HESI with Rationale 12

A client with a history of cirrhosis and alcoholism is admitted with severe dyspnea and ascites. Which assessment finding warrants immediate intervention by the nurse? A. Jaundice skin tone. B. Muffled heart sounds. C. Pitting peripheral edema. D. Bilateral scleral edema.

Answer B. Muffled heart sounds. Rationale Muffled heart sounds (B) may indicate fluid build-up in the pericardium and is life-threatening. (A, C, and D) are signs of end stage liver disease related to alcoholism but are not immediately life-threatening.

While the nurse is providing morning care for a client with chronic obstructive pulmonary disease (COPD), the client becomes very dyspneic and starts to panic. What action should the nurse implement first? A. Instruct the client to perform diaphragmatic breathing. B. Use a calm voice to tell the client to breathe slowly. C. Administer two puffs of a metered-dose inhaler. D. Assist the client to an upright position.

Answer D. Assist the client to an upright position. Rationale The nurse should first assist the client to an upright position (D), which allows the lungs to expand fully. After this, the nurse can implement (A, B, and C) as needed.

A nurse assesses a client whose hand begins to spasm when the blood pressure cuff is inflated. The client complains of parenthesia in the fingers and toes. Which serum laboratory findings should the nurse expect to find? A. Elevated serum potassium. B. Low serum magnesium. C. Elevated serum calcium. D. Low serum calcium.

Answer D. Low serum calcium. Rationale Trousseau's sign is carpal spasms induced by inflating a blood pressure cuff above the systolic pressure for a few minutes and is an early sign of tetany associated with hypocalcemia (D). Although (A, B, and C) are related to muscular contractility, a Trousseau's sign supports a low serum calcium level.

A client who is having an allergic reaction receives a prescription for epinephrine 0.4 mg subcutaneously. The available vial is labeled, Epinephrine Injection, USP, 1:1000 (1 mg/ml) For Subcutaneous use only. How many ml should the nurse administer? (Enter numerical value only. If rounding is required, round to the nearest tenth.)

Answer 0.4 Rationale Using the formula, D/H x Q 0.4 mg/ 1 mg x 1 ml = 0.4 ml

The nurse is caring for a client who is taking a macrolide to treat a bacterial infection. Which finding should the nurse report to the healthcare provider before administering the next dose? A. Jaundice. B. Nausea. C. Fever. D. Fatigue.

Answer A. Jaundice. Rationale Macrolides can cause hepatoxicity (liver toxicity), which is manifested by jaundice (A) and should be reported to the healthcare provider before further doses of the medication are administered. (B) is a common side effect of macrolides, and measures to help the client cope with nausea should be provided throughout the course of therapy. Fever (C) and fatigue (D) are expected findings when a client has an infection.

The nurse is interviewing a 18-year-old female client who was released 3 weeks ago following two months of treatment for anorexia nervosa. Which statement is characteristic of a young woman who has been successfully treated for anorexia nervosa? A. "My parents attempt to smother me, but I will not allow them to make my decisions." B. "If I don't get a college scholarship my parents will be very disappointed in me." C. "I know that I am fat and I plan to lose at least 10 more pounds." D. "I will not binge eat, vomit after I eat, or take laxatives or diuretics."

Answer A. "My parents attempt to smother me, but I will not allow them to make my decisions." Rationale The family of an adolescent with anorexia nervosa is often rigid and overprotective of the child and the client's reaction to their behavior is accepting and healthy (A). (B) might be made by a client with bulimia since they believe they are judged by their success. (C) would be expected on admission, but not after two months of treatment. (D) is related to clients with bulimia, not anorexia nervosa.

Four clients arrive on the labor and delivery unit at the same time. Which client should the nurse assess first? A. A 39-week primigravida with biophysical profile score of 5 out of 8. B. A 36-week multigravida with a prescription for serial blood pressures. C. A 38-week primigravida who reports contractions occurring every 10 minutes. D. A 41-week multigravida who is scheduled induction of labor today.

Answer A. A 39-week primigravida with biophysical profile score of 5 out of 8. Rationale The client with a biophysical profile (BPP) score of 5 out of 8 has the highest priority (A) because low scores result from fetal hypoxia and are an accurate indicator of impending fetal death. (B) should be assessed for preeclampsia. (C and D) do not have the priority of (A).

An elderly client seems confused and reports the onset of nausea, dysuria, and urgency with incontinence. Which action should the nurse implement? A. Auscultate for renal bruits. B. Obtain a clean catch mid-stream specimen. C. Use a dipstick to measure for urinary ketones. D. Begin to strain the client's urine.

Answer B. Obtain a clean catch mid-stream specimen. Rationale This elderly client is experiencing symptoms of urinary tract infection. The nurse should obtain a clean catch mid-stream specimen (B) to determine the causative agent so an anti-infective agent can be prescribed. (A) is performed to assess for obstruction of the renal arteries. If the client demonstrates symptoms of ketosis or severe hyperglycemia, the nurse should implement (C). (D) should be initiated if the client exhibits signs of renal calculi.

While caring for a client with a cervical spine injury, which assessment finding should the nurse report to the healthcare provider immediately? A. Heart rate 140 beats/minute. B. Respiratory rate 6 breaths/minute. C. Average urinary output 20 mL/hour. D. Sluggish pupillary response.

Answer B. Respiratory rate 6 breaths/minute. Rationale With a cervical spinal injury the respiratory status can quickly become compromised and require mechanical ventilation. A slowing respiratory rate (B) is a critical sign that the client is decompensating. (A, C, and D) are important but do not have the priority of (B).

While caring for a client who is mechanically ventilated, the nurse response to a high-pressure alarm. Which assessment finding warrants immediate intervention by the nurse? A. Bilateral crackles with increased secretions. B. Restless client who is biting the endotracheal tube. C. Decreased lung compliance when ventilation. D. Endotracheal cough pressure greater than 25 cm H2O.

Answer B. Restless client who is biting the endotracheal tube. Rationale Clients who are restless and biting the endotracheal tube (B) are in immediate danger of cutting off the oxygen and ventilation that the ventilator is trying to provide, so this finding requires the most immediate intervention. Crackles with secretions (A) indicate a need to suction the client. Decreased lung compliance (C) indicates that the lungs are stiff and the client may need sedation to assist with maximum ventilation. Cuff pressures over 5 cm H2O may cause a esophageal erosion and should be decreased and reassessed regularly.

While administering a continuous insulin infusion to a client with diabetic ketoacidosis, it is essential for the nurse to monitor which serum lab value? A. Hemoglobin. B. Protein. C. Calcium. D. Potassium.

Answer D. Potassium. Rationale As insulin lowers the blood glucose of a client with diabetic ketoacidosis, the serum potassium level also decreases as potassium returns to the cell. This can cause potentially fatal hypokalemia, so it is essential for the nurse to monitor the clients serum potassium (D). It is less critical to monitor (A, B and C) while an intravenous insulin infusion is being administered.

The client with which type of wound is most likely to need immediate intervention by the nurse? A. Laceration. B. Abrasion. C. Contusion. D. Ulceration.

Answer A. Laceration. Rationale A laceration (A) is a wound that is produced by the tearing of soft body tissue. This type of wound is often irregular and jagged and often contaminated with bacteria and debris from whatever object caused the cut, so this type of wound is likely to require the most immediate nursing intervention. (B) is an open wound, but is superficial and less likely to cause significant bleeding than a laceration. (C) is a closed wound that appears ecchymotic because of damaged blood vessels. (D) is typically more chronic in nature requiring less immediate intervention than an acute laceration.

A client is admitted with the diagnosis of Wernicke's Syndrome. What assessment finding should the nurse use in planning the clients care? A. Right lower abdominal pain. B. Confusion. C. Peripheral neuropathy. D. Depression.

Answer B. Confusion. Rationale Wernicke's syndrome is related to thiamine deficiency in clients with alcohol dependency and is manifested by confusion (B), ataxia, and vision changes. (A, C, and D) May be complications of alcoholism but are not specific in Wernicke's syndrome.

When providing diet teaching for a client with cholecystitis, which types of food choices should the nurse recommend to the client? A. High protein. B. Low fat. C. Low sodium. D. High carbohydrate.

Answer B. Low fat. Rationale A client with cholecystitis is at risk for gall stones that can move into the biliary tract and cause pain or obstruction. Reducing dietary fat (B) decreases stimulation of the gall bladder, so bile can be expelled, along with possible stones, into the biliary tract and small intestine. Protein (A) and carbohydrate (D) intake do not need to be altered. Sodium restriction (C) is not indicated.

When conducting diet teaching for a client who was diagnosed with hypoparathyroidism, which foods should the nurse encourage the client to eat? (Select all that apply.) A. Nuts. B. Yogurt. C. Fresh turkey. D. Fresh chicken. E. Processed cheese.

Answer B. Yogurt. E. Processed cheese. Rationale (B and E) are correct. In hyperparathyroidism, the client's diet should be supplemented with calcium rich foods which include dairy products (B and E). (A, C, and D) do not contain high calcium content.

When entering a client's room, the nurse discovers that the client is unresponsive and pulseless. The nurse initiate CPR and Calls for assistance. Which action should the nurse take next? A. Prepare to administer atropine 0.4 mg IVP. B. Gather emergency tracheostomy equipment. C. Prepare to administer lidocaine at 100 mg IVP. D. Place cardiac monitor leads on the client's chest.

Answer D. Place cardiac monitor leads on the client's chest. Rationale Before further interventions can be done, the client's heart rhythm must be determined. This can be done by connecting the client to the cardiac monitor (D). (A and C) are not a first-line drug given for any of the life-threatening, pulses dysrhythmias. (B) is not performed unless the airway is unable to be maintained by other means (CPR mask, oral or nasal intubation with an endotracheal tube).

A 16-year-old adolescent with meningococcal meningitis is receiving a continuous IV infusion of penicillin G, which is prescribed as 20 million units in a total volume of 2 liters of normal saline every 24 hours. The pharmacy delivers 10 million units/ liter of normal saline. How many ml/hr should the nurse program the infusion pump? (Enter numeric value only. If rounding is required, round to the nearest whole number.)

Rationale To deliver the prescribed dose of 20 million units/2 liters q24 hours, the available solution, 10 million units/liter, should be delivered in 12 hours. 1000 ml : 12 hours :: X ml : 1 hour 12X = 1000 X = 83.33 = 83 ml/hour

A client is scheduled to receive an IV dose of ondansetron (Zofran) eight hours after receiving chemotherapy. The client has a saline lock and is sleeping quietly without any restlessness. The nurse caring for the client is not certified in chemotherapy administration. What action should the nurse take? A. Ask a chemotherapy-certified nurse to administer the Zofran. B. Administer the Zofran after flushing the saline lock with saline. C. Hold the scheduled dose of Zofran until the client awakens. D. Awaken the client to assess the need for administration of the Zofran.

Answer B. Administer the Zofran after flushing the saline lock with saline. Rationale Zofran is an antiemetic administered before and after chemotherapy to prevent vomiting. The nurse should administer the antiemetic using the accepted technique for IV administration via saline lock (B). Zofran is not a form of chemotherapy drug and does not need to be administered by a chemotherapy-certified nurse (A). (C and D) may result in post-chemotherapy vomiting, since the medication should be administered on a prescribed schedule to prevent this side effect.

While receiving a male postoperative client's staples the nurse observe that the client's eyes are closed and his face and hands are clenched. The client states, "I just hate having staples removed". After acknowledging the client's anxiety, what action should the nurse implement? A. Encourage the client to continue verbalize his anxiety. B. Attempt to distract the client with general conversation. C. Explain the procedure in detail while removing the staples. D. Reassure the client that this is a simple nursing procedure.

Answer B. Attempt to distract the client with general conversation. Rational Distraction (B) is an effective strategy when a client experiences anxiety during an uncomfortable procedure. (A and C) continue to focus on the procedure and may increase the client's anxiety. (D) is less likely to reduce the client's anxiety than (B) during a procedure.

The nurse is evaluating the diet teaching of a client with hypertension. What dinner selection indicates that the client understands the dietary recommendations for hypertension? A. Tomato soup, grilled cheese sandwich, pickles, skim milk, and lemon meringue pie. B. Baked pork chop, applesauce, corn on the cob, 1% milk, and key-lime pie. C. Grilled steak, baked potato with sour cream, green beans, coffee, and raisin cream pie. D. Beef stir fry, fried rice, egg drop soup, diet coke, and pumpkin pie.

Answer B. Baked pork chop, applesauce, corn on the cob, 1% milk, and key-lime pie. Rationale (B) is limited in sodium, is high in fiber, and no additional fat is added through cooking, so it is the best choice for an antihypertensive meal. (A) is high in sodium and cholesterol, which should be avoided. (C) is high in fat and caffeine which can elevate the BP. (D) is high in sodium and cholesterol and includes caffeine, all of which should be avoided.

A client refuses to ambulate, reporting abdominal discomfort and bloating caused by "too much gas buildup". The client's abdomen is distended. Which prescribed PRN medication should the nurse administer? A. Hydrocodone/acetaminophen (Lortab). B. Simethicone (Mylicon). C. Promethazine (Phenergan). D. Nalbuphine (Nubain)

Answer B. Simethicone (Mylicon). Rationale Simethicone (Mylicon) is an antiflatulent that is used to increase the clients ability to expel flatus (B), which relieves the client's discomfort. (A and D) are analgesics used to manage pain but do not alleviate the cause of the pain. (C) is an antiemetic used to treat nausea and does not relieve excess flatus.

The healthcare provider changes a client's medication prescription from IV to PO administration and doubles the dose. The nurse notes in the drug guide that the prescribed medication, when given orally, has a high first-pass effect and reduced bioavailability. What action should the nurse implement? A. Continue to administer the medication via the IV route. B. Give half of the prescribed oral dose until the provider is consulted. C. Administer the medication via the oral route as prescribed. D. Consult with the pharmacist regarding the error in prescription.

Answer C. Administer the medication via the oral route as prescribed. Rationale Bioavailability refers to the percentage of drug available in the systemic circulation. An increase in dosage (C) is necessary to provide a therapeutic affect for oral medications with significantly reduced bioavailability. (A, B, and D) are not indicated for this safe prescription.

The nurse is assessing an older adult with Type 2 diabetes mellitus. Which assessment finding indicates that the client understands long- term control of diabetes? A. The fating blood sugar was 120 mg/dl this morning. B. Urine ketones have been negative for the past 6 months. C. The hemoglobin A1C was 6.5 g/100 ml last week. D. No diabetic ketoacidosis has occurred in 6 months.

Answer C. The hemoglobin A1C was 6.5g/100 ml last week. Rationale A hemoglobin A1C level reflects the average blood sugar the client had over the previous 2 to 3 months, and level of 6.5 g/100 ml suggests that the client understands long-term diabetes control (C). (A) only reflects the client's blood sugar level that morning. (B) is associated with a state of diabetic ketoacidosis or low carbohydrate intake. A state of ketoacidosis is an emergency situation that indicates poor management of diabetes, and (D) is a good sign, but not an indicator of control.

What explanation is best for the nurse to provide a client who asks the purpose of using the log-rolling technique for turning? A. Working together can decrease the risk for back injury to the nurses. B. Using two or three people increases client safety. C. The technique is intended to maintain straight spinal alignment. D. Turning instead of pulling reduces the likelihood of skin damage.

