Chronic NCLEX practice

While reading a client's optical chart, the nurse notices that the client has emmetropia. Which assessment findings does the nurse anticipate? A. No corrective lenses; this is a normal finding B. Reading glasses C. Contact lenses D. Bilateral eye patches

A. No corrective lenses; this is a normal finding Emmetropia is perfect refraction (bending of light rays from the outside world into the eye) of the eye. Emmetropia is a normal (and ideal) condition that does not require any treatment.Eye patches, contact lenses, and reading glasses are not needed.

The nurse is preparing to give multiple prescribed medications to an older adult client. Which serum laboratory test value would the nurse review as the priority prior to medication administration? A. Blood urea nitrogen B. Hematocrit C. Creatinine D. Sodium

C. Creatinine Most drugs are excreted via the kidneys so it is important that the client has adequate kidney function. Creatinine is a protein waste product that is excreted by the kidneys with only a small amount remaining in the bloodstream. Therefore, it is the most important laboratory test value to review.

A postoperative client is vomiting and states, "I am having a lot of pain—a 7 on a scale of 0-10." Which route of administration will the nurse choose to administer an analgesic to the client? A. Oral B. Rectal C. IV D. Transdermal

C. Intravenous The intravenous route is the best choice for fast relief of nausea and pain.Oral pain medication may exacerbate the client's nausea and is not the best choice. The rectal route and the transdermal route are not the routes of choice for short-term pain control because their effect is not as rapid or controlled as that of other routes.

The nurse is caring for a client who is actively dying. What nursing action is appropriate? (Select all that apply.) A. Do not encourage the client to stay awake. B. Offer to insert a Foley catheter for comfort. C. Place warm blankets on the client to keep them warm. D. Use moist swabs to keep the mouth and lips moist. E. Encourage the client to eat ice chips and drink as much as possible. F. Make sure the room is well-lit.

A, B, D When caring for a client who is actively dying, the skin may become cold and mottled. Do not apply heating blankets. Using moist swabs will help to keep the client's mouth and lips more comfortable. The room should be dimly lit, with minimal noise and stimulation. The client should be offered ice chips or drink but do not force to drink as much as possible. Allow the client to rest, do not force them to stay awake. The nurse can offer a Foley catheter for comfort.

What roles does the rehabilitation nurse have in the functioning of the rehabilitation team? (Select all that apply.) A. Plans continuity of care for discharge. B. Coordinates rehabilitation team activities. C. Coordinates holistic care. D. Develops the client's fine motor skills. E. Retrains clients with swallowing challenges.

A, B, C Providing holistic care and coordinating all activities of the rehabilitation team is a role for the rehabilitation nurse—perhaps the primary role. The rehabilitation team is diverse and multi-skilled; getting the right skills and services to the client is a primary role for the rehabilitation nurse. The rehabilitation nurse coordinates the care that the client will continue to receive after discharge; this coordination actually begins as the client is admitted to the rehabilitation unit.Fine motor skill development is the responsibility of specialized members of the rehabilitation team. The rehabilitation nurse may be the one who sees these needs and gets the physical therapist, the occupational therapist, and activity therapist involved. Working with clients who have swallowing difficulties is the responsibility of the speech therapist; this activity would not be a role for the rehabilitation nurse.

Which client does the nurse identify that is at high risk for developing hearing problems? (Select all that apply.) A. Teenager listening to music using ear buds B. Airline mechanic C. Drummer in a rock band D. Client with Down syndrome E. Telephone operator

A, B, C, D Clients who are at high risk for hearing problems include an airline mechanic who is exposed to excessive noise, a client with Down syndrome, (a genetic condition associated with frequent hearing problems), a drummer in a rock band due to exposure to loud noise, and a teenager listening to music using ear buds. Ear buds are known risk factors for increasing potential hearing loss among people who use them on a regular basis with elevated noise levels.A telephone operator is not at risk for hearing problems simply because he or she may wear headphones or audio equipment.

The nursing is using the pain assessment in advanced dementia pain scale to assess a client. What categories of pain indicators will the nurse assess? (Select all that apply.) A. Body language B. Facial expression C. Breathing pattern D. Ability to calm the client E. Ability to distract the client F. Picking at skin or clothing G. Vocalizations

A, B, C, D, G Pain Assessment in Advanced Dementia (PAINAD) scale has been tested in patients with severe dementia (Herr et al., 2011). The tool groups behavioral indicators into five categories for scoring using a graduated scale of 0 (least intense behaviors) to 2 (most intense behaviors) per category for a maximum behavioral score of 10:· Breathing (independent of vocalization)· Negative vocalization· Facial expression· Body language· Consolability (ability to calm the patient)Picking at the skin or clothing as well as ability to distract the client are not portions of the PAINAD scale

In which newly admitted client situations does the nurse initiate a conversation about advance directives? (Select all that apply.) A. The laboring mother expecting her first child B. A client with a non-life-threatening illness C. A person who currently has advance directives D. The comatose client who was injured in an automobile crash E. The client with end-stage kidney disease

A, B, C, E All clients who are hospitalized need to be asked about advance directives by the nurse when they are admitted to a hospital. This is a requirement of the Patient Self-Determination Act. Many nurses feel uncomfortable discussing advance directives with "healthy" clients, but the circumstances of admission do not relieve the nurse of this responsibility. The client with preexisting advance directives still needs to be questioned; it is possible that the client's wishes have changed since the documents were established. Clients who have potentially life-threatening diseases or conditions should establish advance directives while they are able to do so.The comatose client is not considered capable of making decisions about his or her wishes concerning advance directives.

The hospital nurse is assigned to establish a rehabilitation milieu on the unit. What elements will the nurse include? (Select all that apply.) A. Protecting clients from embarrassment (e.g., bowel training) B. Making the inpatient unit a more homelike environment C. Allowing time for clients to practice self-management skills D. Keeping to a structured hospital schedule (e.g., medication administration) E. Carefully monitoring fluid and dietary intake F. Encouraging clients and providing emotional support

A, B, C, F As clients undergo rehabilitation, they must learn skills to function independently after they are discharged. Incorporating self-management skills in the environment is crucial. Rehabilitation nurses in hospital settings must provide an environment that encourages and supports clients who are undergoing rehabilitative efforts. The rehabilitative milieu needs to be less structured and more homelike for the client to begin to develop the skills and behaviors that will be needed after discharge. Along with the homelike environment, clients need to be protected from embarrassing situations in this milieu.Although keeping a structured schedule and monitoring fluid and dietary intake are important in the inpatient setting, they are less a matter of focus in the rehabilitation environment. They would not be a primary concern in establishment of this milieu.

The nurse is teaching the client about the use of medical marijuana. What teaching will the nurse include? (Select all that apply.) A. "Medical cannabis is a controlled substance in the United States". B. "Federal and state law often vary in the legality of medical cannabis use." C. "The psychoactive component of medical cannabis is removed." D. "Your health care provider can prescribe cannabis for you." E. "Side effects of cannabis can include dizziness and increased appetite."

A, B, E Cannabis is a schedule I controlled substance and has been since 1970. Federal and state law often vary in the legality of cannabis use. A health care provider cannot prescribe cannabis in any state; however, they may assess and determine whether a client has a qualifying condition in accordance with state law. Side effects of cannabis include: increased heart rate, increased appetite, dizziness, decreased blood pressure, dry mouth, hallucinations, paranoia, altered psychomotor function, and impaired attention. The psychoactive component, THC, is not removed from medical cannabis.

Which systemic disorder may affect vision and require yearly eye examination by an ophthalmologist? (Select all that apply.) A. Hypertension B. Diabetes mellitus C. Hepatitis D. Anemia E. Multiple sclerosis (MS)

A, B, E Clients who are diabetic are at risk for diabetic retinopathy and are in need of annual eye examinations. Clients with elevated blood pressure need to have annual eye examinations because of the increased risk for retinal damage. Clients with MS should have annual examinations because of changes that occur with the neurologic effects of MS that impact visual acuity.Anemia does not require eye examination on a routine basis. Hepatitis does not increase eye risk and is not indicated as a disorder requiring annual examinations.

The nurse is caring for an adult client who has been prescribed quetiapine last year for bipolar disorder. For which adverse drug effects would the nurse observe? (Select all that apply.) A. Urinary retention B. Hypoglycemia C. Restlessness D. Hypertension E. Parkinsonism

A, C, E The nurse would observe for these adverse effects, as well as hypotension and hyperglycemia.

The nurse is in the room while the assistive personnel (AP) is providing incontinence care to a client. Which action by the AP would require the nurse to intervene? (Select all that apply.) A. Allowing the client to remain in the same position. B. Applying moisture barrier cream to the perineal area. C. Using soap and water to clean soiled areas on the perineum. D. Rubbing areas on the sacrum that are slightly red. E. Drying the sacral area carefully with a towel. F. Placing a bed pillow between the client's knees.

