Kaplan nursing questions

An older client has an order for digoxin 0.25 mg PO daily. Which information would cause the nurse to withhold the medication and contact the health care provider? 1 Apical pulse of 55 bpm 2. Respirations of 16 per min. 3. Plasma digoxin level of 2.1 ng/ml 4. Blood pressure of 122/62 5. Apical rhythm has 20 skipped beats in 1 minute 6. Temperature 100.5F

1 Apical pulse of 55 bpm - Pulse below 60bpm 3. Plasma digoxin level of 2.1 ng/ml - Normal digoxin plasma level are 0.8-2 ng/mL 5. Apical rhythm has 20 skipped beats in 1 minute - Dysrhythmias may be caused by the digoxin Strategy: What are side effects or toxic symptoms related to digoxin?

The nurse cares for an older patient scheduled for a colon resection this morning. The nurse notes the patient had polyethylene glycol-electrolyte solution (GoLYTELY) and a soapsuds enema the previous evening. This morning the patient passes a medium amount of soft brown stool. Which of the following conclusions by the nurse is MOST accurate? 1. The bowel preparation is incomplete 2. The patient ate something after midnight. 3. This is an expected finding before this type of surgery. 4. The patient passed the last stool left in the colon.

1) Colon should not have remaining soft stool.

The nurse changes the dressing on the client who had a mastectomy 2 days ago. After the nurse removes the old dressing, the client turns their head away. Which statement is the BEST response by the nurse? 1. "I notice that you turn your head away as if you don't want to look at your incision." 2. "It's good that you turn your head away while I am doing this sterile procedure." 3. "Your incision looks like it's healing nicely." 4. "Why don't you look at the incision while I have the old dressing off?"

1. "I notice that you turn your head away as if you don't want to look at your incision." - states observation Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?

In planning diet teaching for a child in the early stages of nephrotic syndrome, the nurse should discuss w/ the parents which of the following dietary changes? 1. Adequate protein, low sodium intake 2. Low protein, low potassium intake 3. Low potassium, low calorie intake 4. Limited protein, high carb intake

1. Adequate protein, low sodium intake - If child can tolerate the protein intake, then this diet is encouraged to speed healing; sodium is usually restricted.

The 10-year-old child weighing 50 lb (23.6 kg) returns from surgery for a skin graft to the left leg. The child has an IV of D5W infusing into the left arm. The health care provider's orders read: "D5W 2,000 cc/24hr." It is MOST important for the nurse to take which action? 1. Call the health care provider to clarify the IV fluid order. 2. Keep accurate records of the child's intake and output 3. Set the controller on the IV pump to infuse at 88 gtt/min 4. Monitor the child for fluid and electrolyte balance.

1. Call the health care provider to clarify the IV fluid order. - implementation, amount is excessive for child and there are no electrolytes in fluid Strategy: Answers are a mix of assessments and implementations. Does this situation require validation? No. Determine the outcome of each implementation. Is it desired?

The nurse performs discharge teaching for the client after abdominal surgery. The nurse determines that teaching is effective if the client chooses which foods for lunch? 1. Chicken breast, peas, mashed potatoes, orange, and ice cream 2. Hamburger, boiled potatoes, corn, pudding, and grapefruit juice 3. Chicken salad with lettuce, tomatoes, carrots, zucchini, and broccoli, jello, pears, and soda. 4. Shrimp salad with green beans, and broccoli, peaches, cookies, and coffee 5. Salmon steak, baked potato, lima beans, tangerine, and milk 6. Ham sandwich, lettuce salad, coleslaw, apple, and low fat milk.

1. Chicken breast, peas, mashed potatoes, orange, and ice cream - has high protein, vitamin C, and high calories 2. Hamburger, boiled potatoes, corn, pudding, and grapefruit juice - has high protein, vitamin C, and high calories 5. Salmon steak, baked potato, lima beans, tangerine, and milk - has high protein, vitamin C, and high calories Strategy: Nutrition following surgery needs to have increased protein, calories, and vitamin C for wound healing. What meals contain those items?

A woman is evaluated for infertility, and the physician prescribes clomiphene citrate (Clomid) 50 mg daily for 5 days. The client asks the nurse about how the med works. Which of the following responses by the nurse is BEST? 1. Clomiphene citrate (Clomid) induces ovulation by changing hormonal effects on the ovary 2. Clomiphene citrate (Clomid) changes the uterine lining to be more conductive to implantation 3. Clomiphene citrate (Clomid) alters the vaginal pH to increase sperm motility 4. Clomiphene citrate (Clomid) produces multiple pregnancy for those who desire twins.

