on the position description such as physician or pharmacist. The individual functioning in this role performs these tasks through passive delegation. Instructing the LPN to administer diazepam, medication that was already prescribed by the primary healthcare provider, is passive delegation. Instructing the LVN to administer sedatives that were already prescribed by the primary healthcare provider is passive delegation. Instructing the LPN to monitor vital signs is active delegation as the RN directs assistive personnel to perform certain tasks and holds the individual accountable. Instructing the UAP to reposition the client is also an active delegation as the UAP is carrying out certain tasks that are directed by the RN. Instructing the UAP to place the oxygen mask is an active delegation as the RN directs assistive personnel to perform certain tasks.

541. The nurse is preparing dose # 7 of an IV piggyback infusion of tobramycin for a 73-year-ol client with... Infected pseudomonas aeruginosa. Which assessment data warrants further intervention by the nurse?

Peak and through levels has not been drawn since the tobramycin was started

588. A client who has been in active labor for 12 hours suddenly tells the nurse that she has a strong urge to have a bowel movement. What action should the nurse take?

Perform a sterile vaginal exam

133. The rapid response team's detects return of spontaneous circulation (ROSC) after 2 min of continuous chest compressions. The client has a weak, fast pulse and no respiratory effort, so the healthcare provider performs a successful oral, intubation. What action should the nurse implement?

Perform bilateral chest auscultation.

A patient's cardiac monitor shows a pattern of undulations of varying contours and amplitude with no measurable ECG pattern. The patient is unconscious and pulseless. Which action should the nurse take first?

Perform immediate defibrillation.

168. The nurse is teaching a postmenopausal client about osteoporosis prevention. The client reports that she smokes 2 packs of cigarettes a day and takes 750 mg calcium supplements daily. What information should the nurse include when teaching this client about osteoporosis prevention?

Postmenopausal women need an intake of at least 1,500 mg of calcium daily.

During shift report the nurse learns that a patient with MG deteriorated toward the end of the shift and the physician was called. A tensilon test indicated that the patient was having a myasthenic crisis, what is the priority problem for this patient

Potential for inadequate oxygenation

A patient who was admitted with a myocardial infarction experiences a 45-second episode of ventricular tachycardia, then converts to sinus rhythm with a heart rate of 98 beats/minute. Which of the following actions should the nurse take next?

Prepare to give IV amiodarone (Cordarone) per agency dysrhythmia protocol.

The clinic nurse identifies an elevation in the results of the triple marker screening test for a client who is in the first trimester of pregnancy. Which action should the nurse prepare the client for?

Preparing for other diagnostic testing. The triple marker screen measures maternal serum levels for alpha-fetoprotein (AFP), human chorionic gonadotropin (HCG), and estriol, which screens for indications of possible fetal defects. An elevated result may be a false indicator, so other tests are indicated (B).

A patient is scheduled for a transesophageal echocardiogram (TEE). What information should the nurse expect to be provided from this test?

Presence of clots in the atria

An older client who has been bedridden for a month is admitted with a pressure ulcer on the left trochanter area. The nurse determines that the ulcer extends into the subcutaneous tissue. At which stage should the nurse document this finding?

Pressure ulcers develop over skin surfaces usually covering bony prominences and are caused by external pressure that impedes blood flow, causing ischemia of the skin and underlying tissue. The stage of the pressure area is determined by the depth of tissue damage, and this client's lesion should be documented as a Stage 3 (C) because it is a full thickness tissue loss with visible subcutaneous fat that does not expose bone, tendon, or muscle. (A) is a nonblanchable pressure point over intact skin. (B) is a partial thickness ulcer, such as a ruptured blister or shallow open ulcer with a pink wound bed. (D) is a full thickness tissue loss with exposed bone, tendon or muscle, slough or eschar, and often includes undermining and tunneling.

Neostigmine (Prostigmin) Precaution

Prevention of Aspiration: teach patient to take meds on time especially BEFORE meals to prevent aspiration

Selegiline (Eldepryl) is prescribed for a client with Parkinson disease who is having an inadequate response to dopar (Levodopa) therapy. When teaching the client about the addition of this drug to the regimen, the nurse should explain that the: Primary health care provider should be contacted immediately if a severe headache occurs. Therapeutic blood level of the drug should be monitored each month. Dosage of the drug can be adjusted daily depending on the client's response that day. Side effects of dopar will decrease when the Eldepryl and dopar are taken concurrently

Primary health care provider should be contacted immediately if a severe headache occurs.

584. A client's telemetry monitor indicates ventricular fibrillation (VF). What should the nurse do first?

Provide immediate defibrillation

A delegator is providing feedback to four delegatees. Which feedback is constructive feedback that can help the delegatee to improve quality of care? 1 A 2 B 3 C Correct 4 D

Providing feedback to delegatee D that the procedure properly performed followed by demonstrating a more effective way to perform the task improves quality of client care. Therefore, the feedback given to delegatee D is constructive feedback. Saying to delegatee A that the work was nice is vague feedback, which does not specify the behavior of the delegatee and is not constructive feedback. Providing feedback to delegatee B asking what had gone wrong with him or her today is a verbal attack that does not produce effective change and potentially may undermine a long-term working relationship. Asking delegatee C how the client responded after the task was done is an open-ended question that allows the delegator to gain pertinent information from the delegatee.

The nurse is caring for four different clients with different health conditions. Which client care task delegated to the licensed vocational nurse (LVN) would be appropriate to develop a suitable care outcome? 1 Client 1 2 Client 2 3 Client 3 Correct4 Client 4

Providing oral medication to the client who has undergone hysterectomy can be done by the licensed vocational nurse (LVN). The LVN is not eligible to write a nursing care plan for the client with hysterectomy; this must be performed only by the registered nurse (RN). An LVN cannot provide intravenous fluids. Continuous peritoneal dialysis is not performed by an LVN; this procedure requires a more experienced practitioner such as an RN.

363. A low-risk primigravida at 28-weeks gestation arrives for her regular antepartal clinic visit. Which assessment finding should the nurse consider within normal limits for this client?

Pulse increase of 10 beats/minute

The nurse is assessing a client and identifies the presence of petechiae. Which documentation best describes this finding?

Purplish-red pinpoint lesions of the skin.

91. A client is admitted with an epidural hematoma that resulted from a skateboarding accident. To differentiate the vascular source of the intracranial bleeding, which finding should the nurse monitor?

Rapid onset of decreased level of consciousness.

629. The nurse is assessing a client with a small bowel obstruction who was hospitalized 24 hours ago. Which assessment finding should the nurse report immediately to the healthcare provider?

Rebound tenderness in the upper quadrants

The nurse is preparing a client for a scheduled surgical procedure. What client statement should the nurse report to the healthcare provider?

Recalls drinking a glass of juice after midnight. The risk of aspiration while under general anesthesia is increased when the stomach is not empty prior to a surgical procedure, so the client's intake of juice (B) after midnight should be reported the healthcare provider. Preoperative fear and anxiety (A) are common and should be further explored by the nurse. (C) should be communicated using allergy identification tags on the client's records and bracelets on the client's wrist. (D) is a common and expected side effect of perioperative medications.

The nurse is reviewing the admission and history notes for a patient admitted for GBS. Which medical condition is most likely to be presented before the onset of GBS

Recent GI illness

What factors are associated with development of GBS

Recent immunization, systemic lupus erythematosus, acute illness, trauma

115. A client who is newly diagnosed with type 2 diabetes mellitus (DM) receives a prescription for metformin (Glucophage) 500 mg PO twice daily. What information should the nurse include in this client's teaching plan? (Select all that apply.)

Recognize signs and symptoms of hypoglycemia. Report persist polyuria to the healthcare provider. Take Glucophage with the morning and evening meal.

What information best supports the nurse's explanation for promoting the use of alternative or complementary therapies?

Recognizes the value of a client's input into their own health care. Alternative and complementary therapies offer human-centered care based on philosophies that recognize the value of the client's input and honor cultural and individual beliefs, values, and desires (C).

350. When assessing the surgical dressing of a client who had abdominal surgery the previous day, the nurse observes that a small amount of drainage is present on the dressing and the wound's Hemovac suction device is empty with the plug open. How should the nurse respond?

Recompress the wound suction device and secure to plug

Who is most accountable for an initial assessment and the ongoing evaluation of client care? 1 Client Correct2 Registered nurse 3 Licensed practical nurse 4 Unlicensed nursing personnel

Registered nurses are accountable for initial assessment and the ongoing evaluation of client care. The client is not responsible for assessment and evaluation. The licensed practical nurse has a responsibility to assess and report client care. Unlicensed nursing personnel perform tasks as delegated by the registered nurse.

What happens when a registered nurse does not trust other individuals in the healthcare organization? Select all that apply. Correct1 Altered client care 2 Appropriate delegation Correct3 Compromised healthcare Correct4 Limited career opportunity 5 Efficient time management

Registered nurses who do not trust other individuals in a healthcare organization may choose to perform the tasks themselves and this leads to altered client care. Consistently choosing to perform tasks themselves may lead to compromised healthcare and limit career opportunities. Registered nurses who do not trust other individuals in a healthcare organization are unable to delegate appropriately because they choose to perform the tasks themselves. Doing the work themselves increases the time to complete client care and affects time management.

During the physical assessment, which finding should the nurse recognize as a normal finding?

Regular pulsation at the epigastric area when the client is supine Recognizing normal findings in the physical exam is a necessity. The regular and recurrent expansion and contraction of an artery produced by waves of pressure caused by the ejection of blood from the left ventricle as it contracts is a normal finding (A). (B, C, and D) are abnormal findings that require further assessment.

Which hospital care setting is most appropriate for a case manager to perform tasks as a delegatee? 1 Hospice care 2 Extended care Incorrect3 Long-term care Correct4 Rehabilitative care

Rehabilitative care settings are the most suitable for a case manager to perform tasks as a delegatee. Hospice care settings are generally delegated to the registered nurse (RN). In extended care and long-term care settings, tasks are delegated to unlicensed assistive personnel (UAP).

143. An 18-year-old female client is seen at the health department for treatment of condylomata acuminate (perineal warts) caused by the human papillomavirus (HPV). Which intervention should the nurse implement?

Reinforce the importance of annual papanicolaou (Pap) smears.

