Comprehensive

The nurse instructs a client that, in addition to building bones and teeth, calcium is also important for:

Blood clotting

A client who weighs 176 pounds is receiving 8 mg/kg cyclosporine (Sandimmune) each day to prevent organ transplant rejection. How many milligrams should the nurse administer each day? Record your answer using a whole number. _________ mg

640

At the start of the nursing shift, there were 200 mL in a client's intravenous (IV) bag. The nurse took the bag down when there were 50 mL still in the bag and hung a new 1000 mL IV bag. The client received two intravenous piggybacks (IVPBs) during the shift; each contained 100 mL. When calculating the intake and output at the end of the shift, the nurse looks at the IV bag. Refer to the illustration. How many mL of IV fluid did the client receive during the shift? Record the answer as a whole number. ______ mL

950

A nurse identifies the establishment of trust as a major nursing goal for a depressed client. How can this goal best be accomplished?

By visiting frequently for short periods with the client each day

A client admitted to the hospital with a diagnosis of malabsorption syndrome exhibits signs of tetany. The nurse concludes that the tetany was precipitated by the inadequate absorption of which electrolyte?

Calcium

A nurse is taking care of a client who is extremely confused and experiencing bowel incontinence. What measures can the nurse take to prevent skin breakdown in this client?

Check the client's buttocks at least every two hours; clean the patient immediately after discovering incontinence.

Which nursing interventions require a nurse to wear gloves? (Select all that apply.)

Cleaning a newborn immediately after delivery Emptying a portable wound drainage system.

According to Erikson, a person's adjustment to the period of senescence will depend largely on the adjustment the individual made to the earlier developmental stage of:

Generativity versus stagnation

A client has been diagnosed as "brain dead". The nurse understands that this means that the client has:

No cortical functioning with some reflex breathing

When providing preoperative teaching, the nurse should focus primarily on:

Providing general information to reduce client and family anxiety.

A client who is to have brain surgery has a signed advance directive in the medical record. In what situation should this document be used?

Client cannot consent to his or her own surgery

How can a nurse best evaluate the effectiveness of communication with a client?

Client feedback

An adult is found to have schizotypal personality disorder. How should a nurse describe the client's behavior?

Introverted and emotionally withdrawn

The nurse should monitor for which involuntary physiological response in a client who is experiencing pain?

Perspiring

Following a surgery on the neck, the client asks the nurse why the head of the bed is up so high. The nurse should tell the client that the high-Fowler position is preferred for what reason?

To reduce edema at the operative site

What physiological changes that occur with aging must be taken into consideration when the nurse provides care for the older adult? (Select all that apply.)

Urinary urgency Loss of skin elasticity Swallowing difficulties Elevated blood pressure

For which adverse effect should the nurse continually observe a client who is receiving valproic acid (Depakene)?

Yellow sclerae

When talking with a client who has alcoholism, the nurse notes that the client becomes irritable, makes excuses, and blames family and friends for the drinking problem. Which defense mechanisms does the nurse conclude that the client is using? (Select all that apply.)

projection rationalization

A 2½-year-old child is admitted for treatment of injuries supposedly sustained in a fall down a flight of stairs. Child abuse is suspected. What statements might the nurse expect from a parent who engages in child abuse? (Select all that apply.)

"Every time I turn around the kid is falling over something." "I can't understand it. He didn't have a problem using the stairs without my help before this."

Emptying a portable wound drainage system.

"I should obtain a pneumococcal vaccination each year."

A family member brings a relative to the local community hospital because the relative "has been acting strange." Which statements meet involuntary hospitalization criteria? (Select all that apply.)

"I'd like to end it all with sleeping pills." "The voices say I should kill all prostitutes."

When talking with a client who has been receiving Paroxetine (Paxil), the nurse determines that more clarification is needed when the client says:

"I've been on the medication for 8 days now, and I don't feel any better."

A client has been taking escitalopram (Lexapro) for treatment of a major depressive episode. On the fifth day of therapy the client refuses the medication, stating, "It doesn't help, so what's the use of taking it?" What is the best response by the nurse?

"It can take 1 to 4 weeks to see an improvement."

A 50-year-old client being seen for a routine physical asks why a stool specimen for occult blood testing has been prescribed when there is no history of health problems. What is an appropriate nursing response?

"It is performed routinely starting at your age as part of an assessment for colon cancer."

