HESI PRACTICE

Heparin 20,000 units in 500 ml D5W at 50 ml/hour has been infusing for 5½ hours. How much heparin has the client received? A. 11,000 units. B. 13,000 units. C. 15,000 units. D. 17,000 units.

(A) is the correct calculation: 20,000 units/500 ml = 40 units (the amount of units in one ml of fluid). 40 units/ml x 50 ml/hr = 2,000 units/hour (1,000 units in 1/2 hour). 5.5 x 2,000 = 11,000 (A). OR, multiply 5 x 2,000 and add the 1/2 hour amount of 1,000 to reach the same conclusion = 11,000 units. Correct Answer: A

A client is to receive 10 mEq of KCl diluted in 250 ml of normal saline over 4 hours. At what rate should the nurse set the client's intravenous infusion pump? A. 13 ml/hour. B. 63 ml/hour. C. 80 ml/hour. D. 125 ml/hour.

(B) is the correct calculation: To calculate this problem correctly, remember that the dose of KCl is not used in the calculation. 250 ml/4 hours = 63 ml/hour. Correct Answer: B

The healthcare provider prescribes the diuretic metolazone (Zaroxolyn) 7.5 mg PO. Zaroxolyn is available in 5 mg tablets. How much should the nurse plan to administer? A. ½ tablet. B. 1 tablet. C. 1½ tablets. D. 2 tablets.

(C) is the correct calculation: D/H × Q = 7.5/5 × 1 tablet = 1½ tablets. Correct Answer: C

An IV infusion terbutaline sulfate 5 mg in 500 ml of D5W, is infusing at a rate of 30 mcg/min prescribed for a client in premature labor. How many ml/hr should the nurse set the infusion pump? A. 30 B. 60 C. 120 D. 180

(D) is correct calculation: 180 ml/hr = 500 ml/5 mg × 1mg/1000 mcg × 30 mcg/min × 60 min/hr. Correct Answer: D

The nurse mixes 50 mg of Nipride in 250 ml of D5W and plans to administer the solution at a rate of 5 mcg/kg/min to a client weighing 182 pounds. Using a drip factor of 60 gtt/ml, how many drops per minute should the client receive? A. 31 gtt/min. B. 62 gtt/min. C. 93 gtt/min. D. 124 gtt/min.

(D) is the correct calculation: Convert lbs to kg: 182/2.2 = 82.73 kg. Determine the dosage for this client: 5 mcg × 82.73 = 413.65 mcg/min. Determine how many mcg are contained in 1 ml: 250/50,000 mcg = 200 mcg per ml. The client is to receive 413.65 mcg/min, and there are 200 mcg/ml; so the client is to receive 2.07ml per minute. With a drip factor of 60 gtt/ml, then 60 × 2.07 = 124.28 gtt/min (D) OR, using dimensional analysis: gtt/min = 60 gtt/ml X 250 ml/50 mg X 1 mg/1,000 mcg X 5 mcg/kg/min X 1 kg/2.2 lbs X 182 lbs. Correct Answer: D

A client with terminal cancer is to receive 2 mg of hydromorphone (Dilaudid) IV every 4 hours as needed for severe breakthrough pain. The vial contains10 mg/mL. When the client complains of severe pain, how much solution of hydromorphone should the nurse administer? Record your answer using one decimal place. Include a leading zero if applicable. ___ mL

0.2 mL

A primary care provider prescribes cefazolin (Kefzol) 125 mg intramuscularly (IM) for a client. The vial contains 0.5 gm of cefazolin in powdered form. The instructions indicate to add 2 mL of sterile water to provide a solution that contains 225 mg per mL. Record your answer using one decimal place, including leading zero if applicable. ___ mL

0.6 Use the "Desire over Have" formula of ratio and proportion to solve this problem. Desire 125 mg = x mL Have 225 mg 1 mL 225x = 125 X = 125 ÷ 225 X = 0.55 mL. Round the answer up to 0.6 mL

The healthcare provider prescribes 1,000 ml of Ringer's Lactate with 30 Units of Pitocin to run in over 4 hours for a client who has just delivered a 10 pound infant by cesarean section. The tubing has been changed to a 20 gtt/ml administration set. The nurse plans to set the flow rate at how many gtt/min? A. 42 gtt/min. B. 83 gtt/min. C. 125 gtt/min. D. 250 gtt/min.

gtt/min = 20gtts/ml X 1000 ml/4hrs X 1 hr/60 min Correct Answer: B

The primary health care provider instructs the nurse to administer a high dose of acyclovir (Zovirax) 60 mg/kg/day to a neonate with a body weight of 4.4 lbs. What dose does the nurse administer to the neonate each day? Record your answer in milligrams using a whole number. _______ mg

120 Acyclovir is used to treat herpes virus infection in a neonate. A high dose of 60 mg/kg/day of acyclovir reduces the mortality rate in children. The neonate has a birth weight of 4.4 lbs or 2 kg [2.2 lbs = 1 kg]; therefore, the nurse should administer 2 × 60 = 120 mg of acyclovir per day to the neonate

A nurse is caring for a client after a total knee replacement who is requesting Vicodin in addition to the patient-controlled analgesia (PCA). The client reports having taken two Vicodin tablets every 4 hours for several weeks before surgery. If each tablet contains 500 mg of acetaminophen, how much acetaminophen had the client been ingesting per day? Record your answer using a whole number. ___ mg

6000 mg Two tablets every 4 hours over 24 hours equals a total of 12 tablets daily. Because each tablet has 500 mg, then 500 × 12 = 6000 mg. This is more than the recommended maximum dose of 4000 mg/24 hr for short-term use.

A client is receiving a cephalosporin antibiotic IV and complains of pain and irritation at the infusion site. The nurse observes erythema, swelling, and a red streak along the vessel above the IV access site. Which action should the nurse take at this time? A. Administer the medication more rapidly using the same IV site. B. Initiate an alternate site for the IV infusion of the medication. C. Notify the healthcare provider before administering the next dose. D. Give the client a PRN dose of aspirin while the medication infuses.

A cephalosporin antibiotic that is administered IV may cause vessel irritation. Rotating the infusion site minimizes the risk of thrombophlebitis, so an alternate infusion site should be initiated (B) before administering the next dose. Rapid administration (A) of intravenous cephalosporins can potentiate vessel irritation and increase the risk of thrombophlebitis. (C) is not necessary to initiate an alternative IV site. Although aspirin has antiinflammatory actions, (D) is not indicated. Correct Answer: B

A client who had a right total hip replacement is progressing from the use of a walker to the use of a cane. In which hand should the nurse teach the client to hold the cane? a. Left hand b. Right hand c. Stronger hand d. Dominant hand

A! A cane should be used on the unaffected side. Weight-bearing can be shared by a cane and an affected leg when they are advanced forward together. Teaching with the right hand promotes leaning toward the affected side and does not permit sharing of weight by the stronger left side of the body. Teaching with the stronger hand is unsafe; the stronger hand may not be the left hand. Teaching with the dominant hand is unsafe; the dominant hand may not be the left hand.

Why is it important for the nurse to teach a caregiver how to monitor the oxygen saturation level of a relative who will receive home ventilator therapy? a. Potential problems can be identified and acted on before serious consequences occur. b. Performance of the assessment will allow the caregiver to identify whether the client has pain. c. Caregiver participation will allow the home care nurse to perform more advanced assessments. d. Information about the cardiac and respiratory status of the client can be used by the caregiver to change ventilator settings.

A! Alterations in oxygen saturation can provide information about impending complications, permitting early intervention. Although a low oxygen saturation may be altered in the presence of pain, it is not the most specific way to determine whether a client is experiencing pain. The nurse still should obtain the oxygen saturation level when performing an assessment of a client in the home. Nonprofessionals do not have the expertise to alter ventilator settings. Ventilator settings should be maintained as prescribed by the health care provider.

A nurse in charge in the surgical intensive care unit notes that a number of clients do not seem to be responding to morphine that was administered for pain. Later in the evening the nurse finds a staff nurse dozing in the nurses' lounge. When awakened, the staff nurse appears uncoordinated and drugged, with slurred speech. What should the nurse in charge do? a. Ask the nurse manager to be present before confronting the staff nurse. b. Ask other staff members whether they have noticed anything unusual lately. c. Tell the staff nurse that everyone now knows who has been stealing the morphine. d. Arrange to secretly observe the staff nurse the next time the staff nurse administers morphine.

A! Arranging for the nurse manager to be present before confronting the staff nurse is a serious allegation, and confrontation should occur in the presence of a person in a supervisory position. Asking other staff members whether they have noticed anything unusual is unprofessional. The nurse in charge has enough information to confront the other nurse. Telling the staff nurse that everyone now knows who has been stealing the morphine may result in an altercation; a witness should be present. Arranging to secretly observe the staff nurse the next time the staff nurse administers morphine is unprofessional; the nurse in charge has a legal responsibility to intervene.