A, D The nurse will need to intervene if the AP attempts to rub reddened areas on the client's sacrum or allows the client to remain in the same position. Rubbing reddened areas can cause additional damage to the already fragile capillary system. The client should be repositioned at least every 2 hours. Since the AP is already providing incontinence care, this is an appropriate time to reposition the client to prevent skin breakdown.It is appropriate to dry the sacral areas carefully with a towel and apply moisture barrier cream to the perineal area. This ensures that the skin is dry and protected from moisture. Using soap and water to clean soiled areas on the perineum is appropriate as it placing a bed pillow between the client's knees to avoid areas of pressure from bony prominences.

The nurse is documenting a pain assessment. Which pain descriptions document location of pain? (Select all that apply.) A. Localized pain B. Sharp pain C. Negative vocalization D. Radiating pain E. Referred pain F. Pain rated as a 4 on a scale of 0-10.

A, D, E Pain can be described as belonging to one of four categories related to its location: localized, projected, referred, and radiating. Localized pain is confined to the site of origin. Projected pain is diffuse around the site of origin and is not well localized. Referred pain is felt in an area distant from the site of painful stimuli. Radiating pain is felt along a specific nerve or nerves.Pain rated as a 4 on a scale of 0-10 describes the intensity of the pain, not the location. Sharp pain describes the quality of the pain, not the location. Negative vocalization is an indicator of the presence of and quality of pain in adults with dementia.

The nurse is assessing a client with recent changes in hearing. After taking a medication history, which drug does the nurse identify as a possible cause of the client's hearing change? (Select all that apply.) A. Furosemide B. Acetaminophen C. Insulin D. Ibuprofen E. Erythromycin F. Atenolol

A, D, E The nurse identifies erythromycin, ibuprofen, and furosemide as medications known to increase the risk for ototoxicity and hearing problems.Acetaminophen, beta blockers, and insulin are not known ototoxic drugs.

The nurse is teaching a class of older adults about ways to promote their cognitive health. Which collaborative interventions will be most helpful for them? (Select all that apply.) A. Joining a peer group with a common learning goal B. Meditating for 30 minutes every day C. Allowing for increased rest and relaxation time D. Having solitary times to reminisce about life experiences E. Starting a new physical activity F. Learning a new skill

A, E, F Increased rest time, meditation, and increased solitude may be helpful for other aspects of aging but do not benefit the older adult's cognitive capabilities.

A client reports increasing pain during dressing changes to the nurse. Which interventions are recommended for the client? (Select all that apply.) A. Music therapy B. Assistance by the client with the dressing change C. Epidural analgesic D. Transcutaneous electrical nerve stimulation (TENS) E. Distraction F. Premedication

A, E, F Interventions recommended for the client include distraction, music therapy, and premedication. Distraction stimulates efferent nerve fibers and reduces the client's perception of painful experiences. Music therapy provides a distraction and can reduce the client's pain perception; efferent nerve fibers are stimulated. Premedication before painful treatments is a good method of controlling pain during treatment.Involving the client in an uncomfortable dressing change would tend to increase the client's perception of pain; it is a better tactic to distract the client. Although epidural analgesia is effective, it is a method of providing pain relief that requires an epidural catheter to be in place; the use of such an invasive procedure would not be indicated for pain relief during a dressing change. Use of a TENS unit is effective in controlling certain types of pain, such as incisional pain, but its use during a dressing change would not be feasible.

The nurse is talking to a group of active senior citizens about making healthy lifestyle choices. Which suggestion is most important in promoting health and safety? A. "Enroll in a safe driving refresher course and avoid risky driving situations." B. "Continue to eat healthy foods, especially protein." C. "Walk 30 minutes three to five times a week." D. "Seek counseling for depression, because it is not a normal part of aging."

A. "Enroll in a safe driving refresher course and avoid risky driving situations." Safe driving refresher courses are one method to help older adults identify and manage these lifestyle choices. Motor vehicle crashes are the most common cause of injury-related death for those between 65 and 74 years of age. To promote health and safety, driving should be discontinued when vision, reflexes, or confidence begin to suffer.Eating healthy foods and exercise promote health but not safety. Encouraging good mental health promotes well-being but not safety.

The nurse is assessing the nutritional status of an older adult client. Which statement made by the client needs to be explored further? A. "For protein in my diet, I like to get the fish sandwich and fries at the fast-food drive-through at least three times a week." B. "With less activity and exercise in my life these days, I should reduce my total calorie intake." C. "To keep my bowel movements regular, I try to eat some fresh fruits or vegetables each day." D. "Although I enjoy eating sweets and desserts, I need to balance them with healthier foods."

A. "For protein in my diet, I like to get the fish sandwich and fries at the fast-food drive-through at least three times a week." Fast food is a contributor to high carbohydrate and caloric intake in older adults. Because fast food is relatively inexpensive and convenient, this population tends to abuse it, thus gaining weight from unhealthy calories.Older adults do enjoy sweets and desserts because their taste acuity changes, but they still need to eat a variety of foods that are high in protein and vitamins, as well as with different textures and fiber content. Consuming fresh fruits and vegetables is characteristic of a healthy lifestyle in older adults; this practice will help keep bowel habits routine. As older adults begin to lead a more sedentary lifestyle, they need to decrease their caloric intake to match a diminished basal metabolic rate.

A client in rehabilitation says, "This is too hard. My life will never be the same again!" What is the nurse's BEST response? A. "How did you handle challenges before you were injured?" B. "Why don't you try a relaxation exercise?" C. "Should I call a family member to help?" D. "You will be fine, don't worry so much."

A. "How did you handle challenges before you were injured?" The nurse's BEST response is to ask the client how challenges were handled before the injury. The nurse should assess the client's previous coping strategies and support systems so that they can be used during rehabilitation, if needed. This open-ended question allows the client to problem solve and explore plausible ways to cope.Besides being a "closed" question requiring a "yes-or-no" response, asking if a family member should be called could provide a supportive environment for the client, but would not build coping skills. Suggesting a relaxation exercise minimizes the client's current situation, and "why" questions are not therapeutic because they place the client in a defensive mode. Also, relaxation may be an option, but is one that has to be learned. Telling the client that he or she will be fine minimizes the client's current situation. Giving reassurances is not considered a therapeutic response; it closes communication.

An older adult client admitted to a nursing home for rehabilitation asks the nurse if the client's care will be covered by Medicare. What response by the nurse is correct? A. "Medicare A should cover 100% of your rehabilitation skilled care for a limited period of time." B. "Medicare D should pay for the total costs of drugs you take while you are here." C. "Medicare G should pay 80% of your lab and x-rays while you are here." D. "Medicare B should pay 100% of your rehabilitation therapy sessions while you are here."

A. "Medicare A should cover 100% of your rehabilitation skilled care for a limited period of time." Medicare A pays for skilled care in hospitals and other settings. However, the client must be certified as requiring skilled care requiring licensed health professionals to provide assessments and interventions for the client. The maximum limit for skilled care with 100% Medicare coverage is 100 days. Medicare B does not pay for 100% of therapy and Medicare D may not pay for the total costs of drugs. There is no Medicare G plan.

A client with right-sided weakness is receiving antihypertensive medications. What does the RN communicate to the physical therapist (PT), who is planning to help the client walk? A. "Move the client from lying to standing slowly." B. "Monitor the client for weakness and fatigue during exercise." C. "Use a gait belt when ambulating the client." D. "Remind the client to use the left side to grip."

A. "Move the client from lying to standing slowly." The RN tells the PT to move the client from lying to standing slowly. Because the PT may not be aware of the client's medications or that antihypertensives can cause orthostatic hypotension, the nurse should discuss this with the PT before the client is ambulated.The PT will not need instruction about how to safely exercise (monitor for weakness), to use the left side to grip, or to ambulate the client, because these activities are included in the role of the PT in rehabilitation.

A client who is using patient-controlled analgesia (PCA) is asleep. The nurse observes a family member pushing the PCA button for the sleeping client. What will the nurse say to the visitor? A. "Please allow the client to push the button when needed." B. "Please don't touch any equipment in the client's room." C. "Thank you. I am sure the client appreciated that." D. "The client is asleep and is not in pain."

A. "Please allow the client to push the button when needed." The nurse will request that the visitor allow the client to push the button for medication when needed. The "PC" in "PCA" means "patient-controlled," so having someone else push the button and administer analgesia defeats the purpose. More important, this action could cause oversedation and possible serious safety issues.Telling the family member not to touch any equipment in the client's room is not only nonspecific, but it may also be perceived as disrespectful. Expressing appreciation is inappropriate because the nurse is condoning an unauthorized and potentially unsafe action. The fact that the client is asleep does not mean that the client is pain-free.