1. Clomiphene citrate (Clomid) induces ovulation by changing hormonal effects on the ovary - Clomiphene citrate (Clomid) induces by altering estrogen and stimulating follicular growth to produce a mature ovum.

The multidisciplinary team decides to implement behavior modification with a client. Which of the following nursing actions is of primary importance during this time? 1. Confirm that all staff members understand and comply with the treatment plan. 2. Establish mutually agreed-upon, realistic goals. 3. Ensure that the potent reinforcers (rewards) are important to the client. 4. Establish a fixed interval schedule for reinforcement.

1. Confirm that all staff members understand and comply with the treatment plan. - to implement a behavior modification plan successfully, all staff members need to be included in program development, and time must be allowed for discussion of concerns from each nursing staff member; consistency and following-through is important to prevent or diminish the level of manipulation by the staff or client during implementation of this program. I picked 2. Establish mutually agreed-upon, realistic goals. wrong because not of primary importance in designing an effective behavior modification program. Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?

A patient is treated in the telemetry unit for cardiac disease. The patient receives propranolol hydrochloride (Inderal) 20mg PO at 2100. When the nurse enters the room to give the med to the patient wheezing w/ a nonproductive cough and SOB. INITIALLY, the nurse should take which of the following actions? 1. Hold the med and count the resp 2. Hold the med and call the physician 3. Take an apical pulse and then give the med 4. Give the med as ordered

1. Hold the med and count the resp - side effects include increased airway resistance; patient is experiencing bronchospasm; should assess and then call the physician

The nurse cares for the client diagnosed with venous thromboembolism of the left leg. Which nursing goal is appropriate for the client? 1. Decrease inflammatory response in the affected extremity and prevent embolus formation. 2. Increase peripheral circulation and oxygenation of the affected extremity. 3. Prepare the client and family for anticipated vascular surgery on the affected extremity. 4. Prevent hypoxia associated with the development of a pulmonary embolus.

1. Decrease inflammatory response in the affected extremity and prevent embolus formation. - important to prevent the complication of pulmonary embolism in clients at high risk. I picked 4. Prevent hypoxia associated with the development of a pulmonary embolus. - preventing embolism is the first priority Strategy: Think about each answer choice.

The nurse cares for an elderly client who is receiving IV fluids of 0.9% NaCl at 125mL/hr into the left arm. During a routine assessment, the nurse finds that the client has distended neck veins, SOB, and crackles in both lung bases. Which of the following actions should the nurse take FIRST? 1. Decrease the IV rate at 20mL/h and notify the physician 2. Decrease the IV rate at 100mL/h and continue to monitor 3. Discontinue the IV and start O2 at 6L/min 4. Assess for infiltration of the IV solution

1. Decrease the IV rate to 20mL/hr and notify the physician -KVO (20cc/h) will keep access open I picked 3 - wrong because IV line may be necessary; diuretics may be ordered

The client tested positive for the tuberculosis antibody and was placed on isoniazid 4 weeks ago. The nurse observes the client in the outpatient clinic. The nurse is MOST concerned if which finding is observed? 1. Fatigue and dark urine 2. Malaise and glucosuria 3. Proteinuria and lethargy 4. Diluted urine and epigastric distress

1. Fatigue and dark urine - initial indications of hepatic dysfunction I picked 3. Proteinuria and lethargy - wrong because seen with renal problems Strategy: Determine how each answer choice relates isoniazid

The older client comes to the outpatient clinic for a routine health screening. The nurse learns the client is a retired teacher who lives alone on a limited income. A history indicates the client drinks about 1,500 mL a day and the client's diet consists primarily of starches. It is MOST important for the nurse to encourage the client to take which action? 1. Increase protein intake 2. Increase intake of vitamins 3. Reduce caloric intake 4. Reduce fluid intake

1. Increase protein intake - protein needed to slow down degeneration process of aging I picked 2. Increase intake of vitamins - wrong because necessary but not most important Strategy: "MOST important" indicates priority. Each answer choice is an implementation. Determine the outcome of each answer choice. Is it desired?