Drugs for BPH: PDE-5 Inhibitors Tadalafil

Relaxes smooth muscle in the bladder, prostate, and urethra Adverse effects include HypoTN and priapism (persistent and painful erection)

A postoperative client is being weaned from mechanical ventilation. What is the most important factor for the nurse to consider when organizing activities? 1 Remain with the client to assess responses. 2 Allow family members to participate in the process. 3 Permit the client more extended times alone for independence. 4 Observe monitoring devices at the control panel of the ventilator

Remain with the client to assess responses.

When caring for an intubated client receiving mechanical ventilation, the nurse hears the high-pressure alarm. Which action is most appropriate? 1 Remove secretions by suctioning. 2 Lower the setting of the tidal volume. 3 Check that tubing connections are secure. 4 Obtain a specimen for arterial blood gases (ABGs)

Remove secretions by suctioning.

299. The leg of a client who is receiving hospice care have become mottled in appearance. When the nurse observes the unlicensed assistive personal (UAP) place a heating pad on the mottled areas, what action should the nurse take?

Remove the heating pads and place a soft blanket over the client's leg and feet.

93. When preparing a client for discharge from the hospital following a cystectomy and a urinary diversion to treat bladder cancer, which instruction is most important for the nurse to include in the client's discharge teaching plan?

Report any signs of cloudy urine output.

342. An older adult male who had an abdominal cholecystectomy has become increasingly confused and disoriented over the past 24 hours. He is found wandering into another client's room and is return to his room by the unlicensed assistive personnel (UAP). What actions should the nurse take? (Select all that apply).

Report mental status change to the healthcare provider Assess the client's breath sounds and oxygen saturation Review the client's most recent serum electrolyte values

513. A female client is taking alendronate, a bisphosphate, for postmenopausal osteoporosis. The client tells the nurse that she is experiencing jaw pain. How should the nurse respond?

Report the client's jaw pain to the healthcare provider.

96. The nurse enters a client's room and observes the client's wrist restraint secured as seen in the picture. What action should the nurse take?

Reposition the restraint tie onto the bedframe.

When caring for a client on mechanical ventilation, the nurse should monitor for which signs of hyperventilation? 1 Hypoxia 2 Hypercapnia 3 Metabolic acidosis 4 Respiratory alkalosis

Respiratory alkalosis

The licensed practical nurse (LPN) has been asked to monitor the blood pressure of a client with hypertension. The LPN reports to the registered nurse (RN) that the blood pressure monitor is malfunctioning. Which component of the duty is the LPN practicing? 1 Authority 2 Supervision Correct3 Responsibility 4 Accountability

Responsibility refers to the reliability, dependability, and obligation to accomplish a task; it is allocated by the delegator and accepted by the delegatee. Authority is the ability of an individual to perform duties in a specific role, it also involves the responsibility of the delagatee to inform the delegator about limitations that may impede completion of a task, such as malfunctioning equipment. Supervision involves the delegator providing guidance and oversight. Accountability involves the delegator determining whether the appropriate actions are being performed and the delegatee providing a detailed explanation of what is happening in the ongoing process.

A nurse is caring for a group of clients on the psychiatric unit. What clinical findings should alert the nurse that serotonin syndrome has developed in one of the clients? Continuous involuntary movement of the tongue and jaw Extremely high blood pressure with headache and flushing Blurred vision, urine retention, dry mouth, and constipation Restlessness, tachycardia, fever, diarrhea, and altered mental status

Restlessness, tachycardia, fever, diarrhea, and altered mental status

A 6-year-old child is alert but quiet when brought to the emergency center with periorbital ecchymosis and ecchymosis behind the ears. The nurse suspects potential child abuse and continues to assess the child for additional manifestations of a basilar skull fracture. What assessment finding would be consistent with a basilar skull fracture?

Rhinorrhoea or otorrhoea with Halo sign. Raccoon eyes (periorbital ecchymosis) and Battle's sign (ecchymosis behind the ear over the mastoid process) are both signs of a basilar skull fracture, so the nurse should assess for possible meningeal tears that manifest as a Halo sign with CSF leakage from the ears or nose (D). (A) is consistent with orbital fractures. (B) occurs with wrenching traumas of the shoulder or arm fractures. (C) occurs with blunt abdominal injuries.

Which right of delegation would the nurse describe as most instrumental in shaping quality and safety outcomes according to Anthony and Vidal? 1 Right task 2 Right person 3 Right supervision Correct4 Right communication and direction

Right communication and direction is most instrumental in shaping quality and safety outcomes because timely and effective communication enhances the safety and quality of client care. Right task is important to prevent legal issues. Right person is important for ensuring the delegatee has the knowledge and experience to perform the specific task safely. Right supervision is important for monitoring and evaluating appropriately.

A client is being admitted to the medical unit from the emergency department after having a chest tube inserted. What equipment should be brought to this client's room?

Rubber-tipped clamps.

Antidepressants

SSRIs, SNRIs, TCAs, MAOIs, Atypical antidepressants, St. John's Wort 1-3 wks initial response; max response takes up to 12 wks (NOT PRN) first line: SSRIs, SNRIs, bupropion, mirtazapine second line: MAOIs and TCAs (old drugs)

69. When preparing to discharge a male client who has been hospitalized for an adrenal crisis, the client expresses concern about having another crisis. He tells the nurse that he wants to stay in the hospital a few more days. Which intervention should the nurse implement?

Schedule an appointment for an out-patient psychosocial assessment.

The nurse is delegating someone to care for a client with diabetes mellitus. Which instruction given by the nurse better explains the selling relationship with the delegatee? 1 "Record the client's blood glucose level each morning." 2 "You may approach me for further assistance and questions. Thank you." 3 "I will guide and assist you while you learn how to check the client's blood glucose." Correct4 "You will take complete care of the client with diabetes and make sure to record the blood glucose level."

Selling includes ongoing relationships with an explanation of the delegated new task. This is better explained in the statement, "You have to take complete care of the client with diabetes and make sure that you record the blood glucose level." Telling is ordering the delegate to record the client's blood glucose level each morning. Delegation, involving established relationships and expertise, is better explained by, "You may approach me for further assistance and questions. Thank you." Participation is mutual involvement to accomplish the task. It is better explained by the statement, "I will guide and assist you while you learn how to check the client's blood glucose."

The patient is scheduled to receive immunoglobulin therapy, before administering the medication, the nurse ensures that which laboratory test has been completed

Serum IgA

47. A male client reports the onset of numbness and tingling in his fingers and around his mouth. Which lab is important for the nurse to review before contacting the health care provider?

Serum calcium

83. A client with intestinal obstructions has a nasogastric tube to low intermittent suction and is receiving an IV of lactated ringer's at 100 ml/H. which finding is most important for the nurse to report to the healthcare provider?

Serum potassium level of 3.1 mEq/L or mmol/L (SI)

The nurse is assessing the laboratory results for a client who is admitted with renal failure and osteodystrophy. Which findings are consistent with this client's clinical picture?

Serum potassium of 5.5 mEq and total calcium of 6 mg/dl. In renal failure, normal serum electrolyte balance is altered because the kidneys fail to activate vitamin D, calcium absorption is impaired, and serum calcium decreases, which stimulates the release of PTH causing resorption of calcium and phosphate from the bone. A decreased tubular excretion and a decreased glomerular filtration rate results in hypocalcemia, hyperphosphatemia, and hyperkalemia (C). (A) is reflective of a non-renal cause, such as dehydration or liver pathology. (B) is more indicative of infection. Renal failure causes anemia and hyperphosphatemia, not (D).

The registered nurse oversees five unlicensed nursing personnel (UNP), and each UNP cares for five clients, so the registered nurse in effect has responsibility for five UNPs and 25 clients. What do these numbers of subordinate and clients indicate? Incorrect1 Supervision Correct2 Span of control 3 Passive delegation 4 Appropriate authority

Span of control is the number of individuals the supervisor or delegator is responsible for. In this instance, the RN is responsible for the delegatees as well as the clients they are caring for. Supervision involves ensuring that the appropriate oversight and guidance is provided for a delegated task. Passive delegation occurs when licensed members of an organization perform tasks that are essential to their normal practice. Appropriate authority is the specific ability to perform the work or task.

The nurse is caring for critically ill clients. Which client should be monitored for the development of neurogenic shock? A client with

Spinal cord injuries (C) place the client at high risk for the development of neurogenic distributive shock. The development to watch for in (A) is cardiogenic shock, in (B) is hemorrhagic shock, and in (D) is hypovolemic shock.

Which element creates an integrative process that fosters effective delegation decisions by the registered nurse? 1 Ability 2 Liability Correct3 Stability 4 Ethnicity

Stability is the element that creates an integrative process that fosters effective delegation decisions. Ability is the factor that needs to be assessed to determine the level the leaders determine. Liability is the person's responsibility and accountability for individual actions. Ethnicity does not play a role in the process of delegation.

A patient whose heart monitor shows sinus tachycardia, rate 132, is apneic and has no palpable pulses. What is the first action that the nurse should take?

Start cardiopulmonary resuscitation (CPR).

The scope of professional nursing practice is determined by rules promulgated by which organization?

State's Board of Nursing.

Following an emergency Cesarean delivery, the nurse encourages the new mother to breastfeed her newborn. The client asks why she should breastfeed now. Which information should the nurse provide?

Stimulate contraction of the uterus.

109. A client who was admitted yesterday with severe dehydration is complaining of pain a 24 gauge IV with normal saline is infusing at a rate of 150 ml/hour. Which intervention should the nurse implement first?

Stop the normal saline infusion.

127. The nursing staff on a medical unit includes a registered nurse (RN), practical nurse (PN), and an unlicensed assistive personnel (UAP). Which task should the charge nurse assign to the RN?

Supervise a newly hired graduate nurse during an admission assessment.

Which intervention should the nurse include in the plan of care for a female client with severe postpartum depression who is admitted to the inpatient psychiatric unit?

Supervised and guided visits with infant.

A primipara with a breech presentation is in the transition phase of labor. The nurse visualizes the perineum and sees the umbilical cord extruding from the introitus. In which position should the nurse place the client?

Supine with the foot of the bed elevated.