Which medication should the nurse anticipate the health care provider will prescribe to relieve the pain experienced by a client with rheumatoid arthritis? a. Acetylsalicylic acid (Aspirin) b. Hydromorphone (Dilaudid) c. Meperidine (Demerol) d. Alprazolam (Xanax)

A! Because of its antiinflammatory effect, acetylsalicylic acid is useful in treating arthritis symptoms. Opioids should be avoided because they promote drug dependency and do not affect the inflammatory process. Alprazolam is an antianxiety, not an antiinflammatory, agent.

After surgery a 5-year-old child experiences intense pain and an analgesic is prescribed. What should the nurse consider when administering the analgesic? a. Even though children do not like medicines, analgesics will make them more comfortable. b, Pain is not felt as strongly by children as by adults; therefore analgesics are not needed as frequently. c. Children should rarely receive analgesics because they could cause addiction or respiratory depression. d. Children do not need analgesics because they quickly return to playing or sleeping when they are distracted.

A! Children feel pain and should receive analgesics when needed. The idea that pain is not felt as strongly by children as it is by adults is a myth; it may be difficult for children to communicate pain. Not giving analgesics to children is a common but unsound belief; addiction and respiratory depression are rare. Some sources suggest that returning to play or sleep is a child's way of coping with unrelieved pain; however, it is no reason to withhold medication.

Health promotion efforts with the chronically ill client should include interventions related to primary prevention. What should this include? a. Encouraging daily physical exercise b. Performing yearly physical examinations c. Providing hypertension screening programs d. Teaching a person with diabetes how to prevent complications

A! Primary prevention activities are directed toward promoting healthful lifestyles and increasing the level of well-being. Performing yearly physical examinations is a secondary prevention. Emphasis is on early detection of disease, prompt intervention, and health maintenance for those experiencing health problems. Providing hypertension screening programs is a secondary prevention. Emphasis is on early detection of disease, prompt intervention, and health maintenance for those experiencing health problems. Teaching a person with diabetes how to prevent complications is a tertiary prevention. Emphasis is on rehabilitating individuals and restoring them to an optimum level of functioning.

A client who had a brain attack (stroke) is admitted to the hospital with right-sided hemiplegia. The nurse recognizes that it is important to identify restrictions of mobility or neuromuscular abnormalities because: a. Shortening and eventual atrophy of the muscles will occur. b. Hypertrophy of the muscles eventually will result from disuse. c. Rigid extension can occur, making therapy painful and difficult. d. Decreased movement on the affected side predisposes the client to infection.

A! Shortening and eventual atrophy of muscles occur, resulting in contractures. Muscles will atrophy, not hypertrophy, from disuse. Flexion contractions, not extension rigidity, occur. Hemiplegia does not predispose to infection but to atrophy and contractures. Study Tip: Enhance your time-management abilities by designing a study program that best suits your needs and current daily routines by considering issues such as the following: (1) Amount of time needed; (2) Amount of time available; (3) "Best" time to study; (4) Time for emergencies and relaxation.

A client is receiving patient-controlled analgesia (PCA) after surgery. The nurse determines that with this type of therapy the: a. Client is able to self-administer pain-relieving drugs as necessary b. Amount of medication received is determined entirely by the client c. Amount of drug used for analgesia fluctuates greatly over a given period d. Self-administration relieves the nurse of monitoring the client for pain relief

A! The ability of the client to self-administer pain-relieving medications as necessary is the purpose of patient-controlled analgesia; usually smaller amounts of analgesics are used with self-administration. The amount and dosage of the medication are programmed to prevent accidents or abuse. Drug levels are kept in a maintenance range, and pain relief is achieved without extreme fluctuations. The nurse is not absolved of responsibility when PCA is used; monitoring the client for effectiveness, refilling the apparatus with prescribed narcotic, charting the amount administered, and the client's response are required.

A client reports experiencing nausea, dyspnea, and right upper quadrant pain unrelieved by antacids. The pain occurs most often after eating in fast-food restaurants. Which diet should the nurse instruct the client to follow? a. Low fat b. Low carbohydrate c. Soft textured and bland d. High protein and kilocalories

A! The presence of fat in the duodenum stimulates painful contractions of the gallbladder to release bile; fat intake should be restricted. Carbohydrates do not have to be restricted. A reduction in spices and bulk is not necessary. Although a high protein and kilocalories diet might be desirable as long as the protein is not high in saturated fat, a high-calorie diet generally is not prescribed. Test-Taking Tip: Note the number of questions and the total time allotted for the test to calculate the times at which you should be halfway and three-quarters finished with the test. Look at the clock only every 10 minutes or so.

A 26-year-old homosexual client is diagnosed with acquired immune deficiency syndrome (AIDS). The primary nurse reports to the nursing team that the client cried when told of the diagnosis. One of the nursing assistants responds, "I don't feel sorry for him. He made his bed, and now he can lie in it." To best help the nursing assistant, the nurse manager must first identify that this comment most likely is a result of the nursing assistant's: a. Values and beliefs about sexual lifestyles. b. Anger and mistrust of homosexual males in general. c. Discomfort with men who are unable to control their emotions. d. Hostility over having to care for someone with a sexually transmitted infection

A! This statement reflects values and beliefs regarding homosexuality as being bad and deserving of punishment. There is not enough evidence presented to justify drawing the conclusion that the nursing assistant has anger and mistrust of homosexual males in general or discomfort with men who are unable to control their emotions. Although there may be hostility over having to care for someone with a sexually transmitted infection, no information is given to suggest that the nursing assistant has been assigned to care for this client.

When caring for a client who is receiving enteral feedings, the nurse should take which measure to prevent aspiration? a. Elevate the head of the bed between 30 and 45 degrees. b. Decrease flow rate at night. c. Check for residual daily. d. Irrigate regularly with warm tap water.

A! To prevent aspiration, the nurse should keep the head of the bed elevated between 30 and 45 degrees. Decreasing flow rate, checking residual, and irrigating regularly will not prevent aspiration.

A nurse is caring for an older adult who is taking acetaminophen (Tylenol) for the relief of chronic pain. Which substance is most important for the nurse to determine if the client is taking because it intensifies the most serious adverse effect of acetaminophen? a. Alcohol b. Caffeine c. Saw palmetto d. St. John's wort

A! Too much ingestion of alcohol can cause scarring and fibrosis of the liver. Eighty-five to 95% of acetaminophen is metabolized by the liver. Acetaminophen and alcohol are both hepatotoxic substances. Metabolites of acetaminophen along with alcohol can cause irreversible liver damage. Caffeine affects (stimulates) the cardiovascular system, not the liver. In addition, caffeine does not interact with acetaminophen. Saw palmetto is not associated with increased liver damage when taking acetaminophen. It often is taken for benign prostatic hypertrophy because of its antiinflammatory and antiproliferative properties in prostate tissue. St. John's wort is classified as an antidepressant and is not associated with increased liver damage when taking acetaminophen. However, it does decrease the effectiveness of acetaminophen.

A nurse is providing teaching to a client who is learning how to self-administer gastrostomy tube feedings. The teaching should include: a. Administering water after the feeding is completed b. Maintaining the supine position during the feeding c. Heating the feeding to slightly above body temperature d. Determining tube placement by instilling water before the feeding

A! Water is administered after the tube feeding to prevent the thicker feeding solution from obstructing the lumen of the tube. To prevent regurgitation and aspiration, a Fowler position is recommended. Tube feedings are tolerated best at body temperature. Instilling fluid before the feeding to ensure that the tube is in the stomach is unsafe; gastric contents should be aspirated from the stomach to determine placement.

What client behavior indicates to the nurse that a woman needs further teaching about breastfeeding her newborn? a. When she leans forward to place her breast in the infant's mouth b. If she holds the infant level with her breast while in a side-lying position c. If she touches her nipple to the infant's cheek at the beginning of the feeding d. When she puts her finger in the infant's mouth to break the suction after the feeding

A! When the breast is pushed into the infant's mouth, typically the infant's mouth closes too soon, resulting in inadequate latching on. Holding the infant level with her breast while in a side-lying position facilitates latching on and maintains the infant's head in correct alignment, which promotes sucking and swallowing. Touching the nipple to the infant's cheek at the beginning of the feeding will stimulate the rooting reflex and promote latching on. Putting her finger in the infant's mouth to break the suction after the feeding prevents trauma to the nipple when the infant is removed from the breast. Test-Taking Tip: Never leave a question unanswered. Even if answering is no more than an educated guess on your part, go ahead and mark an answer. You might be right, but if you leave it blank, you will certainly be wrong and lose precious points.

A client is being prepared for surgery to have placement of a percutaneous endoscopic gastrostomy (PEG) tube. The client asks why the PEG tube is preferred over the existing nasogastric tube that is being used for feedings. The nurse explains that a PEG tube is preferred for administering a tube feeding because: a. There is less chance of aspiration b. This procedure does not require a pump c. Self-administration of the feeding is possible d. More tube feeding mixture can be given each time

A! When tube feedings are given via a PEG tube, they bypass the upper gastrointestinal tract (oropharynx, esophagus, cardiac sphincter of the stomach), which reduces the risk of tracheal aspiration. A gastrostomy tube may be attached to a pump for continuous feedings. Clients can be taught to feed themselves with either method. The amount of the feeding is not affected.