Answer C. The technique is intended to maintain straight spinal alignment. Rationale The main rationale for use of the log-rolling technique is to maintain the client's spine in straight alignment (C). (A and B) described additional benefits to of log-rolling. Log-rolling involves the use of a palling motion (D).

In assessing an adult client with a partial rebreather mask, the nurse notes that the oxygen reservoir bag does not deflate completely during inspiration and the client's respiratory rate is 14 breaths / minute. What action should the nurse implement? A. Encourage the client to take deep breaths. B. Remove the mask to deflate the bag. C. Increase the liter flow of oxygen. D. Document the assessment data.

Answer D. Document the assessment data. Rationale The reservoir bag should not deflate completely during inspiration and the respiratory rate is within normal limits, so the nurse should document the respiratory assessment (D). (A, B, and C) are not indicated.

A nurse-manager is preparing the curricula for a class for charge nurses. A staffing formula based on what data ensures quality client care and is most cost-effective? A. Client geographic location and age. B. Number of staff and number of clients. C. Weekend and weekday staff availability. D. Skills of staff and client acuity.

Answer D. Skills of staff and client acuity. Rationale (D) considers both client need and staff competence. (A, B, and C) might be important data when making client assignments, but should not be the basis for deriving a formula for staffing.

A client who is taking an oral dose of a tetracycline complains of gastrointestinal upset. What snack should the nurse instruct the client to take with the tetracycline? A. Fruit-flavored yogurt. B. Cheese and crackers. C. Cold cereal with skim milk. D. Toasted wheat bread and jelly.

Answer D. Toasted wheat bread and jelly. Rationale Dairy products decrease the effect of tetracyclines so the nurse should instruct the client to eat a snack such as toast (D), which contains no dairy products and may decrease GI symptoms. (A, B, and C) contain dairy products.

The nurse provides sliding scale insulin administration instructions to an adult who was recently diagnosed with diabetes mellitus. The client demonstrates an understanding of the instructions provided by performing the procedure in which order? (Arrange with the first on top and the last on the bottom.) A. Obtain blood glucose level. B. Verify the insulin prescription. C. Cleanse the selected site. D. Draw insulin into insulin syringe.

Answer 1. Obtain blood glucose level. 2. Verify the insulin prescription. 3. Draw insulin into insulin syringe. 4. Cleanse the selected site. Rationale The client should administer a sliding scale dose of insulin by first obtaining a blood glucose level to determine sliding scale insulin dose, then verifying the insulin prescription. Next, the insulin is drawn into the insulin syringe and the selected site cleansed.

During a family group meeting, the client's daughter tells the group, "I hope I didn't cause mom to be depressed." Which response should the nurse provide? A. "You seem worried. What about your mom is bothering you?" B. "It is not unusual for children to feel guilty about a parent's illness." C. You seem concerned. Are you too suffering from depression?" D. "Why does the reason for your mom's important to you?"

Answer A. "You seem worried. What about your mom is bothering you?" Rationale To provide a therapeutic response, this teenager's feelings should be acknowledged, and the teen should be encouraged to disclose the reasons for her concerns (A). Although children sometimes feel guilty about a parent's illness (B), this information is not useful and negates the girl's feelings. (C) is jumping to an interpretation of the daughter's feelings, and it does not reflect the adolescent's concern for her parent. "Why" questions (D) are often interpreted as confrontational and should be avoided whenever possible.

The nurse working in a critical care unit is assigned the care of two clients, one with pneumonia who is being mechanically ventilated and the other who had a thoracotomy yesterday and is complaining of incisional pain. What should the nurse to first? A. Assess the level of consciousness and vital signs for both clients. B. Complete a head to toe assessment of the client with pneumonia. C. Change the surgical dressing to observe the appearance of the incision. D. Review the plan of care and the medications that are due for both clients.

Answer A. Assess the level of consciousness and vital signs for both clients. Rationale Assessing the level of consciousness and vital signs for both clients (A) provides a quick measurement of priority need. Before a complete assessment (B) is done on one client, the nurse should at least do a quick assessment of the other client. Changing the dressing and observing the incision (C) may be indicated, but only after both clients are quickly assessed. Reviewing the plan of care and medications due for administration (D) should wait until the nurse has evaluated both clients for any urgent clinical needs.

A postpartum client who is bottlefeeding develops breast engorgement. What is the best recommendation for the nurse to provide this client? A. Avoid stimulation of the breasts and wear a tight bra. B. Express a small amount of breastmilk by hand. C. Take a prescribed analgesic and expose breasts to air. D. Place warm packs on both of the breasts.

Answer A. Avoid stimulation of the breasts and wear a tight bra. Rationale Compressing the milk sinuses by wearing a tight-fitting bra and preventing breast stimulation (A) decreases prolactin secretion and milk production. (B) stimulates an increase in milk production, although it will provide temporary relief. (C) is an intervention used for sore nipples, not engorgement. (D) increases vasodilation and engorgement.

A client who returns from surgery after the removal of a malignant thyroid tumor has a serum calcium level of 4.5 mg/dL or 1.125 mmol-L (SI). Which findings require immediate action by the nurse? (Select all that apply.) A. Carpopedal spasms with inflation of the blood pressure cuff. B. Spasm of the cheek and mouth when the facial nerve is tapped. C. Low serum thyroglobulin (Tg) level. D. Decreased gastrointestinal peristalsis. E. Changes in platelet closure time (PCT).

Answer A. Carpopedal spasms with inflation of the blood pressure cuff. B. Spasm of the cheek and mouth when the facial nerve is tapped. Rationale (A and B) are correct. In well-differentiated thyroid cancers, it is important that as much thyroid tissue as possible is removed. Extensive tissue removal often includes parathyroid glands, so that postoperatively radioactive iodine can target metastatic thyroid cells. The presence of a positive Trousseau (A) and Chvostek signs (B) after thyroid and parathyroid surgery indicate life-threatening tetany that is precipitated by hypocalcemia (normal serum calcium 9.0 to 10.5 mg/dL or 2.25 to 2.625 mmol/L). Tg (C), a tumor marker of thyroid tumor volume, should be low or undetectable after surgical or radioactive treatment. (D) is not uncommon after general anesthesia. PCT (E) differentiates platelet function influenced by aspirin.

When conducting diet teaching for a client who is diagnosed with Crohn's Disease, which foods should the nurse encourage the client to eat? (Select all that apply.) A. Clams. B. Raisins. C. Buttermilk. D. Orange juice. E. Processed cheese.

Answer A. Clams. B. Raisins. Rationale (A and B) are correct. Crohn's Disease should be supplemented with additional iron in the diet. Foods that are high in iron content are some seafoods , such as clams (A), and a dark red fruits (B). (C, D, and E) are not iron rich sources.

A male client is admitted for the removal of an internal fixation that was inserted for a fracture ankle. During the admission history, he tells the nurse he recently received vancomycin (Vancocin) for a methicillin-resistant Staphylococcus aureus (MRSA) wound infection. Which action should the nurse take? (Select all that apply.) A. Collect multiple site screening culture for MRSA. B. Call healthcare provider for a prescription for linezolid (Zyvox). C. Place the client on contact transmission precautions. D. Obtain sputum specimen for culture and sensitivity. E. Continue to monitor for client sign of infection.

Answer A. Collect multiple site screening culture for MRSA. C. Place the client on contact transmission precautions. E. Continue to monitor for client sign of infection. Rationale (A, C, and E) are correct. Until multi-site screening cultures come back negative (A), the client should be maintained on contact isolation (C) to minimize the risk for nosocomial infections. Linezolid (Zyvox), a broad spectrum anti-infectant, is not indicated, unless the client has an active skin structure infection cause by methicillin-resistant or multidrug-resistant strains (MDRSP) of Staphylococcus aureus. A sputum culture is not indicated (D) based on the client's history is a wound infection. (E) is a component of

During an assessment by the home health nurse of an older man who lives alone, the client reports that he is troubled by constipation. To formulate a plan of care, what additional information should the nurse obtain? (Select all that apply.) A. Daily food and fluid intake. B. Current prescribed and over-the-counter medications. C. Next scheduled visit with healthcare provider. D. Level of physical activity and exercise. E. Methods currently used to treat constipation.

Answer A. Daily food and fluid intake. B. Current prescribed and over-the-counter medications. D. Level of physical activity and exercise. E. Methods currently used to treat constipation. Rationale (A, B, D, and E) are correct. Older adults have a high risk for chronic constipation due to decreased gastrointestinal muscle tone leading to reduced motility. Obtaining a diet history (A) is crucial since low fluid intake is common in the elderly, and the client's diet may be low in fiber, especially since he lives alone and is likely to prepare his own meals. Medications (B) may include diuretics which increase urine output, or have constipation as a common adverse response. Decreased activity (D) may contribute to decreased GI motility. Many older adults use enemas (A) for constipation, so this information should be considered when developing a plan of care. Next scheduled visit with the healthcare provider (C) is not helpful in addressing changes needed to resolve constipation.

The unlicensed assistive personnel (UAP) reports that a client's blood pressure cannot be measured because the client has casts on both arms and is unable to be turned to the prone position for blood pressure measurement in the legs. What action should the nurse implement? A. Demonstrate how to palpate the popliteal pulse with the client supine and the knee flexed. B. Advise the UAP to document the last blood pressure obtained on the client's graphic sheet. C. Estimate the blood pressure by assessing the pulse volume of the clients radio pulses. D. Document why the blood pressure cannot be accurately measured at the present time.

Answer A. Demonstrate how to palpate the popliteal pulse with the client supine and the knee flexed. Rationale The popliteal pulse can be used to measure blood pressure while the client is in the prone or supine position, and the nurse should demonstrate the technique with the client in the supine position and the knee flexed (A). Recording a previously obtained blood pressure as the current reading (B) is falsification of the medical record. The blood pressure cannot be accurately estimated by palpating the radial pulse volume (C). The blood pressure can be accurately measured at this time (D).

The charge nurse observes a new nurse preparing to irrigate an intravenous catheter. The new nurse is attaching a 16 gauge needle. What action should the charge nurse take? A. Direct the nurse to remove the needle before the procedure. B. Override the medication scanning device's variance warning. C. Send an unlicensed assistive personnel to gather equipment. D. Instruct the nurse to use water with 5% dextrose (D5W).

Answer A. Direct the nurse to remove the needle before the procedure. Rationale And IV catheter should be irrigated without a needle by inserting the irrigating syringe's luer-lock tip into the IV catheter or IV tubing port. The charge nurse should direct the nurse to remove the 18 gauge needle before the procedure (A). (B, C, and D) are not indicated.

A morbidly obese woman is scheduled for gastric bypass surgery. She completes the required preoperative nutritional counseling and signs the operative permit. To promote effective discharge planning, which intervention is most important for the nurse to implement? A. Discuss small, low-fat, low sugar meal preparation techniques. B. Encourage the client to keep a daily dietary diary for two weeks. C. Suggest that the client's husband do the family grocery shopping. D. Advise the client to arrange for dietary counseling after discharge.

Answer A. Discuss small, low-fat, low sugar meal preparation techniques. Rationale Following gastric bypass surgery, a lifestyle changes required, one which includes eating small portions and avoiding high-fat foods. Discussing with the client and family how to prepare such meals (A) reinforces the necessary lifestyle change and helps them start the process. (B, C, and D) might be helpful interventions, but further information is needed about the family to determine the value of these interventions for the client and the family.

The nurse is preparing to send a client to the cardiac cath lab for elective cardioversion. Which intervention should the nurse implement before the client leaves the medical unit? A. Document that the client has remained NPO. B. Secure cardioversion pads on the client's chest. C. Notify the rapid response team of the transfer. D. Confirm monitor reading in synchronous mode.

Answer A. Document that the client has remained NPO. Rationale A client undergoing elective cardioversion should be NPO prior to the procedure, and the nurse should confirm the client's NPO status and document in the electronic record (A). (B and D) are completed in the cardiac cath lab just prior to the procedure, and (C) is not necessary.

An older adult female asks the clinic nurse about getting a Herpes vaccination because she gets cold sores on her mouth when she is sick or stressed. How should the nurse respond? A. Explain the use of the vaccination to reduce risk for Herpes zoster. B. Describe the use of the vaccination to treat Herpes Symplex Type 2. C. Confirm that a consent form is signed before administering the vaccination. D. Arrange for skin testing to evaluate if the client is a candidate for the vaccine.

Answer A. Explain the use of the vaccination to reduce risk for Herpes zoster. Rationale Herpes zoster (shingles) is a virus that resides in the root ganglia and causes outbreaks of multiple lesions in segmental distribution patterns on the skin dermatomes that are innervated by the infected nerves. Varicella zoster (Chicken Pox) is the virus that precedes Herpes zoster and can manifest lesions in a dermatome because it lies dormant in the root ganglia. The Herpes vaccine is given to prevent shingles outbreaks in adults over the age of 60 who had chickenpox as a child (A). (B) provides inaccurate information. Obtaining signed consent may be indicated if the client first makes an informed decision (C). (D) is not necessary.

A neonate with a congenital heart defect (CHD) is demonstrating symptoms of heart failure (HF). Which interventions should the nurse include in the infant's plan of care? A. Give O2 at 6 L/nasal cannula for 3 repeated oximetry screens below 90%. B. Administer diuretics via secondary infusion in the morning only. C. Evaluate heart rate for effectiveness of cardiotonic medications. D. Use high energy formula 30 calories/ounce at q3 hour feeding via soft nipples. E. Ensure uninterrupted and frequent rest periods between procedures.

Answer A. Give O2 at 6 L/nasal cannula for 3 repeated oximetry screens below 90%. C. Evaluate heart rate for effectiveness of cardiotonic medications. D. Use high energy formula 30 calories/ounce at q3 hour feeding via soft nipples. E. Ensure uninterrupted and frequent rest periods between procedures. Rationale (A, C, D, and E) are correct. Pulse oximetry screening supports prescribed level of O2 (A), which can be difficult to assess when oral mucosa changes color. HR provides an evaluative criterion for cardiac medications (C), which reduce heart rate, increase strength of contraction (inotropic effects), and consequently affect systemic circulation and tissue oxygenation. Breast milk or basic formula provide 20 calories/ounce, so frequent feedings with high energy formula (D) helps minimize fatigue is necessary.

The home health nurse is visiting an older client who was just charge from the hospital 3 days ago following hip pinning surgery. The client lives with her daughter, who prepares the family meals. In discussing nutrition for postoperative healing it, which meal choices should the nurse suggest for this clients diet? (Select all that apply.) A. Low-fat milk. B. Oat bran. C. White rice. D. Grilled salmon. E. Baked chicken.

Answer A. Low-fat milk. B. Oat bran. D. Grilled salmon. E. Baked chicken. Rationale (A, B, D, and E) are correct. Dairy products such as low-fat milk (A) provide calcium, Vitamin D, and protein. Salmon and tuna fish are high in omega 3 (D), which provides Vitamin D which promotes absorption of dietary calcium. Decreased mobility following hip surgery, combined with slower peristalsis, leads to constipation, so including oat bran foods (B) provides increased dietary fiber. Protein (E) is important for healing. White rice (C) does not provide nutritional value that promotes healing.

A male client who was just discharged 3 days ago after an exploratory laparoscopic biopsy is admitted to the hospital with a warm, tender, reddened, and swollen lower left leg. The nurse is preparing to initiate heparin therapy. What additional intervention should the nurse include in this clients plan of care? A. Maintain the client on bed rest. B. Encourage the client to dangle his legs frequently. C. Administer the clients routine daily aspirin. D. Encourage a diet high in iron and asorbic acid.