137. The nurse is caring for a group of clients with the help of a licensed practical nurse (LPN) and an experienced unlicensed assistive personnel (UAP). Which procedures can the nurse delegate to the UAP? (Select all that apply)

Take postoperative vital signs for a client who has an epidual following knee arthroplasty Collect a sputum specimen for a client with a fever of unknown origin Ambulate a client who had a femoral-popliteal bypass graft yesterday

During the assessment of a 21-year-old female client with bipolar disorder, the client tells the nurse that she has not taken her medication for three years, her mother will not let her return home, and she does not have transportation or a job. Which client goal is most important for this client?

Taking medication, with community follow-up.

478. A male client returns to the mental health clinic for assistance with his anxiety reaction that is manifested by a rapid heartbeat, sweating, shaking, and nausea while driving over the bay bridge. What action I the treatment plan should the nurse implement?

Teach client to listen to music or audio books while driving

167. A client with muscular dystrophy is concerned about becoming totally dependent and is reluctant to call the nurse to assist with activities of daily living (ADLs). To achieve maximum mobility and independence, which intervention is most important for the nurse to include in the client's plan of care?

Teach family proper range of motion exercises.

What nursing action should be included in the plan of care for a client who had a permanent fixed (asynchronous) pacemaker inserted? 1 Instruct the client that it is better to sleep on two pillows. 2 Encourage the client to reduce activity from former levels. 3 Teach the client to keep daily accurate records of the pulse. 4 Inform the client that the pacemaker functions when the heart rate drops below a preset rate

Teach the client to keep daily accurate records of the pulse

While working with a delegatee, the registered nurse says to the delegate, "It's easy; you can do the procedure tomorrow after watching me do it today. Just follow the steps I have demonstrated." What is the behavior of the registered nurse in this situation? 1 Telling Correct2 Selling 3 Delegating 4 Participating

Telling the delegatee that the procedure is easy and he or she can do it by following the demonstrated steps utilizes persuasion. According to Hersey's model, persuading statements of a delegator indicates selling behavior. According to Hersey's model, directing statements indicate telling behavior. According to Hersey's model, monitoring statements indicate delegating behavior. According to Hersey's model, problem-solving statements indicate participating behavior.

89. A client with multiple sclerosis (MS) has decreased motor function after taking a hot bath (Uhthoff's sign). Which pathophysiological mechanism supports this response?

Temporary vasodilation

The registered nurse is organizing a community health care program for administering tetanus vaccinations. Which member of the health care team is most suitable for being delegated the task of administering vaccinations? 1 Nursing aide 2 Certified technician 3 Patient care associate Correct4 Licensed practical nurse

Tetanus vaccination is administered through the intramuscular route. The licensed practical nurse can administer oral, topical, and intramuscular medications, except for intravenous. The nursing aide, certified technician, and patient care associate are unlicensed assistive personnel whose scope of practice is limited for administering medications.

When evaluating a task performed by a delegatee, the registered nurse finds that the delegatee fails to provide appropriate feedback. Which right of delegation is compromised in this situation? 1 Right task 2 Right person Correct3 Right supervision Incorrect4 Right communication

The "right supervision" includes assessing whether the delegatee can provide feedback related to the task when appropriate. "Right task" involves providing tasks to the delegatee in accordance with legal and institutional policies. "Right person" involves delegating tasks to team members who are competent and show willingness towards the task. "Right communication" involves the delegator providing clear, concise instructions and the delegate understanding those instructions.

A client presents to the physician with a rash. The physician orders the application of a topical medication. Which healthcare team member will most likely carry out this order? 1 Nurse manager (NM) 2 Registered nurse (RN) Correct3 Licensed practical nurse (LPN) 4 Unlicensed assistive personnel (UAP)

The LPN administers oral and topical medications and monitors all vital signs. The NM is the designated individual to whom all nursing professionals are answerable regarding a given task. The RN is responsible for performing the administration of intravenous medications and the delegation of tasks to LPNs and UAPs. The UAP assistive personnel performs all hygiene tasks.

A healthcare team is caring for a postsurgical client who underwent knee surgery. Which task is most suitable to be delegated to a licensed practical nurse (LPN) to provide effective client care? Select all that apply. Correct1 Changing the dressing 2 Ambulating the client Correct3 Administration of oral analgesics Correct4 Reinforcing leg exercise instructions 5 Administering intravenous antibiotics

The LPN scope of practice includes changing the dressing of the surgical site and administration of oral analgesics. Reinforcing leg exercise instructions may also be performed by the LPN. Ambulating the client who underwent knee surgery is usually performed by a physical therapist. Instructing the LPN to administer intravenous medication may not be appropriate according to guidelines.

The registered nurse (RN) assigned the task of providing client care to four clients to a licensed practical nurse (LPN). In which order of priority should the LPN provide care to the clients? Correct 1. Client C Correct 2. Client A Incorrect 3. Client B Incorrect 4. Client D

The LPN should prioritize care to client C who underwent surgery for a heart attack and was hospitalized for 2 days to monitor the conditions post-surgery. Client A should be the next priority, so the LPN should assign a UNP to monitor the client for any changes. Third, the LPN should provide care for client D who has severe diarrhea and who has been hospitalized for 2 days. Finally, the LPN should monitor client B.

The newly hired nurse is delegated the task of preparing the client care plan for a diabetic client who underwent amputation. Which task in the care plan is inappropriate according to guidelines? 1 The registered nurse (RN) administering antidiabetic medications Correct2 Instructing the licensed practical nurse (LPN) to monitor vital signs 3 The RN assessing the client's blood glucose levels at regular intervals Incorrect4 Instructing the licensed practical nurse (LPN) to change the dressing at the amputation site

The LPN's scope of practice includes monitoring vital signs in clients with a stable condition. Instructing the LPN to monitor the vital signs of a client in an acute condition is inappropriate according to the guidelines. Administering antidiabetic medications to a diabetic client who underwent amputation should be done by the RN because the condition of the client is acute. The RN is responsible for assessing the blood glucose levels of the client who underwent amputation. The LPN is instructed to change the dressing at the amputation site.

The registered nurse (RN) delegates the task of caring for a client with a leg fracture to a licensed practical nurse (LPN) and asks the LPN to alert her if any issues arise. What approach is the RN taking as delegator in this instance? 1 Providing supervision Incorrect2 Providing explanation Correct3 Providing little guidance 4 Establishing mutual expectations

The RN as delegator asks the LPN as delegatee to contact her if any issues arise while caring for the client; this approach involves the RN providing little guidance to the LPN. Supervision involves more than simply requesting that the delegatee alert the delegator if any issues arise. The delegator provides explanation when a new task is being delegated to a delegatee who has an established relationship with the delegator. The delegator and delegatee must establish mutual expectations when the delegatee has willingness and ability but the relationship is new.

The charge nurse is teaching the newly-hired registered nurse (RN) about delegating tasks to unlicensed nursing personnel (UNPs). Which statement made by the newly hired RN indicates the need for further teaching? 1 "I should assist the staff in interpreting." Incorrect2 "I should assist the staff in decision-making." 3 "I should assist the staff in achieving optimal functioning." Correct4 "I should assist the staff in sorting out and articulating values."

The RN does not assist the staff in sorting out and articulating the values, the healthcare provider or the physicians do. The RN should assist the staff in interpreting to achieve better outcomes. As a delegator, it is the duty of the RN to help the staff in decision-making. The RN should assist the staff in achieving optimal functioning because the allotted task can have a better outcome only under the supervision of the RN.

A healthcare team is caring for a client who is hospitalized with severe diarrhea. According to the principle of right of supervision of delegation, what does the RN do in this situation? 1 Feed the client every 2 hours. Correct2 Monitor the hemodynamic status. 3 Assess the resources required in the client's care. 4 Follow the institutional procedures for administering fluids.

The RN should monitor the hemodynamic status of the client according to the right of supervision of delegation. It is the responsibility of the RN to supervise the delegated task. Feeding the client is usually performed by a licensed practical nurse, unlicensed nursing professional, or any member of the healthcare team. Assessment of resources is monitored before assigning tasks to the healthcare team. Following institutional procedures for administration of fluids is actually done by the RN, so it is not supervised by the RN.

A registered nurse (RN) diagnosed with chemical impairment issues is transferred to work at a rehabilitation center as a part of treatment. Which actions performed by the nurse manager at the new work place result in effective outcome of treatment for chemical impairment? Select all that apply. Correct1 Restricting the RN from working near the abused chemical 2 Delegating other staff to assist the RN in providing client care Correct3 Restricting the RN from administering any controlled substances 4 Requiring the RN to share what he or she is doing to control the problem Incorrect5 Permitting the RN to share the problem with other members of the healthcare team

The RN's job has been moved to a rehabilitation center because of chemical impairment issues and the RN is restricted from working at a facility where the drug is used, which helps the RN in his or her recovery. Controlled substances may be abused, so restricting the RN from administering such substances may result in effective outcome of therapy. Delegating the other staff the task of assisting the RN in providing client care may be a positive experience for the staff, but this intervention may not result in positive outcome of the treatment. Requiring the RN to share what he or she is doing to control the problem or allowing the RN to share his or her problem with other staff of the healthcare team may not result in positive outcome of the treatment.

Which quality of the nursing assistant should be known by the delegator when assigning a task? Correct1 Ability 2 Willingness 3 Interaction 4 Relationship

The ability of the nursing assistant to perform a task should be known by the delegator before assigning a task. The willingness of the delegatee to work on a task can be understood by the delegator while communicating with the delegatee. Interaction is the quality of a delegatee, which can determine the effectiveness of the delegatee to perform a task. Relationship between the delegator and delegatee is not an aspect that should be known by the delegator before assigning a task.

Which statements are true regarding the primary nursing care developed by Marie Manthey as a method for organizing client care? Select all that apply. Correct1 The associate nurse provides input into the client's plan of care. 2 The charge nurse will be accountable for the care from admission to discharge. Correct3 If the client develops complications, the associate nurse should notify the primary nurse. 4 According to the associate nurse's care specifications, the primary nurse should provide care. Correct5 The registered nurse functions autonomously as the primary nurse throughout the client's hospital stay.

The associate nurse cares for the client according to the care specifications provided by the primary nurse in the care plan. The associate nurse provides input to the client's plan care if the associate nurse notices any complications and also notifies the primary nurse for alterations in the care plan. The registered nurse functions autonomously as the client's primary nurse by taking the responsibility and accountability of the client care from admission through discharge. It is the primary nurse, rather than the charge nurse, who will be accountable for the care of the client from the admission through discharge. According to the primary nurse's care specifications, the associate nurse should provide care.