The nurse cares for patient placed in balanced suspension traction with a Thomas splint and Pearson attachment because of a fractured right femur. The nurse notes that the patient's left leg is externally rotated. The nurse should take which of the following actions? 1. Place a trochanter roll on the outer aspect of the thigh 2. Perform resistive range of motion of the left leg 3. Adduct and internally rotate the left leg. 4. Instruct the patient to maintain the left leg in a neutral position.

1. Place a trochanter roll on the outer aspect of the thigh - holds hip in neutral position and leg in normal alignment, entire weight of leg cannot be help by props placed below knee. I picked 4. Instruct the patient to maintain the left leg in a neutral position. Wrong because leg will externally rotate unless propped in proper alignment. Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired?

The nurse cares for the client recovering from abdominal surgery. During ambulation, the client reports a dull ache in the left leg. Which action should the nurse take FIRST? 1. Place the client on bedrest with extremity elevated 2. Place a pillow under the client's knee 3. Encourage the client to ambulate more frequently 4. Obtain thigh-high compression stockings.

1. Place the client on bedrest with extremity elevated - promotes venous return and decrease venous pressure, relieving pain and edema I picked 4. Obtain thigh-high compression stockings. wrong because it's used to prevent DVT, should be on bedrest initially Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?

The nurse notes that one of the staff members caring for clients has a watery discharge from the right eye and the eye appears red. Which action, if taken by the nurse, is BEST? 1. Send the staff member home 2. Assess the staff member's compliance with standard precautions 3. Assign the staff member only to clients with chronic diseases 4. Reassign the staff member to clean the supply closet

1. Send the staff member home - extreme tearing, redness, foreign body sensation are symptoms of viral conjunctivitis; highly contagious, infected employees cannot work until symptoms have resolved in 3 to 7 days; the nursing supervisor should be notified Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?

The nurse cares for clients in the hospital. Which nursing activities best promote nighttime rest for elderly hospitalized clients? 1. Tell the client how to call for help if needed. 2. Place a clock at the bedside 3. Postpone explanation of further tests the client will need. 4. Restrict visitors so that the client is not stimulated in the evening 5. Identify normal evening bedtime routines. 6. Keep bright light in room to prevent falls.

1. Tell the client how to call for help if needed. - If the client does not need to worry about getting up, sleep will be easier. 3. Postpone explanation of further tests the client will need. - Giving the client information that may be troubling will not help with sleep 5. Identify normal evening bedtime routines. - Following normal routines will help the client fall asleep and stay asleep. Strategy: Think about going to sleep and resting, what is needed?

The nurse cares for clients in the ED. Prioritize the order in which the nurse will see these clients starting with the most urgent. All options must be used. - The 8-month-old infant crying loudly with facial ecchymosis. - The 34-year-old client with a distended abdomen and splenomegaly. - The 44-year-old client with possible whiplash from an automobile accident. - The 12-year-old child with a possible fractured ankle.

1. The 34-year-old client with a distended abdomen and splenomegaly. - Unstable, circulation; Distended abdomen indicates possible bleeding 2. - The 12-year-old child with a possible fractured ankle. - Unstable: Possible fracture needs to be attended to as soon as possible 3. The 8-month-old infant crying loudly with facial ecchymosis. - Stable, potential airway; Young children need assessment as their problems may not be visible 4. The 44-year-old client with possible whiplash from an automobile accident. - Stable, potential pain; The client with whiplash is stable and not urgent. Strategy: Which clients are unstable? Move from the most unstable to the most stable.

The nurse cares for clients in the outpatient clinic. The nurse returns to the desk and finds four phone messages. In what order should the nurse return the messages? (Place in the correct order starting with the first message to return. All options must be used.) - The client is nauseated and has vomited 6 times in the previous 24 hours - A client reports leg pain after walking half a mile - The client with cold symptoms has an oral temp of 103F - The client with stage 2 decubitus ulcer reports the dressing has come off.

1. The client is nauseated and has vomited 6 times in the previous 24 hours - Unstable, circulation. The client with nausea and vomiting needs to be called first as dehydration may be a significant problem; need to find out what is causing the vomiting 2. The client with cold symptoms has an oral temp of 103F - Unstable, the temp of 103 is quite elevated for any client and additional information needs to be obtained 3. The client with stage 2 decubitus ulcer reports the dressing has come off. - Stable, infection. The decubitus ulcer dressing needs to be addressed soon, but is not of as much importance as the previous two. 4. A client reports leg pain after walking half a mile - Stable, Client is not in pain at the time. May be intermittent claudication and needs to have this addressed by they are the most stable. Strategy: Identify the two most stable clients. Use the ABCs to determine the most unstable client.