Answer A. Maintain the client on bed rest. Rationale A warm, tender, reddened, and swollen lower leg is indicative of a potential deep vein thrombosis (DVT) related to blood pooling during the surgical procedure. Bed rest (A) with evaluation of the affected extremity (B) is maintained until anticoagulation is started. Aspirin (C) causes an additive effect if given concomitantly with anticoagulants, such as warfarin or heparin, used in the treatment of DVT to prevent clot propagation and emobilization. (D) is not indicated.

A client who had a right total knee replacement two days ago is progressed to a soft diet. Which food selections should the nurse recommend to this client? (Select all that apply.) A. Pasta with a cream sauce. B. Pancakes with syrup. C. Scrambled eggs and potatoes. D. Steamed rice and cooked squash. E. Ice cream with nuts. F. Fried chicken and green salad.

Answer A. Pasta with a cream sauce. B. Pancakes with syrup. C. Scrambled eggs and potatoes. D. Steamed rice and cooked squash. Rationale The correct selections are (A, B, C, and D). A soft diet includes foods with a soft consistency they can be chewed easily. Nutritionally dense foods such as whole grains, nuts (E), fried meats and fresh fruits and vegetables (F) should be avoided on a soft diet.

In caring for the body of a client who just died, which tasks can be delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) A. Place personal religious artifacts on the body. B. Confirm the clients wishes for tissue donation. C.Observe consent for autopsy signature by family. D. Attach identifying name tags to the body. E. Follow cultural beliefs in preparing the body.

Answer A. Place personal religious artifacts on the body. D. Attach identifying name tags to the body. E. Follow cultural beliefs in preparing the body. Rationale With adequate supervision and instruction, (A, D, and E) can be delegated to the UAP. (B and C) require the expertise of the nurse and should not be delegated to the UAP.

A 56-year-old man shares with the nurse that he is having difficulty making a decision about terminating life support for his wife. What is the best initial action by the nurse? A. Provide an opportunity for him to clarify his values related to the decision. B. Encourage him to share memories about his life with his wife and family. C. Advise him to seek several opinions before making a decision. D. Offer to contact the hospital chaplain or social worker to offer support.

Answer A. Provide an opportunity for him to clarify his values related to the decision. Rationale When a client is faced with a decisional conflict, the nurse should first provide opportunities for the client to clarify values important in the decision (A). (B, C, and D) may also be beneficial once the client has clarified the values that are important to him in the decision-making process.

To evaluate the effectiveness of a male clients new prescription for ezetimibe, what action should the clinic nurse implement? A. Remind the client to keep his appointments to have his cholesterol level checked. B. Teach the client to weigh himself weekly and keep a log of the measurements. C. Assess the elasticity of the client's skin at the next scheduled clinic appointment. D. Encourage the client to keep a diary of his food intake until his next visit to the clinic.

Answer A. Remind the client to keep his appointments to have his cholesterol level checked. Rationale Ezetimibe lowers total cholesterol and LDL levels, so it is important for the nurse to remind the client to keep his appointments at the laboratory (A). Ezetimibe does not promote weight loss or gain (B) or alter fluid volume (C). Although the client's dietary choices (D) may influence his serum lipid levels, laboratory findings provide the best indicator of the drug's therapeutic response.

During shift report, the central electrocardiogram (EKG) monitoring system alarms. Which client alarm should the nurse investigate firs? A. Respiratory apnea of 30 seconds. B. Oxygen saturation rate of 88%. C. Eight premature ventricular beats every minute. D. Disconnected monitor signal for the last 6 minutes.

Answer A. Respiratory apnea of 30 seconds. Rationale The priority is the client whose alarm indicating respiratory apnea (A) that should be assessed first. (B) is experiencing poor oxygen perfusion, but the client who is having apnea is the priority. Excessive premature ventricular beats (C) indicate an increased risk for ventricular fibrillation, but immediate action is required for the client who is not breathing. (D) should be re-connected to the monitor so the client's EKG and hemodynamic status can be monitored.

A male client receives a thrombolytic medication following a myocardial infarction. When the client has a bowel movement, what action should the nurse implement? A. Send stool sample to the lab for a guaiac test. B. Observe stool for a clay-colored appearance. C. Obtain specimen for culture and sensitivity analysis. D. Asses for fatty yellow streaks in the client's stool.

Answer A. Send stool sample to the lab for a guaiac test. Rationale Thrombolytic drugs increase the tendency for bleeding, so a guaiac (occult blood test) test of the stool (A) should be evaluated to detect bleeding in the intestinal tract. (B, C, and D) are not indicated.

The nurse is assisting a new mother with infant feeding. Which information should the nurse provide that is most likely to result in a decreased milk supply for the mother who is breastfeeding? A. Supplemental feedings with formula. B. Maternal diet high in protein. C. Maternal intake of increased oral fluids. D. Breastfeeding every 2 or 3 hours.

Answer A. Supplemental feedings with formula. Rationale Infant sucking at the breast increases prolactin release and proceeds a feedback mechanism for the production of milk. The nurse should explain that supplemental bottle formula feeding (A) minimizes the infant's time at the breast and decreases milk supply. (B) promotes milk production and healing after delivery. (C) supports milk production. (D) is a recommended routine for breast feeding that promote adequate milk supply.

A 26-year-old female client is admitted to the hospital for treatment of a simple goiter, and levothyroxine sodium (Synthroid) is prescribed. Which symptoms indicate to the nurse that the prescribed dosage is too high for this client? The client experiences A. palpitations and shortness of breath. B. bradycardia and constipation. C. lethargy and lack of appetite. D. muscle cramping and dry, flushed skin.

Answer A. palpitations and shortness of breath. Rationale An overdose of thyroid preparation generally manifests symptoms of an agitated state such as tremors, palpitations, shortness of breath, tachycardia, increased appetite, agitation, sweating and diarrhea (A). (B, C, and D) are not related to overdosage of thyroid preparations.

When delegating a task to an unlicensed assistive personnel (UAP) newly assigned to a nursing unit, what question is most important for the nurse to ask the UAP? A. "How long have you been working as a UAP?" B. "What experience do you have performing this task?" C. "Did you receive training in performing this task?" D. "Where did you work before coming to this unit?"

Answer B. "What experience do you have performing this task?" Rationale It is most important for the nurse to determine the UAP's prior experience in performing any task (B) before assigning care. (C) May also provide useful information, but the UAP may have received training for the skill necessary, yet never had experience in performing the task. (A and D) provide less useful information than (B).

In determining the one minute Apgar score of a male infant, the nurse assesses a heart rate of 120 beats per minute and 44 respirations per minute. He has flaccid muscle tone with slight flexion and slight resistance to straightening. He has a loud cry with stimulation, and his color is acrocyanotic. What is the correct Apgar score for this infant? A. 7. B. 8. C. 9. D. 10.

Answer B. 8. Rationale The maximum Apgar score is 10 (2 points for 5 variables). Subtract one point for muscle tone (slight flexion with slight resistance to straightening), and subtract one point for color due to acrocyanosis (bluing of the extremities is normal at birth). A heart rate over 100 earns 2 points, respirations of 40 earns 2 points, and a loud cry in response to stimulation indicates reflex irritability and earns 2 points. The correct Apgar score for this child is, therefore, 8 (B). Three variables received a score of 2 (2x3=6) and two a score of 1 (2x1=2) for a total of 8 (6+2=8).

The nurse has completed the diet teaching of a male client who is being discharged following treatment of a leg wound. A high protein diet is encouraged to promote wound healing. Which lunch choice by the client indicates that the teaching was effective? A. A peanut butter sandwich with soda and cookies. B. A tunafish sandwich with chips and ice cream. C. A salad with three kinds of lettuce and fruit. D. Vegetable soup, crackers, and milk.

Answer B. A tunafish sandwich with chips and ice cream. Rationale (B) contains the highest amount of protein. Four ounces of tuna contains 11 g of protein, and ice cream 5 g of protein per cup. Chips are a fat with virtually no protein value. (A) contains 4 grams of protein per tablespoon. (C) contains only 1 gram of protein per 1 cup serving. (D) may have beef flavoring but it consist mostly of vegetables and would therefore be low in protein.

A 3-year-old boy is brought to the emergency department after the mother found the child in the back yard holding a piece of a toy in his hand and in respiratory distress. The child is dusky with a loud, inspiratory stridor and weak attempts to cough. Which actions should the nurse implement? A. Obtain a pulse oximetry reading and arterial blood gases. B. Auscultate all pulmonary lung fields and attempt a Heimlich maneuver. C. Request a stat chest x-ray and prepare medications for an asthmatic episode. D. Determine if the child ingested a toxic substance and if vomiting occurred.

Answer B. Auscultate all pulmonary lung fields and attempt a Heimlich maneuver. Rationale Sudden onset of strider, dusky color, and weak ineffective cough strongly suggest that the child aspirated a foreign body. After auscultation of lung fields to determine the quality of air exchange, a Heimlich maneuver (B) is indicated to release the obstruction. After effective breathing is restored, the child may be assessed for complications (A). A history of asthma with symptoms of wheezing (C) is not a part of this child's clinical findings. Although respiratory distress may occur with laryngeal chemical exposure, oral facial burns and systemic manifestations are more likely indications of toxic substance ingestion (D).

The nurse is assessing a client with diabetes mellitus who is at risk of developing acute renal failure. Which assessment finding is earliest indication of acute renal failure? A. Urine output of 30 mL/hour. B. Blood urea nitrogen 35 mg/dL (12.4 mmol/L SI units). C. Creatinine 1.3 mg/dL (114.5 mmol/L SI units). D. Concentrated urine.

Answer B. Blood urea nitrogen 35 mg/dL (12.4 mmol/L SI units). Rationale In acute renal failure, the blood urea nitrogen (BUN) and creatinine levels rise and urinary output decreases. The normal BUN is 5 to 20 mg/dL (B) (or 3.6-7.1 mmol/L SI units), so this client's increased BUN is possibly an early indication of acute renal failure. Urinary output of less than 30 mL (A) and creatinine over 1.3 mg/dL (C) (norm creatinine 0.6 to 1.2 mg/dL or 50 to 106 mmol/L SI units) indicate renal failure. Concentrated urine (D) is not a definitive symptom of acute renal failure.

An older client is admitted with pneumonia, and the healthcare provider prescribes penicillin G potassium IV. Which assessment finding increases the risk of adverse reactions in this client? A. Previous treatment with penicillin for pneumonia. B. Daily use of spironolactone for hypertension. C. Documented allergy to sulfa drugs. D. Sputum culture results of streptococcus pneumoniae.

Answer B. Daily use of spironolactone for hypertension. Rationale. Spironolactone (B) is a potassium-sparing diuretic, and the administration of penicillin G potassium can lead to hyperkalemia, so the client's potassium level should be carefully monitored during this treatment. Previous treatment with penicillin (A) increases the likelihood of an allergic reaction, but hyperkalemia is a greater risk for this client. Sulfa drug allergy (C) does not increase the risk of adverse reaction. Penicillin G potassium is the drug of choice for Streptococcus pneumoniae (D) infection.

An increased number of elderly persons are electing to undergo a new surgical procedure which cures glaucoma. What effect is the nurse likely to note as a result of this increase in glaucoma surgeries? A. Decreased morbidity in the elderly population. B. Decreased prevalence of glaucoma in the population. C. Increased mortality in the elderly population. D. Increased incident of glaucoma in the population.

Answer B. Decreased prevalence of glaucoma in the population. Rationale Prevalence (B) describes the number of existing cases of glaucoma. Since glaucoma occurs mostly in the elderly population and the elderly are obtaining the curative surgery, a decreased prevalence of glaucoma in the population at large can be expected. (A) refers to the number of people who become afflicted with glaucoma within the population, and would likely be unchanged. (C) refers to the number of deaths, which should not be affected by a low-risk outpatient surgical procedure. (D) is the occurrence of new diagnoses of glaucoma, which would likely be unchanged.

The nurse is preparing to administer a histamine 2-receptor antagonist to a client with peptic ulcer disease. What is the primary purpose of this drug classification? A. Neutralize hydrochloric acid (HCl) in the stomach. B. Decreases the amount of HCl secretion by the parietal cells in the stomach. C. Inhibits action of acetylcholine by blocking parasympathetic nerve endings. D. Destroys microorganisms causing stomach inflammation.

Answer B. Decreases the amount of HCl secretion by the parietal cells in the stomach. Rationale (B) correctly describes the action of histamine 2 receptor-antagonists in helping to prevent peptic ulcer disease. (A) describes the action of antacids, (C) of anticholinergic agents, and (D) of anti-infectives.

After a colon resection for colon cancer, a male client is moaning while being transferred to the Postanesthesia Care Unit (PACU). Which intervention should the nurse implement first? A. Assess the client's dressing for bleeding. B. Determine client's pulse, blood pressure, and respirations. C. Administer a PRN dose of IV morphine. D. Check the client's orientation to time and place.

Answer B. Determine client's pulse, blood pressure, and respirations. Rationale Colon resection, a major abdominal surgical procedure, causes severe pain in the immediate postoperative period and requires administration of IV morphine regularly to maintain analgesic serum levels. Before administering a central nervous system (CNS) depressing analgesia, the client's vital signs should be assessed (B) to determine the client's current level of CNS depression. In the immediate postoperative period, during admission to PACU, (A, C, and D) should be evaluated.

A client who received partial thickness (second degree) burns over the anterior surfaces of both arms, legs, and chest in a burning vehicle collision receives a prescription for daily dressing changes and therapeutic baths. The nurse determines that a hoist is required to move the immobile client from a stretcher into the therapeutic bath. Which intervention should the nurse implement first? A. Obtain the hoist from the supply room. B. Explain the procedure to the client. C. Medicate the client with an analgesic. D. Remove all bandages prior to moving the client.

Answer B. Explain the procedure to the client. Rationale Before implementing any new procedure, an explanation of the procedure should be provided (B). Bringing large pieces of equipment into the client's room (A), such as a mechanical lift, may alarm the client if the procedure has not been explained. The client should be medicated (C), but first explaining what is involved in the procedure helps prepare the client for subsequent actions. Dressing bandages provide protection for the wounds and help eliminate exposure to air, which can cause pain, so removal should be done immediately prior to submersion in the bath (D).

A mother brings her 6-year-old child, who has just stepped on a rusty nail, to the pediatrician's office. Upon inspection, the nurse notes that the nail went through the shoe and pierced the bottom of the child's foot. Which action should the nurse implement first? A. Cleanse the foot with soap and water and apply an antibiotic ointment. B. Provide teaching about the need for a tetanus booster within the next 72 hours. C. Have the mother check the child's temperature q4h for the next 24 hours. D. Transfer the child to the emergency department to receive a gamma globulin injection.

Answer A. Cleanse the foot with soap and water and apply an antibiotic ointment. Rationale The nurse should cleanse the wound first (A), and implement (B) next. (C and D) are not indicated in this situation.

A client is admitted to the mental health unit with relationship distress with spouse and depressed mood. Findings of which diagnostic tests provide the most information for developing this client's plan of care? A. Urine drug screen. B. Complete blood count. C. Basic metabolic panel. D. Electrocardiogram.

Answer A. Urine drug screen. Rationale Substance-related disorders often interfere with primary support support systems, causing marital discord and depressed mood. A urine drug screen (A) identifies substance abuse, which determines if the client is at immediate risk for toxicity or withdrawal. (B, C, and D) are common admission laboratory tests routinely obtained to screen for comorbidities.