Alternative therapy measures have become increasingly accepted within the past decade, especially in the relief of pain. Which methods qualify as alternative therapies for pain? Select all that apply. a. Prayer b. Hypnosis c. Medication d. Aromatherapy e. Guided

A, B, D, & E! Prayer is an alternative therapy that may relax the client and provide strength, solace, or acceptance. The relief of pain through hypnosis is based on suggestion; also, it focuses attention away from the pain. Some clients learn to hypnotize themselves. Aromatherapy can help relax and distract the individual and thus increase tolerance for pain, as well as relieve pain. Guided imagery can help relax and distract the individual and thus increase tolerance for pain, as well as relieve pain. Analgesics, both opioid and nonopioid, long have been part of the standard medical regimen for pain relief, so they are not considered an alternative therapy.

A client has received instructions to take 650 mg aspirin (ASA) every 6 hours as needed for arthritic pain. What should the nurse include in the client's medication teaching? Select all that apply. a. Take the aspirin with meals or a snack. b. Make an appointment with a dentist if bleeding gums develop. c. Do not chew enteric-coated tablets. d. Switch to Tylenol (acetaminophen) if tinnitus occurs. e. Report persistent abdominal pain.

A, C, & E! Acetylsalicylic acid (aspirin) is irritating to the stomach lining and can cause ulceration; the presence of food, fluid, or antacids decreases this response. Bleeding gums should be reported to the practitioner, not the dentist. Enteric-coated tablets must not be crushed or chewed. Acetaminophen does not contain the anti-inflammatory properties present in aspirin; tinnitus should be reported to the practitioner. Aspirin therapy may lead to GI bleeding, which may be manifested by abdominal pain; if present, the prescriber must be notified immediately.

A client with acute hemorrhagic anemia is to receive four units of packed RBCs (red blood cells) as rapidly as possible. Which intervention is most important for the nurse to implement? A. Obtain the pre-transfusion hemoglobin level. B. Prime the tubing and prepare a blood pump set-up. C. Monitor vital signs q15 minutes for the first hour. D. Ensure the accuracy of the blood type match.

All interventions should be implemented prior to administering blood, but (D) has the highest priority. Any time blood is administered, the nurse should ensure the accuracy of the blood type match in order to prevent a possible hemolytic reaction. Correct Answer: D

A female client who has recurrent urinary tract infections (UTIs) is inquiring about the prevention of future UTIs. What information should the nurse include when teaching the client? Select all that apply. a. Avoid fluid intake after 6 pm b. Drink 8 to 10 glasses of water each day c. Urinate immediately after sexual intercourse d. Increase the daily intake of carbonated beverages e. Clean the perineal area with an astringent soap twice a day

B & C! Drinking 8 to 10 glasses of water spaced throughout the day flushes the urinary tract and minimizes urinary stasis. Urination flushes the urethra and urinary meatus, limiting the presence of microorganisms. Limiting fluid intake contributes to stasis of urine. Carbonated and caffeinated beverages irritate the bladder and should be avoided. Cleaning the perineum with harsh soaps is irritating to the skin and mucous membranes, and can contribute to the development of UTIs in susceptible women.

A nurse is assessing a newly admitted client with a pressure ulcer indicated in the picture. What stage pressure ulcer should the nurse document on the admission history and physical? a. Stage I b. Stage II c. Stage III d. Stage IV

B! A stage II pressure ulcer is a partial-thickness ulceration of epidermis or dermis; it presents as an abrasion, blister, or shallow crater, has a red/pink wound bed, has no tissue sloughing, and may have an intact/open serum filled blister. A stage I ulcer has tissue injury with a purple or maroon localized area of intact skin or blood-filled blister; the area may be firm, boggy, warmer, cooler, or painful in comparison with nearby tissue. A stage III pressure ulcer has full-thickness ulceration involving the epidermis, dermis, and subcutaneous tissue; sloughing may be present, it presents as a deep crater with or without undermining, and bone, tendon, or muscle are not exposed. A stage IV pressure ulcer involves full-thickness skin loss and damage to muscle, bone, or tendon; sloughing or eschar may be present on parts of the wound bed, and it often includes undermining and tunneling.

A client with rheumatoid arthritis takes aspirin (ASA) routinely to reduce pain. The client asks whether it is the arthritis, the aspirin, or some other ear problem that causes the bilateral ear buzzing the client is now experiencing. What is an appropriate nursing response? a. "The ringing in your ears is a sign of otitis media." b. "Aspirin may have damaged your eighth cranial nerve, the acoustic nerve." c. "Accumulation of cerumen, or ear wax, causes ringing in the ears." d. "Your symptoms are an expected response to the aging process."

B! ASA may damage the eighth cranial (acoustic) nerve, causing ringing in the ears and impaired hearing. Pain, not ringing in the ears, is a sign of otitis media; ASA toxicity affects the eighth cranial nerve, not the middle ear. Diminished hearing, not ringing, occurs because of mechanical obstruction of the outer ear. Aging may cause decreasing acuity in the extremes of pitch, but it does not cause ringing in the ears.

A female client in the terminal stage of cancer is admitted to the hospital in severe pain. The client refuses the prescribed intramuscular analgesic for pain because it puts her to sleep and she wants to be awake. One day, despite the client's objection, a nurse administers the pain medication saying, "You know that this will make you more comfortable." The nurse in this situation could be charged with: a. Assault b. Battery c. Invasion of privacy d. Lack of informed consent

B! Battery is the intentional touching of one person by another without permission of the person being touched. Assault is an intentional act without touching that makes a person fearful or produces reasonable apprehension of bodily harm. Invasion of privacy refers to the right of clients to have their private affairs protected. Informed consent applies to permission for procedures and treatments to be performed.

A nurse provides instruction when the beta blocker atenolol (Tenormin) is prescribed for a client with moderate hypertension. What action identified by the client indicates to the nurse that the client needs further teaching? a. Move slowly when changing positions. b. Take the medication before going to bed. c. Expect to feel drowsy when taking this drug. d. Count the pulse before taking the medication. BBs.

B! Beta blockers (BBs) should not be taken at night because the blood pressure usually decreases when sleeping. This medication blocks beta-adrenergic receptors in the heart, which ultimately lowers the blood pressure. Therefore, the drug should be taken early in the morning to maximize its therapeutic effect. Orthostatic hypotension is a side effect of BBs, and the client should change positions slowly to prevent dizziness and falls. Drowsiness is a side effect of BBs, and the client should be taught precautions to prevent injury. The pulse rate should be taken before administration because ventricular dysrhythmias and heart block may occur

A slightly overweight client is to be discharged from the hospital after a cholecystectomy. What is most important for the nurse to include in teaching the client about nutrition? a. Listing those fatty foods that may be included in the diet. b. Explaining that fatty foods may not be tolerated for several weeks. c. Teaching the importance of a low-calorie diet to promote weight reduction. d. Encouraging the client to join a weight reduction program in the local community.

B! Bile, which aids in fat digestion, is not as concentrated as before surgery. Once the body adapts to the absence of the gallbladder the client should be able to tolerate a regular diet that contains fat. Initially the client should avoid fatty foods unless otherwise indicated. Although teaching the client about a low-calorie diet to promote weight reduction is important, it is not as important as temporary avoidance of fatty foods with the gradual resumption of a regular diet. Encouraging participation in a weight reduction program is inappropriate at this time; a temporary avoidance of fatty foods with the gradual resumption of a regular diet is the priority.

A client reports severe pain two days after surgery. After assessing the characteristics of the pain, which initial action should the nurse take next? a. Encourage rest. b. Obtain vital signs. c. Administer the prescribed analgesic. d. Document the client's pain response.

B! Immediately before administration of an analgesic, an assessment of vital signs is necessary to determine whether any contraindications to the medication exist (e.g., hypotension, respirations ≤12 breaths/min). Pain prevents both psychological and physiologic rest. Before administration of an analgesic, the nurse must check the health care provider's prescription, the time of the last administration, and the client's vital signs. A complete assessment including vital signs should be done before documenting.

A client who had a cerebrovascular accident (also known as a "brain attack") becomes incontinent of feces. What is the most important nursing action to support the success of a bowel training program? 1 Using medication to induce elimination. b. Adhering to a definite time for attempted evacuations. 3 Considering previous habits associated with defecation. 4 Timing of elimination to take advantage of the gastrocolic reflex.

B! Bowel training is a program for the development of a conditioned reflex that controls regular emptying of the bowel. The key to success is adherence to a strict time for evacuation based on the client's individual schedule. The indiscriminate use of laxatives can result in dependency. Although previous habits should be considered, the brain attack affects the responses of the client by altering motility, peristalsis, and sphincter control despite adherence to previous habits. The passage of food into the stomach does stimulate peristalsis, but it is only one factor that should be considered when planning a specific time for evacuation.