Which statements are true regarding the primary nursing care developed by Marie Manthey as a method for organizing client care? Select all that apply. Correct1 The associate nurse provides input into the client's plan of care. 2 The charge nurse will be accountable for the care from admission to discharge. Correct3 If the client develops complications, the associate nurse should notify the primary nurse. Incorrect4 According to the associate nurse's care specifications, the primary nurse should provide care. Correct5 The registered nurse functions autonomously as the primary nurse throughout the client's hospital stay.

The associate nurse cares for the client according to the care specifications provided by the primary nurse in the care plan. The associate nurse provides input to the client's plan care if the associate nurse notices any complications and also notifies the primary nurse for alterations in the care plan. The registered nurse functions autonomously as the client's primary nurse by taking the responsibility and accountability of the client care from admission through discharge. It is the primary nurse, rather than the charge nurse, who will be accountable for the care of the client from the admission through discharge. According to the primary nurse's care specifications, the associate nurse should provide care.

A client with asthma receives a prescription for high blood pressure during a clinic visit. Which prescription should the nurse anticipate the client to receive that is least likely to exacerbate asthma?

The best antihypertensive agent for clients with asthma is metoprolol (Lopressor) (C), a beta2 blocking agent which is also cardioselective and less likely to cause bronchoconstriction. Pindolol (A) is a beta2 blocker that can cause bronchoconstriction and increase asthmatic symptoms. Although carteolol (B) is a beta blocking agent and an effective antihypertensive agent used in managing angina, it can increase a client's risk for bronchoconstriction due to its nonselective beta blocker action. Propranolol (D) also blocks the beta2 receptors in the lungs, causing bronchoconstriction, and is not indicated in clients with asthma and other obstructive pulmonary disorders.

Which action by the nurse constitutes constructive feedback for the delegatee? 1 Providing verbal attacks on feedback Incorrect2 Providing feedback to individual delegatee 3 Providing nonspecific feedback about the behavior Correct4 Providing open feedback about specific strategies for change

The best strategy is to provide open, honest, and constructive feedback. The feedback should be about work-related performance and specific strategies for change in the quality of performance. A verbal attack on a delegatee does not produce effective change and could undermine any long-term working relationship. Providing feedback to an individual delegatee as satisfactory may diminish the credibility of the nurse. Creating a work environment in which specific feedback about performance is provided is the best strategy for shaping the future behavior of the delegatee.

During the delegation process, which healthcare professional acts as a liaison between the team leader and healthcare provider? Correct1 Charge nurse 2 Nurse manager 3 Nursing supervisor 4 Chief nursing officer

The charge nurse is responsible for acting as a liaison between the team leaders and healthcare providers. Nurse managers cannot act as a liaison between the team leader and other healthcare providers because they are often responsible for more than one unit and have other managerial responsibilities. The nursing supervisor will be delegated to supervise and ensure effective outcomes for the tasks delegated to the delegatees. The chief nursing officer is responsible for establishing the systems for assessment.

Which intervention should the charge nurse perform to manage a task when the unlicensed nursing personal (UNP) is lacking competence? 1 Provide constructive feedback and assign another task. 2 Provide open vocal feedback and withdraw the UNP from task. Correct3 Provide additional support and temporarily lower expectations. Incorrect4 Provide accountability to the organization and undergo training again.

The charge nurse should manage a task by temporarily lowering expectations and providing additional support to an unlicensed nursing personal (UNP) who is lacking competence. This strategy allows the UNP to build on strengths, minimize weaknesses, and gain confidence. Providing constructive feedback and assigning another task may not improve the strategy of the UNP and may affect the productivity of the new task. Withdrawing the UNP from the task and providing open vocal feedback may weaken the working relationship and the UNP may lose confidence or become frustrated. The charge nurse should be aware of accountability to the organization in case of a failure of the delegation, but assigning the UNP for further training may lead to high risk for legal liability.

A male client is angry and is leaving the hospital against medical advice (AMA). The client demands to take his chart with him and states the chart is "his" and he doesn' t want any more contact with the hospital. How should the nurse respond?

The chart is the property of the facility, but the client has a legal right to the information in it, even if he is leaving AMA, so a copy of the record (D) should be provided. The client does not lose his legal rights to his medical record if he leaves AMA (A). The medical record is confidential, but the hospital protects the client's privacy by not allowing unauthorized access to the record, so the hospital may provide the client with a copy (B). The hospital must maintain records of the care provided and should not release the original record (C).

The nurse is assessing a child's weight and height during a clinic visit prior to starting school. The nurse plots the child's weight on the growth chart and notes that the child's weight is in the 95th percentile for the child's height. What action should the nurse take?

The child is overweight for height, so assessment of the child's daily diet (C) should be determined. The child does not need (A or B), both of which will increase the child's weight. Poor nutrition (D) is commonly seen in underweight children, not overweight.

A child with Tetrology of Fallot suffers a hypercyanotic episode. Which immediate action by the nurse can lessen the symptoms of this "TET spell?"

The child should be placed on his or her back in the knee-to-chest position (B) to increase blood vessel resistance. The increased pressure reduces the rush of blood through the septal hole and improves blood circulation.

The registered nurse is caring for an elderly client who is admitted with severe asthma. Which task delegated by the nurse is most suitable to be performed by the client attendant? Incorrect1 Assessing the vital signs 2 Monitoring respiratory rate 3 Administering inhalational medications Correct4 Assisting the client during nebulization

The client attendant is the unlicensed assistive personnel whose scope of practice is limited to providing basic care and comfort to the client. Assisting the client during nebulization is considered basic care and comfort and can be safely carried out by the client attendant. Assessing vital signs should be performed by the registered nurse. Monitoring respiratory rate can be delegated to the client attendant if the client condition is stable; however, since this client's condition is not stable, this task should not be delegated. Administering inhalational medications is not performed by unlicensed personnel such as a client attendant.

33. After the nurse witnesses a preoperative client sign the surgical consent form, the nurse signs the form as a witness. What are the legal implications of the nurse's signature on the client's surgical consent form? (Select all that apply)

The client voluntarily grants permission for the procedure to be done The client is competent to sign the consent without impairment of judgment The client understands the risks and benefits associated with the procedure

596. A 35 years old female client has just been admitted to the post anesthesia recovery unit following a partial thyroidectomy. Which statement reflects the nurse's accurate understanding of the expected outcome for the client following this surgery?

The client will be restricted from eating seafood

What does the decision strategy of "offering" include in delegation? Incorrect1 Allowing the delegator to examine the situation differently 2 Demonstrating the specific task or behavior to improve client care 3 Asking questions related to the problem or issue regarding client care Correct4 Making a suggestion to facilitate the achievement of a desirable client care outcome

The decision strategy of offering involves making a suggestion to facilitate the achievement of a desirable client care outcome. The decision strategy of asking allows the delegator to examine the situation differently. The decision strategy of doing includes demonstrating the specific task or behavior to improve client care. The decision strategy of asking includes questioning issues related to the problem regarding client care.

The delegatee is performing a task and in the process loses confidence in what he or she is doing. Which delegator's action may have contributed to the delegatee's loss of confidence? Correct1 Intervening when the delegatee is performing the task 2 Providing feedback about the work performed Incorrect3 Communicating with the delegatee about the work being performed 4 Stating that the task should be completed by a specified time

The delegatee may lose confidence and get frustrated if the delegator intervenes. Therefore intervening in tasks is not encouraged. The delegator can instead provide feedback about the task being performed to help improve the effectiveness of the delegation. Communication generally opens lines between the delegator and delegatee and will be helpful in effective delegation. The delegator should brief the delegatee about the specified time the task should be completed; this would not make the delegatee lose confidence.

When does delegation become more challenging? Select all that apply. Incorrect1 When the client is stable Correct2 When the client is pregnant Incorrect3 When the geographic area is small 4 When the resources are abundant Correct5 When school children are receiving care

The delegation process becomes more challenging when vulnerable populations such as pregnant women and school children are receiving care. Delegation can be safely and successfully carried out in the stable client. Delegation can be accomplished successfully when the geographical area is small and resources are abundant.

What order should the nurse follow during the delegation decision-making process when delegating client care? 1.Assessing the health needs exhibited by the client 2.Assessing the abilities demonstrated by unlicensed personnel 3.Seeking client care issues 4.Ensuring the stability of the client 5. Monitoring the task 6.Providing feedback to unlicensed personnel

The delegation process starts with assessing the health needs of the client and the skills of unlicensed personnel (UNP). The key component of delegation decision-making is assessing the UNP's ability to perform the work, including, safety, critical thinking, stability, and time. It is also vital to make client care decisions at the same time. The nurse has to make sure that the client is stable and steady to ensure the best care. The greater the stability of a client, the more likely the UNP can provide safe client care. The nurse should then monitor the task being performed by the UNP. The nurse should also maintain an open line of communication with the UNP to seek client care updates and limitations. The nurse should always provide direct feedback to the UNP for professional growth and development to improve client care outcomes.

A registered nurse delegates the task of administering oral antibiotics for a client with diabetes. Which statements are true in this scenario? Select all that apply. Correct1 The registered nurse (RN) is accountable for the delegatee's work. Correct2 The licensed practical nurse (LPN) should report to the RN once the task is completed. 3 The unlicensed nursing practitioner (UNP) can also be delegated the task of administering oral antibiotics. Correct4 The licensed practical nurse (LPN) can be held responsible for any failure in administration of oral medication. 5 The licensed practical nurse (LPN) can change the medication dosage according to the client's physiological needs in the absence of the RN.

The delegator (RN in this case) is accountable for the tasks of the delegatee. The LPN should report the completion of tasks to the RN. The LPN is responsible for tasks delegated by the RN. UNPs are not authorized to administer oral antibiotics to clients, since their role is limited only to hygiene maintenance and assessing vital signs under the supervision of the RN. The duty of the LPN is only to administer the prescribed drug dosage.