The nurse has just received report from the previous shift. In what order should the nurse see these clients? Place in order starting with the first client. Place in the correct order starting with the first message to return. - The client on high doses of antibiotics reporting diarrhea. - The client with type 1 diabetes melitus states, "I have a quivering feeling in my abdomen." - The client with chronic renal failure reporting swollen fingers and ankle edema. - The client 1 day post-op with dried blood on the abdominal dressing

1. The client with type 1 diabetes melitus states, "I have a quivering feeling in my abdomen." - Unstable, unexpected; The diabetic client is likely experiencing hypoglycemia. 2. The client with chronic renal failure reporting swollen fingers and ankle edema. - Stable, unexpected, circulation, renal; The client with renal failure is retaining fluid and needs to be assessed. 3. The client 1 day post-op with dried blood on the abdominal dressing - Stable, expected, circulation; New post-op clients need to be assessed early in the shift. 4. The client on high doses of antibiotics reporting diarrhea. - Stable, expected, circulation; The diarrhea needs to be addressed, but is least important of these clients. Strategy: Identify the least stable clients to see first and the most stable to see last.

The client is admitted with a diagnosis of a fractured right hip. The health care provider writes an order for Buck's traction. Which action, if taken by the nurse, is MOST important? 1. Turn the client every 2 hours to the unaffected side 2. Maintain the client in a supine position 3. Encourage the client to use a bedside commode 4. Place a footboard on the bed.

1. Turn the client every 2 hours to the unaffected side - immobility is a leading cause of problems with Buck's traction; important to turn client to unaffected side I picked 4. Place a footboard on the bed. - wrong because would interfere with the traction Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?

The nurse cares for a client in her third trimester of pregnancy. The nurse is MOST concerned by which assessment finding? 1. The client reports epigastric pain 2. The client reports shortness of breath 3. The client states she has increased rectal pressure 4. The client has gained of 33 pounds during her pregnancy.

1. the client reports epigastric pain - is usually indicative of an impending convulsion. Strategy: Think about the cause of each symptom and how it relates to pregnancy.

The client comes to the clinic for the hepatitis B vaccine. The client asks if more than one injection is necessary. Which response by the nurse is BEST? 1. "A booster shot is required yearly." 2. "Additional injections are given at one and six months" 3. "Repeat doses are given at two and four months" 4. "Revaccination is not required."

2. "Additional injections are given at one and six months" - hepatitis B vaccine is repeated at 1 and 6 months Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?

A woman has been recently diagnosed with systemic lupus (SLE) and shares with the nurse, "I am thinking about getting pregnant, but I don't know how I will be able to tolerate a pregnancy because I have lupus." Which of the following responses by the nurse is BEST? 1. "Most women find that they feel better when they are pregnant." 2. "How long have you been in remission?" 3. "Women with lupus frequently have slightly longer gestations." 4. "It is best to become pregnant within the first 6 months of diagnosis."

2. "How long have you been in remission?" - should be in remission for at least 5 months prior to conceiving I picked 1 wrong because maternal morbidity and mortality are increased with SLE. Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes

Which of the following statements, if made by a client to the nurse, indicates that the client is using the defense mechanism of conversion? 1. "I love my family with all my heart, even though they don't love me" 2. "I was unable to take my final exams because I was unable to write." 3. "I don't believe I have diabetes. I feel perfectly fine" 4. "If my wife was a better housekeeper I wouldn't have such a problem"

2. "I was unable to take my finale exams because I was unable to write." - client has converted his anxiety over school performance into a physical symptom that interferes w/ his ability to perform.

A young adult is involved in a motorcycle accident and is brought to the ER. The physician diagnoses a closed head injury with suspected subdural hematoma. Although complaining of a severe headache, the client is alert and answers questions appropriately. The nurse should question which of the following orders? 1. "Promethazine (Phenergan) 25mg IM 3 h." 2. "Morphine sulfate 10 mg IM q3 4h." 3. "Docusate sodium (Colace) 50 mg PO bid." 4. "Ranitidine (Zantac) 50 mg IVPB q12."

