CAT 3 baby

A client diagnosed with chronic obstructive pulmonary disease (COPD) experiences rapid atrial fibrillation. Which medication will the nurse expect to be prescribed for this client to treat the heart rhythm? 1. Propranolol. 2. Carvedilol. 3. Metoprolol. 4. Labetalol.

1) Propranolol is a noncardioselective medication that can cause bronchospasm in clients with COPD. 2) Carvedilol is a noncardioselective medication that can cause bronchospasm in clients with COPD. 3) CORRECT — Metoprolol is a cardioselective medication that is appropriate for use in clients with COPD. 4) Labetalol is a noncardioselective medication that can cause bronchospasm in clients with COPD.

The nurse provides cares for a client with a sodium level of 156 mEq/L (156 mmol/L). Which health care provider prescription does the nurse anticipate? 1. A 3% saline solution. 2. A 5% dextrose solution. 3. A 0.9% saline solution. 4. A lactated ringer solution.

1) A 3% saline solution contains sodium; therefore, not indicated for a client experiencing hypernatremia. 2) CORRECT — This client is experiencing hypernatremia. The normal range for serum sodium is 135 to 145 mEq/L (135 to 145 mmol/L). The nurse anticipates a prescription for a sodium-free intravenous fluid such as D5W, which dilutes excess serum sodium. 3) A 0.9% saline solution contains sodium; therefore, not indicated for a client experiencing hypernatremia. 4) A lactated ringer solution contains sodium; therefore, not indicated for a client experiencing hypernatremia.

The nurse provides care for a client diagnosed with new onset atrial fibrillation. The client's health care provider prescribes a transesophageal echocardiogram (TEE). What reason will the nurse give to the client as the primary reason for performing a TEE? 1. To measure the cardiac index. 2. To rule out thrombus in the heart. 3. To estimate the ejection fraction. 4. To observe ventricular wall motion.

1) A TEE is not used to measure cardiac index. 2) CORRECT — In clients with atrial fibrillation, a TEE is done to rule out blood clots in the heart chambers, especially if the client is being considered for cardioversion. 3) A TEE might be able to estimate the ejection fraction; however, this is not the main reason for doing a TEE for clients with atrial fibrillation. 4) Wall motion can be observed in TEE; however, it is not the main reason for doing a TEE for clients with atrial fibrillation.

The nurse notes that the last immunization a 15-year-old client received was at age 6. Which vaccine will the nurse administer to the client? (Select all that apply.) 1. Varicella vaccine (VAR). 2. Influenza vaccine (LAIV). 3. Tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap). 4. Pneumococcal conjugate vaccine (PCV13). 5. Human papillomavirus vaccine (HPV).

1) A child should receive two doses of the VAR vaccine, the first between 12 and 15 months and the second between 4 and 6 years of age. 2) CORRECT — All children older than 6 months of age should receive an annual influenza vaccine. The nurse should plan to administer LAIV to the adolescent. 3) CORRECT — The adolescent should have received five doses of diphtheria, tetanus, and acellular pertussis, at 2 months, 4 months, 6 months, 15 to 18 months and again at 4 to 6 years. Following this series of vaccines, the adolescent should have received the Tdap again at 11 to 12 years of age. Therefore, the nurse should plan to administer a Tdap booster vaccine. 4) A child should receive four doses of PCV 13, the first dose at 2 months, followed by others at 4 months, 6 months, and between 12 and 15 months. 5) CORRECT — The adolescent should have received three doses of HPV immunization between the ages of 11 and 12. Therefore, the nurse should plan to administer the first dose of HPV immunization at this visit.

Which client does the nurse monitor for a heart block after a myocardial infarction (MI)? 1. A client with a non-ST elevation MI. 2. A client with a septal wall MI. 3. A client with an inferior wall MI. 4. A client with a subendocardial wall MI.

1) A non-ST elevation MI does not cause heart blocks. 2) A septal wall MI does not put client at risk for heart blocks. 3) CORRECT — The SA node is supplied by the right coronary artery, is located in the inferior wall, and is the type of infarct to SA node that leads to heart blocks and the related bradyarrhythmia. 4) A subendocardial wall MI does not put client at risk for heart blocks.

A client who is pregnant is prescribed a medication that is pregnancy category D. Which statement does the nurse make to the client when explaining this drug category? 1. "Studies indicate adverse effects in animal fetuses, but human fetuses are unknown." 2. "Studies indicate that a possible fetal risk in humans has been reported." 3. "Studies indicate fetal abnormalities have been reported." 4. "Studies indicate no risk to animal fetuses, but human fetuses are unknown."

1) Adverse effects in animal fetus with unknown human fetal effects defines a category C medication. 2) CORRECT - A category D medication means that possible fetal risk has been reported. 3) Reports of fetal abnormalities defines a category X medication. 4) No risk to animal fetuses and unknown human fetal risks defines a category B medication.

The nurse instructs a client recovering from an ischemic stroke on risk factors for the disorder. Which modifiable risk factor does the nurse expect the client to state as a measure that teaching has been effective? (Select all that apply.) 1. Age. 2. Atrial fibrillation. 3. Family history. 4. Obesity. 5. Hypertension.

1) Age is a non-modifiable risk factor for ischemic stroke. 2) CORRECT - Atrial fibrillation can be treated with medications or cardioversion. 3) Family history is a non-modifiable risk factor for ischemic stroke. 4) CORRECT - Weight loss decreases the risk for ischemic stroke. 5) CORRECT - Hypertension is a primary risk factor for an ischemic stroke that can be modified with medication.

The nurse prioritizes care for a group of clients after receiving hand-off communication. Which client does the nurse see first? 1. An older adult client with pneumonia requiring intravenous access for the next dose of antibiotics. 2. A middle-age adult client with urinary retention who has not voided for 8 hours. 3. A middle-age adult client receiving morphine by patient-controlled analgesia with a respiratory rate of 12 breaths/min. 4. An older adult client with confusion identified as being at risk for falling.

1) Airway, breathing, and circulation take priority. The client with pneumonia is in no acute distress and can safely wait to have a new intravenous catheter inserted before the next dose of antibiotics. 2) The client who has not voided for 8 hours has a diagnosis of urinary retention; this is not a new problem. This client can safely wait for urinary catheterization. 3) CORRECT - Airway, breathing, and circulation take priority. The nurse should first address the middle-age adult client receiving patient-controlled analgesia who had a reported respiratory rate of 12 breaths/min to assess for respiratory depression as a result of therapy. 4) The safety needs of the client at risk for falling can be addressed after attending to the physiologic needs of the other clients.

The nurse provides care for a client who requests testing for human immunodeficiency virus infection (HIV). Which intervention is most important for the nurse to perform before administering testing? 1. Discuss prevention practices to prevent the transmission of HIV to others. 2. Explain that all tests must be repeated twice to be valid. 3. Ask the client to identify all sexual partners. 4. Determine when the client thinks the exposure to HIV occurred.

1) Although risky behaviors that expose the person to HIV should be discussed, it is most important to determine the exact exposure time to appropriately schedule the testing. 2) Positive results on initial testing will automatically be verified by additional testing. 3) This is important, but does not relate to the immediate issue about the timing of the testing. 4) CORRECT - Because there is a delay of several weeks after infection before antibodies can be detected, testing in the interim may result in false-positive results.

The nurse provides care for a client who had a cystectomy. Four hours after the surgery, the nurse observes no drainage from the ileal conduit. Which action is priority for the nurse? 1. Irrigate the stoma and conduit. 2. Notify the health care provider (HCP). 3. Request an order for a bladder scan. 4. Loosen the dressing.

