Comprehensive Final

A nurse is assessing a preschooler who has recurrent and persistent otitis media. When obtaining the child's history from her parent, which of the following questions should the nurse ask? "Does your child wear a hat outdoors in cold weather?" "Does anyone smoke around or in the same house as your child?" "Have you given your child any aspirin recently?" "Is your child's diet high in gluten?"

"Does anyone smoke around or in the same house as your child?" [Otitis media is an infection of the middle ear. Passive smoking promotes adherence of respiratory pathogens to the lining of the middle ear space. It also prolongs the inflammation and impedes drainage from the ear.]

A nurse in a substance use disorder program is interacting with a client. Which of the following statements indicates that the client is using intellectualization as a way of coping with the anxiety of admission? "I was just using the medication to help me out during a rough time in my life. I can stop whenever I want." "This all happened because my spouse is unemployed. That puts an enormous amount of stress on me." "I have read that problems with substances can have a variety of predisposing factors." "I just don't want to talk about it. There is nothing you can do about it anyway."

"I have read that problems with substances can have a variety of predisposing factors." The nurse should identify this response as a use of intellectualization. Intellectualization is an attempt to use intellectual processes to avoid expressing the emotions that stem from stressful situations.

A nurse in a provider's office is talking with an older adult client who reports having trouble sleeping. Which of the following statements should the nurse identify as a possible cause for the client's sleeping difficulties?

"I often have a cup of coffee with my dessert before going to bed."

A nurse is teaching a client who has a spinal cord injury to perform intermittent urinary self-catheterization at home after discharge. Which of the following statements indicates that the client understands the procedure? "I'll drink less water so I don't have to catheterize myself too often." "I must use sterile technique to do each of the catheterizations." "I should stop the catheterization when I have removed 150 mL of urine." "I will perform intermittent self-catheterization every 2 to 3 hours."

"I will perform intermittent self-catheterization every 2-3 hours." The client might initially require self-catheterization every 2 to 3 hr, with the frequency eventually increasing to every 4 to 6 hr. A longer interval can result in bladder distention and increased risk for urinary tract infection.

A nurse is teaching the parent of a child who has type 1 diabetes mellitus how to manage the child's disorder during illness, such as colds. Which of the following statements by the parent indicates an understanding of the teaching?

"I'll check his blood glucose more often."

A nurse is providing discharge teaching for a client who had a bone marrow transplant and has thrombocytopenia. Which of the following statements indicates that the client understands the precautions he must take at home? "I'll stick with soft foods for now." "My family will be bringing me fresh flowers today." "I'll use a new disposable razor each day." "I'll blow my nose more often to avoid nosebleeds."

"I'll stick with soft foods for now." Thrombocytopenia (a low platelet count) is common after a bone marrow transplant. To prevent bleeding until his platelet count improves, the client should avoid hard foods that could cause mouth trauma.

A nurse is reviewing the use of side rails with an assistive personnel (AP). Which of the following statements by the AP should indicate that further teaching is required? "I should not leave all four side rails up unless there is a prescription for restraints." "An alert client will be safest if I raise the two upper side rails at the head of the bed." "If the client seems confused, I'll raise all four side rails so that he doesn't hurt himself." "If a client is sedated, I should raise all four side rails to prevent a fall out of bed."

"If the client seems confused, I'll raise all four side rails so that he doesn't hurt himself."

A nurse is caring for a client who takes warfarin to treat chronic A-fib and has early manifestations of Alzheimer's disease. The client's partner asks the nurse if the client would benefit from taking ginkgo biloba. Which of the following responses should the nurse make?

"It is likely that ginkgo biloba will interfere with the effectiveness of his other medications."

A provider tells a client who reports practicing Hinduism that at 12-weeks of gestation she needs more protein in her diet and suggest eating more meat. After the provider leaves the examination room, the client tells the nurse that eating animal products will cause her to miscarry. Which of the following responses should the nurse make?

"Let's discuss other foods that are also high in protein that you could substitute for meat."

A nurse is assessing a 66-year-old client during a routine physical examination at her first clinic visit and does not have her medical records. When the nurse asks if she has received the pneumococcal immunization, the client replies, "I am not sure, but it's been at least 5 years since I had any immunizations." Which of the following responses should the nurse make?

"Let's go ahead with giving you this immunization."

A nurse on a pediatric mental health unit is caring for a school-age child. Which of the following questions or statements should the nurse make to foster rapport and engage him in conversation?

"Tell me about your favorite video game."

A client at a routine prenatal care visit asks the nurse if it is common to develop vaginal yeast infections during pregnancy. Which of the following responses should the nurse make? "Have you discussed this with your doctor yet?" "The hormonal changes of pregnancy change the acidity of the vagina, making yeast infections more common." "Women who are already prone to vaginal yeast infections get them during pregnancy." "Why are you concerned about yeast infections during pregnancy?"

"The hormonal changes of pregnancy change the acidity of the vagina, making yeast infections more common." [This is an information-seeking question; therefore, the therapeutic response is an answer that provides the client with the information she requested.]