When caring for a client who has acute respiratory distress syndrome (ARDS), the nurse elevates the head of the bed 30 degrees. What is the reason for this intervention? A. To promote retraction of the intercostal accessory muscle of respiration. B. To reduce abdominal pressure on the diaphragm. C. To promote bronchodilation and effective airway clearance. D. To decrease pressure on the medullary center which stimulates breathing.

Answer B. To reduce abdominal pressure on the diaphragm. Rationale A semi-sitting position is the best position for matching ventilation and perfusion and for decreasing abdominal pressure on the diaphragm, so that the client can maximize breathing (B). (A) is an indication of worsening of respiratory effort, rather than a measure to promote respirations. (C) is incorrect. Bronchodilation is not affected by a change in position, and is not the cause of respiratory distress in ARDS. The respiratory center is not particularly affected by body position (D).

A newly hired male unlicensed assistive personnel (UAP) is assigned to a home healthcare team along with two experienced UAPs. Which intervention should the home health nurse implement to ensure adequate care for all clients? A. Assign the newly hired UAP to clients who receive the least complex level of care. B. Ask the most experienced UAP on the team to partner with the newly hired UAP. C. Evaluate the newly hired UAP's level of competency by observing him deliver care. D. Review the UAP's skills checklist and experience with the person who hired him.

Answer C. Evaluate the newly hired UAP's level of competency by observing him deliver care. Rationale Before delegating tasks to a UAP, his skills should be evaluated (C). Prior to assigning the newly hired UAP to care for clients (A and B), his skills should be evaluated. A skills checklist (D) needs to be validated.

A client has been taking an oral corticosteroid for two weeks. Nursing assessment reveals that the client has developed a rounded face. What action should the nurse take in response to this finding? A. Withhold the next dose of medication. B. Review the client's current allergies. C. Explain this side effect to the client. D. Assess the client's intake and output.

Answer C. Explain this side effect to the client. Rationale Corticosteroids may cause many side effects, including a "moon face" appearance, caused by abnormal fat deposits. The nurse should explain this side effect to the client (C), including information that this effect is reversible when the medication is discontinued. (A, B, and D) are not necessary.

The healthcare provider prescribes methylergonovine maleate for a postpartum client with uterine atony. What findings should indicate to the nurse to withhold the next dose of the medication? A. Excessive lochia. B. Saturation of more than one pad per hour. C. Hypertension. D. Difficulty locating the uterine fundus.

Answer C. Hypertension. Rationale Methylergonovine, an ergot alkaloid, has vasoconstrictive effects that can exaggerate primary hypertension. The nurse should withhold the medication if the client's blood pressure is elevated (C) and notify the healthcare provider. (A, B, and D) are signs of uterine atony and are indications for the use of the medication.

The pathophysiological mechanism are responsible for ascites related to liver failure? (Select all that apply) A. Bleeding that results from a decreased production of the bodies clotting factors. B. Fluid shifts from intravascular to interstitial area due to decreased serum protein. C. Increased hydrostatic pressure in portal circulation increases fluid shifts into abdomen. D. Increased circulating aldosterone levels that increase sodium and water retention. E. Decreased absorption of fatty acids in the duodenum leading to abdominal distention.

Answer B. Fluid shifts from intravascular to interstitial area due to decreased serum protein. C. Increased hydrostatic pressure in portal circulation increases fluid shifts into abdomen. D. Increased circulating aldosterone levels that increase sodium and water retention. Rationale (B, C, and D) are correct. When the liver fails, production of albumin is reduced. Since albumin is the primary serum protein creating intravascular osmotic pressure, decreased serum protein (B) allows a fluid shift into the interstitial space. Pressure increases in the portal circulation (C) when venous return from the upper gastrointestinal tract cannot flow freely into a sclerosed liver, which causes a pressure gradient to further increase fluid shifts into the abdomen. A failing liver ineffectively inactivates steroidal hormones, such as aldosterone (D), resulting in sodium and water retention that produces fluid overload leading to ascites and edema. Decreased clotting factor production (A) and fatty acid absorption (E) are not related to ascites.

A 60-year-old female client asks the nurse about hormones replacement therapy (HRT) as a means preventing osteoporosis. Which factor in the client's history is a possible contraindication for the use of HRT? A. Her 60-year-old sister has Alzheimer's disease. B. Her mother and sister have a history of breast cancer. C. She is taking medication for high blood pressure. D. She had problems with "hot flashes" several years ago.

Answer B. Her mother and sister have a history of breast cancer. Rationale HRT may be contraindicated for a woman with a high risk for breast cancer (B). A woman whose mother and sister had breast cancer may have the BRCA 1 & 2 gene (BReast CAncer genes, discovered in 1994 and 1995), which indicate a tendency for development of breast and ovarian cancer. (A) is not a contraindication for HRT because estrogen provides a protective effect against Alzheimer's disease. Estrogen also protects against heart disease by increasing high density lipids (C). "Hot flashes" (D) are relieved by estrogen.

Assessment by the home health nurse of an older client who lives alone indicates that client has chronic constipation. The client's fluid and fiber intake is deficient and he eats microwaved foods at home and frequents fast-food restaurants. Daily medications include furosemide for hypertension and heart failure and laxatives. To manage the client's constipation, which suggestions should the nurse provide? (Select all that apply) A. Decrease laxative use to every other day, and use oil retention enemas as needed. B. Include oatmeal with stewed pruned for breakfast as often as possible. C. Increase fluid intake by keeping water glass next to recliner. D. Recommend seeking help with regular shopping and meal preparation. E. Report constipation to healthcare provider related to cardiac medication side effects.

Answer B. Include oatmeal with stewed pruned for breakfast as often as possible. C. Increase fluid intake by keeping water glass next to recliner. D. Recommend seeking help with regular shopping and meal preparation. Rational (B, C, and D) are correct. Older adults are at higher risk for chronic constipation due to decreased gastrointestinal muscle tone leading to reduced motility. Oatmeal with prunes (B) increases dietary fiber and bowel stimulation, thereby decreasing need for laxatives. Increased fluid intake (C) also decreases constipation. Assistance with food preparation (D) might help the client eat more fresh fruits and vegetables and result in less reliance on microwaved and fast foods, which are usually high in sodium and fat with little fiber. Laxatives can be reduced gradually by improving the diet, without resorting to using enemas (A). Although the use of diuretics promotes fluid loss which contribute to constipation, it is not necessary to contact the healthcare provider (E).

A woman with an anxiety disorder calls her obstetrician's office and tells the nurse of increased anxiety since the normal vaginal delivery of her son three weeks ago. Since she is breastfeeding, she stopped taking her antianxiety medications, but thinks she may need to start taking them again because of her increased anxiety. What response is best for the nurse to provide this woman? A. Describe the transmission of drugs to the infant through breast milk. B. Inform her that some antianxiety medications are safe to take while breastfeeding. C. Encourage her to use stress relieving alternatives, such as deep breathing exercises. D. Explain that anxiety is a normal response for the mother of a 3-week-old.

Answer B. Inform her that some antianxiety medications are safe to take while breastfeeding. Rationale There are several antianxiety medications that are not contraindicated for breastfeeding mothers (B). The woman is apparently already aware that drugs can be transmitted through breastmilk, so (A) is not helpful. Stress relieving alternatives (C) might be helpful but the client's history suggests that nonpharmacologic methods of anxiety management do not produce the best outcome. Although (D) is incorrect, the mother's history of places her at risk for severe anxiety.

A client experiencing withdrawal from the benzodiazepines alprazolam (Xanax) is demonstrating severe agitation and tremors. What is the best initial nursing action? A. Administer naloxone (Narcan) per PNR protocol. B. Initiate seizure precautions. C. Obtain a serum drug screen. D. Instruct the family about withdrawal symptoms.

Answer B. Initiate seizure precautions. Rationale Withdrawal of CNS depressants, such as Xanax, results in rebound over-excitation of the CNS. Since the client exhibiting tremors, the nurse should anticipate seizure activity and protect the client (B). (A) is used to treat opioid overdose. (C and D) can be implemented after the client has been protected from him/herself.

The nurse is teaching a client how to perform colostomy irrigations. When observing the client's return demonstration, which action indicates that the client understood the teaching? A. Turns to the left side to instill the irrigating solution into the stoma. B. Keeps the irrigating container less than 18 inches above the stoma. C. Instills 1,200 ml of irrigating solution to stimulate bowel evacuation. D. Inserts irrigating catheter deeper into stoma when cramping occurs.

Answer B. Keeps the irrigating container less than 18 inches above the stoma. Rationale Keeping the irrigating container less than 18 inches above the stoma (B) permits the solution to flow slowly with little force so that excessive peristalsis does not cause immediate release of stool. A side-lying position (A) does not facilitate the irrigate's flow into stoma. The amount of irrigate (C) needed to stimulate peristalsis varies from client to client. Inserting the catheter (D) too deeply may cause damage to the stoma.

An adult woman who was seen earlier today in the clinic is admitted to the hospital because she is very nervous, has a racing heart beat, and reports a weight loss of 15 pounds in the last month. The healthcare provider suspects that she has hyperthyroidism and prescribes further testing. What intervention should the nurse include in this client's plan of care? A. Provide extra blankets to prevent heat loss. B. Monitor the client for shortness of breath. C. Assess for hyperactive bowel sounds. D. Prepare the client for a thyroidectomy.

Answer B. Monitor the client for shortness of breath. Rationale The client is at risk for heart failure related to thyrotoxicosis if treatment is not initiated. Monitoring the client for shortness of breath, and early sign of poor cardiac output and a failing heart, should be included in the plan of care. Hyperthyroidism may cause heat intolerance due to a hypermetabolic state, so (A) is not indicated. Bowel sounds (C) are more closely monitored after therapy is initiated when constipation is a potential side effect of drug therapy. Further testing must be completed to evaluate the need for surgical intervention, so (D) is not needed at this time.

An older male adult resident of a long-term care facility is hospitalized for a cardiac catheterization that occurred yesterday. Since the procedure was conducted, the client has become increasingly disoriented. The night shift nurse reports that he attempted to remove the sandbag from his femoral artery multiple times during the night. What actions should the nurse take? (Select all that apply.) A. Recommend a 24-hour caregiver on discharge to the long-term facility. B. Notify the healthcare provider of the client's change in mental status. C. Include q2 hour reorientation in the client's plan of care. D. Request immediate evaluation by Rapid Response Team. E. Apply soft wrist restraints so that the operative site is protected.

Answer B. Notify the healthcare provider of the client's change in mental status. C. Include q2 hour reorientation in the client's plan of care. Rationale (B and C) Are correct. The client's condition reflects mental changes that could be related to post procedure stress, sundowner's syndrome, or cerebral complications. The nurse should inform the healthcare provider of the client's change in mental status (B). For the client's safety, q2 hour reorientations and evaluations should be included in the plan of care (C). A 24-hour caregiver (A) is not indicated at this time, but the client should be reassessed for cognitive dysfunction when he is psychologically stable enough for discharge. The Rapid Response Team provides treatment for life-threatening emergencies, so (D) is not indicated at this time. Restraints may protect the client from self injury (E), but may also increase his confusion.

A female client's estranged husband arrives at the hospital and demands that his wife have no other visitors. The client becomes angry and insists that the estranged husband be barred from visiting her. Which intervention should the nurse implement? A. Obtain a prescription to allow client to dictate who can visit. B. Request a multidisciplinary care conference to discuss husband's demands. C. Have the hospital's medical-legal department meet with the client. D. Encourage the client to speak with husband regarding his disruptive behavior.

Answer B. Request a multidisciplinary care conference to discuss husband's demands. Rationale A multi-disciplinary care conference involves the healthcare team to evaluate difficult situations that conflict with client safety and autonomy. During this conference, the client's wishes regarding her health care decisions can be clarified to all team members. All other options are not indicated.

To reduce staff nurse role ambiguity, which strategy should the nurse-manager implement? A. Confirm that all the staff nurses are being assigned to equal number of clients. B. Review the staff nurse job description to ensure that it is clear, accurate, and current. C. Assign each staff nurse a turn as the unit charge nurse on a regular, rotating basis. D. Analyze the amount of overtime needed by the nursing staff to complete assignments.

Answer B. Review the staff nurse job description to ensure that it is clear, accurate, and recurrent. Rationale Role ambiguity occurs when there is inadequate explanation of job descriptions (B) and assigned tasks, as well as the rapid technological changes that produce uncertainty and frustration. (A and D) may be implemented if the nurse-manager is concerned about role overload, which is the inability to accomplish the tasks related to one's role. (C) is not related to role ambiguity.

The nurse is caring for a group of clients with the help of a licensed practical nurse (LPN) and an experienced unlicensed assistive personnel (UAP). Which procedures can the nurse delegate to the UAP? (Select all that apply.) A. Change a saturated surgical dressing for a client who had an abdominal hysterectomy. B. Take postoperative vital signs for a client who has an epidual following knee arthroplasty. C. Start a blood transfusion for a client who had a below-the-knee amputation. D. Collect a sputum specimen for a client with a fever of unknown origin E. Ambulate a client who had a femoral-popliteal bypass graft yesterday.

Answer B. Take postoperative vital signs for a client who has an epidual following knee arthroplasty. D. Collect a sputum specimen for a client with a fever of unknown origin E. Ambulate a client who had a femoral-popliteal bypass graft yesterday. Rationale (B, D, and E) are correct. Measuring vital signs (B), collecting specimens (D), and ambulating a mobile client (E) are within the scope of practice for a UAP. Surgical dressing changes (A) and initiating blood transfusions (C) should be performed by a licensed nurse.

A client who recently underwear a tracheostomy is being prepared for discharge to home. Which instructions is most important for the nurse to include in the discharge plan? A. Explain how to use communication tools. B. Teach tracheal suctioning techniques. C. Encourage self care and independence. D. Demonstrate how to clean tracheostomy site.

Answer B. Teach tracheal suctioning techniques. Rationale Suctioning (B) helps to clear secretions and maintain an open airway, which is critical. Communication (A) is impaired and independence (C) is altered, but these are not life-threatening problems. Keep the tracheostomy site clean (D) helps prevent infection and should be taught prior to discharge, but this content does not have the priority of suctioning.

An elderly client with degenerative joint disease asks if she should use the rubber jar openers that are available. The nurse's response should be based on which information about assistive devices? A. They can contribute to increased dependency. B. They decrease the risk for joint trauma. C. They promote muscle tone and strength. D. They diminish range of motion ability.

Answer B. They decrease the risk for joint trauma. Rationale Assistive devices of this kind are very beneficial in reducing joint trauma (B) caused by excessive twisting. These devices promote independence (A), rather than increasing dependency. (C and D) are not impacted by the use of these devices.

The nurse is assigned to care for clients on a medical unit. Based on the notes taken during the shift report, which client situation warrants the nurse's immediate attention? A. A young adult with Crohn's disease who reports having diarrheal stools. B. An older adult with type 2 diabetes whose breakfast tray arrives 20 minutes late. C. A 10-year-old who is receiving chemotherapy and the infusion pump is beeping. D. A teenager who reports continued pain 30 minutes after receiving an oral analgesic.