The registered nurse (RN) is delegating tasks to several health care team members caring for a client with a bacterial infection and high fever. Which statements by the registered nurse would be most appropriate for the licensed practical nurse (LPN)? Select all that apply. Correct1 "You should administer an antipyretic after the meal." 2 "You should assess the client's condition." 3 "You should change the bed sheets and dress the client every day." Correct4 "You should administer prescribed antibiotics to the client twice a day." Correct5 "You should collect data that can be used in the assessment of client's condition."

The delegator can delegate tasks such as administration of antipyretic for the client who has fever. This particular task should be delegated only to the licensed nursing personnel, such as LPN. The delegator can delegate the task such as administration of antiallergic medication to the licensed professional, such as LPN. The RN is responsible for all the assessments performed, but the UAP or LPN can collect the data that can be used for the assessment. The RN is responsible for assessing the client's condition. The RN should delegate basic tasks such as changing the bed sheets and dressing the client to unlicensed nursing personnel.

A registered nurse teaches a student nurse about delegation. Which statement made by the student nurse indicates appropriate learning? 1 "Licensed practical nurses are accountable for the tasks they perform." 2 "Complete client care can be delegated to the licensed practical nurse." Incorrect3 "Professional aspects of care can be carefully delegated to the licensed practical nurse." Correct4 "Licensed practical nurses can be expected to perform tasks with which they have experience."

The delegator can safely delegate the task to the LPN if the task is within the scope of function or if the LPN is very experienced in performing the task. The LPN, being a delegatee, is not held accountable for the delegated work; the LPN is held responsible for the delegated task. The delegator is held accountable for the LPN's work. The delegator can never delegate complete client care to the LPN, but can only transfer functions and tasks. Basic skills such as activities of daily living and personal hygiene can be delegated by the delegator, but professional aspects of care should not be delegated.

Which questions should the delegator assess to determine the right task? Select all that apply. Correct1 "Is the task legally appropriate to delegate?" 2 "Is the environment conducive to completing the task safely?" 3 "Does the delegator provide clear and concise directions for the task?" Correct4 "Is the task appropriate to delegate based on institutional policies and procedures?" 5 "Does the delegatee have the knowledge and experience to perform the specific task safely?"

The delegator has to determine right task by assessing whether the task is legally appropriate to delegate. The delegator must also check that the task is appropriate to delegate based on institutional policies and procedures. The right circumstance can be assessed by asking, "Is the environment conducive to completing the task safely?" The right direction and communication is assessed by asking, "Does the delegator provide clear and concise directions for the task?" The right person eligible to accomplish the task is assessed by asking, "Does the delegatee have the knowledge and experience to perform the specific task safely?"

The delegator explains the procedure of the task to the delegatee and asks to provide regular feedback on the events. Which delegation right is the delegator referring to in this situation? 1 The right person Correct2 The right supervision 3 The right circumstances 4 The right communication

The delegator is supervising the task by asking the delegatee to provide regular feedback on the events of the specific assigned task. The delegator has to understand and assess the abilities and skills of the delegatee to determine that the right person is selected to perform the specified task. The right circumstance may be assessed by checking the environment, equipment, and resources to perform the task. The delegator has to develop and maintain open lines of communication to promote a positive work environment.

A registered nurse (RN) delegates a task to a licensed practical nurse (LPN). What should the RN do when the LPN executes the task improperly? Correct1 Provide constructive feedback. 2 Engage in a verbal attack on the delegate. 3 Express satisfaction with the LPN's execution of the task. 4 Ignore the task for now but stop considering the LPN for further delegation.

The delegator should provide constructive and positive, yet honest, feedback about the work of the delegatee. A verbal attack will destroy the relationship between the delegatee and delegator. The RN would lose credibility by conveying satisfaction with the delegatee's work, which is not satisfactory. Ignoring the task and not giving feedback will not promote a healthy relationship.

Which activity performed by the registered nurse (RN) indicates effective delegation? 1 Following one-way communication with the delegatee 2 Assigning a task to a new licensed practical nurse(LPN) 3 Providing feedback to the delegatee while performing the task Correct4 Supervising and monitoring the licensed practical nurse (LPN) about the different activities

The delegator should supervise and monitor the delegatee when the work is being assigned to the delegatee. The communication between delegatee and delegator should always be two-way to get the expected outcome. The delegator should evaluate the ability of the delegatee and should supervise the different tasks before assigning the work to the new delegatee. The delegator should always provide feedback at the end of the task.

Which behavior of the delegator with respect to the work delegated to a delegatee is characterized as "selling" according to the Hershey's Model? 1 Guiding or directing Correct2 Explaining or persuading 3 Observing or monitoring 4 Encouraging or problem solving

The delegator's behavior when explaining or persuading the delegatee is characterized as "selling" according to Hershey's Model. The delegator's behavior when guiding or directing the delegatee is characterized as "telling." The delegator's behavior when observing or monitoring the delegatee is characterized as "delegating." The delegator's behavior when encouraging or problem solving is characterized as "participating."

The nurse is performing patient teachign about plasmapheresis, which statement by the patient indicates understanding of the material

The goal of the treatment is to decrease symptoms, but it is not a cure

Which of these clients can be provided care safely by unlicensed nursing personnel? Select all that apply. 1 A client with pain 2 A client who is upset Correct3 A client who is stable Correct4 A client who is recovering 5 A client with suicidal intention

The greater the stability of a client, the more likely it is that unlicensed nursing personnel (UNP) can provide safe client care. It is also easy for a UNP to care for a client who is recovering. A client with pain is anxious and agitated, and it will take the UNP time to calm the client. Client care may be affected when the client is psychologically upset and has suicidal intentions.

619. The husband of a client with advanced ovarian cancer wants his wife to have every treatment available. When the husband leaves, the client tells the nurse that she has had enough chemotherapy and wants to stop all treatments but knows her husband will sign the consent form for more treatment. The nurse's response should include which information?

The husband cannot sign the consent for the client, her signature is required The client's specific wishes should be discussed with her healthcare provider The healthcare team will formulate a plan of care to keep the client comfortable

The registered nurse considers the qualification of the unlicensed nursing personnel (UNP) before delegating a task. Which right of delegation is followed by the nurse? 1 Task Correct2 Person 3 Direction 4 Supervision

The knowledge and experience to perform the specific task safely by the delegatee is assessed by the qualification of the delegatee, which determines whether he or she is the right person. The right task involves assessing whether the task is legally appropriate to delegate or whether it is appropriate under institutional policies. The right direction involves the delegator providing clear and concise directions to perform the task. The right supervision is determined by whether the delegator is able to monitor and evaluate the client appropriately.

A healthcare team is caring for a client with food poisoning. Which task is most suitable to be delegated to licensed practical nurse (LPN)? 1 Collecting vital signs 2 Performing a stomach wash Correct3 Administering oral antiemetic medication 4 Administering intravenous replacement fluids

The licensed practical nurse (LPN) can perform activities such as administering oral medication for the client. Monitoring vital signs can also be performed by the LPN but since the condition of the client is acute, it will be performed by the registered nurse. Performing a stomach wash and administering intravenous replacement fluids are performed by the registered nurse.

Which healthcare team member would the nurse expect can be delegated with the task of administering oral medication to a client per the functional model? 1 Registered nurse 2 Patient care associate Correct3 Licensed practical nurse 4 Unlicensed assistive personnel

The licensed practical nurse can give oral medication to a client. The registered nurse gives IV medication to a client. Patient care associates assist and monitor vital signs. Unlicensed assistive personnel perform all hygienic tasks.

A healthcare team is caring for clients after a fire. The charge nurse delegates different tasks to the healthcare team according to the functional model of nursing. Which team member is eligible and accessible to provide oral medications to any clients? 1 Nursing manager 2 Chief nursing officer Correct3 Licensed practical nurse 4 Unlicensed nursing professional

The licensed practical nurse is eligible and accessible to provide oral medications to clients. The nursing manager is responsible for more than one unit and has other managerial responsibilities and may not be available for providing oral medications to the clients. The chief nursing officer is busy assessing, monitoring, and verifying requirements. The unlicensed nursing professional is not eligible to provide oral medications; they can only monitor and assist the clients.

The registered nurse (RN) assigns a task to a licensed practical nurse (LPN) to take care of a client admitted with severe burns. Which tasks are being performed by the LPN in this situation? Select all that apply. Incorrect1 Performing hygiene tasks Correct2 Monitoring the heart rate 3 Evaluating the medical reports Correct4 Monitoring the blood pressure Correct5 Administering the oral medication

The licensed practical nurse monitors the heart rate, monitors blood pressure, and administers oral medications. Hygienic tasks are performed by the unlicensed assistive personnel. Evaluating medical reports is performed by the RN, not by the LPN.

The registered nurse (RN) delegates a task to a licensed practical nurse (LPN) to take care of the client who underwent a tracheostomy. Which task should be performed by the LPN in this situation? 1 Developing a plan to avoid aspiration 2 Assessing the client's condition after tracheostomy Correct3 Providing tracheostomy care using sterile techniques 4 Teaching a client and caregiver about home tracheostomy care

The licensed practical nurse provides tracheostomy care using sterile techniques. Developing a plan to avoid aspiration in a client with tracheostomy is done by the registered nurse. Assessing the client's condition after tracheostomy is done by the registered nurse. Teaching a client and caregiver about home tracheostomy care is done by the registered nurse.

The nurse is teaching breathing exercises to a client who underwent surgery. Which member of the healthcare team is most suitable for reinforcement of teaching in the client? 1 Certified technician 2 Case manager 3 Cross-trained technician Correct4 Licensed vocational nurse (LVN)

The licensed practical nurses (LPN) are most suitable to be delegated the task of reinforcement teaching. A certified technician is an unlicensed member who can only record the vital signs or provide basic hygiene to the client. A case manager can provide primary education to the client. These personnel can delegate the task of reinforcement teaching to the assistive nursing personnel. Cross-trained technicians may perform respiratory therapy, draw blood samples, and monitor electrocardiography.

508. Following breakfast, the nurse is preparing to administer 0900 medications to clients on a medical floor. Which medication should be held until a later time?

The mucosal barrier, sucralfate (Carafate), for a client diagnosed with peptic ulcer disease.

What are the three strategies that the nurse can perform while assisting other nurses in making delegation decisions? Select all that apply. Correct1 Doing 2 Telling Correct3 Asking Correct4 Offering 5 Participating

The nurse can assist other registered nurses with delegation decisions by using three strategies: asking, offering, and doing. Telling and participating are the strategies used by the nurse to communicate with the delegatee.