A nurse is providing teaching to a client who has type 2 DM. The client states, "I eat pasta every day. I can't imagine giving it up." Which of the following responses should the nurse make?

"You don't have to give up pasta; just adjust the amount you eat."

A nurse is providing preoperative teaching for a client who will undergo laser-assisted in situ keratomileusis (LASIK) surgery. Which of the following information should the nurse include?

"You might need glasses after surgery." [LASIK is a type of refractive laser eye surgery ophthalmologists perform to correct myopia, hyperopia, and astigmatism, which are common causes of nearsightedness. However, overcorrection or undercorrection of refractive errors is possible, so some clients will need prescription eyeglasses despite having had LASIK surgery.]

A nurse is providing teaching to a client who has come to the family planning clinic requesting an intrauterine device (IUD). Which of the following information should the nurse provide the client? If you lose weight, you will need a refitting for your IUD." "An IUD provides protection from certain sexually transmitted infections." "Your risk for ectopic pregnancy increases with an IUD." "You shouldn't use an IUD if you want to have children later on."

"Your risk of ectopic pregnancy increases with an IUD." [An IUD is a family planning device the provider inserts through the cervix into the uterus to prevent pregnancy. The IUD works by changing the lining of the uterus and fallopian tubes, making fertilization in the uterus more difficult. Consequently, an IUD increases the risk for ectopic pregnancy.]

A nurse is teaching a client how to use an albuterol metered dose inhaler. After removing the cap from the inhaler and shaking the canister, identify the sequence of instructions the nurse should give the client. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

1. The client should hold the mouthpiece 2-4 cm (1-2 in) from his mouth 2. Tilt his head back slightly, and then open his mouth 3. Next, he should depress the medication canister while taking a deep breath to facilitate delivery of the medication through the airway 4. After holding his breath for 10 seconds, the client should resume his usual breathing pattern.

A nurse in the emergency department is caring for an unaccompanied infant following a motor-vehicle crash. During assessment, the nurse notes that the infant's anterior fontanel is almost closed. She has six teeth, is able to sit unsupported, and can drink from a cup. The child cries whenever anyone new to her enters the room, says a few words, and is asking for "mama" and "dada". The nurse should make which of the following age assessments for this child?

12 months old

A community health nurse is planning care for four high-risk newborns who were discharged yesterday. Which of the following newborns should the nurse plan to care for first? A 1-week-old newborn who needs another phenylketonuria screening test A 4-day-old newborn who has an elevated bilirubin level and requires phototherapy A 10-day-old newborn who is small for gestational age and who requires daily weighing A 2-week-old newborn who was born at 35 weeks of gestation and weighed 2,268 g (5 lb) at discharge

A 4-day-old newborn who has an elevated bilirubin level and requires phototherapy. An elevated bilirubin level can lead to kernicterus; therefore, it is imperative for the nurse to initiate phototherapy immediately to help prevent this dangerous outcome.

A charge nurse on a pediatric unit receives the laboratory results for several clients. Which of the following results should the nurse report to the provider?

A client who has DKA and a blood glucose of 375 mg/dL. [The initial goal of therapy for DKA is a blood glucose level below 240 mg/dL. To accomplish this, the client should receive regular insulin via continuous IV infusion, and the nurse should monitor the blood glucose level hourly. The nurse should report the client's result so that the provider can adjust the insulin dosage.]

A nurse on an oncology unit receives report at the beginning of her shift about four clients who are postoperative. Which of the following clients should the nurse see first? A client who is 1 day postoperative following a lobectomy for small-cell carcinoma and has a chest tube with 35 mL/hr of bright red, bloody drainage A client who is 2 days postoperative following a colectomy due to colorectal cancer and has an ostomy bag full of bright red, bloody drainage. A client who is 2 days postoperative following excision of an abdominal mass and has a portable wound suction device with 20 mL/hr of serosanguineous drainage A client who is 1 day postoperative following excision of a bladder wall tumor and prostate and has continuous bladder irrigation with 300 mL/hr reddish-pink urine

A client who is 2 days postoperative following a colectomy d/t colorectal cancer and has an ostomy bag full of bright red, bloody drainage. An ostomy bag full of blood indicates that the client's bowel is hemorrhaging and the nurse must report this finding to the surgeon immediately. The client might require fluid replacement, transfusion, and additional surgery to repair the bleeding vessel. This finding poses an immediate threat to the client's circulation.

During a client care staff meeting, a nurse manager discusses potential problems with data security that affect confidential client information. Which of the following environments should the nurse manager identify as an acceptable area for discussing clients' information? Areas with no public access Outside the door of a client's room In the cafeteria during break In the hallway near the nurses' station

Areas with no public access Nurses should only discuss clients' information in private areas where no one else can overhear the discussion. A unit medication room is a non-public area where nurses can privately discuss client information that pertains to the client's care.

A nurse is developing a plan of care for a client who has gastroesophageal reflux disease (GERD). The nurse should plan to monitor the client for which of the following complications?

