HESI NCLEX Quiz 2

The nurse caring for an 8-month-old child at the pediatrician's office is reviewing medication instructions with the father. The client has otitis media and has been prescribed amoxicillin 250 mg three times daily. The medication comes as a liquid suspension of 500 mg/10 mL. The nurse would advise the father to give how many milliliters per dose? Fill in the blank and round answer to the nearest whole number. _______ milliliters

1.5 ml

The charge nurse on a women's health unit is making a client room assignment. Which clients would be least appropriate to assign to share a room with a woman who is pregnant? Select all that apply. A client with hepatitis B A client with herpes zoster A client with pyelonephritis A client with hashimotos thyroiditis A client with a urinary tract infection

A client with hepatitis B A client with herpes zoster Rationale: Viral infections such as hepatitis B and herpes zoster can be very serious for the mother and fetus if exposed and clients with these conditions should not share a room with a pregnant client. Pyelonephritis, hashimotos thyroiditis, and urinary tract infections can all have adverse effects on a pregnant woman; however, these are not contagious conditions, and therefore clients with these conditions can safely room share with a pregnant woman.

The charge nurse is making a client assignment for the upcoming shift. In order to create a safe assignment, the charge nurse plans to assign those clients requiring airborne precautions amongst different nurses. Which clients should be assigned to different nurses? Select all that apply. A client with measles. A client with C. difficle. A client with influenza. A client with pneumonia. A client with tuberculosis.

A client with measles. A client with tuberculosis. Rationale: Airborne precautions are used for those clients that are diagnosed with or suspected to have a condition spread through airborne transmission. Measles and tuberculosis are transmitted via airborne transmission. A client with influenza should be placed on droplet precautions. A client with C. difficile should be placed in contact and enteric precautions and a client with pneumonia only requires standard precautions.

A client informs the nurse that she has recently started taking the herbal supplement black cohosh for her menopausal symptoms. When reviewing the client's medical record, what finding would warrant the need for follow-up? Refer to chart. TSH result Incorrect BNP result Heart failure Glipizide prescription

Glipizide prescription Rationale: Black cohosh is an herbal product used to treat hot flashes, irritability, and palpitations. It potentiates insulin, oral hypoglycemic agents, and anti-hypertensive agents. Therefore, follow-up would be necessary if the client was taking glipizide, a sulfonlyrea oral hypoglycemic agent. The TSH result is a normal finding. The BNP result would be expected with a known diagnosis of heart failure and additionally would not be affected by black cohosh.

The emergency department nurse is caring for a client at risk for respiratory failure. Which nursing actions are important in the care of this client? Select all that apply. Listen to breath sounds Evaluate chest expansion Insert a naso-gastric tube Look for physical abnormalities Request a needle decompression

Listen to breath sounds Evaluate chest expansion Look for physical abnormalities Rationale: After the airway is secured or determined to be patent, the nurse should assess the client's breathing. The nurse should listen to breath sounds, evaluate chest expansion and assess the client for chest wall trauma and any physical abnormalities. There is no evidence that a naso-gastric tube is necessary. It would be inappropriate to request a needle decompression; these are typically performed on clients with a tension pneumothorax. In addition this is not a nursing action.

The home care nurse is providing care to a client with heart failure. Which assessment findings should alert the nurse to worsening heart failure? Select all that apply. Pallor Confusion Chest pain Warm extremities Activity intolerance

Pallor Confusion Chest pain Activity intolerance Rationale: The focus of the home care nurse's interventions is assessment and health teaching. During assessment of the client, the nurse should look for signs of worsening heart failure. These include pallor, confusion, complaints of chest pain, and activity intolerance, which indicate hypoxia. The nurse would expect to find cool extremities in a client with worsening heart failure.

The nurse on a post-partum unit is assessing a client for signs of post-partum depression. Which statements would be the most appropriate for the nurse to make in order to assess the client for depression? Select all that apply. "How are things going for you today?" "Do you have anyone to help you at home?" "Can you tell me how you are feeling today?" "I'm sure you're so happy with your new baby." "It is not very common to feel sad after giving birth."

"How are things going for you today?" "Do you have anyone to help you at home?" "Can you tell me how you are feeling today?" Rationale: Asking if the client feels sad, how things are going, and inquiring if the client has help at home are good ways to engage the client in conversation and determine if there is evidence of depression. Assuming that the client feels happy or making general statements are not ways that the nurse can effectively assess for post-partum depression.

The nurse is providing education to the client who is receiving external radiation therapy to the face. Which statements by the client indicate understanding? Select all that apply. "It is okay to wash off the ink or dye markings." "I should not use soap at all when washing my face." "I need to avoid exposing the irradiated area to the sun." "I should use my hands to wash my face, rather than a washcloth." "I can use lotions or powders that are prescribed by the radiation oncology department."

"I need to avoid exposing the irradiated area to the sun." "I should use my hands to wash my face, rather than a washcloth." "I can use lotions or powders that are prescribed by the radiation oncology department." Rationale: The immediate and long-term side effects of all types of radiation are limited to the tissues exposed to the radiation. When educating the client, the nurse should evaluate the client's understanding. Education has been successful when the client states understanding of the need to avoid sun exposure, use hands rather than a washcloth when washing the skin, and only using lotions and powders that are prescribed. These actions will help protect the integrity of the skin. The nurse should also educate the client to avoid washing off the ink or dye markings until radiation is complete, and that it is ok to use a mild soap to wash.

The nurse is caring for a woman who is starting medroxyprogesterone injections for birth control. What statements by the client would indicate a need for further teaching? Select all that apply. "I may experience some weight gain." "I may not have regular periods while taking this medication." "I should return in approximately 6 months for my next injection." "Because it is highly effective, I can use this medication for many years." "Depression is a side effect, and I should let my doctor know if I experience any mood changes."

"I should return in approximately 6 months for my next injection." "Because it is highly effective, I can use this medication for many years." Rationale: Medroxyprogesterone is an injectable progestin given every 3 months to prevent ovulation and pregnancy. It suppresses ovulation for 15 weeks, and therefore, timing of the next injection is very important and should be no longer than exactly 3 months. Although medroxyprogesterone is highly effective, it should not be taken for more than 2 years due to the risk of osteoporosis. Weight gain, irregular periods, and depression are all known side effects.

A 22-year-old African American woman is 28 weeks pregnant. She is concerned about pre-term labor and asks the nurse what she should look out for. What statements made by the client would indicate the need for further teaching? Select all that apply. "I should stay well hydrated." "I am at a higher risk because of my race." "Stress levels can impact my chance of preterm labor." "My age puts me at a higher risk of having the baby early." "As long as I'm not obese, my weight does not increase my risk."

"My age puts me at a higher risk of having the baby early." "As long as I'm not obese, my weight does not increase my risk." Rationale: Preterm labor is defined as delivery between 20 to 37 weeks' gestation. A woman aware of the possibility, risk factors, and signs and symptoms of preterm labor may be more likely to take action and prevent it. Age impacts the risk for preterm labor. Less than 18 or over the age of 40 increases the risk. Obesity increases the risk of preterm labor, as does being underweight for height. Hydration is important, and non-whites have a greater risk for preterm labor.

The nurse is listening to an information presentation on the new objectives for Healthy People 2020. Which statements by the nurse indicate an understanding of the objectives? Select all that apply. "One of the objectives is to increase the 1 year survival rates for infants with Down Syndrome." "Healthy People 2020 will aim to increase the percentage of women ages 18 to 44 who have impaired fecundity." "An objective of Healthy People 2020 is to increase the percentage of employers who have worksite lactation programs." "Healthy People 2020 will strive to increase the percentage of newborns to receive formula supplementation during the first two days of life." "Healthy People 2020 aims to increase the percentage of live births that occur in facilities that provide recommended care to lactating mother and their babies."