During an interview, the nurse discovers that the spouse of a debilitated, chronically constipated client digitally removes stool from the client's rectum. What response to disimpaction is the nurse attempting to prevent by presenting other strategies to regulate the client's bowel movements? a. Increased pulse rate b. Slowing of the heart c. Dilation of the bronchioles d. Coronary Artery Vasodilation

B! Disimpaction can cause vagal stimulation, which slows the heart. The vagus is the principal nerve of the parasympathetic portion of the autonomic nervous system, and its axon terminals release acetylcholine. The response of the viscera to acetylcholine varies, but in general the organ is in a relaxed state. Increased pulse rate is an action of the sympathetic nervous system (accelerator nerve) caused by the release of norepinephrine. Stimulation of the sympathetic nervous system dilates bronchioles in the lungs; the vagus nerve constricts them. There are parasympathetic fibers to the coronary blood vessels; sympathetic impulses dilate these vessels. Test-Taking Tip: You have at least a 25% chance of selecting the correct response in multiple-choice items. If you are uncertain about a question, eliminate the choices that you believe are wrong and then call on your knowledge, skills, and abilities to choose from the remaining responses.

A nurse is teaching the parents of an 8-year-old child who is taking a high dose of prednisone (Meticorten) for asthma. What critical information about prednisone should be included? a. It protects against infection. b. It should be stopped gradually. c. An early growth spurt may occur. d. A moon-shaped face will develop.

B! Gradual weaning from prednisone (Meticorten) is necessary to prevent adrenal insufficiency or adrenal crisis. Prednisone depresses the immune system, thereby increasing susceptibility to infection. The drug usually suppresses growth. A moon face may occur, but it is not a critical, life-threatening side effect.

A client who had abdominal surgery is receiving patient-controlled analgesia (PCA) intravenously to manage pain. The pump is programmed to deliver a basal dose and bolus doses that can be accessed by the client with a lock-out time frame of 10 minutes. The nurse assesses use of the pump during the last hour and identifies that the client attempted to self-administer the analgesic 10 times. Further assessment reveals that the client is experiencing pain still. What should the nurse do first? a. Monitor the client's pain level for another hour. b. Determine the integrity of the intravenous delivery system. c. Reprogram the pump to deliver a bolus dose every eight minutes. d. Arrange for the client to be evaluated by the health care provider.

B! Initially, integrity of the intravenous system should be verified to ensure that the client is receiving medication. The intravenous tubing may be kinked or compressed, or the catheter may be dislodged. Continued monitoring will result in the client experiencing unnecessary pain. The nurse may not reprogram the pump to deliver larger or more frequent doses of medication without a health care provider's prescription. The health care provider should be notified if the system is intact and the client is not obtaining relief from pain. The prescription may have to be revised; the basal dose may be increased, the length of the delay may be reduced, or another medication or mode of delivery may be prescribed.

A nurse teaches a client with varicose veins about prevention of a thromboembolus. Which statement regarding preventive measures indicates that the client requires further teaching? a. "I must increase my fluid intake." b."I will massage my legs twice a day." c. "Elastic stockings should be put on before getting out of bed." d. "Involving my upper and lower extremeties in all exercises is important.

B! Massaging the legs twice a day is unsafe if a thrombus is present because it may dislodge and cause an embolus. Fluids decrease blood viscosity, reducing the risk for thrombus formation. Elastic stockings physically compress veins, preventing venous stasis and lowering the risk for thrombus formation. Range-of-motion exercises prevent venous stasis and promote muscle tone; they propel venous blood toward the heart, facilitated by venous one-way valves.

The parents of an infant ask a nurse why their baby is not receiving the measles, mumps, and rubella (MMR) vaccine at the same time that other immunizations are being given. What explanation should the nurse give about why the MMR vaccine is administered at 12 to 15 months of age? a. There is an increased risk of side effects in infants. b. Maternal antibodies provide immunity for about 1 year. c. It interferes with the effectiveness of vaccines given during infancy. d. There are rare instances of these infections' occurring during the first year of life.

B! Maternal antibodies to measles, mumps, and rubella infection persist in the infant until approximately 15 months of age. Side effects are no more common among infants than in toddlers. The measles vaccination does not interfere with the effectiveness of other vaccines. Although the measles, mumps, and rubella do occasionally occur after the administration of the MMR vaccine during the first year of life, the vaccine is not given during this time because of the presence of maternal antibodies.

After surgery for a ruptured appendix, a 12-year-old child is receiving morphine for pain control by way of a patient-controlled analgesia (PCA) infusion. A bolus of morphine can be delivered every 6 minutes. A parent will be staying with the child during the immediate postoperative period. What statement indicates to the nurse that the instructions about the PCA pump have been understood? 1 "I'll make sure that she pushes the PCA button every 6 minutes." Correct2 "She needs to push the PCA button whenever she needs pain medication." 3 "I'll have to wake her up on a regular basis so she can push the PCA button." 4 "I'll press the PCA button every 6 minutes so she gets enough pain medication while she's sleeping." Morphine, an opioid analgesic, relieves pain; when control of pain is given to the child, anxiety and pain are usually diminished, resulting in a decreased need for the analgesic; only the child should press the PCA button. Having the child press the PCA button every 6 minutes is unnecessary. Although pain medication can be delivered as often as every 6 minutes, it should be used only if necessary. If the child is sleeping, the pain is under control; waking the child will interfere with rest. If the child is sleeping, the pain is under control; also, this will result in an unnecessary and excessive dosage of the opioid.

B! Morphine, an opioid analgesic, relieves pain; when control of pain is given to the child, anxiety and pain are usually diminished, resulting in a decreased need for the analgesic; only the child should press the PCA button. Having the child press the PCA button every 6 minutes is unnecessary. Although pain medication can be delivered as often as every 6 minutes, it should be used only if necessary. If the child is sleeping, the pain is under control; waking the child will interfere with rest. If the child is sleeping, the pain is under control; also, this will result in an unnecessary and excessive dosage of the opioid.

A client receives a prescription for nitroglycerin (Nitrostat) sublingual as needed for anginal pain. What should the nurse include in the teaching about this medication? a.To facilitate absorption, drink a large glass of water after taking the medication b. Place the tablet under the tongue or between the cheek and gum c. It takes 30 to 45 minutes for the nitroglycerin to achieve its effect d. If dizziness occurs, take a few deep breaths and lean the head back

B! Nitroglycerin sublingual tablets should not be chewed, crushed, or swallowed. They work much faster when absorbed through the lining of the mouth. Clients are instructed to place the tablet under the tongue or between the cheek and gum, and let it dissolve. The client should not eat, drink, smoke, or use chewing tobacco while a tablet is dissolving; this will decrease the effectiveness of the drug. If taken with water, the tablet is washed away from the site of absorption or may be swallowed. Nitroglycerin sublingual tablets usually give relief in one to five minutes. If a client experiences dizziness or lightheadedness, the client is instructed to take several deep breaths and bend forward with the head between the knees. This position promotes blood flow to the head.Content Area: Cardiovascular System, Blood, and Lymphatic Systems

The nurse is instructing a female client how to collect a urine specimen. What should the nurse tell the client about obtaining the specimen? a. Start urinating in the cup and then finish urinating in the toilet. b. With the enclosed towelettes, wipe your labia from front to back before collecting the specimen. c. If you can't fill the cup then leave it on the toilet and use it again when you void next time. d. When you finish, leave the cup on the back of the toilet and when the aide makes rounds, she'll get it.

B! The client must use the packaged towelettes and wipe the labia from front to back before urinating. The client needs to urinate a small amount in the toilet first and then hold the cup under the perineal area and finish urinating in the cup. If the client cannot void enough for a specimen then discard that one and obtain another specimen when the client can void a sufficient amount. Tell the client to notify the nurse immediately after the specimen is collected so it can be sent to the laboratory for analysis.

When a nurse requests that a client's pain intensity be rated on a scale of 0 to 10, the client states that the pain is "99." The nurse concludes that the client: a. Needs the instructions to be repeated. b. Requires an intervention immediately. c. Does not understand the numeric scale. d. Is using humor to get the nurse's attention.

B! The client reported a number as instructed but chose a number beyond the stated intensity scale. When numbers above 10 are identified, clients are communicating that the pain is excessive; immediate nursing action is indicated. It is not likely that the client misunderstood the instructions or does not understand the numeric scale; the client reported a number as instructed but chose a number beyond the stated intensity scale. The client has the nurse's attention; the use of humor is not commonly associated with clients in pain.

health care provider prescribes a diuretic for a client with hypertension. What should the nurse include in the teaching when explaining how diuretics reduce blood pressure? a. Facilitates vasodilation b. Promotes smooth muscle relaxation c. Reduces the circulating blood volume d. Blocks the sympathetic nervous system

C! Diuretics block sodium reabsorption and promote fluid loss, decreasing blood volume and reducing arterial pressure. Direct relaxation of arteriolar smooth muscle is accomplished by vasodilators, not diuretics. Vasodilators, not diuretics, act on vascular smooth muscle. Drugs that act on the nervous system, not diuretics, inhibit sympathetic vasoconstriction.