1) An ileal stoma and conduit irrigation in immediate post-op period is not independent nursing intervention. The HCP must be notified. 2) CORRECT - Absence of drainage from the ileal conduit could indicate obstruction or leakage around the surgical anastomosis. A lack of drainage must be report to the HCP immediately. 3) The client no longer has a bladder. 4) Loosening the surgical dressing is not likely to improve drainage from ileal conduit.

The nurse provides care for a client with a pulmonary artery occlusion pressure (PAOP) of 26 mm Hg. Which prescription does the nurse identify as addressing this PAOP? 1. Magnesium. 2. Amiodarone. 3. Metoprolol. 4. Furosemide.

1) Anticonvulsants are not used to manage elevated PAOP. 2) Anti-arrhythmics are not used to manage elevated PAOP. 3) Beta-blockers are not used to manage elevated PAOP. 4) CORRECT — An elevated PAOP signals fluid overload, with a normal range is 4 to 12 mm/Hg, so furosemide is indicated for diuresis.

The nurse provides care for a client who had a splenectomy 2 days ago. The nurse is also assigned a client diagnosed with pneumococcal pneumonia. Which action should the nurse take first? 1. Place the splenectomy client in reverse isolation. 2. Ensure that both clients receive broad-spectrum antibiotics. 3. Request the charge nurse alter the client care assignment. 4. Maintain strict aseptic technique while providing client care.

1) Asepsis is all that is usually necessary for clients with a splenectomy. 2) Both clients may receive antibiotics, but it would not be a result of the nurse's assignment. 3) CORRECT — It is unsafe to risk transferring the pneumococcal infection to the at-risk immune system of the splenectomy client. 4) If the assignment cannot be changed, strict asepsis must be maintained. The first action of the nurse would be to ask that the client with the infection be reassigned.

A nursing unit is short-staffed. The nurse provides care for several more clients than usual. The nurse uses the triage principle to best distribute the nursing care. Which ethical principle will the nurse use in this situation? 1. Beneficence. 2. Justice. 3. Nonmaleficence. 4. Fidelity.

1) Beneficence means the nurse's actions do good, but it does not address how to provide care that is equal to all the clients. 2) CORRECT — Justice means giving each person or group what they are due in terms of fairness, equality, and need, even though short-staffed. 3) Nonmaleficence means doing no harm, which does not address providing care that meets the needs of all clients. 4) Fidelity is keeping a commitment of fairness, truthfulness, loyalty, and advocacy. This principle does not address the nurse providing care that will meet the needs for all clients.

The nurse provides care for a client who is diagnosed with diabetic ketoacidosis. The health care provider prescribes an intravenous (IV) insulin infusion. Which action does the nurse implement when administering the infusion? (Select all that apply.) 1. Monitor blood glucose levels every 4 hours. 2. Prepare the infusion of 100 units of intermediate-acting insulin in 100 mL normal saline solution. 3. Discontinue the insulin infusion as soon as blood glucose levels decrease. 4. Monitor potassium level closely. 5. Administer the insulin infusion via an electronic infusion device.

1) Blood glucose levels should be monitored closely according to the client's condition; typically hourly with initiation of therapy. 2) Only regular insulin, not an intermediate-acting insulin, can be administered by IV infusion. 3) The insulin infusion should be infused continuously until subcutaneous insulin administration can be resumed. Even if blood glucose levels decrease and return to normal, the insulin infusion should be continued until the start of subcutaneous insulin therapy. 4) CORRECT - Potassium levels should be monitored closely because hypokalemia may result as rehydration and insulin therapy begins. 5) CORRECT - An IV insulin infusion must be delivered by an electronic infusion device for accuracy and to maintain client safety.

The nurse teaches a client how to self-administer nasal drops. Which statement is part of these instructions? 1. "Occlude one nostril prior to instilling the drops." 2. "Store the medication vial in the refrigerator between doses." 3. "Shake the medication vial for several minutes before opening." 4. "Sit with the neck flexed backward for 5 minutes after instilling the drops."

1) Both nostrils need to be open and clear before instilling nasal drops. 2) The medication should be stored according to the manufacturer's instructions. If refrigerated, the medication should be brought to room temperature before using. 3) The medication should be prepared according to the manufacturer's instructions. Vigorous shaking is not usually required. 4) CORRECT - The client should be instructed to sit with the neck flexed backward for 5 minutes after instilling the drops. This technique ensures that the medication stays in the nose.

The nurse plans for the discharge of a client with Parkinson disease. Which outcome is appropriate for collaboration between the nurse and the physical therapist? (Select all that apply.) 1. Maintain physical strength and mobility. 2. Bladder training to increase bladder capacity. 3. Optimal use of extremities in performing activities. 4. Proper use of ambulatory assistive devices. 5. Monitor skin for alterations in integrity.

1) CORRECT - A physical therapist can design a personal exercise program to strengthen and stretch specific muscles. 2) Bladder training does not increase bladder capacity. 3) CORRECT - A physical therapist can help optimize independence with activities. 4) CORRECT - A physical therapist can provide expert advice on the proper use of ambulatory assistive devices. 5) Monitoring for skin breakdown is a nursing assessment.

The nurse learns that a client has no running water or electricity in the home. Which action will the nurse take when advocating for this client? 1. Contact the utility companies. 2. Notify the local fire department. 3. Assist to relocate to a homeless shelter. 4. Provide skilled nursing facility information.

1) CORRECT - Advocacy includes working with agencies to ensure the client receives the resources and services to safely live in the home environment. 2) Notifying the local fire department would ensure for the client's safety, but it does not necessarily advocate for this client's needs. 3) Even though the client does not have water or electricity, the client does have a home. Relocating the client to a homeless shelter would not be appropriate. 4) A specific care need must be identified before being accepted as a client in a skilled nursing facility. Lacking water and electricity in the home is not a sufficient reason to consider skilled nursing care.

The nurse performs a preoperative assessment on a client scheduled for aortic valve replacement surgery. Which finding causes the nurse the most concern? (Select all that apply.) 1. Report of allergies to bananas, kiwi, and avocados. 2. History of a rash on the hands that lasted more than 1 week. 3. High-pitched diastolic murmur present on auscultation. 4. Report of weakness that occurs with activity. 5. History of swelling, itching, and hives after contact with a balloon.

1) CORRECT - Allergies to bananas, kiwi, or avocados are common in clients with latex allergy. Latex allergy protocol should be followed for this client. 2) CORRECT - A history of a rash on the hands that lasted more than 1 week may indicate a latex allergy. The latex allergy protocol should be followed for this client. 3) A high-pitched diastolic murmur is an expected sign of aortic valve disease. 4) Weakness with activity is expected in clients who require aortic valve replacement surgery. 5) CORRECT - A history of swelling, itching, and hives after contact with a balloon may indicate a latex allergy. The latex allergy protocol should be followed for this client.

The nurse works in a psychiatric facility that applies behavioral therapy. Which group of clients benefits most from this method? 1. Children in general. 2. Delinquent adolescents. 3. Mentally challenged adults. 4. Socially isolated persons.

1) CORRECT - Children respond especially well to behavioral therapy that uses a reward system, such as sticker charts, and lists of responsibilities that can be checked off. These strategies help reinforce appropriate behaviors. 2) No behavioral technique specifically addresses delinquent adolescents. Behavioral therapy may be useful in combination with other mental health approaches to change behaviors learned over time. 3) No behavioral technique specifically addresses mentally challenged adults. Using reward and praise seems to foster a repeat of positive actions. Behavioral therapy may be useful in combination with other mental health approaches such as repetition. 4) No behavioral technique specifically addresses socially isolated persons. The person needs to be encouraged and taken to social events as a means of reintroduction to social integration. Behavioral therapy may be useful in combination with other mental health approaches.