2. "Morphine sulfate 10 mg IM q3 4h." - narcotic analgesic, causes CNS and respiratory depression, contraindicated in head injury because it masks signs of increased intracranial pressure. I picked 4 wrong because H2 histamine antagonist, reduces acid production in stomach, prevents stress ulcers Strategy: "Question which of the following orders" indicates an incorrect order

The nurse cares for a newborn infant diagnosed w/ fetal alcohol syndrome. The nurse expects to see which of the following physical characteristics? 1. An infant large for gestational age (LGA), craniofacial abnormalities, and hydrocephalus 2. An infant w/ a small head circumference, low birth weight, and undeveloped cheekbones 3. An infant w/ a large head circumference, low birth weight, and excessive rooting and sucking behaviors 4. An infant w/ a normal head circumference, low birth weight and resp. distress syndrome.

2. An infant w/ a small head circumference, low birth weight, and undeveloped cheekbones - seen w/ fetal alcohol syndrome

The nurse prepares a client for a paracentesis. It is MOST important for the nurse to take which action? 1. Keep the client NPO 12 hours before the procedure. 2. Ask the client to void just before the procedure. 3. Initiate a bowel preparation program 24 hours before the procedure. 4. Place the client supine during the procedure.

2. Ask the client to void just before the procedure. - prevents puncture of bladder Strategy: Answers are all implementations. Determine the outcome of each answer choice. Is it desired?

The MOST appropriate nursing action before administrating captopril (Capoten) is to check the client's 1. apical pulse for 60 sec 2. Blood pressure 3. Urine output 4. Temp

2. Blood pressure - Capoten is an anti-hypertensive that necessitates assessment of blood pressure before admin.

The nurse prepares the client for a herniorrhaphy. It is MOST important for the nurse to take which action 1 hour before surgery? 1. Administer an enema 2. Confirm the consent form has been signed 3. Perform a preop shave and scrub 4. Evaluate for food or medication allergies.

2. Confirm the consent form has been signed - surgical consent should be rechecked before going to surgery I picked 3. Perform a preop shave and scrub - wrong because should be done earlier than 1 hour before surgery Strategy: Answers are a mix of assessments and implementations. Is the assessment appropriate 1 hour before surgery? No. Determine the outcome of each implementation.

The nurse cares for the client recently diagnosed with AIDS. The nurse identifies the following nursing diagnosis: Risk for Infection. Which intervention by the nurse is BEST? 1. Inspect the skin daily for signs of breakdown 2. Limit the number of health care personnel caring for the client 3. Use standard precautions when administering parenteral medications 4. Monitor the client's vital signs q4h

2. Limit the number of health care personnel caring for the client - implementation, deceases exposure to microorganisms I picked 3. Use standard precautions when administering parenteral medications - wrong because implementation, done with all clients to protect health care workers Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? No. Determine the outcome of real implementation.

An infant is admitted w/ vomiting and diarrhea. The infant's anterior fontanelle is depressed and temp is 103.2F. Which of the following nursing actions is MOST appropriate? 1. Obtain daily weight and eval weight loss 2. Observe the infant's ability to take in fluids 3. Place a full bottle of Pedi-Lyte at the bedside 4. Start an IV infusion

2. Observe the infant's ability to take in fluids - assessment; will assist in determining if hydration can be done through oral fluids alone.

The nurse is aware that Rh immune globulin (RhoGAM) is administrated to prevent complications in which of the following situations? 1. The baby is Rh-negative, the mother is Rh-negative, and the father is Rh-positive 2. The mother is Rh-negative, the baby is Rh-positive, and there is a negative direct Coombs 3. The mother is Rh-positive and previously sensitized, and the baby is Rh-negative 4. The mother is Rh-positive, the baby is Rh-negative, and there is a history of one incomplete pregnancy.

2. The mother is Rh-negative, the baby is Rh-positive, and there is a negative direct Coombs. - RhoGAM is given to an Rh-negative mother who delivers an Rh-positive baby when the baby has a negative Coombs test.

The nurse observes late decelerations of the fetal heart rate while the client is receiving oxytocin IV to stimulate labor. Which actions should the nurse take? 1. Change the fluids to Ringers lactate 2. Discontinue the oxytocin infusion 3. Assist client to bathroom and measure urine 4. Turn client to the left side 5. Apply oxygen at 8L/min by mask 6. Increase the primary IV infusion flow rate

2. Discontinue the oxytocin infusion - Discontinuing the oxytocin is the first step to take 4. Turn client to the left side - Turning the client to the left side will aid in blood flow to the placenta 5. Apply oxygen at 8L/min by mask - Giving the client oxygen will help provide additional oxygen to the fetus 6. Increase the primary IV infusion flow rate - Increasing the fluid infusion will give more volume for transfer of oxygen to the fetus Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired?