"One of the objectives is to increase the 1 year survival rates for infants with Down Syndrome." "An objective of Healthy People 2020 is to increase the percentage of employers who have worksite lactation programs." "Healthy People 2020 aims to increase the percentage of live births that occur in facilities that provide recommended care to lactating mother and their babies." Rationale: Healthy People 2020 provides science-based 10-year national objectives for improving health and preventing disease in the United States. Some objectives for Healthy People 2020 include increasing the survival rates for infants born with Down syndrome, increasing the percentage of employers with worksite lactation programs, and increasing the percentage of live births that occur in facilities that provide recommended care to lactating mothers and their babies. Healthy People 2020 aims to decrease the percentage of women ages 18 to 44 who have impaired fecundity and strive to increase the percentage of newborns to be breast-fed during the first two days of life.

The nurse is attending an educational session on substance abuse during pregnancy. Which statements by the nurse indicate that the education has been effective? Select all that apply. "Substance abuse generally has no effect on the fetus." "Social stigma, labeling, and guilt are barriers to treatment." "Pregnant women often do not seek help for fear of losing their child." "Most pregnant women end up receiving treatment for their addictions." "In some states, pregnant women who abuse substances may face criminal charges."

"Social stigma, labeling, and guilt are barriers to treatment." "Pregnant women often do not seek help for fear of losing their child." "In some states, pregnant women who abuse substances may face criminal charges." Rationale: It is important that the nurse have a clear understanding of the effects of substance abuse during pregnancy. The nurse should understand the barriers that prevent treatment, such as social stigma, labeling, and guilt. The nurse should know that many pregnant clients avoid treatment out of fear of losing their child. In some states, pregnant clients may face criminal charges for their use of drugs while pregnant. Nurses should recognize that substance abuse has a direct effect on the health and well-being of both the mother and fetus, and that less than 10% of pregnant substance abusers actually receive treatment for their addiction.

The nurse manager is educating a group of nursing students on the educational needs of bariatric clients post-surgery. Which statement by one of the nursing students indicates that the teaching has been effective? Select all that apply. "The client should be encouraged to keep follow-up appointments." "During weight loss, the client may become depressed or even anxious." "Clients should be provided with a list of available community resources." "It is not necessary for clients to adhere to a community-based treatment plan." "Clients are followed by a surgeon and dietician for a few months after the surgery."

"The client should be encouraged to keep follow-up appointments." "During weight loss, the client may become depressed or even anxious." "Clients should be provided with a list of available community resources." Rationale: The nurse manager knows that teaching has been effective when the student states that post-surgical clients should keep follow-up appointments. The client may also become depressed or anxious during this time, and experience a "hibernation period." Clients should receive a list of community resources that are available specifically to them. Clients should be educated about the importance of adhering to a community-based treatment plan, which will give them access to information and support. The client should understand that they will be followed by both a surgeon and dietician for a few years after surgery.

The nurse is instructing a postoperative client how to use a patient controlled analgesia (PCA) pump. What statements made by the client would indicate teaching was effective? Select all that apply. "This machine will deliver pain medication when I push the button." "I should push the button as many times as I want if I have any pain at all." "Itching is a normal side effect and I do not need to worry if I experience this." "If I fall asleep, my wife can push the button for me so I continue to get pain medication." "My oxygen and breathing will be monitored while using this machine to prevent being over medicated."

"This machine will deliver pain medication when I push the button." "My oxygen and breathing will be monitored while using this machine to prevent being over medicated." Rationale: A patient controlled analgesia (PCA) pump allows the client to feel more empowered in the treatment of pain. Oxygen levels and breathing should be assessed frequently to prevent respiratory sedation. Inform the client that pain should be tolerable, but may not be completely gone and to notify the nurse if any adverse side events develop such as itching, nausea or trouble breathing occurs. Instruct the client that no other individual, including the nurse, should push the button.

The nurse is caring for a client who is in labor and preparing for birth. The nurse has been advised that the pregnancy is the result of a rape. Which statements by the nurse would be the most appropriate? Select all that apply. "You are safe here." "We have done this many times before." "Just relax; we know what we are doing." "You are in labor and preparing to give birth to your baby." "Please let us know if any of the examinations are uncomfortable for you."

"You are safe here." "You are in labor and preparing to give birth to your baby." "Please let us know if any of the examinations are uncomfortable for you." Rationale: In order to create a comfortable environment for the client, the nurse should maintain a calm environment and use words that will comfort the client. The nurse should let the client know that the environment is safe and that safety will be maintained at all times. The client should be updated on what is happening, and letting the client know what to expect, what examinations are occurring, and the reason why. The nurse should refrain from making vague statements, and instead should personalize care to the needs of the client. If the pregnancy is a result of rape, the woman may be extremely ambivalent about the baby. If the rape occurred some time ago, the experience of pregnancy with prenatal examinations can trigger memories of the original trauma. It is important to know that she may avoid prenatal examinations because of the anxiety triggered by bodily touch and vaginal examinations.

The nurse is assisting in the examination of a five year old child who was removed from an abusive home. The social worker alerts the nurse that there is a history of violence in the child's home, which has resulted in the removal of the child and siblings. Which behaviors should the nurse expect the child to express? Select all that apply. Smiling during the exam. Blaming the abuser for the injury. A need to find and protect a sibling. Feeling guilty for causing the abuse to occur. Aggressive behavior towards the nurse and health care provider.

A need to find and protect a sibling. Feeling guilty for causing the abuse to occur. Aggressive behavior towards the nurse and health care provider. Rationale: In homes where intimate partner violence (IPV) occurs, children are exposed to that violence at the very least and often become additional recipients of that violence. IPV usually predates abuse of the child. Younger children seem to have more behavioral problems when exposed to intra-family violence. For instance, they often have problems with anxiety, depression, and aggression. They often experience many fears and worries that are developmentally inappropriate. Expressing the need to find and protect a sibling is an example of worry that is developmentally inappropriate for a five year old child. Guilt is another aspect that abused children frequently struggle with, as children often blame themselves for abuse. The nurse would expect the child to portray aggressive behaviors out of fear. Due to the history of violence that this child has been subjected to, the nurse would not expect the child to smile and be receptive to the exam, or blame the abuser for the injury. Another issue of concern that the nurse should be aware of is post-traumatic stress disorder (PTSD). Associated features of PTSD may be more detrimental than the violence itself.

The nurse is assisting a family with end-of-life care for their child. Which actions by the nurse would be the most appropriate? Select all that apply. Acknowledging the emotions of the family members. Taking time to listen to the family talk about their child. Limiting communication with the family, to allow grieving. Reminding the family that their feelings and emotions are normal. Gently reminding the family that they must focus on their remaining children. Incorrect

Acknowledging the emotions of the family members. Taking time to listen to the family talk about their child. Reminding the family that their feelings and emotions are normal. Rationale: It is important that the nurse take the time to listen to the family as they talk about their child. The nurse should also acknowledge the emotions of the family members and remind them that their feelings and emotions are normal. Not acknowledging the family members feelings are often triggers for grief. It would be inappropriate, or even hurtful, to the family if the nurse limited communications or suggested that the family focus on the remaining children. During this time, family members need therapeutic and caring support from the nurse.

The nurse on the labor and delivery unit notes the following fetal heart rate pattern on the fetal monitoring strip (refer to figure). What is the priority nursing action? Assist client to the supine position Increase oxytocin (Pitocin) infusion Administer oxygen via face mask at 8 to 10 L Continue to monitor fetal heart rate patterns

Administer oxygen via face mask at 8 to 10 L Rationale: Late decelerations are a drop in fetal heart rate after the peak of contraction. They are generally a sign of impaired placental exchange and therefore, the nurse should administer oxygen to the client to increase maternal blood oxygenation and increase available oxygen to the fetus. Repositioning the client may be helpful, but the supine position is not recommended as this could decrease perfusion to the fetus. Uterine stimulants such as oxytocin should be stopped. Continued monitoring of the fetal heart rate pattern is important, but late decelerations are a non-reassuring sign requiring intervention.