A pain scale of 1 to 10 is used by a nurse to assess a client's degree of pain. The client rates the pain as an 8 before receiving an analgesic and a 7 after being medicated. What conclusion should the nurse make regarding the client's response to pain medication? a. Client has a low pain tolerance. b. Medication is not adequately effective. c. Medication has sufficiently decreased the pain level. d. Client needs more education about the use of the pain scale.

B! The expected effect should be more than a 1-point decrease in the pain level. Identifying whether a client has a low pain tolerance cannot be determined with the data available. The medication has not achieved an adequate response; pain generally is considered to be tolerable if it is 4 or below on a pain scale of 1 to 10. Determining that the client needs more education about the use of the pain scale cannot be determined with the data available.

A nurse inserts a nasogastric tube before an infant is to receive a tube feeding. What action should the nurse take when the infant begins to cough and gag? a. Auscultating for breath sounds b. Removing the tube, then reinserting it c. Administering the tube feeding slowly d. Observing the infant for circumoral cyanosis

B! The infant's response indicates that the tube may be in the trachea rather than the stomach. The tube should be removed, reinserted, and verified for its placement before the feeding is started. Auscultating for breath sounds does not provide information about the placement of the tube. The tube should be removed immediately; it is unsafe to assess the infant for additional signs of respiratory distress. It is unsafe to administer the feeding until placement in the stomach has been confirmed.

A client is hospitalized with joint pain, loss of hair, yellow pigmentation of the skin, and an enlarged liver. The nurse suspects what type of toxicity? a. Thiamine b. Vitamin A c. Vitamin C d. Pyridoxine

B! These adaptations, as well as anemia, irritability, pruritus, and an enlarged spleen, occur with vitamin A toxicity. Excess thiamine is excreted in the urine and rarely, if ever, causes toxicity; an excessive dose may elicit an allergic reaction in some individuals. Excess vitamin C (ascorbic acid) does not cause these adaptations or toxicity; however, vitamin C may cause diarrhea or renal calculi. Pyridoxine (vitamin B6) is relatively nontoxic, and excess amounts are excreted in the urine.

The nurse is caring for a client who is receiving a thiazide diuretic for hypertension. Which food selected by the client indicates to the nurse that dietary teaching about thiazide diuretics was effective? a. Apples b. Broccoli c. Cherries d. Cauliflower

B! Thiazide diuretics are potassium-depleting agents; broccoli provides 267 mg of potassium per 100 grams. Apples provide 80 to 110 mg of potassium per 100 grams of fruit. Cherries provide 191 mg of potassium per 100 g of fruit. Cauliflower provides 206 mg of potassium per 100 g.

A nurse in the daycare center is teaching several aides about the play behavior of 2-year-old toddlers. What is this type of play called? a. Group b. Parallel c. Dramatic Cooperative

B! Toddlers play independently but beside other children; they are aware of the other children, often grabbing toys from them, but do not socially interact with them. Group play is characteristic of older children. Dramatic play or acting is characteristic of older children, starting at the preschool age; they assume and act out roles. Cooperative play is also characteristic of older children, starting at the preschool age; they learn to share, wait their turn, and become sensitive to their peer's needs.

An adult client is brought to the emergency department after an accident. The client has limitations in mental functioning related to Down syndrome. The nurse can best assess the client's pain level by: a. Asking the client's parent b. Using Wong's "Pain Faces" c. Observing the client's body language d. Explaining the use of a 0 to 10 pain scale

B! An adult client with limited mental capacity may not understand the concept of numbers as an indicator of levels of pain; Wong's "Pain Faces" uses pictures to which the individual can relate. The client, irrespective of mental capacity, is the primary source from whom to obtain information about pain because it is a personal experience. Body language provides some information, but may not accurately reflect the client's level of pain. A client with limitations in mental functioning may not understand the concept of numbers.

A nurse has just finished feeding a 4-year-old child through a nasogastric tube. In what position should the child be placed to help ensure retention of the feeding and prevent aspiration? a. Supine b. Semi-Fowler c. Trendelenburg d. Left side-lying

B! The semi-Fowler position limits the potential for aspiration; the child will be partially upright and fluid will remain in the stomach by means of gravity. The supine, Trendelenburg, and side-lying positions all allow gastric reflux and may lead to aspiration.

A nurse uses the Braden Scale to predict a client's risk for developing pressure ulcers. What data should the nurse use to determine a client's score on this scale? Select all that apply. a. Age b. Anorexia c. Hemiplegia d. History of diabetes e. Urinary incontinence

B, C,D, & E! Anorexia causes nutritional problems; nutrition is a category on the Braden Scale. Hemiplegia causes mobility problems; this impacts on the categories of mobility, activity, and friction on the Braden Scale. Urinary incontinence causes moisture, a category on the Braden Scale. Age is not used in the Braden Scale. Diseases are not used on the Braden Scale.

A nurse is managing the care of a client with recently diagnosed schizophrenia. Effective therapeutic communication will directly affect which client-focused outcomes? Select all that apply. a. The client will become capable of part-time employment. b. The client will effectively express emotional and physical needs. c. The client will demonstrate wellness reflective of physical potential. d. The client will demonstrate an understanding of the mental health disorder. e. The client will recognize the issues most important to managing this disorder.

B, D, & E! Therapeutic communication facilitates the exchange of information between the nurse and the client that focuses on the client's attaining health and wellness. This information can be directed towards the client's health needs such as the effective expression of the client's physical and emotional needs, the understanding of the cause and prognosis of the current mental health problem, and the recognition of issues important to the management of the client's health issues. The client's ability to maintain part-time employment and the client's physical health potential are minimally affected by therapeutic communication.

A nurse in the pediatric clinic discusses the nutrition and feeding needs of an 18-month-old toddler with the child's parents. What information should the nurse include? a. Growth rate increases, so more protein is needed per pound of body size. b. Energy requirements become so high that more calories are needed to meet them. c. Struggling for autonomy may involve refusal of food, but they will eat the amount they need. d. Three meals a day should be offered, with no between-meal snacks, because they are finicky eaters.

C! A toddler's increasing mobility and growing independence affects eating behaviors; slowed physical growth at this age requires relatively fewer calories. A toddler's growth rate and energy requirements decrease compared with the first year of life. Nutritious snacks between meals should be encouraged if the toddler is not eating adequate meals.

The nurse is teaching a class about nutrition to a group of adolescents. Taking into consideration the prevalence of overweight teenagers, what is the best recommendation the nurse can make? a. Join a gym. b. Drink fewer diet sodas. c. Decrease fast food intake. d. Take a multivitamin daily.

C! Eating a variety of healthful foods instead of a fast-food diet that is high in fat and carbohydrates helps decrease excess weight and increase energy with which to engage in physical activities. Joining a gym is expensive and unnecessary. Physical activity can be achieved in the schoolyard or at home. A multivitamin will not promote weight loss. Vitamins and minerals are best obtained in a balanced diet. Diet soft drinks do not contribute to obesity.

An infant has been vomiting after each feeding. Physical assessment reveals poor skin turgor, a sunken anterior fontanel, and tremors. The infant's acid-base balance is outside the expected range. What does the nurse suspect as the cause of this imbalance? a. Retention of potassium in the cells b. Loss of fluid by way of the kidneys c. Loss of chloride ions through vomiting d. Reduction of blood supply to body cells

C! Electrolyte deficits, rather than urinary excretion, precipitate an acid-base imbalance. Loss of gastric secretions, which contain sodium, chloride, and potassium, usually results in metabolic alkalosis. With vomiting, a depletion of cellular potassium occurs. Electrolyte deficits, rather than inadequate blood supply, can precipitate an acid-base imbalance.

A nurse who is teaching a growth and development class to a group of parents at the daycare center explains that the toddler strives for a sense of: a. Trust b. Industry c. Initiative d. Autonomy

D! According to Erikson, the toddler strives for autonomy; most exploratory and negativistic behavior is based on the need to achieve this developmental task. Trust is the developmental task of the infant. Industry is the developmental task of the school-age child. Initiative is the developmental task of the preschool child.

A nurse on the adolescent unit is planning to discuss smoking prevention. What is the most effective approach for the nurse to use? a. Sharing personal experiences with a smoking-cessation program b. Showing pictures of the effects of smoking on the cardiopulmonary system c. Presenting information on how smoking affects appearance and odor of the breath d. Citing statistics about the relationship between smoking and cardiopulmonary diseases

C! Establishing an identity is the major developmental task of the adolescent; to achieve this task, the adolescent needs to conform to group norms that include appearance and acceptance. Appealing to this need may achieve more success than other teaching strategies. Sharing personal experiences with a smoking-cessation program is a teaching strategy that may be successful with an older, more secure group of people. Adolescents tend to believe that they are invincible and probably will not relate to this teaching strategy. They are also concerned about the present, not the future. Because adolescents believe they are invincible, they would not relate to a teaching strategy based on statistics about the harmful effects of smoking. Study Tip: Record the information you find to be most difficult to remember on 3" × 5" cards and carry them with you in your pocket or purse. When you are waiting in traffic or for an appointment, just pull out the cards and review again. This "found" time may add points to your test scores that you have lost in the past.