Answer C. A 10-year-old who is receiving chemotherapy and the infusion pump is beeping. Rationale The nurse should immediately assess the child whose infusion pump is alarming during chemotherapy administration (C) because infiltration of a caustic agent can cause tissue damage and children are at greater risk for fluid volume imbalances. Diarrheal stools are a common occurrence for those with Crohn's disease (A). Late consumption of food for a diabetic is of concern, but 20 minutes late is usually not life-threatening (B). Treatment of pain is important, but it has only been 30 minutes since the client was medicated and this issue can be assessed in 10 minutes or delegated to another nurse (D).

A primigravida client at 36-weeks gestation is admitted to labor and delivery unit because her membranes ruptured 30 minutes ago. Initial assessment indicates 2 cm cervical dilation, 50% effaced, -2 station, vertex presentation, greenish colored amniotic fluid, and contractions occurring 3 to 5 minutes with a decrease in fetal heart rate after the last contraction peaks. Which action should the nurse implement first? A. Apply an internal fetal heart monitor. B. Notify the healthcare provider. C. Administer Oxygen via face mask. D. Use a vibroacoustic stimulator.

Answer C. Administer Oxygen via face mask. Rationale The nurse should administer oxygen (C) to increase the amount of oxygen available to the fetus, because this contraction pattern is characteristic of late deceleration, caused by uteroplacental insufficiency. Applying the internal fetal heart monitor (A) to provide a continuous tracing of the fetal heart rate can be implemented after administering the oxygen, and then, notifying the healthcare provider (B) should be done. (D) is used to awaken the fetus, and it is often used if the fetus is in a sleep cycle during a stress test, which is not the case here.

While changing a client's postoperative dressing, the nurse observes a red and swollen wound with a moderate amount of yellow and green drainage and a foul odor. Given there is a positive methicillin-resistant Staphylococcus aureus (MRSA), which is the most important action for the nurse to take? A. Force oral fluids. B. Request a nutrition consult. C. Administer prescribed antibiotics. D. Reapply a sterile non-adhesive dressing.

Answer C. Administer prescribed antibiotics. Rationale A client who has a postoperative dressing with a red, swollen wound, moderate amount of yellow, green drainage, foul odor, and experiencing a MRSA infection poses a risk for transmission of a healthcare-associated infection (HAI). The most important action for the nurse to take is administer prescribed antibiotics (C). (A, B, and D) are not the priority with highly resistant infections, such as MRSA.

A woman at 24 weeks gestation who has fever, bodyaches, and has been coughing for the last 5 days is sent to the hospital with admission prescriptions for H1N1 influenza. Which prescription has the highest priority? A. Obtain specimens for cultures. B. Vital signs q4 hours. C. Assign private room. D. Ringers lactate IV 125 mL/8 hours.

Answer C. Assign private room. Rationale Novel H1N1 ("swine flu virus"), a new subtype of influenza A virus, is exhibited by fever, cough, sore throat, runny nose, body aches, headache, chills, fatigue, diarrhea, and vomiting. According to the Center for Disease Control, it is best to place a client requiring Contact or Droplet Precautions in a single client room, so to protect others, the client who is exhibiting signs of Novel H1N1 influenza should be assigned to a private room (C). (A, B, and D) do not have the right the priority of (C).

A male client has received a prescription for orlistat for weight and nutrition management. In addition to the medication, the client states he plans to take a multivitamin. What teaching should the nurse provide? A. As a nutritional supplement, orlistat already contains all the recommended daily vitamins and minerals. B. Multivitamins are contraindicated during treatment with weight-control medication such as orlistat. C. Be sure to take the multivitamin and the medication at least two hours apart for best absorption and effectiveness. D. Following a well-balanced diet is a much healthier approach to good nutrition than depending on a multivitamin.

Answer C. Be sure to take the multivitamin and the medication at least two hours apart for best absorption and effectiveness. Rationale Orlistat decreases intestinal absorption of fats, including fat-soluble vitamins. Therefore, it is important to take a multivitamin containing fat-soluble vitamins at least two hours before or after the orlistat, so that the vitamins are absorbed (C). Orlistat is not a nutritional supplement (A). Multivitamins should be taken during treatment (B and D) because of the potential loss of nutrients due to decreased absorption of fats in the intestine caused by the orlistat.

A female client is admitted for diabetic crisis resulting from inadequate dietary practices. After stabilization, the nurse talks to the client about her prescribed diet. What client characteristic is most import for successful adherence to the diabetic diet? A. Frequently eats fruits and vegetables at meals and between meals. B. Knows that insulin must be given 30 minutes before eating. C. Demonstrates willingness to adhere to the diet consistently. D. Has someone available who can prepare and oversee the diet.

Answer C. Demonstrates willingness to adhere to the diet consistently. Rationale And individual's willingness to learn, (defined as change in behavior) is the most important factor for success of any teaching (C). (A) is not essential to a successful diabetic diet regimen. Insulin should be given 30 minutes before eating (B), but many diabetics do not take insulin, and administration does not affect success with a diabetic diet. (D) is neither practical nor necessary. Autonomy and responsibility for self-care are important aspects of successful diabetic management.

In preparing a diabetes education program, which goal should the nurse identify as the primary emphasis for a class on diabetes self-management? A. Prepare the client to independently treat their disease process. B. Reduce healthcare costs related to diabetic complications. C. Enable clients to become active participating in controlling the disease process. D. Increase client's knowledge of the diabetic disease process and treatment options.

Answer C. Enable clients to become active participating in controlling the disease process. Rationale The primary goal of diabetic self-management education is to enable the client to become an active participant in the care and control of disease process (C), matching levels of self-management to the abilities of the individual client. The goal is to place the client in a cooperative or collaborative role with healthcare professionals rather than (A). (B) may occur, but this is not a primary goal of self-management. (D) is an interim goal that facilitates the overall goal of self-management.

A male client's laboratory results include a platelet count of 105,000/mm3. Based on this finding, the nurse should include which action in the client's plan of care? A. Cluster care to conserve energy. B. Initiate contact isolation. C. Encourage him to use an electric razor. D. Asses him for adventitious lung sounds.

Answer C. Encourage him to use an electric razor. Rationale This client is at risk for bleeding based on his platelet count (normal 150,000 to 400,000/ mm3). Safe practices, such as using an electric razor for shaving (C), should be encouraged to reduce the risk of bleeding. (A) is indicated for clients who are anemic or easily fatigued. (B and D) are indicated for clients with a contact contagious infections or clients who may be a risk for pulmonary infections.

When development a teaching plan for a client with newly diagnosed Type 1 diabetes, the nurse should explain that an increased thirst is an early sing of diabetes ketoacidosis (DKA). Which action should the nurse instruct the client to implement if this sign of DKA occurs ? A. Resume normal physical activity. B. Drink electrolyte fluid replacement. C. Give a dose of regular insulin per sliding scale. D. Measure urinary output over 24 hours.

Answer C. Give a dose of regular insulin per sliding scale. Rationale As hyperglycemia persists, ketone body become a fuel source, and the client manifests early signs of DKA that include excessive thirst, frequent urination, headache, nausea and vomiting, which result in dehydration and loss of electrolytes. The client should determine fingerstick glucose levels and self-administer a dose of regular insulin per sliding scale (C). Although physical activity (A) helps glucose utilization and oral electrolyte fluid replacements (B) help restore electrolytes, insulin is needed to ensure glucose uptake by cells and to stop fat mobilization. (C) provides information about fluid and weight loss related to the DKA episode.

The nurse receives a newborn within the first minutes after a vaginal delivery and intervenes to establish adequate respirations. What priority issue should the nurse address to ensure the newborn's survival? A. Hypoglycemia. B. Fluid balance. C. Heat loss. D. Bleeding tendencies.

Answer C. Heat loss. Rationale Adequate thermoregulation is the nurse's next priority (C). The newborn is at risk for significant heat loss due to a large surface area exposed to the environment, a thin layer of subcutaneous fat, and distribution of brown fat. Heat loss increases the neonate's metabolic pathway's utilization of oxygen and glucose. Due to low hepatic stores of glycogen at birth and the immature kidneys' ability to concentrate urine, (A and B) are consequential to the neonate's rate of metabolism. Bleeding tendencies are addressed in the 1st hours of life by administering vitamin K by injection for hepatic synthesis of prothrombin (D).

A client with cirrhosis is receiving a low protein diet. The nurse should explain to the family that the diet restriction is implemented to reduce the risk of which complication of cirrhosis? A. Delirium tremens. B. Abdominal ascites. C. Hepatic encephalopathy. D. Esophageal varices.

Answer C. Hepatic encephalopathy. Rationale Protein end-products (amino acids) are converted (deaminated) by the liver to a fuel source by the removal of ammonia (NH3), which accumulates in the blood in those with cirrhosis and contributes to the potentially fatal complication of hepatic encephalopathy (C). Decreased protein intake does not prevent (A, B, or D).

The nurse learns during shift report that a client is experiencing frequent ectopic beats on the cardiac telemetry monitor. Which assessment findings should the nurse expect this client to exhibit? A. Loose electrode pads. B. S3 or S4 heart sounds. C. Irregular heart rhythm. D. Bounding pulse volume.

Answer C. Irregular heart rhythm. Rationale Ectopic beats originate outside the normal conduction pathway of the heart to usurp the pacemaker's impulse, which causes an irregular cardiac rhythm (C). Ectopic beats are not the result of loose or incorrect electrode pad placement (A), do not result in the production of S3 or S4 heart sounds (B), and may or may not be palpable distally. Ectopic beats are more likely to result in a diminished pulse volume, rather than a bounding pulse volume (D).

A 66-year-old woman is retiring and will no longer have a health insurance through her place of employment. Which agency should the client be referred to by the employee health nurse for health insurance needs? A. Women, Infant, and Children program. B. Medicaid. C. Medicare. D. Consolidated Omnibus Budget Reconciliation Act provisions.

Answer C. Medicare. Rationale Title XVIII of the Social Security act of 1965 created the Medicare Program (C) to provide medical insurance for persons 65 years or older, disabled, or with permanent kidney failure. Women, Infant, and Children (WIC) program (A) provides supplemental nutrition to meet the needs of pregnant or breastfeeding women, infants, and children up to age 6. Title XIX of the Social Security Act of 1965 is Medicaid (B), which provides financial assistance to pay for medical services for poor older adults, blind, disabled, and families with dependent children. Consolidated Omnibus Budget Reconciliation Act (COBRA) health benefit provisions (D) is a limited insurance plan for those who have been laid off or become unemployed.

A female client with possible acute renal failure (ARF) is admitted to the hospital and mannitol (Osmitrol) is prescribed as a fluid challenge. Prior to carrying out this prescription, what intervention should the nurse implement? A. Collect a clean catch urine specimen. B. Instruct the client to empty the bladder. C. Obtain vital signs and breath sounds. D. No specific nursing action is required.

Answer C. Obtain vital signs and breath sounds. Rationale The client's baseline cardiovascular status should be determined before conducting the fluid challenge. If the client manifests changes in the vital signs and breath sounds (C) associated with pulmonary edema, the administration of the fluid challenge should be terminated. Providing a urine specimen (A) and emptying the bladder (B) are difficult for a client with oliguria or anuria associated with ARF. Nursing action is required to evaluate the client's response to the challenge (D).

A client with rheumatoid arthritis (RA) starts a new prescription of etanercept (Enbrel) subcutaneously once weekly. The nurse should emphasize the importance of reporting which problem to the healthcare provider? A. Headache. B. Joint stiffness. C. Persistent fever. D. Increase hunger and thirst.

Answer C. Persistent fever. Rationale Enbrel decreases immune and inflammatory responses, increasing the client's risk of serious infection, so the client should be instructed to report a persistent fever (C), or other signs of infection to the healthcare provider. (A) is a common and non life-threatening side effect. Clients with RA experience joint pain and stiffness (B). (D) is not an anticipated side effect of Enbrel.

Following discharge teaching, a male client with a duodenal ulcer tells the nurse the he will drink plenty of dairy products, such as milk, to help coat and protect his ulcer. What is the best follow-up action by the nurse? A. Remind the client that it is also important to switch to decaffeinated coffee and tea. B. Suggest that the client also plan to eat frequent small meals to reduce discomfort. C. Review with the client the need to avoid foods that are rich in milk and cream. D. Reinforce this teaching by asking the client to list dairy foods that he might select.

Answer C. Review with the client the need to avoid foods that are rich in milk and cream. Rationale Diets rich in milk and cream stimulate gastric acid secretion and should be avoided (C). (A) stimulates gastric acid production as do other caffeinated beverages. (B) is not necessary as long as an antacid or histamine blocker is taken. (D) reinforces incorrect learning.

The nurse identifies the presence of a clear fluid on the surgical dressing of a client who just returned to the unit following lumbar spinal surgery. What action should the nurse implement immediately? A. Change the dressing using a compression bandage. B. Document the findings in the electronic medical record. C. Test the fluid on the dressing for glucose using a chemstrip. D. Mark the drainage area with a pen and continue to monitor.

Answer C. Test the fluid on the dressing for glucose using a chemstrip. Rationale Following lumbar spinal surgery, the nurse should observe the surgical dressing for the presence of clear fluid, which could be cerebrospinal fluid. If the fluid on the dressing is positive for glucose (C), this verifies that it is cerebrospinal fluid and the surgeon should be notified immediately. The nurse should not implement (A) based on this finding. Although the nurse should document the finding (B), this is not a priority action. (D) delays necessary intervention.

A client who receives multiple antihypertensive medications experiences syncope due to a drop in blood pressure to 70/40. What is the rationale for the nurse's decision to hold the client's scheduled antihypertensive medications? A. Increased urinary clearance of the multiple medications has produced diuresis and lowered the blood pressure. B. The antagonistic interaction among the various blood pressure medications has reduced their effectiveness. C. The additive effect of multiple medications has caused the blood pressure to drop too low. D. The synergistic effect of the multiple medications has resulted in drug toxicity and resulting hypotension.

Answer C. The additive effect of multiple medications has caused the blood pressure to drop too low. Rationale When medications with a similar action are administered, the additive effect occurs that is the sum of the effects of each of the medications. In this case, several medications that all lower blood pressure, when administered together, resulted in hypotension (C). A change in urinary drug clearance is unlikely to produce significant diuresis (A). The similar drugs have an additive effect, rather than an antagonistic effect (B). The client's hypotension is the result of an additive effect rather than drug toxicity (D).

The nurse discontinues a continuous IV heparin infusion for a male client on strict bed rest, and is now preparing to administer the client's first dose of in enoxaparin (Lovenox). Prior to giving this subcutaneous injection, which assessment finding requires additional intervention by the nurse? A. Current lab report indicates an aPTT at 1.5 times the client's control. B. Several bruised areas are noted on the client's upper extremities bilaterally. C. The client states that his right calf is aching, and wants pain medication. D. The spouse is assisting the client who is shaving with an electric razor.

Answer C. The client states that his right calf is aching, and wants pain medication. Rationale A calf ache severe enough for the client to request pain medication (C) should be reported to the healthcare provider immediately so that an adjustment in the anticoagulation therapy can be made. Calf pain may be a sign of deep vein thrombosis indicative of ineffective anticoagulant heparin therapy. (A and B) are expected findings. Shaving with an electric razor is recommended to reduce the possibility of bleeding (D) and does not require intervention.

A female client reports that her hair is becoming coarse and breaking off, that the outer part of her eyebrows have disappeared, and that her eyes are all puffy. Which follow-up question is best for the nurse to ask? A. "Is there a history of female baldness in your family?" B. "Are you under any unusual stress at home or work?" C. "Do you work with hazardous chemicals?" D. "Have you noticed any changes in your fingernails?"