Which assets of the nurse as a licensed health care professional help in planning effective nursing care? Select all that apply. Correct1 Critical thinking Correct2 Diagnostic reasoning Correct3 Ability to synthesize information Incorrect4 Establishment of assessment system for the organization Incorrect5 Communication of competency requirements

The nurse uses critical-thinking skills to analyze the process of delegation. Diagnostic reasoning and the ability to synthesize information from various sources are also skills that allow the nurse to deliver an effective nursing care plan that is beneficial for the client. Establishing systems for assessment and the communication of competency requirements are the responsibilities of a chief nursing officer.

A healthcare team is caring for a population according to the functional model of nursing. Which healthcare team member is most appropriate for the delegation of hygiene care? 1 Unit secretary 2 Registered nurse Correct3 Nursing assistant 4 Licensed practical nurse

The nursing assistant is eligible for performing activities such as providing hygiene care and determining vital signs. Unit secretaries are not delegated to provide hygienic care because they do not have formal preparation and legal recognition. The registered nurse performs other activities such as treatment, admissions, and administering intravenous medications. The licensed practical nurse performs activities such as providing oral medications.

A 62-year-old patient who has Parkinson's disease is taking bromocriptine (Parlodel). Which information obtained by the nurse may indicate a need for a decrease in the dose? The patient has a chronic dry cough. The patient has four loose stools in a day. The patient develops a deep vein thrombosis. The patient's blood pressure is 92/52 mm Hg.

The patient's blood pressure is 92/52 mm Hg.

The client is admitted to the medical unit with a diagnosis of pulmonary edema. The client care is assigned to the registered nurse (RN) by the charge nurse. The RN admits and provides a written plan and assigns the client to a licensed practical nurse. Which healthcare personnel is accountable and responsible for the client if there is development of any complications in the client? 1 Charge nurse 2 Associate nurse Correct3 Registered nurse 4 Licensed practical nurse

The registered nurse is responsible and accountable for the client if complications develop. The registered nurse is responsible for the client because he or she delegated client care and wrote the care plan. The charge nurse may be accountable but may not be responsible since the charge nurse gets the task in the absence of the RN. The associate nurse is responsible for the client's condition if the primary nurse's written plan is implemented by the associate nurse. The licensed practical nurse (LPN) is not responsible because the LPN follows the written plan given by the RN.

The client with methicillin-resistant staphylococcus aureus (MRSA) is admitted to the medical unit. Which of the following tasks should be performed by the registered nurse? 1 Feeding 2 Administrating oral medication Correct3 Initiating intravenous (IV) antibiotic therapy 4 Changing the dressing of a postoperative wound

The registered nurse performs the task of administering the IV medication. Feeding the hospitalized client is done by the unlicensed nursing professional. Oral administration of medicine is done by the licensed practical nurse. Changing the dressing of a postoperative wound is done by the unlicensed nursing professional.

The registered nurse finds that the delegatee is only working for half a day in the healthcare unit. Which is the most appropriate leadership style in this situation? 1 Selling Correct2 Telling 3 Delegating 4 Participating

The relationship between the delegator and the delegatee is limited if the delegatee is only working for a half day in the healthcare unit. Therefore, the most appropriate leadership style in this situation is telling because it provides a fair amount of guidance but limits the time spent on the interactions. The leadership style of selling requires more time because the delegator needs to understand the delegatee's motivation related to the situation. Delegating is the leadership style when the relationship between the delegator and delegatee is well established and the delegatee spends more time in the healthcare organization. Participating is the leadership style of sharing and exchanging views, which requires more time and an ongoing relationship between the delegator and the delegatee.

Which right does the question, "Do staffing ratios demand the use of high-level delegation strategies?" indicate? 1 The right task 2 The right person Incorrect3 The right supervision Correct4 The right circumstance

The right circumstance can be assessed by asking, "Do staffing ratios demand the use of high-level delegation strategies?" The right task is assessed by the legally appropriate delegate, using institutional policies and procedures. The right person is selected when the delegatee has the knowledge and experience to perform the specific task safely. Providing feedback related to the task and monitoring the client promote right supervision.

The registered nurse delegates the task of feeding a 90-year-old client suffering from dysphagia to the unlicensed assistive personnel (UAP) who has previously performed this task. The client died of choking and aspiration after being fed by the UAP. Which right of delegation was violated for this client? 1 Task 2 Person Correct3 Circumstance 4 Communication

The right circumstance includes whether the delegation process is appropriate to the situation or not. For this client, the nurse is responsible for supervising during feeding or providing feeding as the client is suffering from dysphagia. In accordance with right task, the UAP can be delegated the task of feeding. As the UAP is caring for this client and has performed this task previously, he or she has experience of performing this task. Therefore he or she is the right person to delegate the task of feeding as per the UAP ability and willingness. The right of direction and communication includes the delegator providing clear instructions to the delegatee; there is no indication that this right was violated.

After delegating the task of administering oral medications to a licensed practical nurse (LPN), the registered nurse (RN) ensures that the LPN is supervised until the task is accomplished. Which right of delegation does the scenario reflect? 1 The right task 2 The right person Incorrect3 The right direction Correct4 The right circumstance

The right circumstance is indicated by the appropriate supervision, availability of equipment and resources, and appropriateness of the given situation. If the task is appropriate to the delegate based on institutional policies and is legal then it represents the right task of delegation. If the delegatee has adequate knowledge and experience to perform a task safely and effectively, it represents the right person of delegation. The right direction is indicated by the clear and concise directions provided for the task.

Which questions should the nurse consider to assess and ensure delegation to the right person? Select all that apply. Correct1 Is the prospective delegatee a willing and able employee? 2 Does the delegatee understand the directions and expected results of the task? 3 Does the delegatee understand how, what, and when to report to the delegator? 4 Is it clear that the delegatee will provide feedback related to the task when appropriate? Correct5 Does the delegatee have the knowledge and experience to perform the specific task safely?

The right delegatee is chosen on the basis of the person's willingness and ability. The nurse should assess the knowledge and experience of the prospective delegatee to perform the specific task safely and fulfill the expected outcomes. Right direction and documentation are assessed by the delegatee's ability to understand the directions and expected results of the task. It can also be assessed on the basis of the delegatee's understanding of how, what, and when to report to the delegator. The right supervision is providing feedback to the delegatee, related to the task, when appropriate.

The registered nurse (RN) is caring for a client with severe diarrhea. Which task of the client care plan can be safely delegated to the unlicensed assistive personnel (UAP) by the registered nurse? 1 Administration of oral antidiarrheal 2 Administration of intravenous antibiotics Correct3 Administration of oral replacement fluids 4 Administration of intravenous antiemetics

The scope of practice of the UAP is limited to perform basic care, feeding, and hygiene. Administering oral replacement fluids can be safely performed by the UAP, as it is a basic care that may also be included under feeding. Administering oral medications such as antidiarrheal drugs can be safely delegated to a licensed practical nurse (LPN) or a licensed vocational nurse (LVN) according to guidelines but not to the UAP. Administering intravenous medication such as antibiotics or antiemetics is the role of the registered nurse.

The registered nurse delegates a task to the unlicensed nursing personnel (UNP). Which client care is suitable for UNP? 1 Client A 2 Client B Correct3 Client C 4 Client D

The task of delivering care to client C is delegated to the UNP because the UNP can monitor the wound discharge in clients who have undergone surgery. Severe burns are an acute condition where the vitals are unstable. Therefore, the UNP is not authorized to provide care to client A with severe burns. UNP's scope of practice is limited for administration of intravenous fluids or medications, so the UNP is not authorized to provide care to client B, who has diabetes insipidus and requires intravenous administration of medications. Cardiogenic shock is an acute condition where the vitals are unstable, so the UNP is not qualified to provide care to client D with cardiogenic shock, and acute condition which may require continuous monitoring of vital signs.

The registered nurse (RN) is caring for a client who underwent a hysterectomy. Which tasks can be delegated to the unlicensed assistive personnel (UAP) to provide quality care to the client? Select all that apply. Correct1 Recording vital signs Correct2 Assisting the client with bathing 3 Administering oral medications 4 Preparing the care plan for the client 5 Administering intravenous antibiotics

The tasks within the scope of unlicensed assistive personnel (UAP) include recording vital signs and providing basic hygiene, such as assisting the client with activities of daily life such as bathing. Administering oral medications is under the scope of licensed practical nurse (LPN) or licensed vocational nurse (LVN), but not the UAP. Depending on the state, administering intravenous antibiotics can be performed by either the RN or an LPN/LVN. Preparing the care plan for the client should be performed by the registered nurse only.

Which client is most appropriate to be delegated to unlicensed assistive personnel (UAP) based on the given data? 1 Client A 2 Client B 3 Client C Correct4 Client D

The unlicensed assistive personnel (UAP) is delegated to work in long-term care settings and extended-care settings as the clients are more stable. The UAP may not be delegated to work in acute care, emergency care, and intensive care settings. In dementia, the client experiences confusion, so long-term care is essential for this client. Since UAPs generally work in long-term care, client D is most appropriate to be delegated to a UAP. As severe diarrhea needs acute care, client A may not be delegated to a UAP. Though a hand fracture may require extended care, the client can do work on his or her own when compared to the client with dementia. Therefore, client B may not be delegated to a UAP. Clients with bronchitis need acute care as they may experience breathing difficulties. Therefore, client C is not delegated to a UAP.

Which questions related to decision making for delegation are appropriate according to the delegation right of "right circumstance"? Select all that apply. 1 Is the task legally appropriate to delegate? 2 Is the prospective delegatee a willing and able employee? Correct3 Are the equipment and resources available to complete the task? Correct4 Does the delegatee have appropriate supervision to complete the task? Incorrect5 Is the task appropriate to delegate based on the institutional policies and procedures?

There are Five Rights of Delegation. Questions related to the equipment and resources available for carrying out the task allotted are appropriate for the delegation right "right circumstance." Asking about the required supervision needed for the delegatee to complete the task is appropriate for the delegation right "right circumstance." Questioning whether the task allotted is legal is appropriate for delegation right "right task." Checking whether the delegatee is an able person to perform the task would come under delegation right "right person." Checking whether the task is based on the policies and procedures of the institution comes under the delegation right "right task."