An older adult client admitted to the hospital for heart failure has a history of a fractured hip due to a previous fall. The client is taking hydrocodone-acetaminophen as needed for pain secondary to an extensive dental procedure. Which risk factor puts this client at greatest risk for a fall? A. History of a fall B. Age C. Opioid use D. Diagnosis

A. History of a fall The client's recent history of falling is the single most important predictor for falls.Adults age 80 years and older and those with multiple diagnoses are at higher risk for falls. Opioids may cause mental changes, but this is not the greatest risk for a fall.

The nurse has been effectively using digital stimulation in older adult clients with constipation problems. For which client is this practice unsafe? A. A 70 year old with recently diagnosed atrial fibrillation B. A 68 year old with a long history of multiple sclerosis (MS) C. A 74 year old who is 4 months poststroke D. An 84 year old with progressive dementia and confusion

A. A 70 year old with recently diagnosed atrial fibrillation The practice is unsafe for a 70 year old with recently diagnosed atrial fibrillation. Digital stimulation is contraindicated in clients with cardiac disease because of the risk of initiating a vagal nerve response. Instead, another method of treatment for constipation should be used, such as diet, fluids, or laxatives.The client with MS, the client who is poststroke, and the client with dementia and confusion are safe risks. These clients would not have a higher risk of negative effects from digital stimulation than the average person without cardiac issues.

A client with terminal lung cancer is receiving hospice care at home. Which nursing action will the RN manager ask the LPN/LVN to do? A. Administer prescribed medications to relieve the client's pain, shortness of breath, and nausea. B. Teach the family to recognize signs of client discomfort such as restlessness or grimacing. C. Clarify family members' feelings about the meaning of client behaviors and symptoms. D. Develop a plan for care after assessing the needs and feelings of both the client and the family.

A. Administer prescribed medications to relieve the client's pain, shortness of breath, and nausea. LPN/LVNs are educated to administer medications and monitor clients for therapeutic and adverse medication effects; the administration of prescribed medications to the client for pain, shortness of breath, and nausea is appropriate to delegate to the LPN/LVN.Clarifying family members' feelings, developing a plan of care, and teaching the family to recognize signs of discomfort all require broader education and are appropriate for the RN practice level.

A client with cancer who is taking pain medication states, "I am still having pain." During the assessment, the client does not exhibit any physical signs of pain. What will the nurse do next? A. Administer the pain medication as requested. B. Withhold the pain medication. C. Decrease the client's standard pain medication dose. D. Give the client a placebo and monitors the outcome.

A. Administer the pain medication as requested. The nurse will administer the pain medication as requested. Both types of persistent (chronic) pain (chronic cancer pain and chronic noncancer pain) do not cause sympathetic reactions. Therefore, some clients do not appear to be in pain, even when they are. Clients with cancer tend to know what medication works for them. The nurse needs to follow the protocol for the client regardless of the client's objective symptoms when managing chronic cancer pain.The nurse would not decrease pain medication under the assumption that, because the client does not exhibit signs of pain, the client must not have any pain. Unless the client is involved in a clinical research trial, giving a placebo in place of medication is never appropriate. It is never appropriate to withhold prescribed pain medication unless the client is medically unstable and the nurse would contact the health care provider.

Which activity does the RN team leader on a large medical-surgical unit assign to the LPN/LVN? A. Complex dressing changes for a sacral wound for a client with type 2 diabetes who was given prescriptions for pain medication before wound care B. Instructions to a postoperative hip replacement client who has just been placed on patient-controlled analgesia for pain relief C. Assessment of a client scheduled for surgery who is crying and expressing fear that the pain will be intolerable D. Assessment of a client using a transcutaneous electrical nerve stimulation unit to relieve chronic pain

A. Complex dressing changes for a sacral wound for a client with type 2 diabetes who was given prescriptions for pain medication before wound care Complex dressing changes for a sacral wound for a client with type 2 diabetes who was given prescriptions for pain medication before wound care would be assigned to the LPN/LVN. LPN/LVN education and scope of practice include working within practice parameters to administer pain medication and to perform dressing changes.Assessments and client education are not within the LPN/LVN scope of practice.

An older adult client who lives with her daughter is admitted to the hospital. During the admission assessment, the nurse notes strong body odor, several large pressure injuries, and limb contractures. What would the nurse do first? A. Contact the hospital social worker. B. Ask the daughter about the ulcers and contractures. C. Give the client a bath. D. Notify the primary health care provider.

A. Contact the hospital social worker The social worker will assess the client's situation and will contact the appropriate authorities if needed.Asking the daughter sets up a potential confrontation that need not be handled by the nurse. The client needs a bath, but this is not the first action to be taken. Notifying the primary health care provider will be appropriate at a later time, but is not the best action to take at this point.

The nurse is caring for a client who is admitted with mastoiditis. Which nursing action is appropriate? A. Don gloves to examine the pinna. B. Prepare to administer IV antibiotics C. Perform a baseline hearing assessment. D. Teach about Swim-Ear to dry the ears better.

A. Don gloves to examine the pinna. The appropriate nursing action when a client is admitted for mastoiditis is to prepare to administer IV medication. Mastoiditis can progress to a brain abscess, meningitis, or death if not appropriately managed.Teaching about Swim-Ear, donning gloves to examine the pinna, and performing a baseline hearing assessment are not parts of care associated with mastoiditis. Interventions are focused on halting the infection before it spreads to other structures.

The nurse is coordinating interprofessional palliative care interventions for the client who is dying. Which goal is the nurse seeking to meet? A. Facilitating a peaceful death for the client B. Ensuring an expedited death C. Meeting all of the client's needs D. Avoiding symptoms of client distress

A. Facilitating a peaceful death for the client Facilitating a peaceful death for the client is one of the goals of palliative care.Symptoms of distress cannot be avoided but can be controlled. Expedited death is not a goal of palliative care. Identifying client needs is a goal of palliative care, but it is not always possible to meet all of the client's needs (e.g., to prevent death or lengthen life).

A client with terminal pancreatic cancer is near death and reports increasing shortness of breath with associated anxiety. Which hospice protocol order will the nurse implement first? A. Morphine sulfate sublingually as needed B. Albuterol solution per nebulizer C. Prednisone elixir 10 mg orally D. Oxygen 2 to 6 L/min per nasal cannula

A. Morphine sulfate sublingually as needed Morphine sulfate is the standard treatment for the dyspneic client who is near death.Albuterol, oxygen, and steroids may be useful, but should be used as adjuncts to therapy with morphine.

The client is struggling with use of eating utensils. Which rehabilitation team member is brought in to help the client with this problem? A. Occupational therapist B. Physical therapist C. Activity therapist D. Physiatrist

A. Occupational therapist The occupational therapist is brought in to help the client with the use of eating utensils. The occupational therapist works to develop the client's fine motor skills used for activities of daily living, such as those required for eating, maintaining hygiene, dressing, and driving.The recreational or activity therapist works to help the client continue or develop hobbies or interests. The physiatrist is a physician who specializes in rehabilitative medicine; this rehabilitation team member is not the best resource for this situation. The physical therapist helps the client achieve mobility (e.g., by facilitating ambulation and teaching the client to use a walker).Mechanical lift A mechanical lift is the transfer technique indicated for this client. Mechanical lifts use slings to lift, transfer, move, and reposition immobile clients. Because the client is older and has a broken collarbone and is unable to use both arms to independently transfer safely, a mechanical lift is the best method for moving this client.In the past, nurses and therapists used a bear-hug technique to lift the client from bed to chair and back again. However, because heavy lifting can result in back injury, many facilities have adopted a "no lift" policy and rely on other methods for client transfers. A cane will hinder transfer of the client. Slide boards are typically used for transferring quadriplegic clients.

A client who is dying cannot swallow and is accumulating audible mucus in the upper airway (death rattles). These noises are upsetting to family members. What nursing action is appropriate? A. Place the client in a side-lying position so secretions can drain. B. Use a Yankauer suction tip to remove secretions from the client's upper airway. C. Position the client in a high-Fowler position to minimize secretions. D. Assist the family in leaving the room so that they can compose themselves.

A. Place the client in a side-lying position so secretions can drain. Placing the client in a side-lying position to facilitate draining of secretions (by gravity) is the appropriate nursing care intervention. As secretions diminish, noisy respirations will decrease.Asking the family to leave at this important time is not appropriate. Placing the client in a high-Fowler position is ineffective in helping the client who has lost the ability to swallow and increases the danger of choking and aspiration. Oropharyngeal suctioning is not recommended for removal of secretions, because it is not effective and may even agitate the client.

A client with lower motor neuron spinal cord dysfunction has not voided, and a bladder scan shows 700 mL of urine in the bladder. Using the client's bladder training plan, what action does the staff RN advise a new graduate nurse to take first with this client? A. Remind the client to try the Valsalva maneuver. B. Insert a straight catheter to empty the bladder. C. Reassess the client's bladder volume in 2 hours. D. Administer a dose of oxybutynin chloride (Ditropan).