The nurse identifies that a client is at risk for falling. Which intervention will the nurse implement to decrease the client's risk for falling? (Select all that apply.) 1. Avoid clutter on floor surfaces. 2. Post signs to alert staff. 3. Advise the client to avoid ambulation if unsteady. 4. Apply a vest restraint to prevent the client from getting out of bed unassisted. 5. Teach family members to use throw rugs sparingly. View Explanation

1) CORRECT - Clutter on floor surfaces poses a trip hazard. Therefore, floors should be kept free of clutter. 2) CORRECT - Signs are important to alert staff of which clients are at risk for falling. 3) Assist the client with ambulation, if unsteady. However, ambulation should not be avoided, as the client can quickly become deconditioned. 4) Physical restraints, such as vests, increase the risk for client injury. 5) CORRECT - It is important to teach family members about risk factors that contribute to falls and how they can reduce these risks, including to sparingly use throw rugs.

The nurse plans the discharge of a client recovering from an ischemic stroke. Which core measure needs to be met for this client? (Select all that apply.) 1. Provide a prescription for a statin medication at discharge. 2. Refer the client for psychotherapy at discharge. 3. Meet goals for nutrition within 1 week. 4. Provide and document stroke education prior to discharge. 5. Prevent venous thromboembolism.

1) CORRECT - Discharging the client on a statin medication is a core measure in stroke care. 2) Psychotherapy is not a stroke care core measure. 3) Meeting a nutritional goal in 1 week is not a stroke care core measure. 4) CORRECT - Providing and documenting stroke education is a stroke care core measure. 5) CORRECT - Preventing venous thromboembolism is a stroke care core measure.

A nurse provides care for a client diagnosed with Graves disease and monitors the client for signs of thyrotoxicosis. Which sign or symptom, if noted by the nurse during the client's physical examination, would alert the nurse to the presence of this crisis? (Select all that apply.) 1. Fever. 2. Bradycardia. 3. Excessive sweating. 4. Pallor. 5. Tachycardia

1) CORRECT - Increased body temperature occurs during this state of extreme thyroid activity. 2) Tachycardia, rather than bradycardia, occurs during thyrotoxicosis. 3) CORRECT - Excessive sweating occurs because of the extreme increase in body temperature during this hyperactive state of thyroid activity. 4) Flushing, rather than pallor, is associated with thyrotoxicosis. 5) CORRECT - Tachycardia occurs due to the increase in body metabolism and increased demand for oxygen supply.

The nurse provides care to a newly admitted client. At which time will the nurse conduct a medication reconciliation? (Select all that apply.) 1. At every clinic appointment. 2. At the pharmacy. 3. Upon discharge to home. 4. Upon entry into the unit. 5. Upon transfer to a skilled unit.

1) CORRECT - Medication reconciliation should be completed at every health care provider appointment. 2) Medication reconciliation should occur before discharge. 3) CORRECT - Medication reconciliation should be done at the time of discharge to ensure that the medications are correctly identified for the client. 4) CORRECT - Medication reconciliation should occur upon admission or entry into a new medical unit. 5) CORRECT - Medication reconciliation should occur when there is any change in level of care.

The nurse teaches a group of nursing students about cultural competency. Which strategy will the nurse include to improve the students' cultural competency? (Select all that apply.) 1. Participate in continuing education classes about culturally congruent care. 2. Develop culturally competent approaches to care. 3. Talk with clients about their cultural views of health. 4. Assess own skill level and seek improvement. 5. Realize that personal preferences can influence the client's preferences.

1) CORRECT - Participating in continuing education classes about culturally congruent care will help with skill development. 2) CORRECT - Developing culturally competent approaches to care is supported by the Cultural Care Theory. 3) CORRECT - Talking with clients about their cultural views of health helps broaden knowledge and appreciation of various cultures. 4) CORRECT - Assessing own skill level and seeking improvement helps identify areas for further education. 5) The personal preferences of the nurse should not interfere with the care preferences of the client.

An older adult client is admitted to the hospital. Which nursing intervention helps prevent complications related to the "hazards of hospitalization"? 1. Avoid bedrest as much as possible. 2. Use physical restraints when needed. 3. Speak with family members often. 4. Provide adequate sedation for sleep.

1) CORRECT - Prolonged bed rest can lead to adverse outcomes, such as pressure injury, compromised respiratory and cardiovascular functioning, and atrophy of muscles. It can also cause depression, promote dependence, and diminish self-care. It should be avoided as much as possible. 2) Restraints are used as a last resort. They can lead to adverse outcomes, such as delirium and physical injury. 3) Speaking with family is part of comprehensive care, but it does not directly impact the "hazards of hospitalization". 4) Sedation is best avoided as a sleep aid for older adults due to higher risk for delirium. It also interferes with normal sleep cycles and can foster a dependency on sleep aids.

The nurse provides care for a client who begins nutritional therapy with parenteral nutrition. The client reports feeling anxious and restless. Which action does the nurse take to prevent the client from being injured? 1. Secure all connections in the system. 2. Monitor vital signs every two hours. 3. Calculate intake and output every four hours. 4. Check blood glucose levels every four hours.

1) CORRECT - Since the client is restless, securing the parenteral nutrition tubing is a priority safety issue to prevent the client from pulling the connections apart. 2) Monitoring vital signs according to agency protocol is important, but does not relate to enhancing the client's safety due to risk for injury. 3) Calculating intake and output according to agency protocol is important, but does not relate to enhancing the client's safety due to risk for injury. 4) Checking blood glucose according to agency protocol is important, but does not relate to enhancing the client's safety due to risk for injury.

The nurse prepares to perform nasopharyngeal suctioning of a newborn. Which action is appropriate for the nurse to implement? 1. Set the newborn's suction device at 60 mm Hg. 2. Advance the tube 2.5 cm (1 in) into the newborn's nose. 3. Instill normal saline into the newborn's nares before suctioning. 4. Apply suction while inserting the tubing into the newborn's nose.

1) CORRECT - The appropriate suction for a newborn is 60 to 100 mg Hg, which will prevent injury to the nasopharyngeal mucosa. 2) The nurse should advance the tube 5 to 7.5 cm (3 to 5 in) into the newborn's nares in order to reach the back of the throat. 3) The nurse should not instill anything into the client's airway before suctioning, as this could leave to aspiration. 4) Applying suction while inserting the tube can cause friction while advancing the tube.

The nurse develops a teaching plan for a client with hyperlipidemia. Which lifestyle change will the nurse include in the plan? (Select all that apply.) 1. Consume a diet low in saturated fat. 2. Engage in regular, high-intensity aerobic activity. 3. Stop tobacco use by any possible means. 4. Avoid exposure to second-hand smoke. 5. Consume a diet low in soluble fiber.

1) CORRECT - The client should be encouraged to consume a diet low in saturated fat and high in soluble fiber. 2) The client should be encouraged to increase physical activity by getting regular, moderate physical activity. The goal for most adults is to engage in moderate-intensity aerobic activity (not high-intensity aerobic activity). 3) CORRECT - The client should be encouraged to use any possible means to stop tobacco use, such as counseling, support groups, complementary therapies, and medications. 4) CORRECT - Exposure to second-hand smoke should be discouraged because it increases the risk for heart disease. 5) The client should consume a diet low in saturated fat and high in soluble fiber (not low in soluble fiber).

The nurse assesses the respiratory status of a 12-hour-old newborn. Which finding does the nurse report to the health care provider? (Select all that apply.) 1. Nasal flaring. 2. Acrocyanosis. 3. Tachypnea. 4. Ten second periods of apnea. 5. Respiratory rate of 40 breaths per minute.

1) CORRECT - The nurse reports respiratory distress including nasal flaring, retractions, cyanosis, grunting, or seesawing to the HCP. 2) Acrocyanosis is a common, normal variation for up to 24 hours, due to poor peripheral circulation of the newborn. This is especially evident if the newborn is exposed to cold. 3) CORRECT - The nurse reports tachypnea. A normal respiratory rate ranges from 30 to 60 breaths per minute. 4) Apneic periods < 20 seconds are a normal finding for a newborn. 5) A respiratory rate of 40 breaths per minute is within the normal range of 30 to 60 breaths per minute for a newborn.