Answer D. "Have you noticed any changes in your fingernails?" Rationale The pattern of reported manifestations is suggestive of hypothyroidism. A question about the finger nails (D) adds data to the clinical picture. The reported pattern of manifestations are not indicators of female baldness patterns (A), and are unlikely to be due to (B or C).

Following a lumbar puncture, a client voices several complaints. What complaint indicates to the nurse that the client is experiencing a complication? A. "I am having pain in my lower back when I move my legs." B. "My throat hurts when I swallow." C. "I feel sick to my stomach and am going to throw up." D. "I have a headache that gets worse when I sit up."

Answer D. "I have a headache that gets worse when I sit up." Rationale A post lumbar puncture headache (D), ranging from mild to severe, may occur as a result of leakage of cerebrospinal fluid at the puncture site. This complication is usually managed by bedrest, analgesics, and hydration. (A, B, and C) are not indicative of a lumbar puncture complication.

The nurse is conducting intake interviews of children at a city clinic. Which child is most susceptible to contracting lead poisoning? A. An adolescent who works part time in a paint factory. B. A 10-year-old who is an insulin-dependent diabetic (Type 1). C. An 8-year-old who lives in a housing project. D. A 2-year-old who plays on aging outdoor playground equipment.

Answer D. A 2-year-old who plays on aging outdoor playground equipment. Rationale Children who ingest dust and soil and paint from playground equipment usually practice pica—the habitual, purposeful, and compulsive ingestion of non-food products, characteristic of toddlers (D). Lead enters the system by ingestion or inhalation, usually from paint, gasoline, dust and soil, food, and water. Though (A) may present a hazard, governmental regulations decrease the risk of contracting lead poisoning by requiring use of respirators in lead paint areas. (B) is not related to lead poisoning. (C) does not practice pica the way a toddler does.

The nurse working in the psychiatric clinic has phone messages from several clients. Which call should the nurse return first? A. A young man with schizophrenia who wants to stop taking his medications. B. The mother of a child who was involved in a physical fight at school today. C. A client diagnosed with depression who is experiencing sexual dysfunction. D. A family member of a client with dementia who has been missing for five hours.

Answer D. A family member of a client with dementia who has been missing for five hours. Rationale Safety is always the priority concern, and the family member of the missing client with dementia (D) needs assistance with contacting authorities as well as psychological support during this time. (A, B, and C) do not have the priority of (D).

Following surgery, a male client with antisocial personality disorder frequently requests that a specific nurse be assigned to his care and is belligerent when another nurse is assigned. What action should the charge nurse implement? A. Ask the client to explain why he constantly requests the nurse. B. Encourage the client to verbalize his feelings about the nurse. C. Reassure the client that his request will be met whenever possible. D. Advise the client that assignments are not based on clients requests.

Answer D. Advise the client that assignments are not based on clients requests. Rationale Those with antisocial personality disorder are manipulative in order to meet their own needs. The charge nurse must set limits (D) on these behaviors. The client's superficial charm and emotional immaturity provide effective therapeutic communication and (A and B) will be used to the client's advantage. Promoting a special relationship (C) between the client and a staff member encourages further manipulative behavior.

A male client with angina pectoris is being discharged from the hospital. What instruction should the nurse plan to include in this discharge teaching? A. Engage in physical exercise immediately after eating to help decrease cholesterol levels. B. Walk briskly in cold weather to increase cardiac output. C. Keep nitroglycerin in a light-colored plastic bottle and readily available. D. Avoid all isometric exercises, but walk regularly.

Answer D. Avoid all isometric exercises, but walk regularly. Rationale Isometric exercises (static contraction) can raise blood pressure for the duration of the exercise, which may be dangerous for a client with cardiovascular disease, while walking (D) provides aerobic conditioning that improves lung, blood vessel, and muscle function. Clients with angina should refrain from physical exercise for 2 hours after meals (A), but exercising does not decrease cholesterol levels. Cold water causes vasoconstriction that may cause chest pain (B). Nitroglycerin should be readily available and stored in a dark-colored glass bottle, not (C), to ensure freshness of the medication.

Which breakfast selection indicates that the client understands the nurse's instructions about the dietary management of osteoporosis? A. Egg whites, toast, and coffee. B. Brand muffin, mixed fruit, and orange juice. C. Granola bar and grapefruit juice. D. Bagel with jelly and skim milk.

Answer D. Bagel with jelly and skim milk. Rationale (D) includes dairy products which contain calcium and does not include any foods that inhibit calcium absorption. The primary dietary implication of osteoporosis is the need for increased calcium, and a reduction in foods that decrease calcium absorption, such as caffeine and excessive fiber. (A, B and C) do not include any source of calcium, and (A and B) contain foods that may reduce calcium absorption.

An older male client with Type 2 diabetes mellitus reports that has experiences leg pain when walking short distances, and that the pain is relieved by rest. Which client behavior indicates an understanding of healthcare teaching to promote more effective arterial circulation? A. Consistently applies TED hose before getting dressed in the morning. B. Frequently elevated legs thorough the day. C. Inspect the leg frequently for any irritation or skin breakdown. D. Completely stop cigarette/ cigar smoking.

Answer D. Completely stop cigarette/ cigar smoking. Rationale Stopping cigarette smoking helps to decrease vasoconstriction and improve arterial circulation to the extremity (D). (A and B) may help to improve arterial circulation by decreasing venous congestion, but these interventions are not as important as (D). (C) is important for early detection of arterial ulcers, but does not improve circulation.

A nurse is conducting a physical assessment of a young adult. Which information provides the best indication of the individual nutritional status? A. A 24-hour diet history. B. History of a recent weight loss. C. Status of current appetite. D. Condition of hair, nails, and skin.

Answer D. Condition of hair, nails, and skin. Rationale The assessment of hair, nails, and skin (D) is most indicative of long-term nutritional status, which is important in the healing process. (A, B, and C) evaluate only recent in short-term nutritional status.

The nurse assesses a client who has just returned from a diagnostic study, as seen in the picture. The client has a prescription for a nasogastric tube to low intermittent suction and now reports feelings of nausea. What action should the nurse implement first? A. Auscultate bowel sounds. B. Administer an IV antiemetic. C. Remove tape from the cheek. D. Connect the tube to suction.

Answer D. Connect the tube to suction. Rationale To relieve the client's nausea, the nurse should first connect the nasogastric tube to the prescribed suction (D). If this does not relieve the nausea, an antiemetic agent (B) should be administered. (A and C) can be completed after initial actions are taken to relieve the client's nausea.

Before preparing a client for the first surgical case of the day, a part-time scrub nurse asks the circulating nurse if a 3 minute surgical hand scrub is adequate preparation for this client. Which response should the circulating nurse provide? A. Ask a more experienced nurse to perform this crowd since it is the first one of the day. B. Validate that the nurse is implementing the OR policy for a surgical hand scrub. C. Inform the nurse that hand scrubs should be 3 minutes between cases. D. Direct the nurse to continue the surgical hand scrub for a 5 minute duration.

Answer D. Direct the nurse to continue the surgical hand scrub for a 5 minute duration. Rationale The surgical hand scrub should last for 5 to 10 minutes, so the nurse should be directed to continue the vigorous scrub using a reliable agent for the total duration of five minutes (D). It is not necessary to reassign staff (A). The length of the hand scrub and subsequent scrubs during the day require the same process for the same amount of time (B and C).

A female client with otosclerosis is scheduled for a stapedectomy. What information is most important to provide the client about the postoperative care? A. Medications to manage pain are available. B. Avoid turning head until dressings are removed. C. Can go to bathroom independently. D. Hearing may seem muffled initially.

Answer D. Hearing may seem muffled initially. Rationale Otosclerosis causes bone conduction deafness due to a calcification of the stapes in the bony labyrinth. Surgical correction requires stapedectomy and a stapes prosthetic implant to restore hearing. In the immediate postoperative period, the client should be prepared for muffled hearing (D) due to interauricular packing, swelling, and external dressings that reduce air conduction. Although information about pain medications (A) should be provided, the client's concern about hearing restoration is usually most significant. (B) is not necessary. Postoperative vertigo is common, so the client should request assistance when resuming ambulation or going to the bathroom (C).

A client with cervical cancer is hospitalized for insertion of a sealed internal cervical radiation implant. While providing care, the nurse finds the radiation implant in the bed. What action should the nurse take? A. Call the radiology department. B. Reinsert the implant into the vagina. C. Applied double gloves to retrieve the implant for disposal. D. Place the implant in a lead container using long-handled forceps.

Answer D. Place the implant in a lead container using long-handled forceps. Rationale Solid or sealed radiation sources, such as Cesium which is removed after treatment, are inserted into an applicator or cervical implant to emit continuous, low energy radiation to adjacent tumor tissues. If the radiation source or the applicator becomes dislodged, long-handled forceps should be used to retrieve the radiation implant to prevent injury due to direct handling. The applicator is then placed in the lead container (D). Although radiology should be notified (A), the sealed source should first be removed from the bed to prevent further contact with the radioactive element. (B) is not a nursing action. (C) places the nurse and others at risk for radiation exposure.

What action should the nurse take first when discontinuing and indwelling urinary catheter? A. Slide the catheter out of the urethra. B. Place the drainage bag in a biohazard container. C. Instruct the client to breathe deeply and exhale. D. Remove the normal saline from the balloon.

Answer D. Remove the normal saline from the balloon. Rationale The nurse should first remove the saline from the balloon (D), which deflates the balloon so the catheter can easily be removed. The nurse should then instruct the client to breathe deeply and exhale (C), sliding the catheter out of the meatus (A) while the client is exhaling. The drainage system can then be discarded (B).

A 6-month-old is admitted to the hospital with diarrhea. The mother is feeding the infant a bottle of tap water and tells the nurse that the baby has taken three 8-ounce bottles of water in the last four hours. Which laboratory finding is most important for the nurse to monitor? A. Creatinine clearance. B. White blood cell count. C. Serum potassium levels. D. Serum sodium levels.

Answer D. Serum sodium levels. Rationale Serum sodium levels (D) should be monitored because the recent water intake places this infants at risk for water intoxication and hyponatremia. (A) evaluates renal function efficiency in removing serum creatinine, and end-product of protein metabolism. (B and C) do not evaluate possible water intoxication.

When assessing a 6-month old infant, the nurse determines that the anterior fontanel is bulging. In which situation would this finding be most significant? A. Crying. B. Straining on stool. C. Vomiting. D. Sitting upright.

Answer D. Sitting upright. Rationale The anterior fontanel closes at 9 months of age and may bulge when venous return is reduced from the head, but a bulging anterior fontanel is most significant if the infant is sitting up (D) and may indicate an increase in cerebrospinal fluid. Activities that reduce venous return from the head, such as crying, a Valsalva maneuver, vomiting or a dependent position of the head, cause a normal transient increase in intracranial pressure, so your bulging anterior fontanelle is an expected finding during (A, B, and C).

A client with a history of a bilateral adrenalectomy is admitted with a weak, irregular pulses, and hypotension. Which assessment finding warrants immediate intervention by the nurse? A. Decreased urinary output. B. Low glucose levels. C. Profound weight gain. D. Ventricular arrhythmias.

Answer D. Ventricular arrhythmias. Rationale Adrenal crisis, a potential complication of bilateral adrenalectomy, results in the loss of mineralcorticoids and sodium excretion that is characterized by hyponatremia, hyperkalemia, dehydration, and hypotension. Ventricular arrhythmias (D) are life-threatening and require immediate intervention to correct critical potassium level. (A, B, and C) require intervention but do not have the priority of (D).

During a postpartum assessment of a client who is five hours post vaginal delivery, the nurse determines the fundus is three finger breadths above the umbilicus and positioned to the client's left side. What action should the nurse implement first? A. Encourage the client to void. B. Catheterize for residual urinary volume. C. Provide additional oral replacement fluids. D. Massage the fundus until firm.

Answer A. Encourage the client to void. Rationale During the immediate postpartum period, bladder distention prevents uterine contraction which predisposes the client to excessive uterine bleeding, so the client should void (A), which allows the uterus to contract and reposition midline between the umbilicus and the symphysis pubis. If the client is unable to void or completely empty the bladder, then (B) may be indicated. (C) does not address the malpositioned uterus. Fundal massage (D) may be indicated if the uterus does not become firm after voiding.

The nurse plans to collect a 24-hour urine specimen for a creatinine clearance test. Which instruction should the nurse provide to the adult male client? A. Cleanse around the meatus, discard first portion of voiding, and collect the rest in a sterile bottle B. Urinate at specified time, discard the urine, and collect all subsequent urine during the next 24 hours. C. For the next 24 hours, notify the nurse when the bladder is full, and the nurse will collect catheterized specimens. D. Urinate immediately into a urinal, and the lab will collect specimen every 6 hours, for the next 24 hours.

Answer B. Urinate at specified time, discard the urine, and collect all subsequent urine during the next 24 hours. Rationale (B) is the correct procedure for collecting a 24-hour urine specimen. Discarding even one voided specimen invalidates the test. (A) is the procedure for collecting a clean-catch midstream urine specimen. A 24-hour urine specimen does not require (C). (D) is not the correct procedure for collecting a 24-hour urine specimen.

Which action should the nurse implement with auscultating anterior breath sounds? (Place the first action on top and last action on the bottom.) A. Displace female breast tissue and apply stethoscope directly on chest wall to hear vesicular sounds. B. Place stethoscope in suprasternal area to auscultate for bronchial sounds. C. Auscultate bronchovesicular sounds from side to side of the first and second intercostal spaces. D. Document normal breath sounds and location of adventitious breath sounds.

Answer Correct order: (PADD) 1. Place stethoscope in suprasternal area to auscultate for bronchial sounds 2. Auscultate bronchovesicular sounds from side to side of the first and second intercostal spaces. 3. Displace female breast tissue and apply stethoscope directly on chest wall to hear vesicular sounds. 4. Document normal breath sounds and location of adventitious breath sounds. Rationale Begin auscultation of anterior breath sounds over the trachea and larynx to identify bronchial breath sounds. Assessment should proceed down the anterior chest from side to side to hear bronchovesicular sounds, which are located over major bronchi around the upper sternum in the first and second intercostal spaces. To hear vesicular sounds over peripheral lungs fields where air flows through smaller airway, the breast tissue should be displaced so the stethoscope lies directly on chest wall. Documentation should include normal breath sounds and any adventitious findings.

The nurse performs a prescribed neurological check at the beginning of the shift on a client who was admitted to the hospital with a subarachnoid brain attack (stroke). The client's Glasgow Coma Scale (GCS) score is 9. What information is most important for the nurse to determine? A. When the client's stroke symptoms started. B. If the client is oriented to time. C. The client's previous GCS score. D. The client's blood pressure and respiration rate.

Rationale The normal GCS is 15, and it is most important for the nurse to determine if this abnormal score is a sign of improvement or a deterioration in the client's condition (C). (A) is a relevant. (B) is part of the GCS. The classic vital signs in late or sudden increasing intracranial pressure or Cushing's triad (widening pulse pressure, bradycardia with full, bounding pulses, and irregular respirations). Additional vital signs and trending of values are needed to evaluate the current findings (D), and (C) is a more sensitive, consistent evaluation.

The healthcare provider prescribed oxycodone/aspirin 1 tab PO every 4 hours as needed for pain, for a client with polycystic kidney disease. Before administering this medication, which component of the prescription should the nurse question? A. Aspirin content. B. Dose. C. Risk for addiction. D. Route.