The nurse understands that the primary reason elderly adults have problems w/ constipation is because of which of the following? 1. Elderly adults eat a small volume of food w/ decreased bulk. 2. Elderly adults have less activity and decreased muscle tone. 3. Elderly adults have neurological changes in the GI tract. 4. Elderly adults have decreased sensation in the GI tract.

2. Elderly adults have less activity and decreased muscle tone. - Reduced GI motility due to decreased muscle tone, decreased exercise; other factors include prolonged use of laxatives, ignoring urge to defecate, side effect of medications, emotional problems, insufficient fluid intake, and excessive dietary fat.

The nurse in the outpatient clinic assists w/ the application of a cast to the left arm of a pre-school-aged child. After the cast is applied, the nurse should take which of the following actions? 1. Petal the edges of the cast to prevent irritation 2. Elevate the client's left arm on two pillows 3. Apply cool, humidified air to dry the cast. 4. Ask the client to move the fingers to maintain mobility

2. Elevate the client's left arm on two pillows - minimizes swelling, elevated for first 24 hours to 48 hours, protects from pressure and flattening the cast.

The physician inserts a temporary pacemaker in a client following a myocardial infarction. The nurse knows that the primary purpose of the pacemaker is which of the following? 1. Increases the force of myocardial contraction 2. Increases the cardiac output 3. Prevents premature ventricular contractions (PVCs) 4. Prevents systemic overload

2. Increases the cardiac output - Acts to regulate cardiac rhythm

The nurse is caring for the client in the ICU. Hemodynamic monitoring is accomplished by way of a Swan-Ganz catheter. The nurse is aware that this type of monitoring will provide which information? 1. measures the circulatory volume in the coronary arteries. 2. Indirectly measures the pressure in the ventricles. 3. Analyzes the adequacy of pulmonary circulation 4. Directly measures the adequacy of carbon dioxide exchange

2. Indirectly measures the pressure in the ventricles. - CVP readings measure the pressure in the right ventricle, the Swan-Ganz catheter measures the pulmonary artery wedge pressure, which is an indirect reading of the pressure in the left ventricle. Strategy: Think about each answer choice.

The client is returned to the room at 1000 following a laparoscopic gall bladder surgery. The nurse plans to get the client out of bed for the first time at 1800. In preparation for this activity, the nurse should take which action? 1. Ask the client to cough and deep-breathe at 1600 2. Offer pain medication to the client at 1730 3. Turn the client from side to side at noon and 1600 4. Encourage the client to use the incentive spirometer.

2. Offer pain medication to the client at 1730 - reduction of pain will allow client to cooperate with activities designed to reduce post-op complications such as ambulation I picked 4. Encourage the client to use the incentive spirometer. - wrong because used to promote complete lung expansion and prevent respiratory complications following surgery, but would not help with ambulation. Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired?

The nurse cares for a multipara client who delivered a female infant 1 hour ago. The nurse observes that the client's breasts are soft, the uterus is boggy to the right of the midline and 2cm below the umbillicus; moderate lochia rubra. It is MOST important for the nurse to take which of the following actions? 1. Perform a straight cath 2. Offer the client the bedpan 3. Put the baby to breast 4. Massage the uterine fundus

2. Offer the client the bedpan - boggy uterus deviated to the right indicates full bladder, encourage client to void

The home health care nurse cares for a client diagnosed with type 1 diabetes. The client is maintained on a regimen of NPH and regular insulin and a 1,800-calorie diabetic diet with normal blood sugar levels. Morning self-monitoring blood sugar (SMBG) readings the past 2 days were 205 and 233 mg/dL. The nurse expects the physician to take which of the following actions? 1. Reduce the client's diet to 1,500 calorie ADA 2. Order three additional units of NPH insulin at 10PM 3. Order an additional 10 units of regular insulin at 8PM 4. Eliminate the client's bedtime snack.

2. Order three additional units of NPH insulin at 10PM - dawn phenomena, treatment is to adjust evening diet, bedtime snack, insulin dose, and exercise to prevent early morning hyperglycemia I picked 4. Eliminate the client's bedtime snack. Wrong because would adjust snack, not eliminate it Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?