Aspiration [Aspiration is a common complication of GERD, which results when the esophageal sphincter malfunctions, allowing gastric acid and undigested food to back up into the esophagus. This places the client at risk for aspiration. GERD causes effortless, uncontrolled regurgitation whether the client is in an upright position or reclining. The most common results of regurgitation are heartburn and indigestion; however, aspiration is also possible. Therefore, the nurse should monitor the client for crackles in the lung fields, which is an indication of aspiration.]

Due to staffing shortages, a nurse manager floats a medical-surgical nurse to the pediatric unit. The nurse has limited experience with children. Which of the following actions should the nurse manager take? Provide constant supervision for the medical-surgical nurse. Have the medical-surgical nurse provide relief for unit nurses during break and lunch times. Assign a unit nurse to act as a resource for the medical-surgical nurse. Delegate to the medical-surgical nurse tasks that assistive personnel perform.

Assign a unit nurse to act as a resource to act as a resource for the medical-surgical nurse. [Assigning a nurse who usually works on the pediatric unit to work with the medical-surgical nurse will provide consistent support]

A nurse is admitting a child who has a UTI and a history of myelomeningocele. After completing the admission history, which of the following actions should the nurse plan to take? Attach a latex allergy alert identification band. Initiate contact precautions. Post signs in the client's bathroom to strain the client's urine. Administer folic acid with meals.

Attach a latex allergy alert identification band. Myelomeningocele, a serious complication of spina bifida, is a neural tube defect in which the spinal cord and meninges are in a cerebrospinal fluid-filled sac at birth. Clients who have neural tube defects are at risk for latex allergy; therefore, the nurse should avoid the use of common medical products containing latex, such as latex gloves, for this client.

A nurse on a mental health unit is caring for a client who has depression. Which of the following actions should the nurse take to foster a therapeutic environment for this client?

Build trust with the client by sitting quietly with him [The nurse should build trust with the client to convey interest in the client's concerns. Offering self by sitting with the client and the use of silence are actions that promote trust which encourages the client to speak more openly about issues and concerns.]

A nurse is assessing a toddler who has AIDS. The nurse should identify which of the following findings as an indication of an opportunistic infection?

Candidiasis [Candidiasis, or oral thrush, results from the overgrowth of Candida albicans, an opportunistic fungus that commonly infects the oral cavity of clients who have immature or compromised immune systems. Candidiasis appears as a cheesy, white plaque that looks like milk curds on the buccal mucosa and tongue. Thrush is often the initial opportunistic infection in an HIV-positive child who is developing AIDS.]

A nurse is preparing to administer medications to a client who is unconscious. The nurse should bring the medication administration record (MAR) to the client's bedside and perform which of the following verification procedures? Check the client's name and medical record number on the MAR against the room and bed number. Call the client by name and check the name on her identification band against the MAR. Compare the medical record number and name on the MAR with the client's identification band. Ask the client's visitor to identify the client by name and to state the client's birth date.

Compare the medical record number and name on the MAR with the client's identification band. The Joint Commission requires the use of two client identifiers when administering medications. The nurse should compare the medical record number and name on the MAR with the client's identification band.

A nurse participating in a community health fair is providing information to a client who has a BP of 150/90 mmHg during a blood pressure screening. Which of the following actions should the nurse take? Give the client a written record of his BP to bring to their provider. Encourage the client to go to the nearest emergency department. Instruct the client to follow up with a provider within 6 months. Explain to the client that he is not at risk unless he has manifestations of hypertension.

Give the client a written record of his BP to bring to their provider. When a client has an elevated reading at a hypertension screening, the nurse should encourage him to see his provider for further evaluation within 2 months. To help facilitate this process, the nurse should give him a written record of the BP at the screening to share with his provider.

A nurse is caring for a client who has dehydration and has developed hypovolemic shock. Which of the following laboratory values should the nurse expect for the client? BUN 18 mg/dL Capillary refill 1.5 seconds Hct 55% Urine specific gravity 1.001

Hct 55% [An elevated hematocrit indicates hypovolemia. Other indications of hypovolemia are a weak pulse, tachycardia, hypotension, tachypnea, slow capillary refill, elevated BUN, increased urine specific gravity, and decreased urine output.]

A nurse in the emergency department is caring for a client who has Addison's disease and reports N/V, diarrhea, and abdominal pain. To prevent Addisonian crisis, the nurse should prepare to administer which of the following medications?

Hydrocortisone

A nurse is teaching the parent of a child who has severe reactive airway disease about glucocorticoid therapy. The parent asks why her child has to inhale the medication instead of taking it orally. Which of the following information should the nurse provide the parent? Inhaled glucocorticoids are less likely to cause thrush. Oral glucocorticoids are hazardous during times of stress. Oral glucocorticoids are more likely to slow linear growth in children. Inhaled glucocorticoids are more effective for acute bronchospasm.

Oral glucocorticoids are more like to slow linear growth in children. Chronic use of oral glucocorticoids in high doses by children can result in decreased linear growth. Inhaled glucocorticoids deliver the anti-inflammatory agent directly to the local target area (pts airways) resulting in an decreased risk for adrenal suppression).