A client is scheduled for a transurethral resection of the prostate (TURP). Which statement made by the client most indicates the need for further preoperative teaching?

"My incision will probably be painful."

A client tells the nurse in the mental health clinic that the practitioner said that the cornerstone of therapy used in the clinic is cognitive therapy. The client asks what this therapy entails. What concept should the nurse explain as the basis of cognitive therapy?

"Negative thoughts can precipitate anxiety."

The physician orders intravenous fluids to be infused at 100 mL/hour. The intravenous tubing delivers 15 drops/milliliters. The nurse would infuse the solution at a flow rate of how many drops per minute to ensure that the client receives 100 mL/hour? Record your answer using a whole number. _____ gtts/min.

25

The health care provider orders 1000 mL normal saline to be infused over 8 hours for a client with a diagnosis of dehydration. The intravenous (IV) tubing delivers 15 drops per milliliter (drop factor). The nurse should administer the IV infusion at a rate of ____ gtts/minute. Record your answer using a whole number.

31

A nurse is working in a daycare center with clients who have cognitive impairments. What does the nurse expect of a client in the middle stages of dementia?

Able to recall events from the past

Which of the following legal defenses is the most important for a nurse to develop?

Accountability

The parent of an 11-month-old infant asks the nurse in the pediatric clinic when to start toilet training. The nurse tells the parent to wait until the infant has achieved more voluntary control and coordination. According to Erik Erikson, in what stage should toilet-training be achieved?

Autonomy versus shame and doubt

A client with cancer is informed that the chemotherapy is no longer working and that death is inevitable. Keeping in mind Kübler-Ross's stages of death and dying, place the following nursing interventions that are most appropriately associated with each stage in order from the stage of denial to acceptance.

Avoid confronting the client. Redirect negative feelings constructively Help the client identify realistic versus unrealistic goals. Help the client celebrate the simple pleasures in everyday life Provide maximal comfort measures.

What is a nurse's responsibility when administering prescribed opioid analgesics? (Select all that apply.)

Count the client's respirations Document the intensity of the client's pain. Verify the number of doses in the locked cabinet before administering the prescribed dose.

A client with type 1 diabetes is found to have a psychosis and is to receive haloperidol (Haldol). Which response should a nurse anticipate with this drug combination?

Decreased control of the diabetes

In her eighth month of pregnancy, a 24-year-old client is brought to the hospital by the police, who were called when she barricaded herself in a ladies' restroom of a restaurant. During admission the client shouts, "Don't come near me! My stomach is filled with bombs, and I'll blow up this place if anyone comes near me." The nurse concludes that the client is exhibiting:

Delusional thinking

A nurse is teaching a community group about the basics of nutrition. A participant questions why fluoride is added to drinking water. The nurse should respond that it is a necessary element added to drinking water to promote:

Dental health.

A client reaches the point of acceptance during the stages of dying. What response should the nurse expect the client to exhibit?

Detachment

A nurse is caring for a client with vascular dementia. What does the nurse expect of this client's mental status?

Difficulty recalling recent events related to cerebral hypoxia

A nurse is caring for an older adult with a hearing loss secondary to aging. What can the nurse expect to identify when assessing this client? (Select all that apply.)

Dry cerumen Difficulty hearing high-pitched voices

A nurse is caring for a 20-year-old client. According to Erikson's developmental psychosocial theory, what is expected by 20 years of age?

Having a coherent sense of self and plans for self-actualization

A nurse is administering medications to clients on a psychiatric unit. What does the nurse identify as the reason that so many psychiatric clients are given the drug benztropine (Cogentin) or trihexyphenidyl in conjunction with the phenothiazine derivatives neuroleptic medications?

It combats the extrapyramidal side effects of the other drug.

A health care provider prescribes a vitamin tablet that contains vitamin B complex. What should the nurse teach the client?

It may turn the urine bright yellow.

A nurse is preparing to administer an oil-retention enema and understands that it works primarily by:

Lubricating the sigmoid colon and rectum.

A nurse administers prescribed anxiolytics to clients with severe emotional disorders. What is the goal of this treatment?

Makes the client more amenable to psychotherapy

A client with arthritis increases the dose of ibuprofen (Motrin, Advil) to abate joint discomfort. After several weeks the client becomes increasingly weak. The client is admitted to the hospital and is diagnosed with severe anemia. What clinical indicators does the nurse expect to identify when performing an admission assessment? (Select all that apply.)