A. Remind the client to try the Valsalva maneuver. The RN advises the new graduate nurse to first try the Valsalva maneuver. Clients with lower motor neuron problems have a flaccid bladder. Increasing pressure on the bladder with the Valsalva maneuver may help the client void.Oxybutynin chloride (Ditropan) is useful in mild cases of overactive bladder. If the Valsalva maneuver is ineffective, straight catheterization may be used to empty the bladder. Because the bladder already holds 700 mL, the nurse should not wait for 2 more hours before taking action to empty the bladder.

At a follow-up homecare visit after repair of a fractured radial bone, an older adult client states, "I am not sleeping at all during the night." The client's partner reports that the client is sleeping all day. Which intervention does the nurse suggest? A. Taking additional pain medication during the day B. Increasing the client's daytime activities C. Placing a "Do not disturb" sign on the door at night D. Taking herbal remedies to enhance sleep

A. Taking additional pain medication during the day Older adult clients should try to stay awake during the day to prevent insomnia at night. Increasing activities will facilitate this goal.The client did not report interruptions, but insomnia; placing a "Do not disturb" sign on the door, although it may be effective in increasing "sleep time," does not address the client's problem. Pain medication is best taken at night because it causes drowsiness. Encouraging herbal remedies to try to promote sleep is not an appropriate suggestion for the nurse to make.

The nurse is caring for a client who reports pain. As an advocate for the client, what will the nurse do first for this client? A. Assess the level of pain B. Administer pain medication C. Accept the client's report of pain D. Call the HCP for a medication order

Accept the client's report of pain. The nurse's primary role in pain management is to advocate for the client by accepting reports of pain, as such, this is the nurse's first action. This has become the clinical definition of pain worldwide and reflects an understanding that the client is the authority and the only one who can describe the pain experience. In other words, self-report is always the most reliable indication of pain.Administering pain medication, assessing the pain level, and calling the provider are responses to the first response which is accepting that the client is in pain.

The nurse recognizes that older adult clients when admitted to the hospital are at high risk for complications and even death. Which risk factors are considered "markers" that can contribute to these negative outcomes? (Select all that apply.) A. Sleep disorders B. Falls C. Nutritional problems D. Confusion E. Incontinence

All of the above

The nurse providing education on eye protection suggests protective eyewear for which client? (Select all that apply.) A. Racquetball player B. Lifeguard C. Cab driver D. Registered nurse E. College student

All of the above are correct All clients are in need of eye protection from ultraviolet (UV) A and UVB rays because of exposure to the sun. People who play sports need to wear protective eyewear to prevent possible eye injury. Nurses may need protective eyewear to avoid getting or transmitting infection.

The nurse is assessing an older adult client to identify possible factors that may negatively impact the client's nutritional status. Which risk factors would the nurse include? (Select all that apply.) A. Loneliness or depression B. Inadequate financial resources C. constipation D. lack of transportation E. tooth loss or poorly fitting dentures F. decreased mobility

All of these factors can prevent clients from eating adequate amounts of or healthy foods.

The nurse is teaching a class on advance directives. What will the nurse include? (Select all that apply.) A. A durable power of attorney for health care is the same as a durable power of attorney for one's health care. B. A living will identifies health care wishes regarding end of life treatment. C. A health care proxy can only make decisions once a person no longer has their own ability to make decisions. D. In order to make a health care decision, a person much be totally oriented. E. A living will contains funeral directives as well as last wishes for family. F. Advance directive are the same from state to state.

B, C Advance directive vary from state to state. While all have similarities, each state is unique. A durable power of attorney for health care is not the same as the durable power of attorney for finances. This can be the same person—but must be defined specifically for both roles. A living will identifies would an individual would (or would not) want when he or she is near death. A living will contains information specific to artificial ventilation, and nutrition or hydration as well as resuscitation directives. It does not contain funeral directives or last wishes for family. In order to make a health care decisions, a person does not need to be totally oriented. However, he or she must be able to receive information and then evaluate, deliberate, and manipulate the information as well as communicate a treatment preference.

The nurse is talking to a client about cerumen removal from the ear canal. Which statement by the client indicates a need for further teaching? A. "I dry my ears using my fingertip and a towel." B. "I use a cotton swab to remove earwax." C. "I use Swim-Ear after I go swimming." D. "I should not use an ear candle to soften the wax."

B. "I use a cotton swab to remove earwax." Further teaching is needed when the client states, "I use a cotton swab to remove earwax." Nothing smaller than the client's own fingertip should be inserted into the ear canal. Use of a cotton swab or other device like a key can scrape the skin of the canal, push cerumen up against the eardrum, and even puncture the eardrum.Using the fingertip and a towel and irrigating the ear canal with tap water are acceptable. Clients are discouraged from using ear candles. Using a product like Swim-Ear to help the ears dry after swimming is appropriate.

The family of a client with chronic cancer pain says to the nurse, "Can you please reduce Dad's pain medication so that we can spend more quality time with him?" How does the nurse respond? A. "Yes, this is a valuable way for all of you to make needed adjustments." B. "Let's ask your father about your request." C. "No, his pain relief is more important than your concerns." D. "I will ask his oncologist about your question."

B. "Let's ask your father about your request." The nurse will respond by indicating that the client's desires about analgesia are the most important consideration in this scenario, and so he would be consulted initially about his family's request. This open-ended type of question acknowledges the family, while keeping the client as the major decision maker.Although the health care provider might have an opinion about the family's request, pain is subjective, and the client's desires about analgesia are the most important consideration. Telling the family that the father's pain control is more important than their concerns is a demeaning response, although technically true; it is dismissive of the family and is nontherapeutic. Giving the family control of pain relief for their father is inappropriate in this situation; the subjective nature of pain places decisions about the use of analgesia with the client who is experiencing the pain. The family and the client may need to make adjustments, but reducing pain relief for the client is not an advisable way to accomplish this goal.

The nurse is planning a dressing change on a postoperative mastectomy client. The client is receiving acetaminophen and oxycodone orally for pain every 4 hours and is due to receive them at 4:00 p.m. When will the nurse change the dressing? A. 3:30PM B. 4:30PM C. 4:00PM D. 7:00PM

B. 4:30PM The nurse will change the dressing at 4:30 p.m. About 30 minutes after administration of an analgesic is an optimal time to perform a procedure on a client. At 4:30 p.m., the opioid has had time to take effect and provide relief for the client.It would be inappropriate to perform a painful procedure, such as a dressing change, just before a scheduled analgesic is received (i.e., 3:30 p.m.), because the pain medication will be at its lowest concentrations in the client's system. At 4:00 p.m., the analgesic has not had time to enter the client's system, so it is too soon to perform the dressing change. If the client received the analgesic at 4:00 PM, it is not at the highest or best concentration at 7:00 p.m. to facilitate a dressing change with minimal discomfort.

The nurse working on an inpatient hospice unit has received the change-of-shift report. Which client does the nurse assess first? A. A 62 year old with lung cancer who has cool, clammy, dusky skin, and blood pressure of 64/20 mm Hg. B. A 26 year old with metastatic breast cancer who is experiencing pain rated at 8 (0-10 scale) and anxiety. C. A 70 year old with cancer of the colon who has a respiratory rate of 8 with loud, wet-sounding respirations. D. A 30 year old with AIDS-associated dementia and agitation who is asking for assistance with calling family members.

B. A 26 year old with metastatic breast cancer who is experiencing pain rated at 8 (0-10 scale) and anxiety. Management of pain is the priority goal for hospice care, so decreasing this client's pain and anxiety should be the first action.The client with AIDS needs rapid assistance, but is the second priority for the nurse in this scenario. The client with lung cancer and the client with colon cancer are exhibiting normal signs and symptoms associated with dying.

Which client does the RN in the rehabilitation unit plan to assess first? A. A 63 year old who had a myocardial infarction (MI) and expresses anxiety about walking B. A 56 year old with a spinal cord injury and new-onset redness over the sacral area C. A 70 year old with a joint replacement who needs medication before exercising D. A 45 year old with multiple sclerosis (MS) reporting constipation

B. A 56 year old with a spinal cord injury and new-onset redness over the sacral area The RN will first assess the 56 year old with a spinal cord injury and new-onset redness over the sacral area. Because new redness over a bony area may indicate the presence of a stage I pressure injury, the nurse should assess this client's skin as soon as possible and implement interventions to improve skin integrity.The client with constipation, the client with anxiety about walking and the client that needs medication to exercise all need assessment and intervention but are not at as high a risk for acute physiologic complications.