The nurse is planning care for several clients who are at high risk for venous thrombosis. The nurse should identify which clients who are at high risk for venous thromboembolism (VTE)? Select all that apply. A 35-year-old with intractable nausea An 88-year-old admitted with confusion A 28-year-old recovering from a paralytic ileus A 45-year-old recovering from a total hysterectomy A 45-year-old in a motor vehicle accident who sustained multiple fractures

An 88-year-old admitted with confusion A 45-year-old recovering from a total hysterectomy A 45-year-old in a motor vehicle accident who sustained multiple fractures Rationale: Clients at risk for VTE include those with prolonged immobility such as those with multiple fractures, those recovering from a surgical procedure, such as a total hysterectomy, obese clients, and those with advancing age. Nausea and paralytic ileus alone do not increase the risk for VTE.

The nurse is caring for a client with known chronic kidney disease (CKD), who is taking digoxin. When assessing the client, which signs/symptoms would alert the nurse to the possibility of digoxin toxicity? Select all that apply. Anorexia Muscle aches Visual changes Sudden ear pain Nausea and vomiting

Anorexia Visual changes Nausea and vomiting Rationale: Clients with CKD are particularly at risk for digoxin toxicity because the medication is excreted by the kidneys. The symptoms include confusion, visual changes, gastrointestinal (GI) disturbances such anorexia, nausea, and vomiting. Muscle aches and sudden ear pain is not indicative of digoxin toxicity.

The nurse is caring for a client with Addison's disease in acute crisis. What priority actions should the nurse implement into the care plan? Select all that apply. Apply telemetry monitoring Monitor strict intake and output Administer spironolactone as prescribed Rapidly infuse normal saline as prescribed Administer oxygen via non-rebreather mask

Apply telemetry monitoring Monitor strict intake and output Rapidly infuse normal saline as prescribed Rationale: Acute adrenal insufficiency as seen in Addison's disease is a life-threatening emergency. Because of the rapid decrease in sodium and elevation of potassium, cardiac monitoring is essential along with intravenous normal saline. Intake and output are closely monitored due to blood volume depletion, rapid electrolyte imbalances, rehydration, and diuretic use. Oxygenation should be assessed, but supplemental oxygen may not be required. Diuretics are used as part of the treatment plan, however, due to elevated potassium levels, potassium-retaining diuretics should be avoided.

The nurse is caring for a client with chronic pain. Which actions should the nurse take in order to assess the client's quality of life? Select all that apply. Withhold pain medications to determine the client's need. Ask if the client has difficulty sleeping or eating due to pain. Ask if the client realizes that opiates cause substance dependence. Ask the client to describe how the pain has affected the daily routine. Ask the client if there are activities that are no longer possible due to pain.

Ask if the client has difficulty sleeping or eating due to pain. Ask the client to describe how the pain has affected the daily routine. Ask the client if there are activities that are no longer possible due to pain. Rationale: In order to assess the client's quality of life, the nurse should ask questions that determine how pain has interfered with the client's daily activities. The nurse should assess the sleep patterns, appetite, side effects, and if the client is unable to perform certain activities because of the presence of pain. Asking the client about substance abuse concerns is non-therapeutic during an assessment of the client's quality of life. The nurse should not withhold pain medications to a client with chronic pain. The nurse should assess the need for medication and how well the client can function with the medication.

The nurse is assessing a client who is two days post-partum and preparing to be discharged from the health care facility. Which interventions would be the most appropriate for the nurse to perform? Select all that apply. Assess the client for risk factors of depression. Determine if a follow-up after discharge is necessary. Provide a listing of community resources to the client and family. Spend time observing the interactions between the client and infant. Educate the client and family on the signs of post-partum depression.

Assess the client for risk factors of depression. Provide a listing of community resources to the client and family. Spend time observing the interactions between the client and infant. Educate the client and family on the signs of post-partum depression. Rationale: It is important that the nurse take time to adequately assess the client and prepare the family for discharge. The nurse should always plan to follow-up with the client after discharge, whether by discharge phone calls or home visit. The nurse should also assess the client for risk factors of depression before discharge, so that proper interventions can be made. Providing a list of community resources to the client and family may help in decreasing the the client and family's anxiety in obtaining help when needed. The nurse should educate the client and family on signs of post-partum depression and where to get help. The nurse should also spend some time observing interactions between the client and infant, and performing any interventions that may be necessary.

The nurse is creating a plan of care for a client who was admitted with an infection. The nurse has been informed that the client will need a peripherally inserted central catheter (PICC) line placed, and in the next few days will be discharged home. Which information about the PICC line should the nurse include in the plan of care? Select all that apply. Avoid heavy lifting once Keep the extremity immobile How to care for the PICC line Reason for PICC line placement How to get dressed with the PICC line

Avoid heavy lifting once How to care for the PICC line Reason for PICC line placement How to get dressed with the PICC line Rationale: A peripherally inserted central catheter (PICC) is a catheter inserted through a vein of the antecubital fossa (inner aspect of the bend of the arm) or the middle of the upper arm. PICCs should be inserted early in the course of therapy before the veins of the extremity have been damaged from multiple venipunctures and infusions. The nurse should plan to educate the client on how to care for the PICC line, how to get dressed and perform other activities of daily living, and the reason for the PICC line placement. The nurse should also educate the client to avoid heavy lifting because this can lead to muscle contraction, which can cause catheter dislodgment.

The nurse is caring for a client with cancer who has just been diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). On assessment, the client complains of weakness, muscle cramps, and loss of appetite. Which specific actions should the nurse include in the plan of care? Select all that apply. Check for peripheral edema Monitor the client for a weak pulse Monitor the client for neck vein that are flat Assess for the presence of crackles in the lungs Observe urine for changes in color or characteristic

Check for peripheral edema Assess for the presence of crackles in the lungs Rationale: The treatment modality for a client with SIADH focuses on safety, maintaining fluid balance, and supportive care. This includes preventing fluid overload, which could lead to pulmonary edema and heart failure. It is important to monitor for increasing fluid overload (bounding pulse, neck vein distention, crackles in the lungs, and peripheral edema). Specific to SIADH is to monitor the amount of urine output specifically for a decrease.

The nurse is providing care to a client who has a tracheostomy. Which actions should the nurse take to prevent a tube obstruction? Select all that apply. Change the tracheostomy ties frequently Suction the tube as needed Humidify the oxygen source Assess the client every shift for tube patency Teach the client how to cough and deep breathe

Change the tracheostomy ties frequently Suction the tube as needed Teach the client how to cough and deep breathe Rationale: Tube obstruction can occur as a result of secretions or by cuff displacement. The nurse can take actions to prevent tube obstruction with interventions such as: suctioning the tube as needed, humidify the oxygen source to keep secretions thin, and teaching the client how to cough and deep breathe. Changing the tracheostomy ties frequently is not necessary and can place the client at higher risk of tube dislodgement. The client should be assessed at least hourly for tube patency.

The nurse is examining an infant with burns that are suspicious for child abuse. Which findings should the nurse report as highly suspicious for abuse? (Select all that apply). A burn mark on the child's finger. Circular burn marks on the infant's buttocks. A bright pink coloring on the infant's cheeks. A dark brown marking on the infant's lower back. A stocking pattern of burn marks on the infant's feet and legs.