A nurse is answering questions about breast cancer at a hospital-sponsored community health fair. A woman asks the nurse to explain the use of tamoxifen (Nolvadex). Which response should the nurse provide?

This anti-estrogen drug inhibits malignancy growth. Tamoxifen (Nolvadex) is used in postmenopausal women with breast cancer to prevent and treat recurrent cancer and inhibit the growth-stimulating effects (C) of estrogen by blocking estrogen receptor sites on malignant cells. A side effect of tamoxifen is hot flashes (A), which is related to the decreased estrogen. Tamoxifen is used for women with estrogen receptor-positive breast cancer, not all women (B), and is classified as a hormonal agent, not (D), used to suppress malignant cell growth.

The nurse is assessing a client who complains of weight loss, racing heart rate, and difficulty sleeping. The nurse determines the client has moist skin with fine hair, prominent eyes, lid retraction, and a staring expression. These findings are consistent with which disorder?

This client is exhibiting symptoms associated with hyperthyroidism or Grave's disease (A), which is an autoimmune condition affecting the thyroid. (B, C, and D) are not associated with these symptoms.

331. Following and gunshot wound, an adult client a hemoglobin level of 4 grams/dl (40 mmol/L SI). The nurse prepares to administer a unit of blood for an emergency transfusion. The client has AB negative blood type and the blood bank sends a unit of type A Rh negative, reporting that there is not type AB negative blood currently available. Which intervention should the nurse implement?

Transfuse Type A negative blood until type AB negative is available.

Which client's care is least likely to be delegated to unlicensed nursing personnel (UNP)? 1 Client A 2 Client B 3 Client C Correct4 Client D

UNP can safely care for clients in stable condition because these cases will not require critical nursing assessment and decision-making. In an emergency setting, the client with accidental poisoning should be kept under constant monitoring and any small detail of fluctuation should be noted. Therefore, client D cannot be safely delegated to UNP. Clients undergoing home care, extended care, or long-term care do not require exhaustive monitoring and do not have life-threatening conditions, so they can be safely delegated to UNP.

The nurse is analyzing the client's rhythm when she notes multiple premature ventricular contractions (PVCs). Each PVC occurs in no particular pattern and looks like all other PVCs. This indicates that the PVCs are: 1 Multifocal. 2 Unifocal. 3 Bigeminal. 4 A pair.

Unifocal

A client is brought to the emergency department following ingestion of pesticides. The primary health care provider orders gastric suction. Which task can be delegated to the unlicensed assistive personnel (UAP) in this situation? 1 Monitoring the vital signs 2 Evaluating the client response 3 Gastric suctioning through vented tube Correct4 Emptying and measuring the gastric drainage

Unlicensed assistive personnel (UAP) scope of practice is limited to providing basic care, comfort, and hygiene. The UAP can measure the drainage and report the finding before emptying it. Unlicensed assistive personnel (UAP) can monitor vital signs only for clients in a stable condition. This client has an acute condition, so monitoring the vital signs is the role of registered nurse. Evaluating the client response is the role of registered nurse. UAP may perform all hygiene tasks; however, gastric suctioning through a vented tube is not within the scope of practice of the UAP.

The registered nurse is caring for a client undergoing chemotherapy. Which statement made by the client shows a need for the registered nurse (RN) to delegate unlicensed assistive personnel (UAP) to help the client with activities of daily living (ADL)? Select all that apply. 1 "I have severe nausea." 2 "I developed rashes after therapy." 3 "I am unable to bear the pain of chemotherapy." Correct4 "I am unable to eat by myself due to the intravenous (IV) catheter." Correct5 "I am unable to get out of bed because I am so weak from the therapy."

Unlicensed assistive personnel are members of the healthcare team whose scope of practice is limited to feeding, providing basic care, hygiene, and comfort. The client reporting an inability to eat due to the intravenous catheter and an inability to get out of bed due to weakness indicates that he or she can be assisted by the UAP. The RN will be required to report the client's severe nausea to the primary healthcare provider. The RN will be required to report the pain experienced by the client undergoing chemotherapy. The client who developed rashes after therapy will require the RN to report the side effects of the medication to the primary healthcare provider.

Which delegation actions may be performed by unlicensed nursing personnel while caring for a client? Select all that apply. 1 Teaching the care plan to the client 2 Infusing intravenous fluids into the client Correct3 Asking the client to wash the hands before meals 4 Instructing the client to take specific medications Correct5 Instructing the client to wear footwear while walking

Unlicensed nursing personnel (UNP) can delegate simple and straightforward client teaching, such as asking the client to wash his or her hands before meals and wear footwear while walking. Complex and multifaceted teaching, such as detailing the care plan to the client, cannot be delegated to a UNP. The UNP has less knowledge and professional skills with which to perform complex procedures such as infusing intravenous fluids into the client and does not have a complete knowledge of medications with which to coach the client about medications.

131. A 4-year-old with acute lymphocytic leukemia (ALL) is receiving a chemotherapy (CT) protocol that includes methotrexate (Mexate, Trexal, MIX), an antimetabolite. Which information should the nurse provide the parents about caring for their child?

Use sunblock or protective clothing when outdoors.

72. Azithromycin is prescribed for an adolescent female who has lower lobe pneumonia and recurrent chlamydia. What information is most important for the nurse to provide to this client?

Use two forms of contraception while taking this drug.

408. A client is discharged with automated peritoneal dialysis (PD) to be used nightly...which instructions should the nurse include?

Wash hands before cleaning exit site

392. A client who is experiencing musculoskeletal pain receives a prescription for ketorolac 15mg IM q6 hours. The medication is depended in a 39mg/ml pre-filled syringe. Which action should the nurse implement when giving the medication?

Waste 0.5 ml from the pre-filled syringe and inject the medication in the ventrogluteal site.

The nurse is performing teaching for the family of a patient with MG about fatigue and activities of daily living, which statement by a family member indicates a need for additional teaching

We should do hygenic care for her to avoid undue frustration and fatigue

397. When teaching a group of school-age children how to reduce the risk of Lyme disease which instruction should the camp nurse include?

Wear long sleeves and pants

172. The nurse is managing the care of a client with Cushing's syndrome. Which interventions should the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply)

Weigh the client and report any weight gain. Report any client complaint of pain or discomfort. Note and report the client's food and liquid intake during meals and snacks.

Metabolic adverse effects of SGAs

Weight gain (monitor every 4 wks until wk 12 then every 3 months) New onset of DM (check fasting blood glucose before therapy, 12 wks later, then yearly Dyslipidemia - increased total LDL and TG but decreased HDL (monitor fasting lipid before therapy, 12 wks later, then every 5 years)

A male client with a history of chronic back pain that was managed with opiate analgesics calls the nurse after having back surgery. The client reports that the back pain is finally gone, but after stopping the pain medication, the client has been having severe diarrhea and painful muscle cramps. Which assessment information should the nurse obtain next?

When did the symptoms begin after the last dose of opiate analgesic? Moderate to severe opiate withdrawal manifests with moderate to severe vomiting, diarrhea, muscle cramps, and elevated blood pressures greater than 110 systolic or 70 diastolic. The onset of withdrawal for opiate analgesics typically coincides with the time of the next habitual drug dose at 4-6 hours and may last as long as 7 to 14 days, so determining the time of the last dose (D) pinpoints the relationship of opiate dependency and withdrawal symptoms.

The registered nurse (RN) who delegates work to a newly hired licensed practical nurse (LPN) says, "Please tell me how you will go about performing this procedure, and I will share my expectations with you." Which behavior strategy of Hersey's model is being applied? 1 Telling 2 Selling Incorrect3 Delegating Correct4 Participating

When the LPN has the willingness and ability to perform a task, but the relationship is new, the RN will share his or her expectations and conditions with the LPN. This is a clinical example of participating. Participating is encouraging the delegatee to perform the task and taking an active part in problem solving, which may occur during the execution of a given task. If the LPN has limited knowledge and ability to perform a task, the RN will provide more guidance, which is an example of telling what is the task to be done and how it is to be performed. If the LPN is delegated a new task, it requires explanation from the RN. This is termed as selling in Hersey's model, which is the process of explaining and persuading; this happens if a situation involves a new task and the relationship is ongoing. If the LPN has an established relationship and experience, he or she requires a little guidance and this is called delegation.

A critically injured client was brought to the hospital following a car accident and the client should be immediately triaged for determining the nature and acuity of the injuries. Who is delegated to perform the task? 1 Nurse manager Correct2 Registered nurse 3 Licensed practical nurse Incorrect4 Primary healthcare provider

When the client arrives at the hospital after a trauma, it is the responsibility of the registered nurse to determine the nature and acuity of injuries. The nurse manager should usually be the delegator for the registered nurses and healthcare providers. Licensed practical nurses' scope of practice does not include caring for critically ill emergency clients. A primary healthcare provider should treat the client by providing required medications and diagnoses.

A client is admitted to the hospital with severe backache and chest discomfort. After reviewing the client's condition, there is a need for 24-hour client care by the registered nurse (RN). Which healthcare professional is responsible for assigning the task to a registered nurse when 24-hour client care is needed? Correct1 Nurse manager 2 Nursing supervisor 3 Chief nursing officer 4 Primary healthcare provider

When the client requires 24-hour care, the nurse manager is responsible for deciding oversight of RN supervised care to the client. The nursing supervisor is responsible for supervising tasks being performed by team members. The chief nursing officer is responsible for establishing systems to provide competent and effective care. The primary healthcare provider cares for the client by diagnosing and prescribing; assigning work to the registered nurse is the responsibility of the nurse manager.

After assessing the delegatee's inability to perform an assigned task, the delegator explains the procedure and demonstrates the task to the delegatee. What can be inferred about the delegatee? 1 The delegatee may have limited knowledge and ability to perform the task. 2 The delegatee has an established relationship with the delegator and expertise. Incorrect3 The delegatee has the willingness and ability, but the relationship with the delegator is new. Correct4 The delegatee may have an ongoing relationship with the delegator, but a new task is assigned.

When the delegatee has an ongoing relationship with the delegator, but a new task is assigned, the delegator should explain and demonstrate the procedure. When the delegatee has limited knowledge and ability to perform the task, the delegator should provide more guidance. When the delegatee has an established relationship with the delegator and the expertise, little guidance is needed from the delegator to perform the task. When the delegatee has the willingness and ability to perform a task, but the relationship is new, it requires both individuals to create mutual expectations and the conditions for performance.