The RN is arriving for night shift at an acute care hospital. Which client does the RN assess first? A. A 70 year old with a history of gout and joint pain B. A 72 year old admitted with postoperative delirium C. A 65 year old scheduled for next-day surgery D. A 68 year old with chronic protein-calorie malnutrition

B. A 72 year old admitted with postoperative delirium The postoperative client with delirium is at risk for injury because associated agitation and/or combativeness may lead to behaviors such as climbing out of bed or pulling at invasive catheters.Clients such as a 65 year old scheduled for next-day surgery, a 68 year old with chronic protein-calorie malnutrition, or a 70 year old with a history of gout and joint pain need to be assessed as soon as possible, but scheduled surgery, malnutrition, and a diagnosis of gout with joint pain do not indicate any acute risk for complications.

The nurse is caring for an older adult client who has been under the care of a psychiatrist for 10 years. What is the most commonly occurring mental health disorder in the older adult population? A. Dementia B. Depression C. Bipolar disorder D. Delirium

B. Depression Depression is the most common mental health disorder, both primary and secondary types. Common factors that predispose this group to this disorder include loss and loneliness.

The nurse is conducting a medication assessment on an older adult client who is being admitted to a long-term care facility for rehabilitation following a total hip arthroplasty. With Beers Criteria used as a resource, which drug poses a potential risk for this client? A. Acetaminophen B. Digoxin C. Celecoxib D. Mesalamine

B. Digoxin Beers Criteria is a guideline for health care professionals to help improve the safety of prescription medications for older adults. It involves potentially inappropriate medication use in older adults. Digoxin is listed in the Beers Criteria as a drug that leads to toxicity and drug interaction problems. Clients receiving this medication are at greater risk for serious side effects and interactions.Acetaminophen, celecoxib, and mesalamine are not listed in the Beers Criteria as drugs that lead to toxicity and drug interaction problems.

An older adult client reports ear pain. Which assessment finding will the nurse report as the priority to the health care provider? A. Pain on movement of the tragus B. Dizziness C. Dry, flaky cerumen D. Ringing in the ears

B. Dizziness Dizziness could be the indication of numerous clinical findings; also, the client's risk for falling (or other safety concerns) is raised when dizziness is present. The nurse will report this symptom as the priority to the health care provider.The other concerns can be reported secondary to dizziness.

Which eye procedure requires the nurse to assure that informed consent has been obtained from the client? A. Ophthalmoscopy B. Fluorescein angiography C. Snellen test D. Eyedrop instillation

B. Fluorescein angiography Fluorescein angiography is an invasive test and requires informed consent from the client.Eyedrop instillation, ophthalmoscopy, and the Snellen test are not invasive procedures and do not require informed consent from the client.

Which drug does the nurse anticipate will be prescribed for a client with Ménière disease to decrease endolymph volume? A. Atorvastatin B. Furosemide C. Ibuprofen D. Doxazosin

B. Furosemide Mild diuretics are often prescribed to decrease endolymph volume. Ménière disease causes an excess of endolymphatic fluid that distorts the entire inner-canal system. This distortion decreases hearing by dilating the cochlear duct, causes vertigo because of damage to the vestibular system, and stimulates tinnitus.Ibuprofen, atorvastatin, and doxazosin are not indicated for Ménière disease. Ibuprofen should actually be avoided, as it can increase water retention.

An older adult client with end-stage lung cancer and metastasis to the brain has been admitted to the hospital. After trying all options to provide a safe environment, the nursing staff has to apply restraints. Which nursing intervention is required for this client? A. Using chemical sedation instead of restraints B. Releasing the restraints at least every 2 hours C. Checking the restraints every 1 to 2 hours D. Using the most restrictive devices to prevent falls

B. Releasing the restraints at least every 2 hours The Joint Commission recommends releasing restraints every 2 hours for client care such as turning, repositioning, and toileting.The restraints must be checked every 30 to 60 minutes and not every 1 to 2 hours. Chemical sedation is also considered a restraint. The least restrictive devices should be used.

A client recently diagnosed with Ménière's disease reports ongoing tinnitus, and difficulty coping, despite treatment. How does the nurse provide support to this client? A. Contact the health care provider. B. Refer the client to the American Tinnitus Association. C. Suggest removing ear-mold hearing aids. D. Conduct further assessment.

B.Refer the client to the American Tinnitus Association. The appropriate action by the nurse is to refer the client to the American Tinnitus Association. This group assists clients in coping with tinnitus when other therapy is unsuccessful.Reassessment and contacting the health care provider is not needed since treatment has already been attempted. Ear-mold hearing aids can amplify sounds to drown out tinnitus during the day, so it is inappropriate to suggest that these be removed.

A client is admitted to the emergency department with metal shards in the right eye. Which diagnostic test ordered by the health care provider does the nurse question? A. Radioisotope scanning B. Snellen chart C. Magnetic resonance imaging (MRI) D. Ophthalmoscopy

C. Magnetic resonance imaging (MRI) Because the client has metal in the eye, MRI is an absolute contraindication.Ophthalmoscopy is used to assess the eye for interior and exterior damage and is not contraindicated for this client. Radioisotope scanning assesses the eye for tumors or lesions and is not contraindicated. The Snellen chart measures distance vision and is not contraindicated.

The nurse is caring for a client in a bowel retraining program. Which nursing actions will facilitate consistent defecation patterns? (Select all that apply.) A. Use digital stimulation inserting the finger into the anus for one minute. B. Administer bisacodyl suppository daily. C. Administer the bisacodyl suppository after the client eats a meal. D. Encourage consumption of a high-fiber diet. E. Insert the bisacodyl suppository just inside the anal sphincter.

C, D Nursing actions that are part of bowel retraining include administering a bisacodyl suppository after the client eats a meal and encouraging a high-fiber diet. The bisacodyl suppository should be administered when the client would expect to defecate, such as after a meal. High-fiber meals soften the stool and can promote regularity.Administering a bisacodyl suppository should not occur daily, rather ever second or third day to re-establish a defecation pattern. The bisacodyl suppository should be inserted past the anal sphincter against the bowel wall the stimulate rectal emptying. Digital stimulation is not the insertion of a finger into the anus, rather it is to massage the anus in a circular motion for no less than 1 minute in an attempt to trigger defecation.

The nurse is teaching a class on safe patient handling and mobility. What will the nurse include? (Select all that apply.) A. Place the bed at hip level when providing direct care. B. Attempt to lift with a team prior to using client-handling equipment. C. Keep the client directly in front of your body while providing care. D. Maintain a wide, stable base with your feet prior to lifting. E. Place the client 1 foot away from your body prior to lifting.

C, D When teaching about safe patient handling, maintain a wide, stable base with your feet prior to lifting and keep the client 1 foot away from your body prior to lifting. The bed should be placed at waist level when providing direct care. The client should be as close to your body as possible when providing care to prevent reaching. If safe patient-handling equipment is available, always use.

The nurse is reviewing postoperative instructions with a client undergoing stapedectomy. Which client statement indicates a need for further teaching? A. "I should not drink from a straw for several weeks." B. "I may have problems with vertigo after the surgery." C. "I will be able to hear better as soon as my dressing is removed." D. "I will have to take antibiotics after the surgery."

C. "I will be able to hear better as soon as my dressing is removed." Further teaching is necessary if the client states that hearing will be better as soon as the dressing is removed. Hearing is initially worse after a stapedectomy. The client would be informed that improvement in hearing may not occur until 6 weeks after surgery. At first, the ear packing interferes with hearing, and swelling in the ear after surgery reduces hearing, but these conditions are temporary.Vertigo, nausea, and vomiting are common after surgery because of the nearness of the surgical site to inner ear structures. Clients must not drink through a straw for 2 to 3 weeks after surgery. Antibiotics are used to reduce the risk for infection.

A rehabilitation nurse is teaching the client with a spastic bladder to perform intermittent catheterizations. Which client statement indicates the need for further education? A. "Before I catheterize myself, I will try to urinate." B. "I will catch myself at 9 a.m. and 9 p.m." C. "I will use the Valsalva and Credé maneuvers before trying to urinate." D. "You can teach my son to help me with the catheterizations."

C. "I will catch myself at 9 a.m. and 9 p.m." The statement by the client that, "I will catch myself at 9 a m and 9 p.m.," indicates the need for further education. The client should not go beyond 8 hours between catheterizations. The time between catheterizations in this scenario is 12 hours. This concept needs to be reinforced to the client.The client with a spastic bladder must attempt to void before the catheterization is performed. The Valsalva and Credé maneuvers should be used to attempt voiding before self-catheterization in clients with spastic or flaccid bladders. If the client cannot catheterize him- or herself, a family member can be taught to do it.

The nurse is teaching an older adult client about visual changes that occur with age. Which statement does the nurse include? A. "You will have to move reading materials closer to your eyes to focus." B. "When the sclera turns yellow, you have developed liver problems." C. "It may take your eyes longer to adjust in a darkened room." D. "Most visual changes occur before age 40."