Circular burn marks on the infant's buttocks. A stocking pattern of burn marks on the infant's feet and legs. Rationale: The nurse should maintain a high degree of awareness for injuries that are not typically seen in the context of day-to-day living—such as unusual patterns of bruising or burn marks. Findings during the physical assessment that would raise suspicion for the nurse are circular burns or burns that occur in a stocking pattern. A burn mark to the finger should be questioned, but is not highly suspicious for child abuse. Bright pink coloring to the checks is typically normal in infants. Dark brown markings located on the lower back or buttocks are known as Mongolian spots.

The nurse is counseling a client who has been diagnosed with human immunodeficiency virus (HIV). In creating a plan of care, which interventions should the nurse include? Select all that apply. Instruct the client not to share towels Discuss options for medication therapy Educate the client about proper condom use Provide education about needle exchange programs Educate the client that sexual intercourse can never take place again

Discuss options for medication therapy Educate the client about proper condom use Provide education about needle exchange programs Rationale: The nurse has an important role when counseling the client who has been diagnosed with HIV. The nurse should educate the client on ways to treat the disease and reduce the risk of spreading the disease to others. These include medication therapy that will halt the growth of the virus, proper condom use, and needle exchange programs to prevent the spread of infection. Sharing towels does not lead to the spread of HIV. It is not appropriate to educate the client to never have sexual intercourse again. However, "safer sex" methods should be discussed.

The nurse is discharging an older client who was admitted for dehydration. Which instructions would be the most appropriate for the nurse to include in the discharge teaching? Select all that apply. Drink caffeine in moderation. Avoid drinking water right before bed. Eliminate juice drinks totally from the diet. Understand how prescribed medications work. Be sure to drink 6 to 8 glasses of water each day.

Drink caffeine in moderation. Understand how prescribed medications work. Be sure to drink 6 to 8 glasses of water each day. Rationale: People older than 65 years are also at risk for dehydration because they have less body water content than younger adults. In severe cases, they require emergency department visits or hospital stays. It is important that the client receive education to prevent dehydration. The nurse should educate the client to drink caffeine in moderation. Juice drinks are appropriate and provide extra vitamins. The client should understand how prescribed medications work, especially diuretics. The client should be encouraged to drink 6 to 8 glasses of water each day. The nurse should not tell the client to avoid drinking water before bed; the client should drink when thirsty.

The nurse is creating a plan of care for a client who is planning to become pregnant. What should the nurse include in the plan to help the client have a good pregnancy outcome? Select all that apply. Eat a healthy diet Avoid the use of alcohol and tobacco Have mammograms to detect breast cancer early Refrain from exercising during preconception Take the recommended amount of folic acid each day

Eat a healthy diet Avoid the use of alcohol and tobacco Take the recommended amount of folic acid each day Rationale: In recent years the concept of preconception care has been recognized as an important contributor to good pregnancy outcomes. The nurse should emphasize the importance of good health including exercise during this time. When creating a plan of care the nurse should include activities such as eating a healthy diet, avoiding the use of alcohol and tobacco, and preventing sexually transmitted infections. The nurse should also direct the client in choosing foods that are rich in folic acid, or recommend an appropriate prenatal vitamin that contains folic acid. It is unnecessary to include information about mammograms at this time.

The home health nurse is caring for an older client recovering from pneumonia. A concerned family member believes that the client is no longer capable of caring for self effectively. The nurse conducts an assessment of the client's basic activities of daily living (BADLs). What activities would the nurse assess? Select all that apply. Eating Bathing Cooking Dressing Taking medications Balancing a checkbook

Eating Bathing Dressing Rationale: ADL's are basic activities that assess functional ability. Daily activities such as eating, bathing, and dressing are considered basic every day needs. Activities such as cooking, taking medication, and balancing a checkbook are considered more complex, instrumental activities.

The nurse reviewing the surgeon's prescriptions in preparation for the client's surgery. Which of the Surgical Care Improvement Project (SCIP) core measures does the nurse identify as appropriate? Select all that apply. Electric clippers are used to remove hair Indwelling catheter will be removed on post-operative day 4 Prophylactic antibiotic will be initiated 15 minutes prior to surgical incision Prophylactic antibiotics discontinued within 24 hours after surgery end time Temperature will be measured 15 minutes after the end of anesthesia administration

Electric clippers are used to remove hair Prophylactic antibiotics discontinued within 24 hours after surgery end time Temperature will be measured 15 minutes after the end of anesthesia administration Rationale: Perioperative nursing places special emphasis on safety, advocacy, and client education, and ensuring a safety is the responsibility of all health care team members. The nurse should be familiar with the SCIP core measures and be prepared to incorporate them into client care. The nurse should identify the core measures as using electric clippers to remove excess hair, instead of using razors which can irritate the skin; discontinuing prophylactic antibiotics within 24 hours after the surgical end time, and measuring the client's temperature 15 minutes after anesthesia administration has ended. The nurse should recognize that indwelling catheter should be removed no later than 48 hours after placement, and that prophylactic antibiotics should be initiated no later than 1 hour prior to the surgical incision.

The nurse in the emergency department is caring for a client just brought in with partial thickness burns to 50% of the body. What actions should the nurse implement as part of the care plan? Select all that apply. Elevate extremities Administer tetanus vaccine for prophylaxis Assess airway patency and provide oxygen as needed Provide the client with a large glass of water to stay hydrated Keep burns uncovered to allow for cooling air to reach the wounds

Elevate extremities Administer tetanus vaccine for prophylaxis Assess airway patency and provide oxygen as needed Rationale: Immediate care for a burn is critical. Ensure in the first hour after a burn that the client's extremities are elevated to prevent edema. Administer a prophylactic dose of tetanus, assess the airway to ensure patency, and administer oxygen as needed. Water should not be provided to the client because the client should remain NPO; initiate fluid rehydration with IV fluids instead. Lastly, cover the client with a blanket to help maintain body temperature.

The nurse is caring for a client who has recently undergone a radical right-sided mastectomy for stage 3 breast cancer. When giving report to the next shift, what information would be essential to communicate to the oncoming nurse? Select all that apply. Elevate the right arm on a pillow. Monitor skin color and for the presence of edema. Educate that a medical alert bracelet is being worn. Ensure the client refrains from any physical activity. Take blood pressure measurements on the right side only.

Elevate the right arm on a pillow. Monitor skin color and for the presence of edema. Educate that a medical alert bracelet is being worn. Rationale: After a mastectomy, the nurse must assess for peripheral tissue perfusion. Therefore it is important to assess skin color and for the presence of edema. Elevation of the extremity will decrease venous pressure and decrease edema. A medical alert bracelet should be worn at all times. A medical alert bracelet should be worn to alert others and prevent anyone from using the affected extremity for blood pressure, intravenous (IV punctures), or blood draws because this could increase the likelihood of infection or decreased tissue perfusion. Although the client should avoid heavy lifting, activity should be encouraged and the client should participate in physical therapy unless contraindicated.

The nurse is caring for a client who has been diagnosed with rheumatoid arthritis. The health care provider has just started the client on methotrexate, to manage symptoms. When creating the plan of care for this client, which adverse effects should the nurse monitor for? Select all that apply. Increased thirst Elevated blood pressure Elevation of liver enzymes A decrease in the platelet count An increase in white blood cells (WBCs)

Elevation of liver enzymes A decrease in the platelet count Rationale: Methotrexate, an immunosuppressive medication, administered in a low, once-a-week dose (generally 25 mg or less per week) is a possible treatment for rheumatoid arthritis. When creating the plan of care, the nurse should monitor for certain adverse effects, and be prepared to treat them. The nurse should assess for an elevation in liver enzymes and a decrease in platelet count. Increased thirst and elevated blood pressure are not adverse effects of methotrexate. The client would experience a decrease in the WBC count, not an increase, during methotrexate therapy.