A nurse is caring for a client who had a precipitous delivery. The nurse should identify which of the following assessments as the priority during the fourth stage of labor? Obtaining the client's temperature Inspecting the client's perineum Palpating the client's fundus Checking the client for hemorrhoids

Palpating the client's fundus A precipitous delivery is one that follows labor of less than 3 hr. Regardless of the cause of the rapid delivery, uterine atony can result, causing postpartum hemorrhage. The nurse should palpate the fundus and massage as needed to monitor for and reduce the risk of hemorrhage.

A nurse is providing teaching to the parents of a child who has strabismus. Which of the following instructions should the nurse include to prevent the development of amblyopia? Patch the unaffected eye. Administer mydriatic eye drops daily. Obtain prescription eyeglasses. Administer antihistamines.

Patch the unaffected eye. Amblyopia is a disorder of the eye in which unilateral central blindness occurs as a result of another problem, such as strabismus. With strabismus, muscle weakness allows one eye to wander so that the child cannot focus on an object with both eyes at the same time. This confusion causes the brain to ignore the signals from the weak eye in favor of the strong one. This will result in central blindness if the child does not receive treatment by 6 years of age. To strengthen the weak eye muscles, the parents should patch the unaffected eye.

A nurse is caring for a client who has pseudomembrane colitis d/t Clostridium difficile infection. Which of the following interventions is the nurse's priority? Performing hand hygiene before and after contact with the client Reducing the client's anxiety due to isolation procedures. Assisting the client in making nutritional choices Monitoring the client's intake and output

Performing hand hygiene before and after contact with the client. C. difficile is a spore-forming, gram-positive anaerobic bacillus that produces two virulent exotoxins that attack the lining of the intestine. The toxins destroy cells and produce pseudomembranes, patches (plaques) of inflammatory cells, and decaying cellular debris on the interior surface of the colon. The spores spread easily by contact with body fluids and inanimate objects. The greatest risk to this client, as well as to the nurse and others, is injury from infection transmission; therefore, the priority intervention is hand hygiene.

A nurse at a LTC facility notes that a client who has dementia is having problems with orientation. Which of the following actions should the nurse take to improve the client's LOC? Encourage the client to make choices about meals and activities. Use written signs to label specific rooms. Post a large calendar on the bulletin board. Place a wander alert electronic alarm bracelet on the client's wrist.

Post a large calendar on the bulletin board.

A nurse is monitoring the electrocardiogram of a client who has hypocalcemia. Which of the following findings should the nurse expect?

Prolonged Q-T intervals [Manifestations of hypocalcemia include tingling, numbness, tetany, seizures, prolonged Q-T intervals, and laryngospasm. Causes include hypoparathyroidism, chronic kidney disease, and diarrhea.]

A nurse is teaching a client who has chronic kidney disease about predialysis dietary recommendations. The nurse should include information about restricting his intake of which of the following nutrients?

Protein

A nurse is caring for a client who is receiving bleomycin IV to treat lymphoma. Which of the following assessments is the nurse's priority?

Pulmonary function [The nurse should apply the safety and risk reduction priority-setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. Bleomycin can cause severe lung injury, including pneumonitis and pulmonary fibrosis, and it affects a significant percentage of clients receiving this medication; therefore, pulmonary function is the priority assessment.]

A nurse is providing teaching to the parents of a child who has a new prescription of lamotrigine for a seizure disorder. The nurse should instruct the parents that which of the following adverse effects is the priority to report to the provider?

Rash [the greatest risk to this client is injury from Stevens-Johnson syndrome or toxic epidermal necrolysis, which are life-threatening reactions that manifest initially as a rash in the first 2-8 weeks of treatment with lamotrigine. The nurse should instruct the parents to report a rash immediately to the provider.]

A nurse is reviewing the medical history of a client who has presbyopia. With which of the following activities should the nurse expect the client to have difficulty? Finding the bathroom in the dark Driving at night Seeing numbers on highway signs Reading the newspaper

Reading the newspaper. [With presbyopia, the lens is unable to change shape to focus on objects close up. Presbyopia develops with aging, beginning in middle age, and results from the decreased elasticity of the lens.]

A nurse is planning to delegate the postoperative care of a client following an appendectomy. Which of the following actions should the nurse assign to an assistive personnel (AP)? Show the client how to use the patient-controlled analgesia pump. Record urinary output after emptying the indwelling urinary catheter. Assist the client out of bed and to the chair for the first time after surgery. Check the client's abdominal wound dressing.

Record urinary output after emptying the indwelling urinary catheter. Emptying an indwelling urinary catheter and recording I&O is within the scope of practice for an AP. This task is routine and has a predictable outcome; therefore, the nurse may delegate this task to an AP.

A nurse is admitting a client who has manifestations that suggest TB. Which of the following actions is the nurse's priority?

Initiate airborne precautions.

A nurse is caring for a client who is receiving mechanical ventilation and develops acute respiratory distress. Which of the following actions should the nurse take first?

Initiate bag-valve-mask ventilation.