C. "It may take your eyes longer to adjust in a darkened room." The nurse teaches the client that, "It may take your eyes longer to adjust in a dark room." With increasing age, the iris has less ability to dilate, which leads to difficulty in adapting to dark environments.Adults older than 40 years are at increased risk for both glaucoma and cataract formation. Presbyopia also commonly begins in the 40s. The sclera appears yellow or blue as a process of aging, and this condition should not be used to assess for jaundice in the older adult. The near-point of vision (the closest distance at which the eye can see an object clearly) increases with aging. Near objects (especially reading material) must be placed farther from the eye to be seen clearly.

The nurse is teaching a client with vertigo about safety precautions for fall prevention. Which statement by the client indicates a need for further instruction? A. "Moving more slowly may help the vertigo subside." B. "I may need to use a cane to keep my balance." C. "Medication alleviates dizziness, so I can drive." D. "My grandchildren need to keep their toys out of the hallway."

C. "Medication alleviates dizziness, so I can drive." The client's statement about taking medication and driving a car indicates further teaching is needed. Medications for vertigo usually cause drowsiness, so the client must not drive or operate machinery while taking these drugs.The client with vertigo may need to use a cane for balance. Clients need to maintain a safe, uncluttered environment to prevent accidents during periods of vertigo. Restricting head motion and moving more slowly may help clients reduce occurrences of vertigo.

The charge nurse is working with a new nurse. Which statement by the new nurse requires additional teaching by the charge nurse? A. "Older adults usually believe that pain is irrelevant and is to be expected." B. "Older adults are at a very high risk for undertreated pain." C. "Older adults typically believe that expressing pain is acceptable." D. "I always assess older adults for present pain."

C. "Older adults typically believe that expressing pain is acceptable." The charge nurse will need to provide further education to the new nurse regarding the statement, "Older adults typically believe that expressing pain is acceptable."Older adults typically do not believe that expressing pain is acceptable. Many older adults believe that pain is irrelevant and is "just part of getting older."As a result, many older adults are at great risk for undertreated pain. In addition, some health care providers have outdated beliefs about older adults' pain sensitivity, tolerance, and ability to take opioids.

A 44-year-old client with osteoarthritis pain tells the nurse, "I take two extra-strength acetaminophen (500 mg) every 8 hours." How does the nurse respond? A. "More acetaminophen is needed to provide effective pain relief for you." B. "You will need to have routine blood draws to monitor clotting time." C. "That is the appropriate dose of acetaminophen for your pain." D. "Aspirin would be a better, more effective choice for your pain relief."

C. "That is the appropriate dose of acetaminophen for your pain." In the healthy adult, a maximum daily dose below 4000 mg is rarely associated with liver toxicity. Many experts recommend reducing the daily dose (e.g., 2500 to 3000 mg daily) when used for long-term treatment in older adults. Acetaminophen does not increase bleeding time and has a low incidence of GI adverse effects, making it the analgesic of choice for many people in pain, especially older adults. The dose is appropriate; more is not indicated or advised.Acetaminophen is a better choice for pain relief than aspirin because it has fewer side effects on the gastrointestinal system, such as bleeding

A client being discharged after hip replacement says, "I am going to use hypnosis instead of medication to manage my pain. I believe in mind over body." Which nursing response is appropriate? A. "I will discuss cancelling your medication order with your health care provider." B. "That sounds like a wonderful idea; and I think it will definitely work!" C. "That sounds like a great plan; can you tell me more about it?" D. "Your plan will not work; people with your type of pain need opioids."

C. "That sounds like a great plan; can you tell me more about it?" Complementary and integrative therapies are most often used to supplement, not replace, medication management. The nurse needs to obtain more data, and will ask for more information about the client's plan.Contacting the health care provider to cancel the medication order is not appropriate. Telling the client that his idea is wonderful and will definitely work is not appropriate, as alternative strategies alone, may not work to relieve the client's pain. Telling the client that his or her plan will not work is dismissive of the client. In addition, the client may not need to be prescribed opioids for the pain.

A client is to undergo gonioscopy. When the client asks what this test is for, what is the appropriate nursing response? A. "This test creates a three-dimensional view of the back of the eye." B. "Retinal circulation is evaluated by this test." C. "The ophthalmologist uses the test to determine if you have open-angle or closed-angle glaucoma." D. "This method of testing will determine if you have blood vessel changes due to disease or drugs."

C. "The ophthalmologist uses the test to determine if you have open-angle or closed-angle glaucoma." Gonioscopy is performed for clients with high IOP to determine whether open-angle or closed-angle glaucoma is present.A three-dimensional view of the back of the eye is created by ultrasonic imaging of the retina and optic nerve (called ocular coherence tomography). Electroretinography helps the eye care provider to determine if a client has blood vessel changes resulting from disease or drugs. Retinal circulation is evaluated by fluorescein angiography.

The nurse is assessing a client for acute or persistent pain. What nursing question allows the nurse to obtain the most data from the client? A. "Is the pain really that bad?" B. "Does it feel like sharp pain?" C. "When does the pain occur?" D. "Did someone do this to you?"

C. "When does the pain occur?" Asking when the pain occurs helps determine precipitating factors to identify the source of pain. It is an open-ended question that requires a descriptive response and allows the nurse to obtain the most data.Asking if someone hurt the client may be appropriate in rare circumstances, but typically it is not an appropriately focused question; the question does not relate to the severity or character of the pain. Further, this is not an open-ended question. The nurse should ask the client open-ended questions, not questions requiring a "yes-or-no" answer, such as "Does it feel like sharp pain?" Asking "Is the pain really that bad?" minimizes the client's perception of pain; it is also a closed-ended question requiring a "yes-or-no" answer.A

A client has just received a bisacodyl suppository. How soon after administration does the nurse expect results to be evident? A. 5 to 10 minutes B. 10 to 15 minutes C. 15 to 30 minutes D. 30 to 45 minutes

C. 15 to 30 minutes The nurse expects results to be evident within 15 to 30 minutes. Bisacodyl suppository agents are often used in bowel training programs. Suppositories must be placed against the bowel wall to stimulate the sacral arc and promote rectal emptying, which occurs within 15 to 30 minutes after administration.Five to fifteen minutes is not enough time for a glycerin suppository to be effective; the mechanism of action requires a longer time period. Action from the suppository should occur by 30 minutes after insertion.

The nurse is caring for a client who had a fractured ankle repaired. Twenty minutes after receiving 1.5 mg of hydromorphone IV push, the client is slow to respond and has constricted pupils and a respiratory rate of 6 breaths/min. What is the priority nursing action? A. Perform a cognitive assessment on the client. B. Call the care provider for a change in the medication order. C. Administer a dose of naloxone 0.4 mg slow IV push. D. Change the order to every 6 hours rather than every 4 hours.

C. Administer a dose of naloxone 0.4 mg slow IV push. The priority nursing action is to administer a dose of naxalone 0.4 mg IV. For an unresponsive client, the nurse would administer naloxone 0.4 mg over a 2-minute time period to reverse the action of the opioid analgesic.The order may need to be altered or changed, but calling for a medication order change is not the first action that the nurse would take in an unresponsive client. Nurses do not change orders in terms of dosage or frequency; the health care provider changes the order. A sedated client will not be able to complete a cognitive assessment, and this action would waste time that should be spent on reversing the effects of hydromorphone.

The medical-surgical nurse is coordinating transfer from acute care to community-based care for a client who requires rehabilitation. Which interprofessional team members will be the primary decision makers in this transition? A. Medical-surgical nurses B. Rehabilitation nurses C. Client and family D. Case managers

C. Client and family Client and family will be the primary decision makers in this transition. Clients in a rehabilitation setting are managed by an interprofessional team, but the client and client's family are at the center of the team and should be the primary decision makers.The case manager, the medical-surgical nurse, and the rehabilitation nurse are important members of the interprofessional team, but are not the most important members.

Following a fall, a 62-year-old client is admitted to the rehabilitation unit with a broken collarbone and a full leg brace. What transfer technique will the nurse use for this client? A. Cane-assisted transfer B. Bear-hug technique C. Mechanical lift D. Slide board

C. Mechanical lift A mechanical lift is the transfer technique indicated for this client. Mechanical lifts use slings to lift, transfer, move, and reposition immobile clients. Because the client is older and has a broken collarbone and is unable to use both arms to independently transfer safely, a mechanical lift is the best method for moving this client.In the past, nurses and therapists used a bear-hug technique to lift the client from bed to chair and back again. However, because heavy lifting can result in back injury, many facilities have adopted a "no lift" policy and rely on other methods for client transfers. A cane will hinder transfer of the client. Slide boards are typically used for transferring quadriplegic clients.

Which condition, when assessed in a client who is dying requires the nurse to take action? A. Alternating apnea and rapid breathing B. Cool extremities C. Moaning D. Anorexia

C. Moaning Moaning indicates pain and requires pain medication.Alternating apnea and rapid breathing, anorexia, and cool extremities are normal assessment findings in the client who is dying.