A client receiving a blood transfusion develops a cough, rales in bilateral lower lung lobes, shortness of breath, and restlessness. Which action will the nurse take? (Select all that apply.) 1. Slow down the blood transfusion. 2. Place client on the left side. 3. Apply oxygen. 4. Administer prescribed furosemide. 5. Monitor vital signs every 2 to 4 hours.

1) CORRECT - The transfusion should be slowed or stopped since the client is demonstrating signs of volume overload. 2) Left lying position will not facilitate respirations. The client should be placed in a high-Fowler position. 3) CORRECT - The client needs respiratory support, so oxygen should be applied. 4) CORRECT - Furosemide is used to remove excess fluid. 5) Vital signs should be monitored every 30 to 60 minutes, or more often, as warranted by the client's condition.

The nurse provides care to an older adult client in the hospital. Which factor increases this client's risk of falling? (Select all that apply.) 1. Glare from bright lights. 2. Hypertension. 3. Obesity. 4. Medication interactions. 5. Previous falls.

1) CORRECT - Vision changes associated with aging can be exacerbated by the glare from bright hospital lights. This can cause difficulty differentiating things that can create tripping hazards. 2) Orthostatic hypotension, not hypertension, increases the risk for falling. 3) Obesity is not identified as a reason for increased falls. 4) CORRECT - Medication interactions can cause drowsiness, decreased coordination, and orthostatic hypotension, which increase the risk of falling. 5) CORRECT - Previous falls can lead to fear and a loss of confidence when walking.

The nurse provides teaching to a client diagnosed with constipation. Which statement by a client to the nurse demonstrates that the teaching is effective? 1. "I will exercise three times per week." 2. "I will drink 1 quart of fluid per day." 3. "I will drink five caffeinated beverages." 4. "I will consume 10 grams of fiber per day."

1) CORRECT — A client should walk, swim, or bike at least three times per week. Exercise stimulates bowel motility and moves stool through the colon. 2) A client should avoid caffeinated coffee, tea, and cola. Caffeine stimulates fluid loss through urination, which is then lost from the bowel. 3) A client should drink 3 quarts of fluids per day to add liquid to the stool to relieve constipation. 4) A client should consume 20 to 30 grams fiber (soluble and bulk forming) per day. Fiber promotes evacuation by softening hard stools and adding bulk to the stool.

The health care provider prescribes fresh frozen plasma for a client with an arterial bleed. Which rationale will the nurse use when explaining the reason for this type of blood product to be transfused in the client? 1. Promote rapid volume expansion. 2. Increase the hemoglobin level. 3. Treat platelet loss. 4. Increase hematocrit level.

1) CORRECT — Fresh frozen plasma is often used for volume expansion caused by fluid and blood loss. 2) Fresh frozen plasma does not specifically increase hemoglobin. 3) Fresh frozen plasma does not contain platelets. 4) Fresh frozen plasma does not specifically increase hematocrit.

The nurse administers a regular insulin intravenous (IV) infusion for a client diagnosed with diabetic ketoacidosis (DKA). Which finding indicates to the nurse that the client is experiencing complications from the insulin infusion? (Select all that apply.) 1. Blood glucose of 66 mg/dL (3.6 mmol/L). 2. Increased urine output. 3. Sodium of 148 mEq/L. 4. Altered mental status. 5. Potassium of 3.0 mEq/L.

1) CORRECT — Insulin can cause hypoglycemia. The normal glucose level is 70 to 99 mg/dL (3.9 to 5.5 mmol/L). 2) Increased urine output is not a complication of insulin therapy. Insulin causes water to move into cells, leading to low urine output. 3) Hypernatremia is not a complication of insulin therapy. Clients with DKA can either have low or high sodium levels. The normal sodium level is 135 to 145 mEq/L. 4) CORRECT — A rapid drop in blood glucose can cause cerebral edema, which can lead to changes in mental status. 5) CORRECT — An insulin infusion moves potassium into the cells, causing hypokalemia. The normal potassium level is 3.5 to 5.0 mEq/L.

A client has a new plaster cast applied for a fractured tibia. Which nursing action ensures that the cast dries appropriately? 1. Reposition the limb every two hours. 2. Turn the limb gently with the fingers. 3. Place the limb on a plastic-encased pillow. 4. Elevate the limb above the level of the heart.

1) CORRECT — Repositioning the limb every 2 hours ensures that the entire cast dries thoroughly. 2) The nurse would use the palms of the hands to turn the limb. Using the fingers can cause indentations in the plaster. 3) A plastic-encased pillow hinders the plaster cast from drying appropriately. 4) Elevating the limb may prevent edema, but will not help dry a plaster cast.

The nurse cares a client who is prescribed digoxin. Which lab finding does the nurse identify as putting the client at risk for digitalis toxicity? 1. Creatinine level of 7 mg/dL (238.6 umol/L). 2. Serum potassium level of 8 mEq/L (3.8 mmol/L). 3. Serum calcium level of 8.5 mg/dL (1.2 mmol/L). 4. Cholesterol level of 240 mg/dL (6.2 mmol/L).

1) CORRECT — Seventy percent of digoxin is excreted via the kidney. An elevated creatinine level increases the client's risk for digitalis toxicity. The normal range for serum creatinine is 0.6 to 1.3 mg/dL (53 to 115 umol/L). 2) An elevated serum potassium level (as noted here) is not at risk for digitalis toxicity. The normal range for serum potassium is 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). The client experiencing hypokalemia, not hyperkalemia, is at increased risk for digitalis toxicity. 3) A low serum calcium level (noted here) is not at risk for digitalis toxicity. The normal range for serum calcium is 9.0 to 10.5 mg/dL (2.25 to 2.75 mmol/L). 4) A high cholesterol level (noted here) does not directly impact risk for digitalis toxicity. The normal range for serum calcium is <200 mg/dL (<5.20 mmol/L).

The nurse manager creates a discharge teaching form for clients with acquired immunodeficiency syndrome (AIDS). Which statement will the manager include on this form? (Select all that apply.) 1. Avoid children who have just gotten a live vaccine. 2. A condom is necessary during sexual activity. 3. Contact sports, such as football, must be avoided. 4. Drug paraphernalia must not be shared with others. 5. Sexual activity must be restricted to a single partner.

1) CORRECT — The client with AIDS is immunocompromised. Children who have just received a live vaccine and children who have not been vaccinated pose a risk. 2) CORRECT — The use of a barrier method during sexual activity is the only way to prevent transmission of the virus to the partner. 3) Avoiding contact sports is unnecessary unless the specific type of sport causes frequent bleeding injuries. If the client feels well enough to participate, engaging in sports may also increase social interaction and well-being. 4) CORRECT — Drug paraphernalia such as needles, syringes, and straws can transfer the virus that causes AIDS to people who share these devices with infected individuals. 5) It is advisable to restrict partners, but the use of condoms during sexual activity is the primary way to prevent transmission to others and the acquisition of an additional sexually transmitted infection.

A client suddenly develops anxiety, dyspnea, and tachypnea immediately after central venous access device (CVAD) insertion. The nurse determines that which complication is the most likely cause of the client's distress? (Select all that apply.) 1. Air embolism. 2. Pneumothorax. 3. Pulmonary edema. 4. Heart failure. 5. Cardiac tamponade.

1) CORRECT — The client's clinical manifestations indicate a possible air embolism, a complication of this procedure. 2) CORRECT — This client's manifestations indicate a possible pneumothorax, a complication of CVAD insertion. 3) This is not an immediate or likely complication of CVAD insertion. 4) This is not an immediate or likely complication of CVAD insertion. 5) This is not an immediate or likely complication of CVAD insertion.