A charge nurse is coordinating the evacuation of clients from a facility following a bomb threat. Which of the following actions should the nurse take when implementing the evacuation process? Call in the clients' family members to provide additional help with moving the clients. Ask clients who are able to ambulate to assist in moving the unstable clients. Instruct clients who are able to ambulate to leave. Direct staff members to close the doors and windows as each room is evacuated.

Instruct clients who are able to ambulate to leave. Clients who are able to ambulate should leave first in an evacuation process because it quickly reduces the number of clients who require evacuation assistance.

A nurse at a long-term care facility hears an assistive personnel (AP) talking with an older adult client who has dementia with periods of confusion. Which of the following statements should indicate that the AP requires further teaching?

"Its almost time for your appointment. Let me do your hair for you and brush your teeth."

A nurse is providing teaching to a school-age child who has just had a fiberglass cast application following lower extremity fracture. Which of the following instructions should the nurse give the child and his parents about care during the first 48 hours? "Use a toothbrush to scratch under the cast if your skin itches." "Avoid moving your leg and the joints above and below the cast." "Keep the cast above the level of your heart." "Clean soil from the cast with soapy water."

"Keep the cast above the level of your heart." [Immediately following the injury, and for at least the first 48 hours, the child should keep the affected limb above the level of the heart to help prevent edema and pain and to promote venous return.]

A nurse is caring for a client who has borderline personality disorder and is expressing concern about needing prolonged hospitalization. Which of the following statements should the nurse make?

"Tell me what concerns you the most about being hospitalized."

A nurse is caring for an adolescent client who gave birth to a stillborn preterm fetus. The client is crying and says to the nurse, "Why did this happen to me?" Which of the following responses should the nurse make? "I understand how you feel." "You are young and can have healthy babies when you are older." "Sometimes this is nature's way." "This must be so difficult for you."

"This must be so difficult for you."

A nurse is teaching a client who has coronary artery disease about the difference between angina pectoris and a myocardial infarction. Which of the following manifestations should the nurse identify as indications of an MI? (Select all that apply)

1. N/V 2. Diaphoresis and dizziness 3. Anxiety and feelings of doom

A community health nurse is conducting a class about body mechanics for county office workers. Which of the following instructions should the nurse include? (Select all that apply.)

1. Sit with your back supported 2. Keep your knees at hip level 3. Use ergonomically designed computer keyboard

A nurse is caring for a toddler. Which of the following objects should the nurse select from the playroom for this child during hospitalization? A small, plastic doll with clothes and accessories Alphabet flash cards A handheld video game A 10-piece wooden puzzle

A 10-piece wooden puzzle. Age-appropriate toys for a toddler include puzzles, large crayons, blocks, picture books, push-pull toys, finger paints, modeling clay, and musical toys. These toys all allow for manipulation and exploration and meet the child's developmental and diversional activity needs.

A nurse in the emergency department is caring for a group of clients who all have an odor of alcohol on their breath and multiple injuries to the head and extremities. Which of the following clients should the nurse assess first?

A client who is difficult to arouse and is unable to respond to questions.

A nurse in the labor and delivery suite is planning care for a group of four clients. Which of the following clients should the nurse see first?

A client who is in active labor and has late decelerations on the fetal heart monitor's strip

A nurse is caring for a client who has a tracheostomy and is receiving mechanical ventilation. The low-pressure alarm on the ventilator sounds, indicating which of the following to the nurse?

A leak within the ventilator's circuitry [The low-pressure alarm means that either the ventilator tubing has come apart or the tubing detached from the client. Low-pressure alarms are often the result of a malfunction or displacement of connections somewhere between the endotracheal or tracheostomy tube and the ventilator.]

A nurse is planning care for a client who is postoperative following a hip arthroplasty. In the client's medical record, the nurse notes a history of chronic obstructive pulmonary disease (COPD). Which of the following oxygen-delivery methods should the nurse plan to use for this client? A simple face mask A nonrebreather mask A bag-valve-mask device A nasal cannula

A nasal cannula [A nasal cannula delivers precise concentrations of oxygen; therefore, it is an appropriate device for a client who has COPD and requires a precise percentage of inspired oxygen.]

A nurse is caring for a group of clients in a long-term facility. One of the clients is walking in the hallway and bumping into walls and does not respond to his name. which of the following actions should the nurse take first?

Accompany the client back to his room.

A nurse on a pediatric unit is planning care for a preschooler who will be having a surgical procedure in the morning. The child has been crying despite his parent's presence at his bedside. The nurse should add engaging the child in therapeutic play to the care plan because it offers which of the following benefits?

Allows the child to manipulate toy medical equipment [A major function of play therapy is making potentially unmanageable situations manageable through symbolic representation, which provides children with opportunities to learn to cope. A preschooler does not have the language development to express his fear of the unfamiliar medical equipment in the hospital. The nurse encourages the child to touch the equipment to decrease the child's fear and intimidation in a safe environment using age-appropriate vocabulary. The use of toys enables children to transfer anxieties, fears, fantasies, and guilt to objects rather than people.]