A nurse has just administered an immunization injection to a 2-month-old infant. What instructions should the nurse give the parent if the infant has a reaction? a. Give aspirin for pain; if swelling at the injection site develops, call the health care provider. b. Apply heat to the injection site for the first day after the injection; apply ice if the arm is inflamed. c. Give acetaminophen for fever; call the health care provider if the child exhibits marked drowsiness or seizures. d. Apply ice to the injection site if soreness develops; call the health care provider if the child comes down with a fever

C! Fever is a common reaction to immunizations, and acetaminophen may be given to minimize discomfort. A central nervous system reaction is rare and requires notification of the health care provider. Aspirin should not be given to infants and children because it is linked to Reye syndrome. Infants do not tolerate the application of ice, which will increase discomfort. Fever is a common reaction to the immunizations; it is not necessary to notify the health care provider.

An 18-month-old child has received all required immunizations. What immunization should the nurse explain to a parent will be one of the vaccines required between 4 and 6 years of age? a. Rotavirus b. Hepatitis B c. Inactivated poliovirus d. Haemophilus influenzae type b

C! Four doses of inactivated poliovirus are administered: at 2 months, 4 months, between 6 and 18 months, and between 4 and 6 years. Rotavirus vaccines are administered at 2, 4, and 6 months of age. The first dose of hepatitis B vaccine is administered at birth, the second dose is administered between 1 and 2 months of age, and the third dose is administered between 6 and 18 months of age. Haemophilus influenzae type b vaccines are administered at 2, 4, and 6 months of age, and a fourth dose is given between 12 and 15 months of age.

A nurse assesses drainage on a surgical dressing and documents the findings. Which documentation is most informative? a. "Moderate amount of drainage." b. "No change in drainage since yesterday." c. "A 10-mm-diameter area of drainage at 1900 hours." d. "Drainage is doubled in size since last dressing change."

C! Gradual weaning from prednisone (Meticorten) is necessary to prevent adrenal insufficiency or adrenal crisis. Prednisone depresses the immune system, thereby increasing susceptibility to infection. The drug usually suppresses growth. A moon face may occur, but it is not a critical, life-threatening side effect.

A client is receiving morphine sulfate (MS Contin) for severe metastatic bone pain. To prevent complications from a common, serious side effect of morphine, the nurse should: a. monitor for diarrhea b. observe for an opioid addiction c. assess for altered breathing patterns d. check for a decreased urinary output

C! Morphine sulfate is a central nervous system depressant that commonly decreases the respiratory rate, which can lead to respiratory arrest. Morphine, an opioid, will cause constipation, not diarrhea. Addiction is not a concern for a terminally ill client. Although morphine sulfate may cause urinary retention, it is not a common side effect and is not life threatening.

An 18-year-old is admitted with an acute onset of right lower quadrant pain at McBurney's point. Appendicitis is suspected. For which clinical indicator should the nurse assess the client to determine if the pain is secondary to appendicitis? a. Urinary retention b. Gastric hyperacidity c. bound tenderness d. Increased lower bowel motility

C! Rebound tenderness is a classic subjective sign of appendicitis. Urinary retention does not cause acute lower right quadrant pain. Hyperacidity causes epigastric, not lower right quadrant pain. There generally is decreased bowel motility distal to an inflamed appendix.

A nurse has provided discharge instructions to a client that received a prescription for a walker to use for assistance with ambulation. The nurse determines that the teaching has been effective when the client: a. Picks up the walker and carries it for short distances b. Uses the walker only when someone else is present c. Moves the walker no more than 12 inches in front of the client during use d. States that a walker will be purchased on the way home from the hospital

C! Safety is always a consideration when teaching a client how to use an assistive device. Therefore the correct procedure regarding using a walker is to move the walker no more than 12 inches in front to maintain balance and to be effective in forward movement. Carrying the walker when ambulating is incorrect. Once the client is instructed and can demonstrate correct use of a walker, there is no need for someone to be present every time the client uses the walker. If the client is ordered to use a walker as part of the discharge plan, it needs to be provided before leaving the hospital.

A nurse hired to work in a metropolitan hospital provides services for a culturally diverse population. One of the nurses on the unit says it is the nurses' responsibility to discourage "these people" from bringing all that "home medicine stuff" to their family members. Which response by the recently hired nurse is most appropriate? a. "Hospital policies should put a stop to this." b. "Everyone should conform to the prevailing culture." c. "Nontraditional approaches to health care can be beneficial." d. "You are right because they may have a negative impact on people's health."

C! Studies demonstrate that some nontraditional therapies are effective. Culturally competent professionals should be knowledgeable about other cultures and beliefs. Many health care facilities are incorporating both Western and nontraditional therapies. The statement "Everyone should conform to the prevailing culture" does not value diversity. The statement "You are right because they may have a negative impact on people's health" is judgmental and prejudicial. Some cultural practices may bring comfort to the client and may be beneficial, and they may not interfere with traditional therapy.

Before administering a nasogastric feeding to a preterm infant the nurse aspirates a small amount of residual fluid from the stomach. What is the nurse's next action? a. Returning the aspirate and withholding the feeding b. Discarding the aspirate and administering the full feeding c. Returning the aspirate and subtracting the amount of the aspirate from the feeding d. Discarding the aspirate and adding an equal amount of normal saline solution to the feeding

C! The aspirate should be returned to ensure that the gastric enzymes and acid-base balance are maintained. The amount of the aspirate returned should be subtracted from the volume to be administered in the next feeding. Withholding the feeding will compromise the infant's fluid and electrolyte balance, as will discarding the aspirate from the full feeding. Discarding the aspirate and adding an equal amount of normal saline solution to the feeding will compromise the infant's fluid and electrolyte balance.

The nurse is teaching crutch-walking to a 12-year-old child. What does the child do that indicates the need for more teaching? a. Takes short steps of equal length b. Looks forward to maintain balance c. Looks down when placing the crutches d.Assumes an erect posture when walking

C! The child should maintain an erect walking posture, without looking down, to ensure equilibrium and avoid losing balance. Taking short steps is the correct technique for safe ambulation while crutch-walking. Looking forward is the correct technique for safe ambulation while crutch-walking; it keeps the body's center of gravity over the hips. Maintaining an erect posture is the correct technique for safe ambulation during crutch-walking; it keeps the body's center of gravity over the hips

How should a nurse assess a 4-year-old child with abdominal pain? a. By asking the child to point to where it hurts b. By auscultating the child's abdomen for bowel sounds c. By observing position and behavior while the child is moving d. By questioning the parents about their child's eating and bowel habits

C! The child with abdominal pain may assume the side-lying position with the knees flexed to the abdomen or self-splint when moving. A 4-year-old may be unable to identify the exact location of the pain; in addition, the pain may be generalized rather than localized. Auscultation may be included in the physical assessment, but it is not specific to the assessment of pain. Questioning the parents may be included when the nurse is taking the health history, but it is not specific to the current assessment of pain.

The nurse is teaching safe transportation techniques to the parents of a baby who are from a low economic background. Which advice given by the nurse is appropriate? a. "You should borrow or buy a secondhand car seat." b. "You should place padding in the car seat behind the baby." c. "You should place the baby's car seat in the rear-facing position in the back seat." d. "You should buy an infant-only model and an infant/toddler convertible car seat."

C! The nurse instructs the parents to place the baby's car seat in the rear-facing position in the back seat, as it prevents injury to the infant from the air bag in case of a crash. It is dangerous to borrow or buy secondhand car seats. Placing padding behind the baby will create slack in the harness, which may result in the baby being ejected from the seat in case of a crash; therefore, this is not a safe intervention. The parents of the baby are from a low economic background. Therefore, convertible-type car seats are preferable. Though convertible-type seats cost more initially, they work out to be less expensive than buying both an infant-only model and an infant/toddler convertible model. Test-Taking Tip: After you have eliminated one or more choices, you may discover that two of the options are very similar. This can be very helpful, because it may mean that one of these lookalike answers is the best choice and the other is a very good distractor. Test both of these options against the stem. Ask yourself which one completes the incomplete statement grammatically and which one answers the question more fully and completely. The option that best completes or answers the stem is the one you should choose. Here, too, pause for a few seconds, give your brain time to reflect, and recall may occur.

A client receives a prescription for morphine via patient-controlled analgesia (PCA). Before beginning administration of this medication, what should the nurse assess first? a. Temperature b. Neurological status c. Respirations d. Urinary output

C! The nurse must be especially alert to any changes in respirations, because morphine decreases the respiratory center function in the brain. An order for morphine should be questioned if the baseline respirations are less than 12 per minute. Neurological status along with pulse and blood pressure would be a priority assessment after respiratory rate. Measurements of temperature and urinary output are part of the overall client assessment but not a priority with morphine.