The nurse cares for the client admitted 4 days ago for treatment of alcohol dependence. The nurse notes the client has slurred speech, ataxia, and uncoordinated movements, and reports a headache. Which action should the nurse take FIRST? 1. Observe the client for 8 hours to collect additional data 2. Perform a complete physical assessment. 3. Collect a urine specimen for a drug screen. 4. Encourage the client to talk about whatever is causing distress.

2. Perform a complete physical assessment. - best way to identify possible physical complications of alcohol dependence is though a complete physical assessment. I picked 3. Collect a urine specimen for a drug screen - should be done after the physical assessment is completed Strategy: Answers are a mix of assessments and implementations. Is this a situation that requires validation? Yes.

The client is diagnosed with a flaccid bladder following a spinal cord injury. The nurse teaches the client about dietary changes. Which beverage, if selected by the client, indicates to the nurse that teaching is effective? 1. Lemonade 2. Prune juice 3. Milk 4. Orange juice 5. Cranberry juice 6. Tomato juice

2. Prune juice - promotes acidic urine, minimizes risk of urinary tract infection and stone formation; also use cranberry, tomato juice, bouillon 5. Cranberry juice - promotes acidic urine, minimizes risk of urinary tract infection and stone formation; also use cranberry, tomato juice, bouillon 6. Tomato juice - promotes acidic urine, minimizes risk of urinary tract infection and stone formation; also use cranberry, tomato juice, bouillon Wrong 3. Milk - excessive amounts of milk promote alkaline urine Strategy: "Teaching is effective indicates a correct statement.

A young adult immobilized for trauma to the spinal cord has periods of diaphoresis, a draining abdominal wound, and diarrhea. On the basis of the nursing assessment, which of the following is the MOST important nursing diagnosis? 1. Risk for constipation related to immobilization. 2. Risk for impaired skin integrity related to immobilization and secretions 3. Risk for wound infection related to involuntary bowel secretions 4. Risk for fluid volume excess related to secretions

2. Risk for impaired skin integrity related to immobilization and secretions - Skin is very susceptible to breakdown because of immobility and bodily secretions; needs numerous nursing interventions to prevent this.

The nurse performs the Rinne tests on a 6-year-old girl. Which of the following is an accurate statement of how this test should be performed? 1. The stem of a vibrating tuning fork is held against the auditory canal until the child indicates that she can no longer hear the sound. Then the turning fork is moved away from the canal. 2. The stem of a vibrating tuning fork is held against the mastoid bone until the child indicates that she can no longer hear the sound. Then the tuning fork is moved in front of the auditory canal. 3. The stem of a vibrating tuning fork is held in the middle of the forehead, and the girl's hearing is assessed in both ears. 4. The stem of a vibrating tuning fork is positioned 2 inches behind the girl's head, and the length of time she hears the sound is documented.

2. The stem of a vibrating tuning fork is held against the mastoid bone until the child indicates that she can no longer hear the sound. Then the tuning fork is moved in front of the auditory canal. - Child should hear sound again when tuning fork is moved from mastoid bone to the front of the auditory canal because air conduction is better than bone conduction.

The nurse observes the student nurse check the placement of a nasogastric (NG) tube prior to administering an intermittent feeding. Which action, if performed by the student nurse, requires an intervention by the nurse? 1. The student nurse checks the pH of the contents aspirated from the NG tube 2. The student nurse positions a stethoscope on the upper abdomen and listens as air is introduced into the NG tube 3. The student nurse uses a large-barreled syringe to aspirate for stomach contents 4. The student nurse flushes the NG tube with 30ml of air before aspirating fluid 5. The student nurse places the end of the NG tube in a cap of water and watches for bubble formation.

2. The student nurse positions a stethoscope on the upper abdomen and listens as air is introduced into the NG tube. - air injected to lungs, pharynx or esophagus may transmit similar sound 5. The student nurse places the end of the NG tube in a cap of water and watches for bubble formation. - not considered acceptable procedure; if tube placed in lungs, may cause bubbling Strategy: "Requires an intervention" indicates incorrect behavior

The teenager comes to the clinic reporting fatigue, a sore throat, and flu-like symptoms for the previous 2 weeks. Physical exam reveals enlarged lymph nodes and temp of 100.3F (37.9C). Which statement by the nurse is BEST? 1. "Cover your mouth and nose when you sneeze or cough." 2. "Eat in a separate room away from your family." 3. "Don't share your drinking glass or silverware with anybody." 4. "Stay in your room until all of your symptoms are gone."