A nurse delegates a LPN to provide one-on-one observation for a client who requires suicide precautions. Which of the following actions by the LPN should indicate to the nurse that she requires further teaching?

Ambulates the client's roommate while the client sleeps.

A nurse is caring for a child who has epistaxis. Which of the following actions should the nurse take?

Apply continuous pressure to the lower part of his nose.

A nurse in an acute care clinic is talking with a client who reports that her osteoarthritis pain in her knees is increasing each day. The client wants to discuss non-pharmacological approaches that would help relieve her pain. Which of the following interventions should the nurse suggest?

Applying warm compresses to sore joints.

A nurse is facilitating a group discussion with preschool teachers about child abuse. Which of the following data should the nurse use as a common example of a suggestive finding?

Arm cast for a spiral fracture of the forearm [Spiral fractures occur from twisting of an extremity. In most instances, spiral fractures of the arm result from an abusive injury.]

A nurse is preparing an older adult client who had a TIA for discharge. The nurse should teach the client to monitor which of the following parameters at home?

Blood pressure

A nurse is caring for a client who spent the past several minutes mumbling about being "doomed to die" and is now pacing in an increasingly agitated and angry manner. Which of the following actions should the nurse take first? Administer PRN medication for agitation. Attempt to reduce environmental stimuli. Request a prescription for physical restraints. Place the client in seclusion.

Attempt to reduce environmental stimuli. The nurse should apply the least restrictive priority-setting framework. This framework assigns priority to nursing interventions that are least restrictive to the client, as long as those interventions do not jeopardize the client's safety. Least restrictive interventions promote the client's safety without using restraints. The nurse should only use physical or chemical restraints when the safety of the client, staff, or others is at risk. Therefore, the nurse should first attempt to calm the client by decreasing environmental stimuli. The nurse should walk with the client to a quiet area that places distance between him and other clients and from objects he could use to hurt himself or others. The nurse should ensure that the area is visible to other staff members in case more restrictive measures become necessary.

A nurse is teaching a client who has extensive deep partial- ad full-thickness burns and requires a topical antimicrobial medication. The nurse should explain to the client that the goal of this medication therapy is to reduce which of the following outcomes? Bacterial growth Scarring Skin graft size Pain

Bacterial growth Topical antimicrobial medications (particularly broad-spectrum antimicrobials) help prevent bacteria from entering the body when a client has an impairment of the protective covering of the skin, as with burns. It creates a protective barrier, along with the dressing, between bacteria and the exposed body tissues. This therapy helps prevent infection.

A nurse is discussing medication administration for an older adult client with a newly licensed nurse. The nurse should identify that, due to physiological changes of aging, older adult clients might need dosage adjustments d/t an increase in which of the following parameters?

Body fat.

A nurse in a prenatal clinic is performing telephone triage for several clients. Which of the following client reports should the nurse identify as an expected physiologic adaptation of pregnancy? Spotting with urination Breast tenderness Thick, white vaginal discharge Facial swelling

Breast tenderness.

A nurse in the emergency department is caring for a client who reports pain in her left leg following a motor-vehicle crash. The nurse notes that her left leg has bruising, swelling, and displacement of the bones. Which of the following actions should the nurse take first?

Check neurovascular status distal to the injury

A client comes to the emergency department in severe respiratory distress following left-sided blunt chest trauma. The nurse finds that the client has absent breath sounds on the left side and a tracheal shift to the right. For which of the following procedures should the nurse prepare the client?

Chest tube insertion

A nurse is caring for a client during her first prenatal visit and notes that she is lactose intolerant. Which of the following foods should the nurse include on a list of calcium sources for this client? Collard greens Cottage cheese Orange juice Broccoli

Collard greens

A health care facility's leadership team is implementing a new computerized charting system. When preparing for the implementation date, which of the following actions should the nurse manager take first?

Collect the staff's input about planning and implementing the change.

A nurse is planning care for a client who has acute systemic lupus erythematosus (SLE) and is to begin treatment for systemic manifestations. Which of the following types of medications should the nurse plan to administer?

Corticosteroids

A nurse is reviewing the medical record of a client who is requesting a prescription for sildenafil citrate. Which of the following data in the client's record should the nurse identify as a contraindication for the use of this medication?

Current use of isosorbide to treat HF.

A nurse is assessing a client who has AIDS and is taking zidovudine. Which of the following findings is the priority for the nurse to report to the provider? Nausea and vomiting Decreased hemoglobin Decreased appetite Anxiety

Decreased hemoglobin Zidovudine can cause severe anemia and neutropenia from bone marrow suppression resulting in hematologic toxicity.

A nurse is caring for a client who is taking acarbose to treat type 2 DM. For which of the following adverse effects of this medication should the nurse monitor? Insomnia Diarrhea Joint pain Polycythemia

Diarrhea The most common adverse effects of acarbose, an alpha-glucosidase inhibitor, are gastrointestinal. They include diarrhea, abdominal distention and cramping, and flatulence.