The nurse in an assisted living facility is providing care to an older client, who has just moved to the facility. Which actions should the nurse include in the plan of care to decrease relocation stress, and help the client adjust to the new environment? Select all that apply. Encourage the client to change bedtime to the facility routine. Explain each procedure to the client as they occur. Allow the client to participate in decision making activities. Establish a trusting relationship with the client as soon as possible. Ask the client's family to refrain from bringing special keepsakes to the facility.

Explain each procedure to the client as they occur. Allow the client to participate in decision making activities. Establish a trusting relationship with the client as soon as possible. Rationale: Being admitted to a hospital or nursing home is a particularly traumatic experience. Older adults often suffer from relocation stress syndrome, also known as relocation trauma. Relocation stress syndrome is the physical and emotional distress that occurs after the person moves from one setting to another. The nurse can take several actions to help decrease this distress in the client. The nurse should take time to assess the client's usual lifestyle, taking note of favorite foods or preferred bathing schedule. The nurse should explain each procedure to the client as they occur. The client should be allowed to participate in the decision making process, if the client is able to make decisions. These actions will allow the nurse to establish a trusting relationship with the client, which will be helpful in the future care of the client and interaction with the family. Encouraging the client to adapt to the facility bedtime routine would not provide individualized care. The nurse should not ask the family to refrain from bringing personal keepsakes in to the client. These items may be comforting to the client and should be allowed in the facility.

The nurse is preparing the client for a bronchoscopy. Which actions should the nurse take to ensure client safety? Select all that apply. Explain the procedure to the client Clarify and document the client's allergies Verify the client using two types of identifiers Keep the client on nothing by mouth status for 2 hours prior to the test Remind the client to take deep breaths as instructed during the procedure

Explain the procedure to the client Clarify and document the client's allergies Verify the client using two types of identifiers Rationale: Safety during the procedure is a priority in nursing care. In order to ensure safety for the client, the nurse should explain the procedure to the client, , clarify and document the client's allergies, and verify the client using two different identifiers. The client should be kept NPO 4 to 8 hours prior to the exam to reduce the risk of aspiration. The client will receive moderate sedation and is not instructed to take deep breaths during the procedure.

The nurse is assessing a client with mitral valve regurgitation. Which manifestations should the nurse expect to note? Select all that apply. Fatigue Orthopnea Chronic weakness Low blood pressure Atypical chest pains

Fatigue Orthopnea Chronic weakness Atypical chest pains Rationale: The fibrotic and calcific changes occurring in mitral valve regurgitation (insufficiency) prevent the mitral valve from closing completely during systole, which allows backflow of blood into the left atrium when the left ventricle closes. During assessment the nurse should anticipate findings such as: fatigue, orthopnea, chronic weakness, and atypical chest pains. Blood pressure is often normal in clients with mitral valve regurgitation.

The nurse is volunteering at a local health fair to educate the public on primary prevention of stress. Which interventions would be the most appropriate for the nurse to recommend to the public, in order to reduce stress levels? Select all that apply. Finding a source of pleasure. Developing a positive attitude. Counseling for chronic anxiety. Engaging in stressful situations. Learning relaxation and deep breathing exercises.

Finding a source of pleasure. Developing a positive attitude. Counseling for chronic anxiety. Learning relaxation and deep breathing exercises. Rationale: It would be most appropriate for the nurse to suggest finding a source of pleasure, whether it is spending time with family or talking a walk each day. Developing a positive attitude, seeking counseling for chronic anxiety and utilizing relaxation and deep breathing exercises are also ways to combat stress. The nurse should recommend that individuals stay away from stressful situations, in order to decrease their overall levels of stress.

The nurse at a long-term care facility is conducting a medication review of a newly admitted older client with dementia, hypertension, diabetes mellitus, and depression. Which medication prescription would warrant the need to contact the health care provider? Select all that apply. Lisinopril 10 mg orally once daily. Furosemide 20 mg orally once daily. Fluoxetine 20 mg orally once daily. Metformin 500 mg orally twice daily. Cyclobenzaprine 5 mg every 8 hours as needed.

Fluoxetine 20 mg orally once daily. Cyclobenzaprine 5 mg every 8 hours as needed. Rationale: A close review of medications is necessary for safe care of any client client but because the aging process affects physiological functioning, medication prescriptions for the older client need to be carefully monitored. The use of fluoxetine and cyclobenzaprine are considered inappropriate in the older client according to the Beers criteria and should not be used. All other medications listed would be appropriate.

The nurse is monitoring a client who is receiving a blood transfusion. The blood has been infusing for 15 minutes. The nurse interprets which assessment findings as a possible allergic reaction? Select all that apply. Increased pallor New onset of hypertension The client reports feeling nervous Palpation of a rapid, thready pulse A change in the client's level of fatigue

Increased pallor Palpation of a rapid, thready pulse Rationale: Nursing actions during transfusions aim at prevention or early recognition of transfusion reactions. Reactions include palpation of a rapid thready pulse, and increased pallor or cyanosis. These findings should alert the nurse to a possible reaction. It is important that the nurse immediately stop the blood infusion if a reaction is suspected. Findings such as hypertension, nervousness, or a change in fatigue level do not typically indicate an allergic reaction. However, the nurse should continue to monitor these symptoms and intervene as necessary.

A client asks the nurse what can be done to prevent colon cancer as the client's father died from it. What information would be appropriate for the nurse to include in the teaching? Select all that apply. Limit alcohol consumption and avoid smoking Screening for colon cancer should begin at age 60 A diet high in fat can increase your risk of colon cancer Fiber can irritate the gastrointestinal tract and should be limited Notify your healthcare provider of any changes in your bowel habits

Limit alcohol consumption and avoid smoking A diet high in fat can increase your risk of colon cancer Notify your healthcare provider of any changes in your bowel habits Rationale: Individuals with a family history of colon cancer should discuss their risk with their healthcare provider. Risk factors for colon cancer include a diet high in alcohol and fat, and smoking. The health care provider should be notified of any changes in bowel habits such as constipation, diarrhea, or blood in stools. Screening for colon cancer should begin at age 50, or earlier if a strong family history exists. Fiber is helpful for gastrointestinal health, and a diet high in fiber is recommended.

The nurse is working in the emergency department when a client is brought in by ambulance. The client reports being bitten by a North American pit viper. Upon assessment, the nurse notices a bite mark on the client's left leg. Which actions should the nurse to take? Select all that apply. Apply ice to the bite mark Initiate cardiac monitoring Prepare to administer oxygen Start two large-bore intravenous (IV) lines Measure the circumference of the bitten extremity every 15 to 30 minutes

Initiate cardiac monitoring Prepare to administer oxygen Start two large-bore intravenous (IV) lines Measure the circumference of the bitten extremity every 15 to 30 minutes Rationale: When providing emergency care to a victim of snakebite, determine if the venom has been injected into the body. The primary functions of venom are to immobilize, kill, and aid in digestion of prey. Therefore venom causes local and systemic toxic effects. The enzymes in venom break down human tissue proteins, alter membrane integrity, and impair blood clotting. The pathophysiologic effects of pit viper envenomation can lead to local tissue necrosis, massive tissue swelling, intravascular fluid shifts and hypovolemic shock, pulmonary edema, renal failure, hemorrhagic complications from disseminated intravascular coagulation (DIC), and death. The nurse should take action to prevent further injury to the client. The nurse should initiate cardiac monitoring to determine the presence of cardiac ischemia as a result of the venom. Establishing two large bore IV line is a priority in the care of this client for the administration of fluids and possible antidotes, as well as preparing to administer oxygen. The nurse should measure the bitten extremity every 15 to 30 minutes, and document the size and assess the site. The nurse should refrain from applying ice to the bite mark; ice can promote tissue necrosis.