The home care nurse provides wound care for a client in a home that does not have running water. Which does the nurse do before performing wound care for this client? 1. Perform hand hygiene using an alcohol-based hand rub. 2. Inform the client that care cannot be given without running water in the home. 3. Notify the nursing supervisor that wound care cannot be performed. 4. Call the water company to have water turned on.

1) CORRECT — The nurse needs to perform hand hygiene before and after caring for the client, even if the client's home does not have running water. Hand hygiene can be performed using an alcohol-based hand rub instead of using soap and water. 2) The resources that are available in an acute care setting are not always accessible in the home care setting. Home care nurses are often required to improvise when providing care. The nurse performs hand hygiene using an alcohol-based hand rub and then proceeds with performing wound care. 3) Wound care can be performed without running water in the home after the nurse performs hand hygiene using an alcohol-based hand rub. 4) The nurse notifies the client's case manager about the lack of running water in the home. The case manager has resources available to address the situation.

A nurse works to establish a nurse-client relationship with a client who is new to the mental health unit. Which task does the nurse perform during the introductory phase of the nurse-client relationship? (Select all that apply.) 1. Discuss confidentiality with the client. 2. Assist the client to explore feelings. 3. Clarify the client's problem. 4. Summarize the client's success. 5. Identify the tasks the client should accomplish.

1) CORRECT — The nurse should discuss confidentiality with the client during the introductory phase so that the client understands how the nurse will handle information the client shares. 2) The nurse should assist the client to explore feelings and thoughts about the client's problems, to work on developing listening skills, and to uncover insight into behavior during later phases of the relationship. 3) CORRECT — The nurse should assist the client to clarify any problems and does so by using therapeutic communication techniques to build trust with the client. 4) The nurse should summarize the client's successes and plans for the future during the termination phase. 5) CORRECT — The nurse should establish the purpose of the relationship and the tasks the client should complete during the introductory phase in order to set priorities and focus the work the client needs to accomplish.

The nurse provides care for a client who is newly diagnosed with active tuberculosis and has just been isolated in a negative airflow pressure room. The client is coughing up a large amount of thick, rust-colored sputum and is short of breath. The client states, "I have been exhausted for weeks! I don't understand why I am not getting better. All these medicines are not working." Which nursing diagnoses are appropriate for the nurse to include in the plan of care? (Select all that apply.) 1. Ineffective health management. 2. Risk for infection (spread/reactivation). 3. Impaired gas exchange. 4. Ineffective airway clearance. 5. Imbalanced nutrition: more than body requirements.

1) CORRECT- The active tuberculosis is newly diagnosed. This nursing diagnosis is related to insufficient knowledge about the disease process and the therapeutic regimen. 2) CORRECT- This nursing diagnosis is related to inadequate primary defenses and an immunocompromised state, as evidenced by active tuberculosis. 3) CORRECT- This nursing diagnosis is related to a ventilation-perfusion imbalance, as evidenced by shortness of breath and fatigue. 4) CORRECT- This nursing diagnosis is related to a productive cough and excess, thick mucous. 5) Imbalanced nutrition is appropriate, but it would be 'less than body requirements,' as clients are exhausted and very ill during the active phase of tuberculosis.

The nurse assesses an older adult client during an annual wellness checkup. Which client statement does the nurse consider to be normal and expected? (Select all that apply.) 1. "Although I am tired frequently during the day, I can only sleep 6 hours each night." 2. "I seem to have less of an appetite lately." 3. "Since my spouse died, I do not feel like going out of the house much anymore." 4. "I am worried that I will be unable to afford my new blood pressure medication." 5. "I really enjoy spending time with my grandchildren."

1) CORRECT— It is normal for an older adult to sleep less than when a younger adult. 2) CORRECT— It is normal for an older adult to have less of an appetite than when a younger adult. 3) This statement indicates ineffective coping mechanisms, such as depression and isolation. 4) This statement indicates that the client may require assistance and resources to obtain a needed medication. 5) CORRECT— It is normal to enjoy the next phase of life as a grandparent instead of a parent.

The nurse develops a brochure noting abbreviations that are no longer acceptable. Which abbreviation does The Joint Commission recommend avoiding? (Select all that apply.) 1. U. 2. c.c. 3. qid. 4. mL. 5. O.S.

1) CORRECT— The abbreviation U (unit) can be mistaken for 0 (zero), the number 4 (four), or c.c. It needs to be written out. 2) CORRECT— The abbreviation c.c. (cubic centimeter) is not recommended. The preferred abbreviation is mL (milliliter). 3) Qid or qid (four times a day) is an acceptable abbreviation. 4) The abbreviation mL (milliliter) is acceptable. 5) CORRECT— The abbreviations O.D. (right eye), O.S. (left eye), and O.U. (both eyes) can be mistaken for each other. These abbreviations need to be written out.

The nurse manager is concerned about increased instances of client confusion and disorientation in the intensive care unit (ICU). Which nursing intervention is most effective in resolving this issue? 1. Promote day time periods of sleep. 2. Monitor noise levels during the night. 3. Prioritize and cluster care activities. 4. Turn off TVs and unnecessary lights.

1) Clients are exhibiting signs of sleep deprivation. Sleeping during the day is difficult due to the treatment and care schedule. Also, short periods of sleep are not as effective as long periods of sleep, which is when deeper stages of sleep are experienced. 2) CORRECT - Noise is a big factor that causes sleep deprivation in an ICU setting. At night, turn the equipment and environmental noise down or off. This promotes undisturbed sleep for all clients. 3) Prioritizing and clustering client care activities is important. It minimizes sleep interruptions, but it benefits only some clients. Also, it does not necessarily promote long, uninterrupted periods of sleep at night. 4) These actions improve the environment for sleeping, but the focus needs to be on monitoring all sources of noise, not just TVs.

A nurse provides care for a client who sustained a fracture of the proximal tibia. The nurse assesses the client following application of a cast. Which finding indicates to the nurse that the client is developing compartment syndrome? (Select all that apply.) 1. 3+ pedal pulse. 2. Pain unrelieved with opioids. 3. Feeling of pressure under the cast. 4. Numbness and tingling in the toes. 5. Foot warm to touch.

1) Compartment syndrome can occur following a fracture as a result of pressure within a small space from a cast, edema, or bleeding. Therefore, the nurse expects a diminished or absent pedal pulse as pressure impedes circulation. 2) CORRECT - The pain that occurs with compartment syndrome does not respond to opioids because the pain is a result of edema and increasing pressure. 3) CORRECT - Compartment syndrome can occur following a fracture as a result of pressure within a small space from a cast, edema, or bleeding. Therefore, the client is likely to report a feeling of pressure. 4) CORRECT - As compartment syndrome continues to progress, obstructed blood flow leads to nerve cell damage. This damage results in numbness and tingling. 5) As compartment syndrome continues to progress, obstructed blood flow leads to pallor and coolness of the extremity.

A 15-year-old client admitted with headache, stiff neck, and fever requires a lumbar puncture. Which factor in the client's history does the nurse identify that permits the client to give informed consent for the procedure? 1. The client's mother is currently at work. 2. The client has a 1-year-old daughter. 3. The client lives in foster care. 4. The client is adopted.

1) Consent is obtained from the parent at work for a 15-year-old child who isn't emancipated. The child can provide assent for the procedure, but consent is obtained from the parent. 2) CORRECT—Clients younger than age 18 who have a child can provide consent for their own treatment. 3) For a child in foster care, the legal guardian must provide legal consent for treatment for the child. 4) For a child younger than age 18, the adoptive parents must provide legal consent for treatment for the child.