A nurse is caring for an infant who has a cleft palate. The parents ask the nurse how long they should wait before he should have corrective surgery. The nurse should explain that the parents should wait no longer than 6-12 months to prevent which of the following outcomes?

Difficulty with language acquisition

A nurse is caring for a client who has methicillin-resistant Staphylococcus aureus (MRSA) infection. A dietary assistant asks the nurse what precautions are necessary for entering the client's room with the lunch tray. Which of the following instructions should the nurse give the dietary assistant? Don a gown before entering the room and remove it before exiting. Wear a mask while in the client's room. Don gloves when entering the room and use hand sanitizer when exiting. Take no special precautions unless you have direct contact with the client.

Don gloves when entering the room and use hand sanitizer when exiting. Clients who have a MRSA infection require contact precautions. In addition to the use of standard precautions and meticulous hand hygiene, contact precautions require that any staff who will have contact with the client's environment don gloves prior to entering the room. Additional precautions, such as a gown, are required for contact with the client, and a mask and goggles if secretions from the infected area could spray into the worker's face. Delivering the tray would require contact with the environment; therefore, the dietary assistant must wear gloves.

A nurse is assessing a client who is receiving hemodialysis for the first time. Which of the following findings indicates to the nurse that the client is developing dialysis disequilibrium syndrome (DDS)?

Headache

A community health nurse is performing client triage while participating in a disaster drill. The nurse should recommend that which of the following clients receives treatment first?

Hemothorax [The nurse should apply the survival potential priority-setting framework. The nurse should reserve the use of this framework for mass casualty situations, when resources are scarce and he must allocate resources to save the greatest number of lives. While it might seem that the client least likely to survive should receive priority care, this is the client who is the lowest priority. The nurse should assign the highest priority to the client who has injuries that are severe but has the potential to survive with treatment. Therefore, the nurse should recommend that the client who has a hemothorax receive treatment first. A hemothorax is life-threatening, but with chest-tube insertion and stabilization the client is likely to survive.

A nurse is reviewing the laboratory report for a client who has chronic kidney disease (CKD). The nurse finds the following laboratory test results: potassium 6.8 mEq/L, calcium 7.4 mg/dL, hemoglobin 10.2 g/dL, and phosphate 4.8 mg/dL. Which of the following findings is the priority for the nurse to report to the provider? Hypocalcemia Hyperkalemia Anemia Hypoalbuminemia

Hyperkalemia [The nurse should apply the urgent versus nonurgent priority-setting framework when caring for this client. Using this framework, the nurse should consider urgent needs the priority need because they pose more of a threat to the client. The nurse may also need to use Maslow's hierarchy of needs, the ABC priority-setting framework, or nursing knowledge to identify which finding is the most urgent. Therefore, hyperkalemia, which can cause life-threatening cardiac dysrhythmias, is the priority for the nurse to report to the provider.

A nurse is caring for a client who is taking warfarin. Which of the following laboratory values should the nurse recognize as an effective response to the medication?

INR 3.0

A nurse in an acute care facility is implementing the facility's disaster plan following a flood in the community. Which of the following actions should the nurse take? Turn clients' televisions on so they can learn about the disaster. Identify stable clients in the ICU to transfer to the medical-surgical units. Ask family members to come to the hospital to provide support to clients. Make announcements of the status of the disaster on the public address system.

Identify stable clients in the ICU to transfer to the medical-surgical units. The nurse should identify clients to transfer to medical-surgical units to increase the availability of ICU beds for clients from the external disaster who are critically ill.

A nurse is assessing a client who has multidrug-resistant TB and takes ethambutol. The nurse should identify which of the following findings as an adverse effect of this medication? Mottling of the extremities Orange-red urine and bodily secretions Yellowing of the sclera Loss of red/green color discrimination

Loss of red/green color discrimination Ethambutol is an antitubercular medication that impairs ribonucleic acid synthesis. A common adverse reaction is the loss of red/green color discrimination due to optic neuritis. The nurse should notify the provider of this finding and expect a prescription to discontinue the medication.

A nurse is caring for a client who has chronic phantom limb pain following an above-knee amputation. Which of the following medication prescriptions should the nurse verify with the provider?

Meperidine.

A nurse in the emergency department is assessing a client who has deep, rapid respirations. Arterial blood gas analysis includes these values: pH 7.25, PaCO2 40, and HCO3_ 18. Which of the following acid-base imbalances should the nurse identify and report to the provider? Respiratory alkalosis Metabolic alkalosis Respiratory acidosis Metabolic acidosis

Metabolic acidosis [A pH of 7.25 indicates acidosis. If the cause is respiratory, the pH and PaCO2 values deviate in opposite directions. Since the PaCO2 is within the expected reference range, despite the low pH, the cause must be metabolic. Therefore, the nurse correctly reports to the provider that the client has metabolic acidosis.]

A nurse is providing discharge teaching to a client who does not speak the same language as the nurse. The client's neighbor, who speaks the client's native language and the nurse's, arrives to drive the client home. Which of the following actions should the nurse take? Ask the client's neighbor to call a family member to interpret. Ask the client's neighbor to translate the information. Obtain the services of an interpreter Document the inability to provide discharge instructions.