Answer A. Aspirin content. Rationale Aspirin containing compounds are (A) contraindicated for clients with polycystic kidney disease because of the risk for bleeding. This is the recommended dose (B) and PO is the correct route administration (D). Addiction (C) is not the main concern regarding this prescription.

The nurse is administering a 750 ml cleansing enema to an adult client. After approximately 150 ml of enema has infused, the client states, "Stop! I can't hold anymore." What action should the nurse take? A. Clamp the tubing and instruct the client to breathe deeply before continuing. B. Discontinue infusing the enema and record the client's response. C. Slow infusion of the enema and instruct the client to use pant breathing. D. Place the client on the bedpan and continue infusion of the enema.

Answer A. Clamp the tubing and instruct the client to breathe deeply before continuing. Rationale Clamping the tubing momentarily (A) allows the muscles to relax and prevents expulsion of the solution prematurely. Though (B) may eventually be necessary, (A) should be tried first. (C) is likely to result in premature expulsion of the enema. (D) is not a practical intervention, and would not assist the client in retaining the prescribed amount of solution.

An unlicensed assistive personnel UAP leaves the unit without notifying the staff. In what order should the unit manager implement these interventions to address the UAPs behavior? (Place the actions in order from first on top to last on bottom.) A. Discuss the issue privately with the UAP. B. Evaluate the UAP for signs of improvement. C. Plan for scheduled break times. D. Note date and time of the behavior.

Answer 1. Note date and time of the behavior. 2. Discuss the issue privately with the UAP. 3. Plan for scheduled break times. 4. Evaluate the UAP for signs of improvement. Rationale Noting the date and time of the behavior is the first action that is important in providing factual information. The unit manager should discuss the behavior with the UAP and describe the problems the behavior causes for the staff. When a problem is identified, it is important to plan and implement solutions, such as scheduled break times during the shift. These interventions should be evaluated based on the UAP's signs of improvement.

In making client care assignment, which client is best to assign to the practical nurse (PN) working on the unit with the nurse? A. An immobile client receiving low molecular weight heparin q12h. B. A client who is receiving a continuous infusion of heparin and gets out of bed BID. C. A client who is being titrated off heparin infusion and started on PO warfarin (Coumadin). D. An ambulatory client receiving warfarin (Coumadin) with INR of 5 seconds.

Answer A. An immobile client receiving low molecular weight heparin q12h. Rationale (A) describes the most stable client. This client should be assigned to the PN. (B, C, and D) are clients at high risk for bleeding problems and require the assessment skills, judgement, and expertise of the RN.

At 1615, prior to ambulating a postoperative client for the first time, the nurse reviews the client's medical record. Based on date contained in the record, what action should the nurse take before assisting the client with ambulation? (Click on each chart tab for additional information. Please be sure to scroll to the bottom right corner of each tab to view all information contained in the client's medical record.) A. Remove sequential compression devices. B. Apply PRN oxygen per nasal cannula. C. Administer a PRN dose of an antipyretic. D. Reinforce the surgical wound dressing.

Answer A. Remove sequential compression devices. Rationale Sequential compression devices should be removed prior to ambulation (A) and there is no indication that this action is contraindicated. The client's oxygen saturation levels have been within normal limits for the previous four hours, so supplemental oxygen is not warranted (B). The client's body temperature of 99° F is not sufficiently elevated to administer an antipyretic (C). A very small amount of drainage is present on the surgical wound dressing and has not increased in the previous four hours, so (D) is not indicated.

A client diagnosed with calcium kidney stones has a history of gout. A new prescription for aluminum hydroxide (Amphogel) is scheduled to begin at 0730. Which client medication should the nurse bring to the healthcare provider's attention? A. Aspirin, low dose. B. Allopurinol (Zyloprim). C. Furosemide (Lasix). D. Enalapril (Vasotec).

Answer B. Allopurinol (Zyloprim). Rationale The effectiveness of allopurinol is diminished when aluminum hydroxide is used leading to an increased chance for gout flare ups. The healthcare provider should be alerted about the allopurinol (B) interaction so any changes in medication regimen may be considered. (A, C, and D) do not have interactions with aluminum hydroxide.

The nurse is palpating the lymph nodes of an 18-month-old. Which findings should the nurse call to the attention of the healthcare provider? A. Small, firm, mobile nodules in the axilla. B. Enlarged, warm, tender preauricular node. C. Enlarged, nontender, movable occipital node. D. Small, discrete, mobile, nontender, inguinal node.

Answer B. Enlarged, warm, tender preauricular node. Rationale Enlargement of a preauricular node with associated warmth and tenderness (B) is not an expected finding in an 18-month-old and requires further investigation. (A, C, and D) are common and expected findings in an 18-month-old child.

The nurse is assisting the mother of a child with phenylketonuria (PKU) to select foods that are in keeping with the child's dietary restrictions. Which foods are contraindicated for this child? A. Wheat products. B. Foods sweetened with aspartame. C. High fat foods. D. High calorie foods.

Answer B. Foods sweetened with aspartame. Rationale Aspartame (B) should not be consumed by a child with PKU because it is converted to phenylalanine in the body. Additionally, milk and milk products are contraindicated for children with PKU. (A) is contraindicated for children with celiac disease, not those with PKU. Although (C and D) may not be the healthiest, they are not specifically contraindicated for children with PKU.

A group of nurse-managers is asked to engage in a needs assessment for a piece of equipment that will be expensed to the organization's budget. Which question is most important to consider when analyzing the cost-benefit for this piece of equipment? A. Will the equipment require annual repair? B. How many departments can use this equipment? C. Is the cost of the equipment reasonable? D. Can the equipment be updated each year?

Answer B. How many departments can use this equipment? Rationale If the equipment can be used by more than one department (B), it can be expensed to interdepartmental cost sharing, thereby sharing not only the cost but also the benefit of the equipment. (A, C, and D) should be considered, but first the usefulness of the equipment should be considered.

An older adult female admitted to the intensive care unit (ICU) with a possible stroke is intubated with ventilator setting of tidal volume 600, PlO2 40%, and respiratory rate of 12 breaths/minute. The arterial blood gas (ABG) results after intubation are pH 7.31. PaCO2 60, PaO2 104, SPO2 98%, HCO3 23. To normalize the client's ABG finding, which action is required? A. Report the results to the healthcare provider. B. Increase ventilator rate. C. Administer a dose of sodium bicarbonate. D. Decrease the flow rate of oxygen.

Answer B. Increase ventilator rate. Rationale This client is experience respiratory acidosis. Increasing the ventilator rate (B) depletes CO2, which returns the pH toward normal. Report findings (A) is important but only after increasing ventilator rate. (C and D) are ineffective.

The nurse is teaching a male adolescent recently diagnosed with type 1 diabetes mellitus (DM) about self-injecting insulin. Which approach is best for the nurse to use to evaluate the effectiveness of the teaching? A. Ask the adolescent to describe his level of comfort with injecting himself with insulin. B. Observe him as he demonstrates the self-technique to another diabetic adolescent. C. Have the adolescent list the procedural steps for safe insulin administration. D. Review his glycosylated hemoglobin level 3 months after his diabetic teaching.

Answer B. Observe him as he demonstrates the self-technique to another diabetic adolescent. Rationale Watching the adolescent perform the procedure (B) with another adolescent provides peer support and the most information regarding his skill with self-injections. Although the client's feelings regarding his level of comfort with performing the procedure (A) influence his ability to perform the skill, these feelings are not an effective measure of the adolescent's skill with the procedure. (C) is not as effective a measure of the client's ability as (B). Glycosylated hemoglobin (D) measures diabetic control average over the past 90 days, which might be influenced by the client's self-injecting technique, but waiting 90 days to evaluate the teaching is unreasonable.

In early septic shock states, what is the primary cause of hypotension? A. Peripheral vasoconstriction. B. Peripheral vasodilation. C. Cardiac failure. D. A vagal response.

Answer B. Peripheral vasodilation. Rationale Toxins released by bacteria in septic shock create massive peripheral vasodilation and increase microvascular permeability at the site of the bacterial invasion (B). (A, C, and D) do not create the hypotensive state associated with early septic shock.

The healthcare provider prescribes acarbose (Precose), an alpha-glucosidase inhibitor, for a client with Type 2 diabetes mellitus. Which information provides the best indicator of the drug's effectiveness? A. Body mass index (BMI) between 20 and 24. B. Blood pressure readings less than 120/80 mm Hg. C. Hemoglobin A1C (HbA1C) reading less than 7%. D. Self-reported glucose levels 120 to 150 mg/dL.

Answer C. Hemoglobin A1C (HbA1C) reading less than 7%. Rationale Acarbose (Precose) delays carbohydrate absorption in the GI tract and causes the blood glucose to rise slowly after a meal. The best indicator of acarbose (Precose) effectiveness is a serum hemoglobin A1C (HbA1C) no greater than 7% (C), an indication of glucose levels over time. Acarbose (Precose) has no effect on pain (A) or blood pressure (B). Self-reported glucose levels of 120-150 mg/dL (D) reflect the blood sugar at the time taken and are not the best indicator of drug effectiveness.

After placing a stethoscope as seen in the picture, the nurse auscultates S1 and S2 heart sounds. To determine if an S3 heart sound is present, what action should the nurse take next? A. Slide the stethoscope across the sternum. B. Move the stethoscope to the mitral site. C. Listen with the bell at the same location. D. Observe the cardiac telemetry monitor.

Answer C. Listen with the bell at the same location. Rationale The nurse uses the bell of the stethoscope (C) to hear low-pitched sounds, such as S3 and S4. The nurse listens at the same site using the diaphragm and bell before moving systematically to the next sites (A and B). The nurse cannot determine the presence of abnormal heart sounds by observing the cardiac telemetry monitor (D).

A mother brings her 3-year-old son to the emergency room and tells the nurse the he has had an upper respiratory infection for the past two days. Assessment of the child reveals a rectal temperature of 102° F. He is drooling and becoming increasingly more restless. What action should the nurse take first? A. Put a cold cloth on his head and administer acetaminophen. B. Listen to Long sounds in place him in a mist tent. C. Notify the healthcare provider and obtain a tracheostomy tray. D. Assist a child to lie down and examine his throat.

Answer C. Notify the healthcare provider and obtain a tracheostomy tray. Rationale This child is exhibiting signs and symptoms of epiglottitis, a bacterial infection causing acute airway obstruction, so (C) is the immediate action to take. (A and B) are not the priority actions. (D) is not indicated at this time.

Two clients ring their call bells simultaneously requesting pain medication. What action should the nurse implement first? A. Prepare both clients' medication and take to them at once. B. Determine when each client last received pain medication. C. Evaluate both client's pain using a standardized pain scale. D. Provide non-pharmacologic pain management interventions.

Answer C. Provide a family tour of the preoperative unit one week before the surgery is scheduled. Rationale Before administering pain medication, each client's level of pain should be evaluated using a standardize scale (C) to determine what type and how much pain medication the clients need. (A, B and D) may be indicated after the pain is evaluated by the nurse.

When assessing and adult male who presents as the community health clinic with a history of hypertension, the nurse note that he has 2+ pitting edema in both ankles. He also has a history of gastroesophageal reflex disease (GERD) and depression. Which intervention is the most important for the nurse to implement? A. Arrange to transport the client to the hospital. B. Instruct the client to keep a food journal, including portions size. C. Review the client's use of over the counter (OTC) medications. D. Reinforce the importance of keeping the feet elevated.

Answer C. Review the client's use of over the counter (OTC) medications. Rationale Sodium is used in several types of OTC medications (C) including antacids, which the client may be using to treat his GERD. Further evaluation is need it to determine the need for hospitalization (A). A food journal (B) may help over, but dietary modifications are needed now since edema is present. Keeping the feet elevated (C) may relieve dependent edema, but not treat the underlying etiology of the edema.

A male client is discharged from the intensive care unit following a myocardial infarction, and the healthcare provider prescribes a low-sodium diet. Which lunch selection indicates to the nurse that this client understands the dietary restrictions? A. Bacon, lettuce, and tomato sandwich. B. Clam chowder. C. Turkey salad sandwich. D. Macaroni and cheese.

Answer C. Turkey salad sandwich. Rationale Turkey (C), while containing some sodium, is considered a low-sodium food. (A, B, and D) contain high sodium foods.

A client with a history of chronic pain requests a nonopioid analgesic. The client is alert but has difficulty describing the exact nature and location of the pain to the nurse. Which action should the nurse implement next? A. Assess the clients vital signs. B. Observe the client's pupils for dilation. C. Document the client's drug tolerance. D. Administer the analgesic as requested.

Answer D. Administer the analgesic as requested. Rationale Chronic pain may be difficult to describe, but should be treated (D) with analgesics as indicated. (A and B) more typically occur with acute pain rather than chronic pain. The client's request for analgesia at this time does not indicate drug tolerance (C), which refers to the need for higher doses of a medication to produce the same effect over time.

A male client, who is 24 hours postoperative for an exploratory laparotomy, complains that he is "starving" because he has had no "real food" since before the surgery. Prior to advancing his diet, which intervention should the nurse implement? A. Discontinue intravenous therapy. B. Obtain a prescription for a diet change. C. Assess for abdominal distention and tenderness. D. Auscultate bowel sounds in all four quadrants.

Answer D. Auscultate bowel sounds in all four quadrants. Rationale Prior to advancing the client, the nurse should ensure that the client has active bowel sounds (D). (A) should be continued until the client proves and ability to tolerate fluids. Assessment of bowel sounds should be conducted prior to (B). (C) is part of an of an abdominal assessment, but is not as important as determining the presence of bowel functioning.

A 13-year-old client with non-union of a comminuted fracture of the tibia is admitted with osteomyelitis. The healthcare provider collects bone aspirate specimens for culture and sensitivity and applies a cast to the adolescent's lower leg. What action should the nurse implement next? A. Administer antiemetic agents. D. Bivalve the cast for distal compromise. C. Provide high- calorie, high-protein diet. D. Begin parenteral antibiotic therapy.

Answer D. Begin parenteral antibiotic therapy. Rationale The standard of treatment for osteomyelitis is antibiotic therapy and immobilization. After blood and bone aspirate specimens are obtained for culture and sensitivity, the nurse should initiate parenteral antibiotics (D) as prescribed. Antiemetics (A) should be administered to manage anorexia, nausea, and vomiting upon onset, but first the nurse should initiate antibiotic therapy. If the healthcare provider is unable to cut the cast, the nurse must be able to bivalve the cast (B) should compartment syndrome occur when the cast has dried. (C) should be implemented when the child can tolerate oral intake.

A client is receiving mesalamine 800 mg PO TID. Which assessment is most important for the nurse to perform to assess the effectiveness of the medication? A. Pupillary response. B. Oxygen saturation. C. Peripheral pulses. D. Bowel patterns.

Answer D. Bowel patterns. Rationale The client should be assessed for a change in bowel patterns (D) to evaluate the effectiveness of this medication, because mesalamine is gastrointestinal antiinflammatory agent, used in inflammatory bowel disease to reduce symptoms such as diarrhea and hyperactivity. Mesalamine does not impact (A, B, or C).

A client with hyperthyroidism is being treated with radioactive iodine (I-131). Which explanation should be included in preparing this client for this treatment? A. Explain the need for using lead shields for 2 to 3 weeks after the treatment. B. Describe the signs of goiter because this is a common side effect of radioactive iodine. C. Explain the relief of the signs/symptoms of hyperthyroidism will occur immediately. D. Describe radioactive iodine as a tasteless, colorless medication administered by the healthcare provider.