The nurse is caring for a client with neutropenia. To monitor for infection, which action by the nurse is a priority? Listen to lung sounds Encourage a nutritious diet Incorrect Take the client's vital signs every shift Place the client in a room close to the nurse's station

Listen to lung sounds Rationale: The priority nursing interventions for the client with neutropenia are protect the client from infection within the health care system and teach the client and family how to reduce infection in the home. To monitor for infection, the priority action for the nurse is to listen to the client's lung sounds to monitor for an existing infectious process. Hospitalized clients are susceptible to hospital-acquired pneumonia, which could be life-threatening to the client with neutropenia. The remaining options are not interventions that will monitor for infection. The vital signs should be monitored more frequently than every shift.

A pregnant client has a history of depression and has been noncompliant with treatment in the past. What actions by the nurse would be the most appropriate? Select all that apply. Remind the client the risk of suicide increases with noncompliance. Maintain a hopeful, caring relationship with the client. Discuss the noncompliance with the client, if the client brings it up. Provide education to the client about depression and treatment options. Ask the client what methods of managing the depression have worked in the past.

Maintain a hopeful, caring relationship with the client. Provide education to the client about depression and treatment options. Ask the client what methods of managing the depression have worked in the past. Rationale: Assessment throughout pregnancy and the postpartum period is critical to the mother's and the baby's health. The nurse should strive to maintain respect for the client's decisions at all times, even though the nurse may not agree with the client's decisions. Maintaining a hopeful and caring relationship with the client, allows for the establishment of trust. The nurse should provide education when the client is open to learning, and utilize teachable moments whenever possible. In order to create a plan of care that works, the nurse should ask the client what methods of depression management have been successful in the past. Telling the client the risk of suicide increases with noncompliance is unhelpful. It would not be effective for the nurse to avoid discussion of depression unless the client's brings up the topic. The nurse should recognize the need for education and begin assessing the client's readiness to learn.

The emergency department nurse has just received a client who was struck by lightning. On initial assessment, the nurse notes a pulse and that the client is breathing. Which immediate actions should the nurse to take? Select all that apply. Monitor for rhabdomyolosis. Prepare the client for discharge. Consult physical therapy for gait training. Request a creatinine kinase measurement. Perform a 12-lead electrocardiogram (ECG).

Monitor for rhabdomyolosis. Request a creatinine kinase measurement. Perform a 12-lead electrocardiogram (ECG). Rationale: Lightning produces injury by directly striking a victim, by splashing off a nearby object, or by traveling through the ground. Although few people die after a lightning strike, many survivors are left with permanent disabilities. The nurse should be prepared to deliver quick and effective care to the client. After the initial assessment, the nurse should perform a 12-lead ECG to detect any cardiac abnormalities. The nurse should continually assess for rhadomyolosis and intervene if necessary. The nurse should collaborate with the health care provider to request a creatinine kinase measurement, in order to monitor closely for rhabdomyolosis. The nurse should not prepare the client for discharge at this time. Physical therapy may be necessary if there is great tissue loss, but it is not a priority.

The nurse is caring for a client who has had a myocardial infarction. After administering intravenous morphine sulfate, which interventions should the nurse take? Select all that apply. Monitor the client's blood pressure Monitor the client's respiratory rate Determine the client's oxygen saturation Ask the client to obtain a urine specimen Prepare the client for cardiac catheterization

Monitor the client's blood pressure Monitor the client's respiratory rate Determine the client's oxygen saturation Rationale: Intravenous morphine sulfate (1 to 2 mg) is often prescribed to reduce myocardial oxygen demand by triggering blood vessel dilation. The nurse should be prepared to monitor the client's status. After administering morphine sulfate, the nurse should monitor the client's respiratory rate, oxygen saturation, and blood pressure. The nurse would not prepare the client for the cardiac catheterization unless specifically indicated by the health care provider. While a urine specimen may be needed, it is not the most important intervention after administration of the medication.

The nurse is providing care to a client following thoracentesis. Which actions should the nurse add to the client's plan of care, in order to promote health and safety? Select all that apply. Monitor vital signs as prescribed Assess the dressing for bleeding Ensure that a chest x-ray is obtained Instruct the client to avoid deep breathing Auscultate breath sounds for absent or reduced sounds

Monitor vital signs as prescribed Assess the dressing for bleeding Ensure that a chest x-ray is obtained Auscultate breath sounds for absent or reduced sounds Rationale: The client should be monitored closely following a thoracentesis. The nurse should adjust the plan of care as needed based on the client's needs. The nurse should plan to monitor vital signs as prescribed to detect changes that could indicate bleeding or pneumothorax, assess the dressing for bleeding and intervene as necessary. A chest x-ray should be obtained right away to rule out a pneumothorax or mediastinal shift from the procedure. Breaths sounds should be assessed for absent or reduced sounds indicating pneumothorax. The nurse should encourage the client to take deep breaths to promote the expansion of the lung.

A client is admitted to hospital for treatment of a respiratory infection. The client was treated with an intravenous (IV) course of ampicillin and is ready to be discharged home on oral antibiotics. What information present in the chart would warrant the nurse to provide further teaching? Anemia Potassium result Chest X-ray result Norgestimate and ethinyl estradiol prescription

Norgestimate and ethinyl estradiol prescription Rationale: Broad-spectrum antibiotics such as ampicillin are commonly used to treat upper respiratory infections. These medications can decrease the effectiveness of oral contraceptive medications and the client should be advised to use alternative birth control options. Anemia has no impact on the use of ampicillin. The chest x-ray results, although abnormal, are expected with a respiratory infection. Serum potassium level is within normal limits. PCOS and the use of metformin is not affected by the oral antibiotic.

The nurse has been assigned a client who is receiving enalapril therapy. After receiving report and reviewing the client's chart, which action should the nurse take first? Obtain a blood pressure Perform a full physical assessment Administer the client's morning medications Order the client's breakfast tray to be delivered at 0800

Obtain a blood pressure Rationale: Enalapril is an angiotensin-converting enzyme (ACE) inhibitor that is used to treat hypertension. Therefore, after receiving report and gathering information from the client's chart, the nurse should first obtain a blood pressure on the client. This will enable the nurse to make decisions about which step to take next, in order to provide safe client care. All other actions can safely wait until the nurse has obtained the client's blood pressure.

A client with diabetes mellitus, heart failure, and hypertension is being seen by the health care provider. The health care provider prescribes lispro insulin pens at mealtime. The client asks the nurse how to store the insulin pens. The nurse should include what information in the teaching? Select all that apply. Once opened, insulin pens are good for one month. When traveling, do not store the insulin pens in a warm car. The insulin pens should be stored in the refrigerator at all times. Keep the insulin pens away from children, for example, on a high windowsill. Unopened insulin pens may be stored in the freezer to lengthen the shelf life.

Once opened, insulin pens are good for one month. When traveling, do not store the insulin pens in a warm car. Rationale: Lispro is a rapid acting insulin used to treat hyperglycemia. Opened pens are good for one month, and when storing insulin it should be protected from extreme temperatures. It should be kept in the refrigerator until opened. The client needs to be taught to avoid exposure to direct sunlight or warm temperatures, so the client should avoid using a windowsill for storage or a warm vehicle. Insulin should never be frozen.

Upon assessment of a client with heart failure, the nurse notes that the client is dyspneic. Which actions should the nurse take initially? Select all that apply. Prepare the client for intubation Place the client in the Trendelenburg position Place pillows under each of the client's arms Assist the client with deep breathing exercises Administer oxygen to keep O2 saturation greater than 90%

Place pillows under each of the client's arms Assist the client with deep breathing exercises Administer oxygen to keep O2 saturation greater than 90% Rationale: The nurse should be prepared to intervene for the client with heart failure who is experiencing dyspnea. Interventions include placing the client in a high Fowler's position (not Trendelenburg) with pillows under each of the client's arms. This position maximizes chest expansion and improves oxygenation. The nurse should also assist the client with deep breathing exercises to improve oxygenation, and administer oxygen to keep O2 saturation greater than 90%. The nurse should try these interventions before preparing the client for intubation. These actions will help the client have the best outcome.