Obtain the services of an interpreter [Federal mandates require that a professional medical interpreter translate the client's health care information into the client's native language.]

A nurse is preparing to care for a client who is in balanced skeletal traction to stabilize a femur fracture. Which of the following actions should the nurse include in the client's plan of care? Offering the client a diet high in fluid and fiber Encouraging active range of motion of the affected leg Removing the weights prior to repositioning the client Inspecting pin sites every 24 hr for drainage

Offering the client a diet high in fluid and fiber.

A nurse is providing teaching to a client who has a new prescription for doxycycline. The nurse should instruct the client to monitor for which of the following adverse effects? Photosensitivity Constipation Ototoxicity Blurred vision

Photosensitivity. An adverse effect of doxycycline, a tetracycline antibiotic, is photosensitivity. The skin reacts abnormally to light, especially ultraviolet radiation or sunlight. Prevention involves avoiding direct exposure to sunlight and ultraviolet light, wearing protective clothing outdoors, and using sunscreen.

A nurse is caring for a client who is postoperative following a laparotomy and has an indwelling urinary catheter and a Jackson-Pratt drain in place. Which of the following findings should indicate that the client is developing a postoperative complication?

Pulse oximetry of 85%

A nurse is assessing a client who has an abdominal aortic aneurysm (AAA). Which of the following findings should indicate to the nurse that the AAA is expanding? Increased BP and decreased pulse rate Jugular-vein distention and peripheral edema Report of sudden, severe back pain Report of retrosternal chest pain radiating to the left arm

Report of sudden, severe back pain [An aortic aneurysm is a weak spot in the wall of the aorta, the primary artery that carries blood from the heart to the head and extremities, that allows the aorta to expand and increase in diameter. Sudden and increasing lower abdominal and back pain indicates that the aneurysm is extending downward and pressing on the lumbar sacral nerve roots.]

A nurse in the emergency department is caring for a child who has bruises that the nurse suspects are d/t child abuse. Which of the following actions should the nurse take?

Report the suspected abuse to local authorities.

A nurse is teaching self-administration of NPH insulin to a client who has type 2 DM. which of the following instructions should the nurse include?

Rotate injection sites within the same area.

A nurse is providing teaching to a client who has a new prescription for sertraline. The client asks the nurse if he should continue to take St. John's wort for depression. Which of the following instructions should the nurse give the client? Take the medication and herbal supplement together. Stop taking the herbal supplement while taking the medication. Take the herbal supplement and the medication at least 2 hr apart. Take an antacid with both the herbal supplement and the medication.

Stop taking the herbal supplement while taking the medication. [Taking the antidepressant sertraline and the herbal supplement St. John's wort together puts the client at risk for serotonin syndrome.]

A nurse is caring for a client who is receiving IV ampicillin and develops urticaria and dyspnea. Which of the following actions should the nurse take first? Elevate the client's feet and legs Administer epinephrine. Infuse 0.9% sodium chloride. Stop the medication infusion.

Stop the medication infusion [The greatest risk to the client is an allergic reaction that can progress to anaphylaxis. The nurse should stop the infusion immediately to halt further exposure of the client to the allergen.]

A nurse is assessing a client who is receiving a transfusion of packed RBCs. Which of the following findings should the nurse identify as an indication of an acute intravascular hemolytic reaction?

Sudden oliguria [The nurse should identify sudden oliguria as an indication of an acute intravascular hemolytic reaction. This type of transfusion reaction causes acute kidney injury resulting in sudden oliguria and hemoglobinuria. This type of reaction results from the client's antibodies reacting to the transfused RBCs.]

A nurse is assessing a client who is receiving clozapine to treat schizophrenia. The nurse should identify an increase in which of the following parameters as an early indication of an adverse effect of this medication? Urine specific gravity Urine output Blood pressure Temperature

Temperature [Antipsychotic medications, such as clozapine, can cause agranulocytosis, which is the depletion of WBCs. This increases the client's risk for infection. Fever is an early indication that the client should have a WBC count checked to detect agranulocytosis.]

A nurse is evaluating the injection site for a client who had a Mantoux skin test 48 hours ago. The nurse finds 10 mm induration with slight redness. Which of the following conclusions should the nurse make?

The client has had an exposure to TB.

A hospice nurse is visiting with the family member of a client. The family member states that the client has insomnia almost nightly. Which of the following practices should the nurse identify as contributing to the client's insomnia?

The client watches television in her bed during the day.

A nurse is accepting a transfer from the PACU of a client who has had a subtotal thyroidectomy. Which of the following equipment should the nurse have available at the bedside for this client?

Tracheostomy tray.

A nurse is preparing to administer 100 units of insulin glargine and 4 units of NPH insulin subcutaneously to a client. Which of the following actions should the nurse plan to take?

Use separate syringes for administering insulin glargine and NPH insulin.

A nurse is planning recreational activities for a young adult client who has an acute exacerbation of schizophrenia. Which of the following activities should the nurse plan for this client?

Walking with a staff member