Answer D. Describe radioactive iodine as a tasteless, colorless medication administered by the healthcare provider. Rationale A single dose of tasteless, colorless radioactive iodine is administered by mouth (D), and the client should be observed for signs of thyroid storm. 85% of clients are cured by one dose. The dose of radioactivity is not enough to warrant (A). (B) is indicated for a client receiving iodine or iodine compound medications in the treatment of hyperthyroidism. It takes 3 to 4 weeks for signs of hyperthyroidism to subside (C).

The nurse walks into a client's room and notices bright red blood on the sheets and on the floor by the IV pole. Which action should the nurse take first? A. Clean up the spilled blood to reduce infection transmission. B. Notify the healthcare provider that the client appears to be bleeding. C. Apply direct pressure to the client's IV site. D. Identify the source and amount of bleeding.

Answer D. Identify the source and amount of bleeding. Rationale The nurse should first assess the client (D) to determine the action that should be taken. (A) is not the most important action. (B) is premature at this time — the nurse needs to determine the nature of the client's problem before attempting to communicate this information to the healthcare provider. (C) may not be a necessary intervention — first the nurse should determine the source of the bleeding. Patient safety is the priority; other options are not priority.

While assisting a client who recently had a hip replacement onto the bed pan, the nurse notices that there is a small amount of bloody drainage on the surgical dressing, the client's skin is warm to the touch, and there is a strong odor from the urine. Which action should the nurse take? A. Obtain a urine sample from the bed pan. B. Remove dressing and assess surgical site. C. Insert an indwelling urinary catheter. D. Measure the client's oral temperature.

Answer D. Measure the client's oral temperature. Rationale The strong odor from the urine and skin that is warm to the touch may indicate that the client has a urinary tract infection. Assessing the client's temperature (D) provides objective information regarding infection that can be reported to the healthcare provider. Urine should be obtained via a clean catch (A), not the bed pan where it has been contaminated. The drainage on the dressing is normal (B) and does not require direct observation at this time. An indwelling catheter (C) should be avoided if possible because it increases the risk of infection.

The nurse is planning the preoperative teaching plan for a 12-year-old child who is scheduled for surgery. To help reduce this child's anxiety, which action is the best for the nurse to implement? A. Give the child syringes or hospital mask to play it at home prior to hospitalization. B. Include the child in pay therapy with children who are hospitalized for similar surgery. C. Provide a family tour of the preoperative unit one week before the surgery is scheduled. D. Provide dolls and equipment to re-enact feeling associated with painful procedures.

Answer C. Provide a family tour of the preoperative unit one week before the surgery is scheduled. Rationale School age children gain satisfaction from exploring and manipulating their environment, thinking about objects, situations, and events, and making judgments based on what they reason. A tour of the unit (C) allows the child to see the hospital environment and reinforces explanations and conceptual thinking. Giving a child the opportunity to manipulate hospital equipment should allow for questions and discussion with the nurse (A). Although play therapy allows identification with a peer group, a group of

A male client with hypertension, who received new antihypertensive prescriptions at his last visit returns to the clinic two weeks later to evaluate his blood pressure (BP). His BP is 158/106 and he admits that he has not been taking the prescribed medication because the drugs make him "feel bad". In explaining the need for hypertension control, the nurse should stress that an elevated BP places the client at risk for which pathophysiological condition? A. Blindness secondary to cataracts. B. Acute kidney injury due to glomerular damage. C. Stroke secondary to hemorrhage. D. Heart block due to myocardial damage.

Answer C. Stroke secondary to hemorrhage. Rationale Stroke related to cerebral hemorrhage (C) is a major risk for uncontrolled hypertension. Poorly managed hypertension increases the risk for blindness due to retinal hemorrhage, not cataracts (A). Kidney damage from hypertension is a chronic process, not an acute injury (B). (D) is unrelated to hypertension.

A 6-year-old who has asthma is demonstrating a prolonged expiratory phase and wheezing, and has 35% of personal best peak expiratory flow rate (PEFR). Based on these finding, which action should the nurse implement first? A. Administer a prescribed bronchodilator. B. Report finding to the healthcare provider. C. Encourage the child to cough and deep breath. D. Determine what trigger precipitated this attack.

Answer A. Administer a prescribed bronchodilator. Rationale If the PEFR is below 50% in an asthmatic child, there is severe narrowing of the airway, and a bronchodilator should be administered immediately (A). (B) should be implemented, but not before a bronchodilator is administered. (C) will not alleviate the symptoms. (D) is not a priority at this time.

Which assessment finding for a client who is experiencing pontine myelinolysis should the nurse report to the healthcare provider? A. Sudden dysphagia. B. Blurred visual field. C. Gradual weakness. D. Profuse diarrhea.

Answer A. Sudden dysphagia. Rationale Osmotic demyelination, also known as pontine myelinolysis, results in destruction of the myelin sheath that covers nerve cells in the brainstem. This condition can be caused by rapid correction of hyponatremia and is often seen in those with syndrome of inappropriate antidiuretic hormone (SIADH). Symptoms of pontine myelinolysis are sudden and can include dysphagia, para or quadraparesis, and dysarthria (slurred speech). Due to the risk of aspiration, the healthcare provider should be notified of the client's sudden onset of difficulty swallowing, dysphasia (A). Diplopia (double vision), not blurred vision (B), maybe experienced. Weakness occurs suddenly, rather than gradually (C). Constipation, not diarrhea (D), is common due to decreased motility.

The mother of the 12- month-old with cystic fibrosis reports that her child is experiencing increasing congestion despite the use of chest physical therapy (CPT) twice a day, and has also experiences a loss of appetite. What instruction should the nurse provide? A. Perform CPT after meals to increase appetite and improve food intake. B. CPT should be performed more frequently, but at least an hour before meals. C. Stop using CPT during the daytime until the child has regained an appetite. D. Perform CPT only in the morning, but increase frequency when appetite improves.

Answer B. CPT should be performed more frequently, but at least an hour before meals. Rationale CPT with inhalation therapy should be performed several times (B) a day to loosen the secretions and move them from the peripheral airway into the central airways where they can be expectorated. CPT should be done at least one hour before meals or two hours after meals. (A) Will increase gastrointestinal upset. (C or D) will increase respiratory secretions and reduce oxygenation.

A client with diabetic peripheral neuropathy has been taking pregabalin (Lyrica) for 4 days. Which finding indicates to the nurse that the medication is effective? A. Full volume of pedal pulses. B. Reduced level of pain. C. Granulating tissue in foot ulcer. D. Improved visual acuity.

Answer B. Reduced level of pain. Rationale Pregabalin is prescribed to decrease the pain associated with diabetic peripheral neuropathy (B). (A, C, and D) are not expected outcomes of this medication's effectiveness.

The nurse identifies an electrolyte imbalance, an elevated pulse rate, and an elevated blood pressure for a client with chronic kidney disease. Which is the most important action for the nurse to take? A. Monitor daily sodium intake. B. Record usual eating patterns. C. Measure ankle circumference. D. Auscultate for irregular heart rate.

Answer D. Auscultate for irregular heart rate. Rationale Chronic kidney failure (CKF) is a progressive, irreversible loss of kidney functions, decreasing glomerular filtration rate (GFR), and the kidney's inability to excrete metabolic waste products and water, resulting in fluid overload, elevated pulse, elevated BP and electrolyte imbalances. The most important action for the nurse to implement is to auscultate for irregular heart rate (D) due to the decreased excretion of potassium by the kidneys. (A, B, and C) are not as important as monitoring for fatal cardiac dysrhythmias related to hyperkalemia.

An adult female client tells the nurse that though she is afraid her abusive boyfriend might one day kill her, she keeps hoping that he will change. What action should the nurse take first? A. Report the findings to the police department. B. Discuss treatment options for abusive partners. C. Determine the frequency and type of client's abuse. D. Explore client's readiness to discuss the situation.

Answer D. Explore client's readiness to discuss the situation. Rationale By assessing the client's level of readiness to discuss her situation (D), the nurse can begin to establish trust so that further action can be taken to protect her. The nurse needs the client's permission to report the abuse to the police department (A), which might be obtained after trust is established. Although (B) might be an option during the discussion, it is most important that the client has a safe refuge even if the abusive partner does not commit to seeking help. Once trust is established, (C) can be implemented.

When performing postural drainage on a client with Chronic Obstructive Pulmonary Disease (COPD), which approach should the nurse use? A. Perform the drainage immediately after meals. B. Instruct the client to breathe shallow and fast. C. Obtain arterial blood gases (ABGs) prior to procedure. D. Explain that the client may be placed in five positions.

Answer D. Explain that the client may be placed in five positions. Rationale Frequently, the client is placed in five positions (head down, prone, right and left lateral, and sitting upright) to aid in drainage of each of the five lobes of the lungs (D). Postural drainage should be performed before meals to prevent nausea, vomiting, and aspiration (A). The client should be instructed to deep breathe slowly (B) and exhale through pursed lips to help keep airways open so that secretions can be drained while assuming the various positions. (C) is not required prior to each treatment.

A 350-bed acute care hospital declares an internal disaster because the emergency generators malfunctioned during a city-wide power failure. The Unlicensed Assistive Personnel (UAP)s working on a general medical unit ask the charge nurse what they should do first. What instruction should the charge nurse provide to these UAPs? A. Go to the emergency department and complete assigned tasks. B. Shut all doors to client rooms on the unit in case a fire erupts. C. Offer to assist in ICU with a ventilator-dependent clients. D. Tell all their assigned clients to stay in their rooms.

Rationale D. Tell all their assigned clients to stay in their rooms. Rationale A power failure leaves a unit in total darkness except for battery operated lighting. The top priority should be ensuring client safety by having clients stay in the rooms, and an unlicensed person can implement this (D). (A) is of higher priority in an external disaster. (B) would further compound the lighting problems, and has not indicated unless fire or smoke is visible. (C) is contraindicated until client safety is insured on the assigned unit.

The nurse is caring for a 4-year-old male child who becomes unresponsive as his heart rate decreases to 40 beats/minute. His blood pressure is 88/70 mmHg, and his oxygen saturation is 70% while receiving 100% oxygen by non-rebreather face mask. In what sequence, from first to last, should the nurse implement these actions? (Place the first action on top and last action on the bottom.) A. Start chest compressions with assisted manual ventilations. B. Apply pads and prepare for transthoracic pacing. C. Administer epinephrine 0.01 mg/kg intraosseous (IO). D. Review the possible underlying causes for bradycardia

Answer 1. Start chest compressions with assisted manual ventilations. 2. Administer epinephrine 0.01 mg/kg intraosseous (IO). 3. Apply pads and prepare for transthoracic pacing. 4. Review the possible underlying causes for bradycardia. Rationale The American Heart Association guidelines recommend that the basic life support (BLS) algorithm should be initiated immediately in pediatric clients who are unresponsive or have a heart rate below 60 beats/minute and exhibit signs of poor perfusion. This child is manifesting poor perfusion as evidenced by a low blood pressure and poor oxygenation, so chest compressions and assisted manual ventilation should be provided first, followed by the administration of drug therapy for persistent bradycardia. Preparations with pad placement for transthoracic pacing should be implemented next, followed by the treatment indicated for the underlying cause of the child's bradycardia.

A client develops urticaria on the trunk and neck shortly after a secondary infusion of piperacillin is initiated. In what order should the nurse implement these interventions? (Arrange the actions in order of priority, with the highest priority first and least priority last or at the bottom.) A. Stop the infusion. B. Assess vital signs. C. Contact the healthcare provider. D. Initiate adverse event report. E. Document reaction to the drug.

Answer 1. Stop the infusion. 2. Assess vital signs. 3. Contact the healthcare provider. 4. Document reaction to the drug. 5. Initiate adverse event report. Rationale The client is exhibiting a drug reaction and quick action is required. When a drug reaction is suspected, first the infusion should be stopped. Then vital signs and airway compromise should be assessed and the findings reported to the healthcare provider. Documentation of the occurrence, including a description of the rash and details of the reaction should be completed after the healthcare provider is notified. Finally, and adverse drug reaction or adverse event report should be completed.

An adult male client is admitted to the emergency room following an automobile collision in which he sustained a head injury. What assessment data would provide the earliest indication that the client is experiencing increased intracranial pressure (ICP)? A. Lethargy. B. Decorticate posturing. C. Fixed dilated pupil. D. Clear drainage from the ear.

Answer A. Lethargy. Rationale Lethargy (A) is the earliest sign of ICP along with slowing of speech and response to verbal commands. The most important indicator of increased ICP is the client's level or responsiveness or consciousness. (B and C) are very late signs of ICP. (D) should be tested to determine if it is cerebrospinal fluid, but would not be an indication of increased ICP.

When assessing a client, the nurse should establish which findings as objective? (Select all that apply.) A. Edema. B. Anxiety. C. Nausea. D. Diaphoresis. E. Hypertension. F. Urticaria.

Answer A. Edema. D. Diaphoresis. E. Hypertension. F. Urticaria. Rationale (A, D, E, and F) Our objective findings or signs that can be observed by another individual. (B and C) are subjective symptoms.

The nurse is auscultating a client's heart sounds. Which description should the nurse use to document this sound? (Please listen to the audio first to select the option that applies.) A. S1 S2. B. S1 S2 S3. C. Murmur. D. Pericardial friction rub.

Answer C. Murmur. Rationale A murmur (C) is auscultated as a swishing sound that is associated with the blood turbulence created by a heart or valvular defect. (A) are normal heart sounds described as the first heart sound (lub) and the second heart sound (dub). (B) includes a third heart sound that is auscultated after S1 S2 (lub dub) and is associated with heart failure (HF). (D) produces a rubbing sound that overlies the intracardiac sounds.

An older male client with a history of Type 1 diabetes has not felt well the past few days and arrives at the clinic with abdominal cramping and vomiting. He is lethargic, moderately, confused, and cannot remember when he took his last dose of insulin or ate last. What action should the nurse implement first? A. Obtain a serum potassium level. B. Administer the client's usual dose of insulin. C. Assess pupillary response to light. D. Start an intravenous (IV) infusion of normal saline.

Answer D. Start an intravenous (IV) infusion of normal saline. Rationale The nurse should first start an intravenous infusion of normal saline (D) to replace the fluids and electrolytes because the client has been vomiting, and it is unclear when he last ate or took insulin. The symptoms of confusion, lethargy, vomiting, and abdominal cramping are all suggestive of hyperglycemia, which also contributes to diuresis and fluid electrolyte imbalance. (A and B) are correct interventions for ketoacidosis, but first the nurse should obtain venous access to administer fluids and obtain serum glucose levels. Based upon the client's current symptoms, (C) is not indicated.

A client with history of bilateral adrenalectomy is admitted with a weak, irregular pulse, and hypotension. Which assessment finding warrants immediate intervention by the nurse? A. Decreased urinary output. B. Low blood glucose levels. C. Profound weight gain. D. Ventricular arrhythmias.

Answer D. Ventricular arrhythmias. Rationale Adrenal crisis, a potential complication of bilateral adrenalectomy, results in the loss of mineralocorticoids and sodium excretion that is characterized by hyponatremia, hyperkalemia, dehydration, and hypotension. Ventricular arrhythmias (D) are life threatening and require immediate intervention to correct critical potassium levels. (A, B, and C) require intervention but do not have the priority of (D).