If a 5½-month-old infant's immunizations are on schedule, which immunizations does the nurse expect the infant to have had already? a. Measles, mumps, and rubella vaccine b. Booster dose of inactivated polio vaccine c. Two doses of diphtheria, tetanus, and pertussis vaccine d. First booster dose of diphtheria, tetanus, and pertussis vaccine

C! The schedule for active immunization is three doses of diphtheria, tetanus, and pertussis (DTaP) at 2-month intervals beginning at 2 months of age. The measles, mumps, and rubella vaccine is not given until 12 to 15 months because maternal antibodies block the formation of the infant's antibodies. An inactivated polio vaccine booster (fourth dose) is due at 4 to 6 years of age. The first booster dose of DTaP is given at 15 to 18 months, or approximately 1 year after the third dose that is given at 6 months of age.

A nurse is teaching a client with hypertension about a sodium-restricted diet. What information should the nurse emphasize? a. Using salt-free natural seasonings can taste the same as salt. b. Desiring the taste for salt is inherent but can be overcome with practice. c. Liking the taste of table salt is learned but it is not a biological necessity. d. Substituting table salt with potassium chloride can be done freely.

C! The taste for salt is learned from habitual use and can be unlearned or reduced with health improvement motivation and creative salt-free food preparation. Substitutes do not taste the same as salt. The taste for salt is learned. Using salt substitutes containing potassium chloride may be unsafe; excessive use can produce abnormally high serum potassium levels.

A client has a hiatal hernia. The client is 5 feet 3 inches tall and weighs 160 pounds. When the nurse discusses prevention of esophageal reflux, what should be included? a. "Increase your intake of fat with each meal." b. "Lie down after eating to help your digestion." c. "Reduce your caloric intake to foster weight reduction." d. "Drink several glasses of fluid during each of your meals."

C! Weight reduction decreases intraabdominal pressure, thereby decreasing the tendency to reflux into the esophagus. Fats decrease emptying of the stomach, extending the period that reflux can occur; fats should be decreased. Lying down after eating increases the pressure against the diaphragmatic hernia, increasing symptoms. Drinking several glasses of fluid during each meal will increase the pressure; fluid should be discouraged with meals.

A nurse is teaching a mother about the immunization schedule for her baby. Between which months of age should the measles vaccine be given? 2 and 5 b. 6 and 8 c. 9 and 11 d. 12 and 15

D! Between 12 and 15 months is the optimal age because maternal antibodies to measles are no longer present to block the formation of the child's own antibodies. The measles vaccine is not given between 2 and 5 months, between 6 and 8 months, or between 9 and 11 months because of the questionable efficacy of the vaccination, due to the presence of maternal antibodies.

A daughter of a Chinese speaking client approaches a nurse and asks multiple questions while maintaining direct eye contact. What culturally related concept does the daughter's behavior reflect? a. Prejudice b. Stereotyping c. Assimilation d. Ethnocentrism

C! Assimilation involves incorporating the behaviors of the dominant culture. Maintaining eye contact is characteristic of the American culture and not Asian cultures. Prejudice is a negative belief about another person or group and does not characterize this behavior. Stereotyping is the perception that all members of a group are alike. Ethnocentrism is the perception that one's beliefs are better than those of others.

A nurse is teaching an older adult client about managing chronic pain with acetaminophen (Tylenol). Which client statement indicates that the teaching is effective? a. "I need to limit my intake of acetaminophen to 650 mg a day." b. "I can take oxycodone with the acetaminophen if it is ineffective." c. "I should take an emetic if I accidentally overdose on the acetaminophen." d. "I have to be careful about which over-the-counter cold preparations I take when I have a cold."

D! Many over-the-counter cold preparations contain acetaminophen; the amount of acetaminophen in cold preparations must be taken into consideration when the total amount of acetaminophen taken daily is calculated. A typical single dose is 650 mg a day for adults. Acetaminophen should not exceed 3 to 4 g a day, with a lower dose preferred in older adults. Taking oxycodone with the acetaminophen may result in an overdose. Oxycodone (Percocet) contains 325 to 650 mg of acetaminophen per dose, which should be calculated into the total grams of acetaminophen permitted daily. An emetic is contraindicated because it may reduce the client's ability to tolerate oral acetylcysteine, the antidote for acetaminophen toxicity.

A 4-month-old infant is to receive the second diphtheria/tetanus/pertussis (DTaP) immunization. The nurse reviews the infant's medical history before administering the vaccine. What information in the infant's history will influence the decision whether to administer the vaccine? a. Allergy to eggs b. Lactose intolerance c. Infectious dermatitis d. High fever after the first dose

D! A temperature of 105° F (40.5° C) or higher after a DTaP immunization is a contraindication to further DTaP immunizations. An allergy to eggs is not a contraindication to the administration of the DTaP vaccine because eggs are not used in the production of the vaccine. Lactose intolerance is not a contraindication to the administration of DTaP vaccine; nor is infectious dermatitis.

The nurse is teaching hygiene practices to a 16-year-old patient who has recently had her first menstrual flow. Under which phase of development does the nurse classify the patient? a. Prepubescence b. Postpubescence c. Late adolescence d. Middle adolescence

D! Adolescence is a period of psychological, social, and maturational growth. There are subphases of adolescence. Middle adolescence occurs between the ages of 15 and 17. Prepubescence occurs 2 years before the onset of puberty. However, this patient has already achieved puberty and had her first menstrual flow. Postpubescence extends for 1 to 2 years after puberty. The patient has recently had her first menstrual flow and is at the point of puberty. Late adolescence occurs between the ages of 18 and 20.

On the third postpartum day a woman who is breastfeeding calls the nurse at the clinic and asks why her breasts are tight and swollen. What should the nurse consider before explaining why her breasts are engorged? a. There is an overabundance of milk. b. Breastfeeding is probably ineffective. c. The breasts have been inadequately supported. d. The lymphatic system in the breasts is congested.

D! An exaggeration of venous and lymphatic circulation caused by prolactin occurs before lactation. Effective breastfeeding does not prevent engorgement; a lag between the production of milk and the efficiency of the ejection reflex often causes engorgement. Engorgement occurs before lactation or milk production. Inadequately support of the breasts does not cause engorgement, but support may relieve some of the discomfort.

A nurse withholds a prescribed opioid medication from a client with intractable pain because the nurse fears the client will become addicted. In this situation the nurse is adhering to the ethical principle of: a. Veracity b. Autonomy c. Paternalism d. Beneficence

D! Beneficence commonly is referred to as "doing of good"; it is related to the nurse's duty to help clients further their legitimate interest within the boundaries of safety. Unfortunately in this situation the client's priority is relief from pain and the nurse should be working with other health team members to achieve this objective. Veracity is defined as telling the truth. Autonomy, as an ethical principle, means that the nurse respects the client and the choices that are made. Paternalism occurs if the nurse interferes with the individual's autonomy by disregarding the client's choices.

A nurse applies a cold pack to treat an acute musculoskeletal injury. Cold therapy decreases pain by: a. Promoting analgesia and circulation b. Numbing the nerves and dilating the blood vessels c. Promoting circulation and reducing muscle spasms d. Causing local vasoconstriction, preventing edema and muscle spasm

D! Cold causes the blood vessels to constrict, which reduces the leakage of fluid into the tissues and prevents swelling and therefore muscle spasm. Cold therapy also may numb the nerves and surrounding tissues, thus reducing pain. Cold does promote analgesia but not circulation. It may numb nerves but does not dilate blood vessels.

A parent and 3-month-old infant are visiting the well-baby clinic for a routine examination. What instruction should the nurse include in the accident-prevention teaching plan? a. Remove small objects from the floor. b. Cover electric outlets with safety plugs. c. Remove toxic substances from accessible areas. d. Test the temperature of water before bathing.

D! Excessively high temperatures can damage the delicate skin of an infant. Although infants are capable of putting small things in their mouths, they are not yet able to crawl and probably will not be placed on the floor. At 3 months of age infants are not yet able to explore the environment to the point that electric outlets pose a problem. At 3 months of age infants are still too small and have not yet developed motor capabilities to get into containers of poison.

A client who recently experienced a brain attack (cerebrovascular accident, CVA) and who has limited mobility complains of constipation. What is most important for the nurse to determine when collecting information about the constipation? a. Presence of distention b. Extent of weight gained c. Amount of high-fiber food consumed d. Length of time this problem has existed

D! First, the nurse should establish when the client last defecated because the client may have perceived constipation. Abdominal distention may or may not be observed with constipation. Weight gain has no relationship to constipation. Although lack of bulk in the diet can lead to constipation, particularly in clients with limited activity or an inadequate fluid intake, the lack of bulk in the diet is not the most significant information to obtain at this time.