Melena Tachycardia

A client has been admitted with a urinary tract infection. The nurse receives a urine culture and sensitivity report that reveals the client has Vancomycin Resistant Enterococcus (VRE). After notifying the physician, which action should the nurse take to decrease the risk of transmission to others?

Move the client to a private room.

A client reports severe pain two days after surgery. After assessing the characteristics of the pain, which initial action should the nurse take next?

Obtain the vital signs.

The nurse is providing post-procedure care for a client that had a liver biopsy. To prevent hemorrhage, it is the nurse's highest priority to place the client in what position?

On the right side

A client is admitted for surgery. Although not physically distressed, the client appears apprehensive and withdrawn. What is the nurse's best action?

Orient the client to the unit environment.

A nurse is interviewing a child with attention deficit disorder. For which major characteristic should the nurse evaluate this child?

Overreaction to stimuli

A nurse is obtaining a health history from the newly admitted client who has chronic pain in the knee. What should the nurse include in the pain assessment? (Select all that apply.)

Pain history including location, intensity and quality of pain Pain pattern including precipitating and alleviating factors

What are the desired outcomes that the nurse expects when administering a nonsteroidal antiinflammatory drug (NSAID)? (Select all that apply.)

Pain relief Antipyresis Reduced inflammation

A nurse is reviewing a plan of care for a client who was admitted with dehydration as a result of prolonged watery diarrhea. Which prescription should the nurse question?

Parenteral albumin (Albuminar)

A nurse assesses for hypocalcemia in a postoperative client. One of the initial signs that might be present is

Paresthesias

A client who is being treated for schizophrenia, paranoid type, arrives at the clinic demonstrating a shuffling gait and tilting his head toward one shoulder. What should the nurse conclude about these clinical manifestations?

Possible side effects of the antipsychotic medication

Antipsychotic drugs can cause extrapyramidal side effects. Which responses should the nurse document as indicating pseudoparkinsonism? (Select all that apply.)

Rigidity Tremors Bradykinesia

A nurse is caring for a client with pulmonary tuberculosis who is to receive several antitubercular medications. Which of the first-line antitubercular medications is associated with damage to the eighth cranial nerve?

Streptomycin

A nurse is caring for a client diagnosed with Methicillin-Resistant Staphylococcus Aureus (MRSA) in the urine. The health care provider orders an indwelling urinary catheter to be inserted. Which precaution should the nurse take during this procedure?

Surgical asepsis

A client has a paracentesis, and the health care provider removes 1500 mL of fluid. To monitor for a serious postprocedure complication, the nurse should assess for:

Tachycardia

A nursing supervisor sends unlicensed assistive personnel (UAP) to help relieve the burden of care on a short-staffed medical-surgical unit. Which tasks can be delegated to UAP? (Select all that apply.)

Taking routine vital signs Answering clients' call lights Changing linens on an occupied bed.

During a well-baby visit, the parents complain that their 2-year-old daughter soils herself because she is lazy. The parents plan to make her wear her soiled clothing to teach her a lesson. The nurse is concerned about the potential for child neglect and abuse. Which nursing intervention will be most therapeutic at this time?

Teaching the parents developmental milestones in relation to acceptable discipline methods

When talking with a female client who displays many of the emotional and physiological symptoms of panic disorder, the nurse should:

Use short sentences and an authoritative voice

A nurse is in the process of developing a therapeutic relationship with a client who has an addiction problem. What client communication permits the nurse to conclude that they are making progress in the working stage of the relationship? (Select all that apply.)

Verbalizes difficulty identifying personal strengths Acknowledges the effects of the addiction on the family Addresses how the addiction has contributed to family distress

A terminally ill client repeatedly tells the nurse all the details of a daughter's wedding that will take place in 6 months and how important it is for her to attend. What Kübler-Ross stage of grieving does the nurse identify?

bargaining

A nurse reinforces teaching a client about Coumadin (warfarin) and concludes that the teaching is effective when the client states, "I must not drink:

cranberry juice

Survivors of a major earthquake are being interviewed on admission to the hospital. The nurse notes that they exhibit a flattened affect, make minimal eye contact, and speak in a monotone. These behaviors are indicative of the defense mechanism known as:

Isolation