The nurse is caring for a client in labor. During assessment, the nurse notes that the client is hypotensive and that the fetus has an abnormal heart rate pattern. Which interventions should the nurse take? Select all that apply. Prepare the client for a cesarean section Encourage the client to ambulate in the room Place the client in a lateral or trendelenburg position Prepare the client for induction of labor with oxytocin Increase the rate of the primary intravenous (IV) infusion

Place the client in a lateral or trendelenburg position Increase the rate of the primary intravenous (IV) infusion Rationale: The nurse should notify the health care provider and should increase the rate of the primary infusion and place the client in a lateral or trendelenburg position to increase blood flow to the fetus. At this time, the nurse does not need to prepare the client for a cesarean section. The client should not be allowed to ambulate in the room due to the increased risk of falling and because of the abnormal heart rate pattern. Labor induction would not be done; this is not an appropriate intervention. In addition, the client is unstable.

The nurse is creating a plan of care for a client with chronic pain. Which alternative therapies should the nurse add into the plan to increase the client's comfort? Select all that apply. Give the client a hug Play soft music during rest times Assist with a warm, soothing bath Educate the client to plan for rest time Increase the client's dosage of pain medication

Play soft music during rest times Assist with a warm, soothing bath Educate the client to plan for rest time Rationale: With chronic pain, the client cannot depend solely on medications for relief. The nurse should offer alternative therapies to the client when appropriate. These treatments include using therapeutic massage, a warm soothing bath and soft music during rest times. The client should be educated to plan for rest times in between activities. Increasing the client's pain medication may be appropriate, but it is not considered an alternative treatment.

The nurse is creating a plan of care for a client with a chest tube. Which actions should the nurse include to promote client safety? Select all that apply. Position the drainage tubing to prevent kinks Strip the chest tube as needed to improve suction Check the system every 4 hours to ensure patency Tape tubing junctions to prevent accidental disconnections Keep sterile gauze(per agency procedure) at the bedside

Position the drainage tubing to prevent kinks Tape tubing junctions to prevent accidental disconnections Keep sterile gauze(per agency procedure) at the bedside Rationale: A chest tube is a drain placed in the pleural space to restore intra-pleural pressure, and allow re-expansion of the lung. When creating a plan of care for a client with a chest tube, the nurse should consider which actions will promote safety for the client. These actions that promote safety include: positioning the chest tube so that there are no kinks, keeping a sterile gauze (per agency procedure) at the bedside in case the chest tube is dislodged from the client, and taping tubing junction to prevent accidental disconnections in the system. Striping the chest tube should be avoided, as this can create negative pressure and damage lung tissue. The tube system should be checked hourly to ensure sterility and patency.

The nurse is providing discharge instructions to a client who has been diagnosed with cystitis. The nurse has been notified that the client does not have health care insurance. Which instruction from the nurse would be the most important for the client to complete in order to continue treatment? Follow up with a health care provider within one week. Call the case manager, in order to arrange payment for care. Fill the prescriptions that have been provided by the health care provider. Review the provided list of available community resources and initiate contact.

Review the provided list of available community resources and initiate contact. Rationale: For the client without health care insurance, the nurse should focus on assisting the client to obtain needed resources, such as follow-up and medications, at a low cost. Otherwise, the client may need to return to the hospital for repeat treatment. The nurse should provide the client with a listing of available community resources, such as a free clinic, and instruct the client in how to initiate contact. Once the client has made contact with the resources, the nurse should instruct the client to receive follow-up care and contact the case manager. Prior to discharge the nurse should assist the client in obtaining the medication needed to continue treatment. This can be completed by contacting a case manager for assistance.

The nurse is at a local pool when alerted of a near drowning event. Which actions should the nurse take? Select all that apply. Send a by-stander to call for help Obtain client history from a family member Initiate cardiopulmonary resuscitation (CPR) Maintain spinal immobilization immediately Handle the client gently to prevent ventricular fibrillation

Send a by-stander to call for help Initiate cardiopulmonary resuscitation (CPR) Handle the client gently to prevent ventricular fibrillation Rationale: The nurse should take immediate action when alerted to a drowning or near drowning, which includes: sending a by-stander to call for help and initiating CPR. If the nurse suspects hypothermia, the client should be handled with care to prevent ventricular fibrillation. The nurse should not spend time obtaining the client's history, but rather spend that time in life-saving efforts to the victim. The nurse should initiate spinal immobilization on clients who are suspected to have a spinal cord injury.

Following thyroid surgery, the nurse notes this response (refer to figure) when taking the client's blood pressure. On further assessment, which laboratory finding would the nurse expect to find? Serum calcium of 8.4 mg/dL (2.1 mmol/L) Sodium level of 138 mEq/L (138 mmol/L) Serum potassium of 5.1 mEq/L (5.1 mmol/L) Thyroid Stimulating Hormone (TSH) of 1.5 mU/L

Serum calcium of 8.4 mg/dL (2.1 mmol/L) Rationale: Hypocalcemia is characterized by tetany, or sustained muscle contractions. Chvostek's sign is facial contractions seen after a light tap of the facial nerve in front of the ear. Trousseau's sign is carpal contraction when a blood pressure cuff is inflated. These two signs are observed in hypocalcemia.

The nurse at an outpatient clinic is performing a health assessment on a 67-year-old client. Her health history includes chronic obstructive pulmonary disorder (COPD) and diabetes mellitus, and she currently has no complaints. On assessment, the client tells the nurse that she has not received any vaccinations other than a tetanus vaccine four years ago. Which routine vaccinations should be recommended given the client's age? Select all that apply. Tetanus vaccine Shingles vaccine Influenza vaccine Rotavirus vaccine Pneumococcal vaccine

Shingles vaccine Influenza vaccine Pneumococcal vaccine Rationale: The Centers for Disease Control (CDC) recommends that a healthy individual over the age of 65 years old should receive the shingles vaccine, an annual influenza vaccine, and a pneumococcal vaccine. Rotavirus is given to infants and the client is not due for a tetanus booster.

On assessment of a client with a normal saline intravenous (IV) infusion, the nurse notes that the IV site has infiltrated. Which actions by the nurse would be appropriate? Select all that apply. Stop the IV infusion Elevate the extremity Apply a warm compress to the IV site Apply a sterile dressing if weeping occurs Restart a new IV below the current IV site

Stop the IV infusion Elevate the extremity Apply a warm compress to the IV site Apply a sterile dressing if weeping occurs Rationale: If infiltration occurs, there are steps the nurse can take to prevent further damage to the tissue involved. These steps include stopping the IV infusion immediately, elevating the extremity to reduce swelling, and applying a warm compress to the IV site after the IV has been removed (per agency procedure). If weeping occurs from the IV site, the nurse can apply a sterile dressing to control the weeping and prevent infection. If the client requires a new IV, the nurse should place the IV in the opposite extremity.

The nurse is caring for a client with infective endocarditis, who is preparing to be discharged home. Which self-management techniques should the nurse teach the client? Select all that apply. Brush teeth once a day, with a soft toothbrush. Take prescribed antibiotics exactly as directed. Follow instructions for care for the infusion site. Clean open sores and apply prescribed antibiotic ointment. Ask the health care provider for prophylactic antibiotics prior to invasive procedures.

Take prescribed antibiotics exactly as directed. Follow instructions for care for the infusion site. Clean open sores and apply prescribed antibiotic ointment. Ask the health care provider for prophylactic antibiotics prior to invasive procedures. Rationale: Care of the client with endocarditis usually includes antimicrobials, rest balanced with activity, and supportive therapy. If these interventions are successful, surgery is usually not required. The nurse should teach the client self-management techniques to reduce the risk of complications and re-hospitalization. These interventions include cleaning any open sores and applying prescribed antibiotic ointment, taking prescribed antibiotics and caring for the infusion site. The nurse should also teach the client to request prophylactic antibiotics prior to invasive procedures. The client should brush teeth at least twice a day with a soft toothbrush, rinsing the mouth afterwards.