A dying client becomes increasingly withdrawn and begins to refuse to eat and drink. What intervention will the nurse implement? A. Administer intravenous hydration. B. Call the family to come in right away. C. Offer ice chips. D. Bring in the client's favorite food.

C. Offer ice chips. The client who is dying should not be forced to eat or drink, but small sips of liquids or ice chips at frequent intervals can be offered if the client is alert and able to swallow. This helps the client with problems of dehydration and "dry mouth."The client's metabolic needs have decreased, so the client will not want any food or drink. Calling the family is not yet necessary in this client's case. Because the dying client's metabolic needs have decreased, invasive procedures are not currently necessary.

A client with extensive burn injuries is to be weaned from long-term opioid use. What type of opioid dependence does the nurse expect this client to have? A. Tolerance B. Pseudoaddiction C. Physical dependence D. Addiction

C. Physical dependence The nurse expects the client to have a physical dependence on the opioid. Physical dependence occurs in people who take opioids over a period of time. When it is necessary to discontinue opioid analgesia for the client who is opioid dependent, slow tapering (weaning) of the drug dosage lessens or alleviates physical withdrawal symptoms.Addiction is a condition influenced by genetic, psychosocial, and environmental factors and characterized by impaired control over drug use, compulsive use, craving, or continued use despite harm; this description does not accurately reflect the client's situation. Tolerance is similar to physical dependence, but occurs earlier and consists of a decrease in one or more of the effects of the opioid. Pseudoaddiction is a condition created by the undertreatment of pain, and is characterized by behaviors such as anger and escalating demands for more or different medications; this description does not accurately reflect the client's situation.

Which intervention does the rehabilitation nurse delegate to assistive personnel (AP) who is caring for a 70-year-old client with right-sided weakness following a stroke? A. Arrange for family members to participate in planning for discharge. B. Teach the client to use an extended shoehorn when putting on shoes. C. Reinforce the client's placing the right arm in the sleeve first when dressing. D. Determine whether the client's passive range-of-motion (ROM) exercises should be increased.

C. Reinforce the client's placing the right arm in the sleeve first when dressing. The assistive personnel (AP) is appropriate to perform the intervention of reinforcing the client's placing the right arm in the sleeve first when dressing. Reinforcement of skills that have been taught by the occupational therapist or nurse is an action that should be done by all caregivers who are involved in the client's care.Planning for discharge, assessing passive ROM exercises, and teaching the use of a shoehorn require broader education and scope of practice and should be done by a licensed staff member such as the RN.

A hospice client becomes too weak to swallow. What does the nurse do initially to increase the client's comfort? A. Explains to the family that aspiration may be a concern. B. Administers nutrition and fluids through a nasogastric tube. C. Teaches the family how to provide oral care. D. Obtains a physician order to initiate an IV line.

C. Teaches the family how to provide oral care. Because the oral mucosa will become dry, the initial action taken by the nurse would be to teach the family members how to moisten the lips and mouth.Although fluids can be given through a nasogastric tube and through an IV line, these are generally considered to increase discomfort by prolonging the client's suffering. Aspiration is not a concern in terminally ill clients, because fluids are not given orally to clients with decreased swallowing.

A client reports "something scratching on the inside of my eyelid." Before examining the eyelid, what is the appropriate nursing action? A. Test the visual field. B. Obtain informed consent. C. Wash the hands. D. Don sterile gloves.

C. Wash the hands. Hands must always be washed, and clean gloves donned, before touching the external eye structures to prevent infection.The eye care provider will test the visual field. An informed consent or sterile gloves is not needed for the nurse to examine the client's eye.

The nurse is assessing an older adult client's alcohol use. Which client statement warrants a follow-up collection of more data? A. "I had three glasses of champagne at my granddaughter's wedding last month." B. "I am a 'teetotaler'; I never drink anything alcoholic." C. "I like to have a glass of wine every once in a while." D. "I usually drink two vodkas to help me get to sleep each night."

D. "I usually drink two vodkas to help me get to sleep each night." The recommended alcohol intake (National Institute on Alcohol Abuse and Alcoholism) for people over 65 years of age is one drink daily or seven drinks weekly. The practice of drinking two vodkas daily exceeds those recommendations and needs to be followed up by the nurse.Although it is impossible to determine whether someone who abstains from alcohol is an alcoholic, many people choose not to drink any alcohol at all. Unless evidence is available to dispute, the client who is a "teetotaler" should be believed. An occasional drink of an alcoholic beverage is within the range of normal consumption for older adults. Unless other alcohol was reported and is used more routinely, the level of consumption for the other clients should cause no alarm on a routine assessment.

When performing an eye or vision assessment, which comment by the client alerts the nurse that immediate care by an ophthalmologist is needed? A. "My vision has been getting worse gradually." B. "One of my eyes is green and the other is blue." C. "My eyes are red and itchy due to allergies." D. "Something hit my eye while I was cutting grass."D.

D. "Something hit my eye while I was cutting grass." The client who is experiencing trauma, a foreign body in the eye, sudden ocular pain, or sudden redness should be seen immediately by an ophthalmologist.All other reports will be communicated to the ophthalmologist, but do not require immediate intervention. Heterochromia is an ocular condition, usually genetically inherited, that causes the iris to vary in color. This is not an emergency. Itching and redness can be caused by allergies, irritation, or ocular drug effects but do not require immediate attention. Gradual vision loss could be caused by uncontrolled hypertension and diabetes, or other eye changes, but this does not require immediate care by an ophthalmologist.

An older adult client whose spouse died the previous year says to the nurse, "Life is not fun anymore." How does the nurse respond? A. "Why don't you go on a vacation? A change of scenery will do you good." B. "Are you getting enough sleep? That makes me feel better!" C. "How are you feeling about the death of your spouse after this length of time?" D. "Tell me about your support network, such as friends or family."

D. "Tell me about your support network, such as friends or family." Establishing and maintaining relationships with others throughout life is especially important to a person's happiness. Older adults who have close, intimate, and stable relationships with others in whom they can confide are more likely to cope with crises.Sleep can affect coping, but this is not the best answer, and is a closed-ended question not allowing for elaboration. The nurse providing information about "self" is also nontherapeutic. Asking about the spouse's death is leading, and the source of the client's statement may have nothing to do with the spouse's death. Suggesting a vacation does not address the issue at hand. "Why" questions are typically nontherapeutic and often place clients in a defensive stance.

A recently injured client who is paraplegic is in rehabilitation. Which client comment indicates that he or she is adapting to new self-care activities? A. "I don't want to do this today." B. "My dog can do this—why can't I do it too?" C. "I am so tired today, I want to rest." D. "This isn't working; I need to try something else."

D. "This isn't working; I need to try something else." The client's comment that he or she needs to try something else indicates an overall willingness to try on the client's part. When one method failed, the client was motivated to try something else.The comment that the client wants to rest can be indicative of depression; the client is not trying to do "more" but rather "less." Not wanting "to do this today" can be indicative of depression or denial; the client is not even making an effort to engage in self-care. Saying that "my dog can do this" exhibits extreme frustration; the client sounds angry, which should be explored to be better understood.

A client who is using eyedrops in both eyes develops a viral infection in one eye. What teaching will the nurse provide? A. "Wash your hands between eyes and put drops in the uninfected eye first." B. "Don't touch the eyes with the dropper, and you can still use the drops in both eyes." C. "The other eye has already likely been infected with the virus." D. "You will need to use a separate bottle of drops for each eye."

D. "You will need to use a separate bottle of drops for each eye." The appropriate nursing response is that the client will need a separate bottle of eyedrops for each eye. Because of the risk of transmitting the infection to the uninfected eye, clients would receive two bottles of drops labeled "right" and "left" to use in the correct eyes.There is still a risk of transmitting the infection when the dropper is kept from contacting the eye or when hands are washed. With proper technique, transmission of infection to the other eye can be prevented.

A postoperative client reports, "I have pain from a mild headache." Which PRN medication will the nurse administer? A. Oxycodone B. Hydromorphone C. Midazolam D. Acetaminophen

D. Acetaminophen The nurse will administer acetaminophen as prescribed. Nonopioid analgesics such as acetaminophen are the first line of therapy for mild to moderate pain.Hydromorphone is appropriate for acute pain, such as pain from surgery, but it is inappropriate to give it for headache pain, especially for a mild headache. Midazolam is not appropriate for routine postoperative pain or headache; it is often used as a preoperative sedative. Oxycodone is an opioid and is not needed for a mild headache.

An older adult client comes in for a routine visit. During the assessment he appears frustrated and says, "Speak up and quit mumbling!" What is the appropriate nursing response? A. Suggests moving to a soundproof examination room. B. Shout to ensure that the client can hear. C. Ask if the client has hearing loss. D. Apologize and speak louder and clearer.