The nurse who is a practicing Muslim requests to wear a hijab while working. Which action will the nurse manager take next? 1. Decline the request. 2. Make the accommodation. 3. Advocate for modification of the organization's dress code. 4. Review the organization's dress code policy.

1) Declining the request should not be done without reviewing the dress code policy. 2) Making the accommodation should not be done without reviewing the dress code policy. 3) The organization's policy should be reviewed prior to advocating for change, because the accommodation may already be included in the policy. 4) CORRECT - Reviewing the dress code policy should take place on a regular basis, from a cultural standpoint, to accommodate the various traditional dress needs of employee groups. In addition, the accommodation for wearing the requested clothing may already be covered in the dress code.

The nurse provides care to a client with a tracheostomy. Which nursing action performed before the client eats poses a risk to the client? 1. Deflate the tracheostomy cuff. 2. Provide thin liquids. 3. Suction the tracheostomy. 4. Raise the head of the bed.

1) Deflating the tracheostomy cuff prior to giving the client solid food makes it easier to swallow. 2) CORRECT — The client is given thickened, rather than thin, liquids to reduce the risk of aspiration. 3) Suctioning after the cuff is deflated and before the client eats reduces the risk of aspiration. 4) Raising the head of the bed ensures adequate oxygenation and reduces the risk of aspiration.

The nurse creates a care plan for a client diagnosed with bilateral lower lobe pneumonia. Which intervention is appropriate for the nurse to delegate to the nursing assistive personnel (NAP)? (Select all that apply.) 1. Instructing the client on the importance of increasing fluid intake. 2. Assisting the client to a high-Fowler position when in bed. 3. Encouraging the client to not talk when receiving a nebulizer treatment. 4. Reminding the client to use the incentive spirometer every hour when awake. 5. Encouraging the client and family to wash their hands frequently.

1) Education is a task the nurse should complete and should not be delegated to the NAP. 2) CORRECT — Assisting a client to a high-Fowler position when in bed is an appropriate task the nurse can delegate to the NAP. 3) CORRECT — Encouraging a client to not talk during a nebulizer treatment is an appropriate task the nurse can delegate to the NAP. 4) CORRECT — Reminding the client to use the incentive spirometer every hour while awake is an appropriate task the nurse can delegate to the NAP. 5) CORRECT — Encouraging the client and family to wash their hands frequently is an appropriate task the nurse can delegate to the NAP.

The nurse provides care for a young school-age child who is injured. The client requires sutures. Which strategy does the nurse use to prepare the child for the suturing procedure? (Select all that apply.) 1. Explain the procedure thoroughly and use correct terms. 2. Involve the child in distraction such as music or a game. 3. Ask the parents to leave the room until the procedure is done. 4. Restrain the child to prevent movement during procedure. 5. Use guided imagery that involves a previous enjoyable event.

1) Explaining the procedure completely is more appropriate for an adult. Depending on the age of a child, explaining the procedure with correct terms may frighten the child. 2) CORRECT — Distraction is a proven pain management technique for this age child. 3) Having the parents leave may increase anxiety and stress for both the child and the parents. Parents can help distract the child and provide nonpharmacological pain management. 4) Restraining a young school-age child may not be necessary if the appropriate distraction techniques are used instead. Utilizing the parent to help the child and explaining to the child that lying quietly is needed may be adequate. 5) CORRECT — Distraction techniques are useful for a young school-age child during a painful procedure.

The nurse provides care for an infant who has a fractured femur. Which statement regarding pain in an infant is accurate? (Select all that apply.) 1. Infants cannot feel pain. 2. Infants cannot express pain. 3. Infants have the same sensitivity to pain as older children. 4. Pain scales do not work well with infants. 5. Absorption of pain medication is faster in an infant than an adult.

1) Infants begin to process pain in utero. 2) Infants respond to pain with behavioral cues such as crying and withdrawing limbs. 3) CORRECT — Infants have the same sensitivity to pain as older children. 4) Behavioral pain scales effectively assess the level of pain in an infant. 5) CORRECT — Absorption of medications is quicker in an infant than an adult.

Upon arriving to the operating room suite, a client tells the nurse that no one provided a paper for the client to sign that gives permission to complete the surgery. Which action will the nurse take first? 1. Explain the surgical procedure to the client. 2. Ask the client to sign the consent form now. 3. Determine if preoperative medications were given to the client. 4. Notify the health care provider that a consent form has not been signed.

1) It is the health care provider's responsibility to explain the procedure as part of informed consent. 2) Informed consent should be provided without coercion or influence of potential mind-altering substances. The client might have already received preoperative medications, which means that the consent form cannot be signed at this time. 3) CORRECT - Before taking any action, the nurse needs to learn if the client has received preoperative medications that would affect the client's decision-making ability. 4) Notifying the health care provider would occur after determining if the client has already received preoperative medications.

The nurse delegates care of a client at risk for venous thromboembolism to the LPN/LVN. Which action by the LPN/LVN causes the nurse to intervene? (Select all that apply.) 1. Reinforce the need to flex and extend legs and feet every 2 hours with the client. 2. Apply sequential compression devices to the client. 3. Administer enoxaparin 80 mg subcutaneously to the client. 4. Teach the client the symptoms of pulmonary embolism. 5. Administer oral norgestimate-ethinyl estradiol to the client.

1) It is within the LPN/LVN's scope of practice to reinforce teaching. 2) It is within the LPN/LVN's scope of practice to apply sequential compression devices. 3) Subcutaneous medication administration is within the LPN/LVN's scope of practice. 4) CORRECT - The nurse should perform initial teaching regarding symptoms of a pulmonary embolism. 5) CORRECT - Although medication administration is within the LPN/LVN's scope of practice, the nurse should intervene because this medication increases the risk of venous thromboembolism.

The nurse is proving care for several clients. Which client need will the nurse address first? 1. Client with a stroke needing a hand splint reapplied. 2. Client with diabetes and a fasting blood glucose of 78 mg/dL requesting a snack. 3. Client with diarrhea needing the bedside commode emptied. 4. Client with emphysema requesting assistance with ambulation. View Explanation

1) Needing a splint applied is a task that is less of a priority than the client with lung disease requesting ambulation. This task should be completed third. 2) A client with diabetes and a stable blood sugar requesting a snack is more stable than the client with lung disease requesting ambulation. This task would be completed second. 3) A client with diarrhea needing the commode emptied would be a task that is not a priority and can wait until last. 4) CORRECT - The client with emphysema has breathing difficulties and wants to ambulate. This client needs to be monitored closely when ambulating and should be the highest priority.

The nurse provides care for a newborn client in the nursery. Which sign indicates to the nurse that the client is experiencing neonatal hypoglycemia? (Select all that apply.) 1. Hyperthermia. 2. Poor feeding. 3. Jitteriness. 4. Hypertonia. 5. Seizures.

1) Newborns are often hypothermic. not hyperthermic, with hypoglycemia. 2) CORRECT—Poor feeding is a common sign of neonatal hypoglycemia. 3) CORRECT—Jitteriness is a common sign of neonatal hypoglycemia. 4) Newborns are often hypotonic with hypoglycemia, not hyperglycemia. 5) CORRECT—Seizures can result from neonatal hypoglycemia.

The nurse cares for a client after a liver transplant. Which assessment finding would cause the nurse to be most concerned about organ rejection? 1. AST 30 U/L (0.50 µkat/L). 2. Pale, yellow urine. 3. Soft, brown stools. 4. Conjunctival icterus.

1) Normal aspartate aminotransferase (AST) is 10 to 40 U/L (0.17 to 0.67µkat/L). An elevated AST and alanine aminotransferase (ALT) indicates liver impairment and possible rejection. 2) Dark-colored urine indicates liver impairment and possible rejection. 3) Light or clay-colored stools indicate liver impairment and possible rejection. 4) CORRECT — Conjunctival icterus ("yellowing of the white of the eye") is a sign of liver impairment and possible rejection.