A client with left-sided heart failure has arrived on the cardiac unit. Which actions should the nurse initially include in the care plan for this client? Select all that apply. Take the apical heart rate for one minute Toilet the client every hour and as needed Teach the client how to regulate breathing Allow the client rest time between activities Allow the client to walk in the hallway a few times a day as desired

Take the apical heart rate for one minute Toilet the client every hour and as needed Teach the client how to regulate breathing Allow the client rest time between activities Rationale: Manifestations of heart failure depend on the type of failure, the ventricle involved, and the underlying cause. The nurse should develop the care plan around the needs of the client. Actions to include are taking the apical heart rate for one minute to detect abnormalities in rate or rhythm, toileting the client every hour and as needed since the client will be most likely treated with diuretics, teaching the client how to regulate breathing for adequate oxygenation. and allowing rest time between activities. Initially, the client should not be allowed to walk in the hallways. Treatment should be initiated and then progressive activity planned.

The nurse is caring for a client with urinary calculi, who is preparing for a surgical procedure to remove the stones. Which action by the nurse is a priority for maintaining the client's psychosocial integrity? Administer pain medications upon the client's request Teach the client actions to take after the procedure if problems arise Prepare the client's consent form and chart to transport to the surgical area Explain to the client that the surgeon will provide education on the procedure

Teach the client actions to take after the procedure if problems arise Rationale: Urolithiasis is the presence of calculi (stones) in the urinary tract. Stones often do not cause symptoms until they pass into the urinary tract, where they can cause excruciating pain. Once the nurse has made the client comfortable, it is important to give attention to the client's psychosocial integrity. Psychosocial preparation is enhanced when clients know what to expect and what actions to take if problems develop. It is a priority for the nurse to educate the client on the surgical procedure, as well as what actions to take after the procedure if problems arise. While administering pain medications it is important for the client's physical comfort, it is not the nurses priority when maintaining psychosocial integrity for the client. Once the client's needs have been met, the nurse can prepare the consent form. The nurse should also be well educated about the surgical procedure so that the client's questions can be answered.

A client will be started on peritoneal dialysis. The nurse should consider which statements in planning care for the client? Select all that apply. Bowel perforation is very rare. The client may experience respiratory distress. The client will require a diet that is high in protein. A complication of peritoneal dialysis is hypoglycemia. The client will experience fewer hemodynamic complications than with hemodialysis.

The client may experience respiratory distress. The client will require a diet that is high in protein. The client will experience fewer hemodynamic complications than with hemodialysis. Rationale: Peritoneal dialysis (PD) allows exchanges of wastes, fluids, and electrolytes to occur in the peritoneal cavity. PD is slower than hemodialysis (HD), however, and more time is needed to achieve the same effect. Complications of peritoneal dialysis include: bowel perforation, respiratory distress, protein loss, and hyperglycemia. An advantage of peritoneal dialysis is that client's experience fewer hemodynamic complications than with hemodialysis.

The nurse is caring for a client with severe anxiety. What goals should the nurse include when creating the care plan for this client? Select all that apply. The client will understand when to seek treatment. The client will be able to perform deep breathing exercises. The client will state where to obtain support group information. The client will state when it is appropriate to ignore the symptoms. The client will verbalize understanding not to take the medication unless feeling panicky.

The client will understand when to seek treatment. The client will be able to perform deep breathing exercises. The client will state where to obtain support group information. Rationale: When creating a care plan, the nurse should focus on outcomes that will help the client function better. The nurse should create a plan that includes: teaching the client when to seek treatment, how to perform deep breathing exercises, and how to obtain support group information. The nurse should stress the importance of acknowledging symptoms and taking steps to prevent a panic attack, such as deep breathing. The nurse should not teach the client to ignore symptoms or to wait and take the medication when panic sets in.

The nurse is preparing to administer bumetanide to a client. What information is the priority for the nurse to obtain prior to administering this medication? The client's current weight The client's potassium level The time of the client's last meal The time of the last bumetanide administration

The client's potassium level Rationale: Bumetanide is a loop diuretic that causes the kidneys to excrete potassium, which can lead to hypokalemia. Therefore it should be the nurse's highest priority to obtain the client's potassium level prior to administering the potassium. While the other options are important in the care of the client, the potassium level is the highest priority for client safety and well-being.

The nurse is assessing the client for placement of a midline catheter. Which factors would prompt the nurse to select a different type of catheter for this client? Select all that apply. Dialysis fistula on the right arm The use of vesicant medications The need for long-term antibiotics Client history of bilateral mastectomy with lymphedema The need for parenteral therapy with osmolarity greater than 600 mOsm/L (600 mmol/kg)

The use of vesicant medications Client history of bilateral mastectomy with lymphedema The need for parenteral therapy with osmolarity greater than 600 mOsm/L (600 mmol/kg) Rationale: An infusion catheter, also known as a vascular access device (VAD), is a plastic tube placed in a blood vessel to deliver fluids and medications. The specific type and purpose of the therapy determine whether the infusion can be given safely through peripheral veins or if the large central veins of the chest are needed. Midline catheters are placed in the peripheral circulation. Fluids and medications infused through a midline catheter should have a pH between 5 and 9 and a final osmolarity of less than 600 mOsm/L (600 mmol/kg). The pH and osmolarity outside these parameters increase the risk for complications like phlebitis and thrombosis. After assessing the client and the client's needs, the nurse would choose another type of catheter if the client will be given any vesicant medications, because leakage of these medications could damage surrounding tissue. The nurse should also avoid use of a midline catheter if the client has had a bilateral mastectomy with lymphedema, or if the client requires parenteral therapy that has an osmolarity greater than 600 mOsm/L (600 mmol/kg).

The nurse works in a busy emergency department and would like to reduce the potential for adverse events. Which actions can the nurse take to accomplish this? Select all that apply. Use room numbers to identify clients Utilize automated electronic track systems Look through the client's belongings for medication bottles Obtain an accurate medical history from the client or family Look for the presence of medical alert bracelets or necklaces

Utilize automated electronic track systems Obtain an accurate medical history from the client or family Look for the presence of medical alert bracelets or necklaces Rationale: A significant risk for all clients who enter the emergency care environment is the potential for medical errors or adverse events, especially those associated with medication administration. There are actions that the nurse can take to reduce the potential for adverse events. These include use of automated tracking systems to prevent errors or duplication of treatments, obtaining an accurate medical history, and looking for medical alert bracelets or necklaces on each client. The nurse should not use room numbers to identify clients. Looking through a client's belongings is an invasion of privacy, but if this needs to be done, then agency policies should be followed.

The nurse is working at a health fair, educating the public on how to prevent heat-related illnesses. Which information would be the most appropriate for the nurse to provide? Select all that apply. Drink iced tea throughout the day Wear sunscreen of at least SPF 30 Limit activity at the hottest time of day Wear clothing suited to the environment Heat illnesses only occur to those who work outside

Wear sunscreen of at least SPF 30 Limit activity at the hottest time of day Wear clothing suited to the environment Rationale: The nurse should educate the public to avoid caffeine and alcohol, and explain that these can lead to dehydration. The best fluid to consume in high heat weather is water. The public should also be educated to wear sunscreen every day, reapplying as needed, which includes an SPF of at least 30 with UVA and UVB protection. The nurse should also advise the public to limit activity at the hottest time of day and wear clothing that is suitable to the environment. The nurse should stress that heat illnesses can happen to anyone, not just those who work outside.