D. Apologize and speak louder and clearer. The nurse would repeat and speak more clearly first and then determine whether further assessment is needed.It would not be assumed that the client has a hearing loss; this suggestion may frustrate the client, especially if he is in denial. Shouting is not recommended because it can make understanding more difficult; this is also considered rude and nontherapeutic. Soundproof rooms are used for hearing tests, not for routine assessments.

The nurse is caring for four clients with eye concerns. Which client, who has a family history of an eye disorder, does the nurse identify at risk for increased intraocular pressure (IOP)? A. Client with family history of diabetic retinopathy B. Client with family history of anisocoria C. Client with family history of presbyopia D. Client with family history of glaucoma

D. Client with family history of glaucoma Glaucoma can be caused by increased IOP, which reduces blood flow to the eyes. Adults with a family history of glaucoma should have their IOP measured once or twice a year.Anisocoria is characterized by unequal pupil size, which normally affects about 5% of the population. This condition is not a sign of increased IOP. Presbyopia is a condition related to aging with a progressive loss of the ability to focus on near objects. Increased IOP is not a factor. Diabetic retinopathy is microvascular damage caused by uncontrolled diabetes, not by increased IOP.

The nurse has just received change-of-shift report about these clients. Which client will the oncoming nurse assess first? A. Client who has had removal of an acoustic neuroma and has complete hearing loss on the surgical side. B. Client with Ménière's disease who is reporting severe nausea and is requesting an antiemetic. C. Client who has acute otitis media and is reporting drainage from the affected ear. D. Client with labyrinthitis who has a temperature of 102.4° F (39.1° C) and a headache

D. Client with labyrinthitis who has a temperature of 102.4° F (39.1° C) and a headache The client with an elevated temperature and headache with labyrinthitis must be assessed first. These findings may indicate that the client has developed meningitis requiring immediate intervention.Severe nausea is an expected finding with Ménière's disease. Complete hearing loss on the surgical side is an expected postoperative finding after an acoustic neuroma. Drainage from the affected ear can be an expected finding with otitis media.

When preparing to examine an ear with drainage, what is the appropriate nursing action? A. Give the client a gown to wear during the examination. B. Provide reassurance that ear drainage is normal. C. Begin testing at 1000 Hz. D. Don clean gloves.

D. Don clean gloves. The nurse needs to don clean gloves to prevent infection, as Contact Precautions need to be used when assessing drainage from a client's ear canal.Testing for hearing loss (1000 Hz) is not used when examining an ear for drainage. Ear drainage is not normal and must be investigated. The client does not need to wear a gown during an ear examination.

An 80-year-old client has limited mobility following a stroke. Which nursing intervention will help prevent skin breakdown? A. Applying moist packs to the skin every shift B. Decreasing calories consumed; avoiding weight gain C. Turning and repositioning at least every 4 hours D. Ensuring the client's skin remains dry and clean

D. Ensuring the client's skin remains dry and clean The nurse ensures that the client's skin stays dry and clean to prevent skin breakdown. Keeping the client's skin clean and dry will ensure early detection and prevention of the problem.Moisture is contraindicated because it can cause further skin breakdown. Decreasing calories is contraindicated because nutrition is needed for good skin turgor; weight gain is likely not an issue for this client. The client should be repositioned at least every 2 hours to prevent skin breakdown.

A client with right-sided hemiplegia is in a rehabilitation unit. Which nursing intervention is effective in promoting the client's independence? A. Assisting the client with all of his or her activities of daily living (ADLs) B. Sending the client to a long-term care facility C. Telling the client to do the "best" that he or she can do D. Instructing the client step-by-step on how to put on his or her robe

D. Instructing the client step-by-step on how to put on his or her robe Instructing the client (step-by-step) on how to put on a garment provides direct teaching of skills. This promotes independence for the client.Assisting the client with all ADLs will not support the client's independence. Telling the client to do her or his best does not help teach new skills and may even add to the client's frustration. Sending the client to a long-term care facility will not support the client in gaining independence.

An older adult client is being relocated from a home setting to a long-term care facility. Which nursing intervention best minimizes the effects of relocation stress syndrome? A. Providing the client with limited decision making to avoid stressful situations B. Explaining all procedures and routines to the client's family at the time of relocation C. Keeping the room clear of personal belongings to reduce the risk of falling D. Reorienting the client frequently to his or her new location

D. Reorienting the client frequently to his or her new location Relocation stress syndrome usually occurs in older adults shortly after moving from a private residence to a nursing home or assisted-living facility. Characteristic symptoms can include anxiety, confusion, hopelessness, and loneliness. Reorienting the client to the new location helps minimize relocation stress syndrome effects.All procedures and routines should be explained to the client as well as to the family just before they occur. Familiar and special personal belongings are helpful to keep at the client's bedside to minimize the effects of relocation stress syndrome. The client needs opportunities to assist in decision making, which helps the client feel more in control.

A client has been hospitalized with a non-life-threatening C-spine neck injury. The interprofessional rehabilitation team has worked with the client who is quadriplegic for 4 months. Which outcome indicates that the team's efforts are effective? A. Personal care is performed with help from the family. B. Mobility requires multiple assistive devices. C. Constipation now occurs only 3 days a week. D. Skin is intact, with no evidence of skin impairment.

D. Skin is intact, with no evidence of skin impairment. The outcome that the skin is intact, with no evidence of skin impairment indicates that the team's efforts are effective. Healthy intact skin indicates good care by this client's interdisciplinary rehabilitation team.A decrease in constipation is not one of the goals of the interdisciplinary rehabilitation team. The client with a C-spine neck injury will have no mobility. Personal care activities are not part of the interdisciplinary rehabilitation program.

An older adult client reports nausea during irrigation of the ear canal to remove impacted cerumen. What is the appropriate nursing action? A. Administer an antiemetic. B. Use less water to irrigate. C. Call the health care provider. D. Stop irrigation immediately.

D. Stop irrigation immediately. If nausea, vomiting, or dizziness develops in the client, the nurse needs to stop the irrigation immediately. The client's nausea may be a sign of vertigo.Antiemetics would not be administered immediately in this case. The client's nausea may be a symptom of vertigo, and further assessment is required first. The health care provider would not be notified before further assessment of the client is done by the nurse. Using less water will not alleviate the client's nausea.

The nurse is reinforcing the physical therapist's teaching on gait training for a client who had a total knee replacement 6 weeks ago. Which ambulatory aid does the nurse expect the client to be using? A. Walker with rollers B. Crutches C. Walker with a built-in seat D. Straight cane

D. Straight cane A straight cane is the most likely ambulatory aid for a client who is 6 weeks postsurgery from a knee replacement. The client should be weight bearing, with some assistance, on the affected leg.Crutches would have been used earlier in the rehabilitation process. Clients who need assistance with both weight bearing and balance would be using a walker, and specialized walkers with a seat (for resting) are especially helpful for clients who tire easily; no indication suggests that this client has those needs.

A client who had a hip replacement 2 days ago, reports having pain rated as a 7 on a pain scale of 0-10. What nursing intervention is the highest priority? A. Teaching key points of the relaxation response B. Incorporating activities of daily living as soon as possible C. Encouraging diversional activities D. Using preemptive analgesia

D. Using preemptive analgesia The nursing intervention with the highest priority in the client's care plan is the use of preemptive analgesia. This technique is designed to decrease pain in the postoperative period, decrease the requirements for a postoperative analgesic, prevent morbidity, and decrease the duration of hospital stay.Use of diversion in treating pain is often effective, but it would not be appropriate for acute pain expected on the second postoperative day. Getting the client to perform activities of daily living is an important step in recovery; however, it is not related to pain relief, but rather to other postoperative complications, such as circulation and elimination problems. Use of the relaxation response in treating pain is often effective, but it would not be appropriate for acute pain expected on the second postoperative day.

A client is in the immediate postoperative period after tympanoplasty. How will the nurse position the client? A. Supine, with eyes toward the ceiling B. On the affected side C. With the head elevated 60 degrees D. With the affected ear facing up

D. With the affected ear facing up The nurse keeps the client flat, with the head turned to the side and the operative ear facing up, for at least 12 hours after surgery.All other choices are incorrect and do not facilitate healing.

The son of an older adult client states that he has noticed progressive periods of forgetfulness in his father over the past year. After noting the son's comments and assessing the client, which cognitive problem does the nurse suspect the client may have? A. Depression B. Delirium C. Drug adverse effects D. Dementia

Dementia Dementia is a broad term used for a syndrome that involves a slowly progressive cognitive decline and recent progressive periods of forgetfulness. It is sometimes referred to as chronic confusion.Drug adverse effects will be related to a specific medication and not appear progressively over time. Further cognitive and medical/neurologic testing would be needed to establish this diagnosis, which would not be done by a nurse. Delirium is an acute state of confusion, which differs from dementia in that it is usually short term and reversible within 3 weeks. It is often seen in older adults when they are in an unfamiliar setting. Depression is broadly defined as a mood disorder that can have cognitive, affective, and physical manifestations.