The charge nurse observes client care provided by staff members. Which observation will the nurse immediately intervene? (Select all that apply.) 1. Speech-language pathologist offers a post-cerebral vascular accident (CVA) client thickened liquid from a spoon. 2. Health care provider uses a personal stethoscope to assess a client with pneumonia caused by Acinetobacter. 3. Nursing assistive personnel (NAP) changes bed linen while the client with Meniere disease ambulates to the bathroom. 4. LPN/LVN gathers normal saline, blood tubing, and premedications for a client going to receive a blood transfusion. 5. Nurse leaves a client's room and enters another before performing hand hygiene.

1) Offering thickened liquid from a spoon is appropriate and manageable for the post-CVA client. 2) CORRECT — Acinetobacter is a multidrug resistant organism (MDRO). The health care provider uses a dedicated stethoscope that stays with the client to avoid transferring this MDRO to other clients. 3) CORRECT — Meniere disease is characterized by severe dizziness or vertigo, resulting in the inability to walk straight. The client does not ambulate unassisted due to a high fall risk. 4) Although the LPN/LVN may not be able to administer blood, depending on state regulations, the LPN/LVN can gather needed supplies, administer premedications such as acetaminophen, and monitor the blood product infusion. 5) CORRECT — Hand hygiene should be performed after completing client care and before beginning care with another client.

The family of a dying client on an oncology unit ask the nurse if there is a difference between palliative sedation and euthanasia. Which response by the nurse is best? 1. "The principles of palliative sedation and euthanasia are almost identical." 2. "Palliative sedation is intended to relieve symptoms that were not responsive to traditional treatments, whereas euthanasia hastens death." 3. "Although palliative sedation and euthanasia are really the same thing, we do not give clients and their families this explanation." 4. "In order to answer this question, I will need to follow hospital policy and consult the Ethics Committee."

1) Palliative sedation is used when symptoms are no longer manageable with non-pharmacological and pharmacological measures. The intent of euthanasia is to hasten death. 2) CORRECT- This response describes the difference between the two types of end-of-life care. 3) This response indicates that the health care team is withholding information from the family or being dishonest in the information they present. 4) The nurse is able to answer questions and meet the needs of clients and families of the unit. The purpose of Ethics Committees vary widely including policy development, education, and/or consultation. However, convening a committee meeting to answer this question is inappropriate and not a timely solution.

The nurse teaches the client's spouse about home care. The client is immobile and incontinent. Which instruction does the nurse include? 1. Place a pillow at the client's abdomen for side-lying position. 2. Position the drawsheet from the shoulders to below the hips. 3. Use three incontinence pads on the bed with changes. 4. Avoid laying the client completely flat during positioning.

1) Place a pillow at the client's back, under the head, and under the uppermost leg or between the knees for the side-lying position. 2) CORRECT— Positioning is easier on both the client and the caregiver if the sheet is positioned from the shoulders to below the hips so that the bulk of the client's weight can be evenly distributed for the person performing the positioning. 3) Using multiple incontinence pads is considered detrimental to the client's skin health as it creates additional areas of pressure at each pad edge and multiple pads tend to become wrinkled more easily. 4) If tolerable, the client should be flat while bathed or turned. This makes the turn easier for the client and caregiver and is more efficient, decreasing shear and friction.

The nurse assists the code team treating a client with asystole. Cardiopulmonary resuscitation (CPR) is in process. Which direction by the code team leader requires the nurse to intervene? 1. "Push hard and push fast during compressions." 2. "Give atropine 1 mg followed by an NS flush." 3. "Give epinephrine 1 mg every 3 to 5 minutes." 4. "Continue CPR for 2 minutes and then check rhythm."

1) Push hard to at least 2 inches depth at 100 to 120 compressions per minute. 2) CORRECT — Atropine is not indicated for a client with no rhythm, but it is used for clients with bradycardia. 3) Epinephrine 1 mg every 3 to 5 minutes is correct. It increases the strength of contractions of the heart and increases the rate of contractions. 4) Perform CPR for 2 minutes before doing rhythm checks.

The nurse suspects that a client with a head injury is developing Cushing triad. Which finding causes the nurse to make this clinical determination? (Select all that apply.) 1. Respiratory rate 20 breaths/min. 2. Pulse oximeter 92%. 3. Pulse 52 beats/min and irregular. 4. Temperature 98.4ºF (36.9ºC). 5. Blood pressure 180/58 mm Hg.

1) Respiratory rate is not used to determine the development of Cushing triad. 2) Pulse oximeter percentage is not used to determine the development of Cushing triad. 3) CORRECT - One criterion for the development of Cushing triad is bradycardia. A heart rate of 52 beats/min indicates bradycardia. 4) Body temperature is not used to determine the development of Cushing triad. 5) CORRECT - An elevated blood pressure with a widening pulse pressure are criteria for the development of Cushing triad.

A client expresses anxiety about waiting for the results of diagnostic tests. Which nursing response is therapeutic? 1. "I'm sure everything will be fine." 2. "Tell me more about your concerns." 3. "I'll tell you as soon as I hear something." 4. "Don't be upset until there is a reason to be."

1) Saying that everything will be fine provides false reassurance, which is a barrier to therapeutic communication. 2) CORRECT— Asking the client to talk more about feelings is a technique to encourage communication. This response is therapeutic. 3) Saying that the client will be told as soon as information is learned is minimizing the client's concerns. This response is not a therapeutic communication technique. 4) Saying that the client should not be upset is passing judgement, which is a barrier to communication. It also dismisses the client's concerns. This response is not a therapeutic communication technique.

The nurse notes that a client is prescribed sevelamer. Which action will the nurse take when providing the client with a dose of the medication? 1. Remind to chew the medication. 2. Ask to drink a full glass of water. 3. Inquire about an allergy to shellfish. 4. Provide with a meal.

1) Sevelamer should not be chewed. 2) Sevelamer does not need to be taken with a full glass of water. 3) Sevelamer does not have a cross-allergy with shellfish. 4) CORRECT - Sevelamer is a phosphate binder and should be taken with meals.

The nurse teaches a parent measures to reduce her school-age client's fever. Which information does the nurse include? 1. Sponge the skin with cold water. 2. Give aspirin for a fever of 100.4° F (38° C) or higher. 3. Cover with warm blankets. 4. Apply clothing lightly.

1) Tepid water should be used to prevent shivering 2) Aspirin and aspirin-containing products are not recommended for a child under 19 years of age with a fever because of a possible risk for Reye syndrome. 3) Warm blankets should be avoided with a fever. Evaporative heat loss is needed. 4) CORRECT - Clothing should be applied lightly to allow for evaporative heat loss.

The nurse prepares to administer an intravenous (IV) vesicant chemotherapy to a client. Which is the correct area to insert an IV catheter for this medication? 1. Antecubital. 2. Wrist. 3. Hand. 4. Forearm.

1) The antecubital area can bend and lead to extravasation with the possible loss of function to surrounding tissues from the vesicant medication. 2) The wrist bends and can lead to extravasation with the possible loss of function to surrounding tissues from the vesicant medication. 3) The hand bends and can lead to extravasation with the possible loss of function to surrounding tissues from the vesicant medication. 4) CORRECT— The forearm is the safest peripheral intravenous site for chemotherapy infusion because it does not involve a movable joint.

The nurse prepares teaching materials to review chest physiotherapy with the parents of a pediatric client diagnosed with cystic fibrosis (CF). Which observation indicates to the nurse that additional teaching is needed? (Select all that apply.) 1. Blood pressure 110/68 mm Hg. 2. Pulse oximetry 88% on room air. 3. Respiratory rate 24 breaths/min. 4. Ecchymosis over the back and lateral chest. 5. Complaint of pain with deep inspiration.