The nurse is teaching a parent of a 2-year-old toddler how to administer ear drops. In what direction should the nurse teach the parent to gently pull the pinna? a. Forward b. Up and back c. Straight back d. Down and back

D! In children younger than 3 years of age the eustachian tube is shorter, wider, and more horizontal. Pulling the pinna down and back facilitates passage of fluid, by way of gravity, to the eardrum. Pulling the pinna forward does not help position the canal for passage of the drops to the eardrum. Pulling the pinna up and back is the technique used for administering ear drops to children older than 3 years of age and adults. Pulling the pinna straight back does not position the canal for passage of the drops to the eardrum.

A client arrives for a vaccination at an influenza prevention clinic. A nursing assessment identifies a current febrile illness with a cough. The nurse should: a. Give the vaccine b. Administer aspirin with the vaccine c. Hold the vaccine and notify the health care provider d. Reschedule administration of the vaccine for the next month

D! The appropriate response is to delay the administration of the vaccine until the client is healthy. Vaccines should not be administered during a febrile illness. Administering an aspirin is a dependent function of the nurse and requires a health care provider's prescription. Although holding the vaccine and administering it after the fever and cough are resolved is appropriate, notifying the health care provider is not necessary.

A client in a hospice home care program is experiencing severe pain. Morphine (MS Contin) has been prescribed for pain management. Which information should the nurse plan to explain to the client in preparation for this pain management regimen? a. Drug addiction is a concern with this drug b. Request the medication before the pain becomes severe c. Intermittent administration of the drug is possible after an intermittent lock is inserted d. Dosages of the drug will be given automatically at regular intervals around the clock

D! The drug will be given routinely to maintain a continuous therapeutic blood level to keep the terminally ill client comfortable. Addiction is not a major concern for the terminally ill client. The client should not have to request this medication; it should be given regularly. Morphine is not administered intermittently; usually, it is prescribed in liquid form and is taken orally when administered in the home.

An 18-month-old toddler who has received the appropriate immunizations on time is visiting the pediatric clinic for the next scheduled immunization. What vaccine should the nurse administer? a. Second hepatitis B (Hep B) vaccine b. Fifth inactivated polio vaccine (IPV) c. First pneumococcal vaccine (PCV) and influenza vaccine (Hib) d. Fourth diphtheria toxoid, tetanus toxoid, and acellular pertussis (DTaP) vaccine

D! The recommended age for the fourth dose of DTaP is 15 to 18 months. The recommended age for the second dose of Hep B is 4 weeks after the first dose, which is given immediately after birth. Four, not five, doses of IPV are recommended. The initial doses of PCV and Hib are given at 2 months

The nurse is caring for an Asian-American client with a diagnosis of depression. While interviewing this client the nurse notes that the client maintains traditional cultural beliefs and values. What is the most important information for the nurse to obtain about the client? a. Dietary practices b. Concept of space c. Immigration status d. Role within the family

D! If an Asian-American client tells the nurse that she adheres to traditional Asian practices, the nurse must recognize that the family is the central and most important social force acting on the individual. Dietary practices, concept of space, and immigration status are not as significant as family dynamics.

A client's infusion of normal saline infiltrated earlier today, and approximately 500 ml of saline infused into the subcutaneous tissue. The client is now complaining of excruciating arm pain and demanding "stronger pain medications." What initial action is most important for the nurse to take? A. Ask about any past history of drug abuse or addiction. B. Measure the pulse volume and capillary refill distal to the infiltration. C. Compress the infiltrated tissue to measure the degree of edema. D. Evaluate the extent of ecchymosis over the forearm area.

Pain and diminished pulse volume (B) are signs of compartment syndrome, which can progress to complete loss of the peripheral pulse in the extremity. Compartment syndrome occurs when external pressure (usually from a cast), or internal pressure (usually from subcutaneous infused fluid), exceeds capillary perfusion pressure resulting in decreased blood flow to the extremity. (A) should not be pursued until physical causes of the pain are ruled out. (C) is of less priority than determining the effects of the edema on circulation and nerve function. Further assessment of the client's ecchymosis can be delayed until the signs of edema and compression that suggest compartment syndrome have been examined (D). Correct Answer: B

A toddler receives a gastrostomy tube feeding every 4 hours. What is the priority nursing intervention for this child? a. Opening the tube 1 hour before feeding b. Keeping the child lying flat during the feeding c. Flushing the tube with normal saline after the feeding d. Positioning the child on the right side after the feeding

Positioning the child on the right side after feeding facilitates digestion because the pyloric sphincter is on this side and gravity aids emptying of the stomach. The feeding may be started immediately after the tube is opened. Keeping the child lying flat during the feeding may result in aspiration; the child's head and torso should be elevated. If the gastrostomy tube is flushed before or after a feeding, water, not normal saline, is used.

The nurse is performing nasotracheal suctioning. After suctioning the client's trachea for fifteen seconds, large amounts of thick yellow secretions return. What action should the nurse implement next? A. Encourage the client to cough to help loosen secretions. B. Advise the client to increase the intake of oral fluids. C. Rotate the suction catheter to obtain any remaining secretions. D. Re-oxygenate the client before attempting to suction again.

Suctioning should not be continued for longer than ten to fifteen seconds, since the client's oxygenation is compromised during this time (D). (A, B, and C) may be performed after the client is re-oxygenated and additional suctioning is performed. Correct Answer: D

The nurse is caring for a client who is receiving 24-hour total parenteral nutrition (TPN) via a central line at 54 ml/hr. When initially assessing the client, the nurse notes that the TPN solution has run out and the next TPN solution is not available. What immediate action should the nurse take? A. Infuse normal saline at a keep vein open rate. B. Discontinue the IV and flush the port with heparin. C. Infuse 10 percent dextrose and water at 54 ml/hr. D. Obtain a stat blood glucose level and notify the healthcare provider.

TPN is discontinued gradually to allow the client to adjust to decreased levels of glucose. Administering 10% dextrose in water at the prescribed rate (C) will keep the client from experiencing hypoglycemia until the next TPN solution is available. The client could experience a hypoglycemic reaction if the current level of glucose (A) is not maintained or if the TPN is discontinued abruptly (B). There is no reason to obtain a stat blood glucose level (D) and the healthcare provider cannot do anything about this situation. Correct Answer: C

The nurse is administering medications through a nasogastric tube (NGT) which is connected to suction. After ensuring correct tube placement, what action should the nurse take next? A. Clamp the tube for 20 minutes. B. Flush the tube with water. C. Administer the medications as prescribed. D. Crush the tablets and dissolve in sterile water.

The NGT should be flushed before, after and in between each medication administered (B). Once all medications are administered, the NGT should be clamped for 20 minutes (A). (C and D) may be implemented only after the tubing has been flushed. Correct Answer: B

The nurse prepares a 1,000 ml IV of 5% dextrose and water to be infused over 8 hours. The infusion set delivers 10 drops per milliliter. The nurse should regulate the IV to administer approximately how many drops per minute? A. 80 B. 8 C. 21 D. 25

The accepted formula for figuring drops per minute is: amount to be infused in one hour × drop factor/time for infusion (min)= drops per minute. Using this formula: 1,000/8 hours = 125 ml/ hour 125 × 10 (drip factor) = 1,250 drops in one hour. 1,250/ 60 (number of minutes in one hour) = 20.8 or 21 gtt/min (C). Correct Answer: C

A client is to receive cimetidine (Tagamet) 300 mg q6h IVPB. The preparation arrives from the pharmacy diluted in 50 ml of 0.9% NaCl. The nurse plans to administer the IVPB dose over 20 minutes. For how many ml/hr should the infusion pump be set to deliver the secondary infusion?

The infusion rate is calculated as a ratio proportion problem, i.e., 50 ml/ 20 min : x ml/ 60 min. Multiply extremes and means 50 × 60 /20x 1= 300/20=150 Correct Answer: 150

The health care provider prescribes nitroglycerin ointment to be applied topically every eight hours for a client who was admitted for chest pain and a myocardial infarction (MI). Which statement, if made by the client, would indicate understanding of the side effects of nitroglycerin ointment? "I may experience: a. A headache." b. Increased blood pressure readings." c. A slow pulse rate." d. Confusion."

The most common side effect of nitroglycerin is a headache. Additional cardiovascular side effects are tachycardia, not bradycardia; hypotension, not hypertension; and dizziness, not confusion.

What is the most important reason for starting intravenous infusions in the upper extremities rather than the lower extremities of adults? A. It is more difficult to find a superficial vein in the feet and ankles. B. A decreased flow rate could result in the formation of a thrombosis. C. A cannulated extremity is more difficult to move when the leg or foot is used. D. Veins are located deep in the feet and ankles, resulting in a more painful procedure.

Venous return is usually better in the upper extremities. Cannulation of the veins in the lower extremities increases the risk of thrombus formation (B) which, if dislodged, could be life-threatening. Superficial veins are often very easy (A) to find in the feet and legs. Handling a leg or foot with an IV (C) is probably not any more difficult than handling an arm or hand. Even if the nurse did believe moving a cannulated leg was more difficult, this is not the most important reason for using the upper extremities. Pain (D) is not a consideration. Correct Answer: B