When delegating a task, the delegator says, "Please tell me how you are going to perform this procedure, and I will share my expectations regarding how we need to communicate with each other." What can be inferred about the delegatee? 1 The delegatee has expertise and an established relationship with the delegator. 2 The delegatee has limited knowledge and ability to perform the task. Correct3 The delegatee has willingness and ability, but the relationship is new. 4 The delegatee has an established relationship with the delegator, but a new task has been delegated.

When the delegatee has the willingness and ability to perform the task but the relationship is new, the delegator tries to establish mutual expectations and conditions for performing the task. The delegator must open the lines of communication with the delegatee. When the delegatee has expertise and an established relationship with the delegator, the delegator asks the delegatee to communicate if any issue or concern arises. When the delegatee has limited knowledge and ability to perform the task, the delegator would provide more guidance to the delegatee by giving detailed instructions. If the delegatee has an established relationship with the delegator but a new task has been delegated, the delegator will need to provide explanation of what is needed to accomplish the task.

While assigning a task, the registered nurse finds that one of the delegatees is not competent to hold the current position. Which strategy does the nurse follow for managing this issue during delegation? 1 Attacking the delegate verbally 2 Doing the task himself or herself Incorrect3 Adjusting the quality of client care Correct4 Lowering the expectations temporarily

When the delegatee is not competent to hold the current position, the registered nurse temporarily lowers expectations. Temporarily lowering the expectations helps the delegatee to build strengths, minimize weaknesses, and gain confidence. Verbal attacking does not help in the situation but will only undermine the relationship between the delegatee and the registered nurse. If the registered nurse does the task herself or himself, the delegatee will not improve. Delegation is a process meant to improve the quality of client care but it is not a strategy to overcome the situation.

Which right is applicable when the delegator and delegatee understand a common work-related language? Incorrect1 Right of person 2 Right of supervision 3 Righty of circumstance Correct4 Right of communication

When the delegator and delegatee understand a common work-related language, then right communication is applicable. Right person is applicable when the delegatee has appropriate knowledge and experience to perform a task. Right supervision is applicable when the delegator is able to monitor and evaluate the client appropriately. Right circumstance is applicable when the delegation process is applicable for the situation.

The registered nurse (RN) who was caring for a postsurgical client went out for a break. The RN assigns the work to a healthcare professional who is also an RN. Which is the correct statement regarding this situation? 1 The situation describes delegation. Correct2 The situation describes assignment. 3 The second nurse holds accountability rather than responsibility for the client. Incorrect4 The second nurse holds responsibility rather than accountability for the client.

When the work is assigned to another registered nurse (RN), it indicates assignment. The RN holds responsibility and also accountability of the assigned task. When the work is assigned to other practitioners, it indicates only responsibility is transferred.

While caring for a client with severe fever, the registered nurse (RN) delegated the task to a new delegatee to assist the RN in recording the temperature. Which instruction given by the RN indicates that the delegatee is new to working with that RN? 1 "Note the temperature every hour." Correct2 "Tell me how you record the temperature." 3 "You can approach me at any time to report any of the client's issues." 4 "Let me show you what is necessary while recording the temperature."

When the work relationship is new, the registered nurse (RN) should ask the delegate to explain how he or she would perform a particular task. So, learning how the delegatee will record the temperature will help to create mutual expectations and conditions for performance. Recording the temperature every hour is the instruction given to the delegatee who has limited knowledge and limited ability to perform the task. Telling the delegatee what is necessary while recording the temperature is important to a delegatee who is new to the assigned task. A delegatee with good knowledge needs minimal guidance, but he or she should remember to report any client issues to the available RN at any time.

The registered nurse (RN) is teaching a newly hired nurse how to communicate with a delegatee while delegating a task. Which statements made by the newly hired nurse indicate effective learning? Select all that apply. Correct1 "I will keep the information simple." 2 "I will share more information than required." Correct3 "I will share the information using electronic media." Correct4 "I will provide an opportunity to clarify the information." Incorrect5 "I will repeat the information in the same way until the new nurse understands it."

While communicating with the delegatee, the information should be simple to enable better understanding. Electronic media is used as a primary communication mechanism to share information. Providing an opportunity to clarify the information helps evaluate the ability of the delegatee. Giving more information than required may lead to confusion. The information should be repeated in different ways if necessary, to ensure better understanding.

54. The nurse administers an antibiotic to a client with respiratory tract infection. To evaluate the medication's effectiveness, which laboratory values should the nurse monitor? Select all that apply

White blood cell (WBC) count Sputum culture and sensitivity

182. The healthcare provider prescribes the antibiotic Cefdinir (cephalosporin) 300mg PO every 12 h for a client with postoperative wound infections. Which feeds should the nurse encourage this client to eat?

Yogurt and/or buttermilk.

533. An African-American man come into the hypertension screening booth at a community fair. The nurse finds that is blood pressure is 170/94 mmHg. The client tells the nurse that he has never been treated for high blood pressure. What response should the nurse make?

Your blood pressure is a little high. You need to have it rechecked within one week

The nurse is caring for a patient with a chest tube. What is the correct nursing intervention for this patient? a. The patient is encouraged to cough and do deep-breathing exercises frequently b. "Stripping" of the chest tubes is done routinely to prevent obstruction by blood clots c. Water level in the suction chamber need not be monitored, just the collection chamber d. Drainage containers are positioned upright or on the bed next to the patient

a

How should the nurse monitor for the complication of subcutaneous emphysema after the insertion of chest tubes? a. Palpate around the tube insertion sites for crepitus b. Auscultate the breath sounds for crackles and rhonchi c. Observe the client for the presence of a barrel-shaped chest d. Compare the length of inspirations with the length of expiration

a Subcutaneous emphysema occurs when air leaks from the intrapleural space through the thoracotomy or around the chest tubes into the soft tissue; crepitus is the crackling sound heard when tissues containing gas are palpated.

A client is shot in the chest during a holdup and is transported to the hospital via ambulance. In the emergency department chest tubes are inserted, one in the second intercostal space and one at the base of the lung. What does the nurse expect the tube in the second intercostal space to accomplish? a. Remove the air that is present in the intrapleural space b. Drain serosanguinous fluid from the intrapleural compartment c. Permit the development of positive pressure between the layers of the pleura d. Provide access for the instillation of medication into the pleural space

a air rises and is removed via a tube inserted in the upper intrapleural space.

Multiple sclerosis

autoimmune, usually women are affected, hereditary S/S: nystigmus, tinnitus, diplopia, blurred vision, dysarthria, dysphagia, urinary retention, spastic bladder, constipation, weakness may progress to paralysis, ataxia, vertigo Onset in the 20s-40s

What clinical indicators should the nurse expect to identify when assessing an individual with a spontaneous pneumothorax? Select all that apply. a. Hematemesis b. Shortness of breath c. Unilateral chest pain d. Increased thoracic motion e. Mediastinal shift toward the involved side

b, c With the reduction of surface area for gaseous exchange the client experiences shortness of breath, tachycardia, and rapid, shallow respirations. Sudden chest pain occurs on the affected side; it may also involve the arm and shoulder.

A patient has a chest tube in place. What does the water in the water seal chamber do when the system is functioning correctly? a. Bubbles vigorously and continuously b. Bubbles gently and continuously c. Fluctuates with the patient's respirations d. Stops fluctuation, and bubbling is not observed

c

The physician's prescriptions indicate an increase in the suction to -20 cm for a patient with a chest tube. To implement this, the nurse performs which intervention? a. Increases the wall suction to the medium setting and observes gentle bubbling in the suction chamber b. Adds water to the suction and drainage chambers to the level of -20 cm c. Stops the suction, adds sterile water to the level of -20 cm in the water seal chamber and resumes the wall suction d. Has the patient cough and deep-breathe and monitors the level of fluctuation to achieve -20 cm

c

Upon observation of a chest tube setup, the nurse reports to the provider that there is a leak in the chest tube and system. How has the nurse identified this problem? a. Drainage in the collection chamber has decreased b. The bubbling in the suction chamber has suddenly increased c. Fluctuation in the water seal chamber has stopped d. There was onset of continuous vigorous bubbling in the water seal chamber

d

During the first 36 hours after the insertion of chest tubes, when assessing the function of a three-chamber, closed-chest drainage system, the nurse identifies that the water in the underwater seal tube is not fluctuating. What initial action should the nurse take? a. Take the client's vital signs. b. Inform the health care provider. c. Turn the client to the unaffected side. d. Check the tube to ensure that it is not kinked.

d Once the drainage tube is patent, the fluctuation in the water column will resume; a lack of fluctuation because of lung reexpansion is unlikely 36 hours after a traumatic open chest injury.

An ambulatory female client with relapsing remitting multiple sclerosis is to receive every other day injections of interferon beta 1a. What adverse effects should the nurse explain may occur when taking this medication

depression, constipation, flulike symptoms, increased heart rate

Memantine interactions

do not combine with other NMDAs (amantadine, ketamine)

An ambulatory patient has sought treatment for symptoms of GBS within two weeks of symptom onset, which drug therapy is likely preferred for this patient

immunoglobulin

The nursing assistant reports to you that a client with myasthenia gravis has an elevated temp 102.2, increased heart rate 120, and rise in BP 158/94, what is your best first action

notify the physician immediately

A client with MS tells the nursing assistant after physical therapy that she is too tired to take a bath, what is the priority nursing diagnosis at this time

self care deficit related to fatigue and neuromuscular weakness

Minimizing "wear off" of levadopa

shorten dose interval give a drug that prolongs levadopa's half life (COMT-1) give a direct dopamine agonist

Edrophonium

ultra short-acting cholinergic causes symptom alleviation in Myasthenic crisis causes worsened symptom in cholinergic crisis

Reducing affects of anticholinergic drugs

use long acting formulations (extended release capsule or transdermal patch) Use drugs that don't cross the BB Use drugs that are selective for muscarinic receptors in the bladder

A patient with GBS is identified as having poor dietary intake secondary to dysphagia, a feeding tube is prescribed, how does the nurse monitor the patients nutritional status

weighing the patient 3 times a week, monitoring weekly serum prealbumin level