1) The blood pressure does not indicate inappropriate technique. 2) CORRECT - Hypoxemia is an adverse effect of incorrectly performed chest physiotherapy. 3) An elevated respiratory rate is to be expected with CF. 4) CORRECT - Bruising is an adverse effect of incorrectly performed chest physiotherapy. It indicates cupping is too forceful or incorrectly done. 5) CORRECT - Pain is an adverse effect of incorrectly performed chest physiotherapy.

The charge nurse notes that a client is seen in the emergency department (ED) for the third time in 5 weeks. The client has a history of a chronic respiratory disorder and diabetes mellitus. The client's record lists multiple home addresses and no family. The client indicates a lack of employment. Which referral is most appropriate for this client? 1. Hospital social worker. 2. Community housing. 3. Case manager. 4. County welfare program.

1) The client may benefit from a hospital social worker referral. However, it does not address the breadth of services needed. 2) The client may benefit from a community housing referral since the client's ED record shows multiple home addresses. However, it addresses only one need. 3) CORRECT - The case manager is the best referral because this person works in collaboration with other departments and community agencies to take care of the client's multiple needs. 4) The client may benefit from a county welfare program referral. However, it does not address the breadth of services needed.

A client sues the nurse and the hospital for malpractice. Which resource will the nurse refer to determine if the client's suit is legitimate? 1. Medical record. 2. Standards of care. 3. American Nurses Association Code of Ethics. 4. The Joint Commission standards.

1) The medical record would be reviewed to determine if prescribed orders were followed. However, this would not help determine if the suit against the nurse is legitimate. 2) CORRECT - The first step in proving malpractice is to determine if negligence occurred. Negligence is defined as conduct that deviates from what another person would do in a similar situation. Standards of care are used to determine if the nurse was negligent when providing care. 3) The American Nurses Association Code of Ethics provides guidance to ensure nurses provide care in an ethical manner. This would not help determine if a client's malpractice suit is legitimate. 4) The Joint Commission standards are used to ensure client safety. These standards are not used to determine if negligence or malpractice occurred.

The nurse provides care for a toddler admitted with pneumonia. Which action by the nurse demonstrates the principles of atraumatic care? 1. Insert an intravenous (IV) catheter in the toddler's right hand. 2. Adopt a hospital routine for the toddler's activities of daily living. 3. Restrain the toddler during IV catheter insertion. 4. Use a topical anesthetic prior to IV catheter insertion.

1) The nurse attempts to insert an IV catheter in a location where the toddler will not require a restraint or arm board. Inserting an IV catheter in the toddler's hand results in restraint or arm board use, which restricts the toddler's movement. 2) Using the principles of atraumatic care, the nurse maintains the child's home routine related to activities of daily living. 3) According to the principles of atraumatic care, alternate positioning, such as therapeutic hugging, is used during invasive or painful procedures, such as IV catheter insertion, instead of a restraint. 4) CORRECT — Following the principles of atraumatic care, the nurse applies a topical anesthetic to the intended insertion location before inserting an IV catheter in a child.

The nurse provides care for a client with sealed radiation implants to treat uterine cancer. Which action is appropriate for the nurse to implement? (Select all that apply.) 1. Keep the client's door open to prevent isolation. 2. Place a dosimeter film badge on the client's gown. 3. Restrict visitors less than 16 years of age. 4. Keep long-handled forceps in the client's room. 5. Limit each visitor to no more than 30 min per day.

1) The nurse should keep the client's door closed as much as possible to prevent radiation exposure outside the room. The nurse should provide distractions for the client to minimize feelings of isolation. 2) The nurse should wear a dosimeter film badge during care of the client to monitor radiation exposure. This badge does not provide any protection against exposure. 3) CORRECT - The nurse should restrict visitors less than 16 years of age and those that are pregnant because these individuals are at greatest risk for injury from radiation exposure. 4) CORRECT - The nurse should keep long-handled forceps in the client's room in case any of the radiation implants are dislodged and the nurse needs to retrieve them. This will prevent direct exposure to the radiation source. 5) CORRECT - The nurse should limit all visitors to no more than 30 min per day to minimize radiation exposure.

The nurse notes these findings in a newborn: skin smooth and transparent, abundant lanugo on back, slow recoil of pinnae, and absent plantar creases. When planning care, the nurse will assess the newborn for which condition? 1. Subinvolution. 2. Hyperglycemia. 3. Postmaturity syndrome. 4. Respiratory distress syndrome.

1) This is a maternal condition in which postpartum uterus does not return to normal size. 2) The findings do not support hyperglycemia. 3) The findings are characteristic of preterm infant. 4) CORRECT - Abundant lanugo and slow recoil of pinnae indicate a preterm infant. Plantar creases are absent in preterm infants <32 weeks' gestation. Respiratory problems are a major concern because of immature lungs and insufficient surfactant. Infants born before adequate surfactant production develop respiratory distress syndrome (RDS).

The nurse notes the client's electrocardiogram (ECG) rhythm is torsades de pointes. Which assessment does the nurse complete after a normal sinus rhythm is restored? 1. Monitor for ST segment depression. 2. Monitor for QT interval prolongation. 3. Monitor for PR interval prolongation. 4. Monitor for narrow QRS complexes.

1) Torsades de pointes is not associated with ST depression. 2) CORRECT — Torsades de pointes is associated with prolonged QT interval. 3) Torsades de pointes is not associated with PR prolongation. 4) Torsades de pointes is not associated with narrow QRS.

The staff nurse attends a presentation on legal and ethical issues in nursing. Which statement by the staff nurse indicates a need for additional teaching? 1. "Putting a client in a geriatric chair with the lap tray in front of the client in the day room to watch television is an example of false imprisonment." 2. "Telling a client that you will insert a feeding tube if the client does not eat is an example of assault." 3. "Telling the hospital chaplain that a client is terminally ill is an example of a breach of confidentiality." 4. "Placing hands on a client who says 'do not touch me' is an example of battery."

1) Unauthorized restraint or detention of a person is false imprisonment. 2) Assault is a threat of bodily harm or violence caused by a demonstration of force by the perpetrator. A feeling of imminent harm or feeling of immediate danger must exist for assault to be claimed. 3) CORRECT— The chaplain is considered a member of the interdisciplinary team and may be given information about clients. Confidentiality has a wide range of meanings. The nurse can convey information to health team colleagues at client-care conferences verbally or by reading nurse's notes. This statement requires additional teaching. 4) Actual or threatened physical harm caused to another person is battery. Battery may involve angry, forceful touching of people, their clothes, or anything attached to them or touching people against their will.

The nurse prepares to administer a unit of packed red blood cells to a client. Which element regarding the age of blood cells is the priority for the nurse to check before the transfusion begins? 1. Clots in the tubing. 2. Blood group and type. 3. Expiration date. 4. Blood identification number.

1) Clots in the tubing are not related to the age of the blood cells. 2) Blood group and type is not related to the age of the blood cells. 3) CORRECT — Careful notation of the expiration date by the nurse is an essential part of the verification process before hanging a unit of blood. 4) The blood identification number is not related to the age of the blood cells.

The nurse provides care for a client who reports a lack of appetite, nausea, and passing a small amount of liquid stool throughout the day for several days. Which action does the nurse do next? 1. Administer prescribed medication for constipation. 2. Consult with the dietitian regarding client's diet. 3. Perform a digital rectal exam. 4. Obtain a stool sample from the client.

1) The nurse needs to assess before implementing. 2) The nurse needs to assess before implementing. 3) CORRECT— The client has signs and symptoms of impaction, which need to be further assessed by performing a digital rectal exam. 4) A stool sample is not indicated.