3. "Don't share your drinking glass or silverware with anybody." - symptoms indicate mononucleosis, spread by direct contact; advise family to avoid contact with cups and silverware for about 3 months I picked 1. "Cover your mouth and nose when you sneeze or cough." - wrong because mononucleosis is spread by direct contact Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?

The 4-week-old infant with symptoms of pyloric stenosis is brought to the outpatient clinic by the parent. Which statement does the nurse expect the parent to make about the infant's symptoms? 1. "My infant's bowel movements have turned black and sticky." 2. "I really have to encourage my infant to suck the bottle." 3. "My infant is fussy and seems hungry all the time." 4. "My infant spits up green liquid after feeding."

3. "My infant is fussy and seems hungry all the time." - becomes lethargic, dehydrated, and malnourished I picked 4. "My infant spits up green liquid after feeding." - wrong because would expect emesis to contain milk or formula, should not be bile-colored Strategy: Determine how each statement relates to pyloric stenosis.

The health care provider (HCP) prescribes cimetidine 300 mg PO aid for an elderly client. The nurse instructs the client about the medication. Which statement, if made by the client, indicates further teaching is needed? 1. "I'll take this pill with meals and before bed." 2. "I may experience mild diarrhea for a while." 3. "My stools may change color while I'm on this medication." 4. "I should call my HCP if I get an acne-like rash."

3. "My stools may change color while I'm on this medication." - no change in stool color I picked 2. "I may experience mild diarrhea for a while." - wrong because common side effect, usually subsides Strategy: "Further teaching" indicates incorrect information

Which of the following should be charted by the nurse to reflect a client's emotional adjustment to being hospitalized in the ICU? 1. "The client is unable to complete activities of daily living w/o assistance." 2. "The client appears to be depressed and anxious regarding his/her surgery" 3. "The client constantly calls for nurses and cries uncontrollably." 4. "The family in unable to visit more often than once a week because they live far away."

3. "The client constantly calls for nurses and cries uncontrollably." - Gives an objective description of the client's behavior and affect.

An older client diagnosed w/ pneumonia is admitted to the med/surg unit. The nurse should place the patient in a room w/ which of the following patients? 1. A 20y/o in traction from multiple fractures of the left lower leg 2. A 35y/o w/ recurrent fever of unknown origin 3. A 50y/o recovering alcoholic w/ cellulitis of the right foot 4. An 89y/o with Alzhemier's disease awaiting nursing home placement.

3. A 50y/o recovering alcoholic w/ cellulitis of the right foot. - generalized nonfollicular infection that involves deeper connective tissue, both patients have infections I picked 2 -wrong because we don't know the cause of the fever

The nurse supervises care given to clients on a med/surg units. The nurse should intervene if which of the following is observed? 1. A nurse and client wears masks during a dressing change for the central catheter used for TPN. 2. A nurse injects insulin through a single-lumen percutaneous central catheter for a client receiving TPN. 3. A nurse applies lip balm to his/her lips immediately after performing a blood draw to obtain a specimen 4. A nurse wears a disposable particular respirator when administering rifampin to a client with TB.

3. A nurse applies lip balm to his/her lips immediately after performing a blood draw to obtain a specimen. - applying lip balm or handling contact lenses is prohibited in work areas where exposure to bloodborne pathogens may occur.

The nurse receives report from the previous shift. Which of the following patients should the nurse see FIRST? 1. A patient post coronary artery bypass graft (CABG) having the atrioventricular (AV) wires removed later in the day 2. A patient w/ type 1 diabetes scheduled for a cardiac cath later today 3. A patient 1 day post-op w/ an edpidual cath in place 4. A patient diagnosed w/ cardiomyopathy being eval for a heart transplant

3. A patient 1 day post-op w/ an epidual cath in place - Epidual used for pain relief, monitor for urinary incontinence, hypotension, resp. depression and n/v.

An elderly man diagnosed w/ chronic schizo is followed in a partial hospitalization program. The client has been on long-term antipsychotic med and recently developed symptoms of tardive dyskinesia. The nurse's documentation should include which of the following? 1. Assessment of ADL (self-care) ability 2. Mini-Mental Status Exam (MMSE) 3. Abnormal Involuntary Movement Scale (AIMS) 4. Modified Overt Aggressive Scale (MOAs)

3. Abnormal Involuntary Movement Scale (AIMS) - is most widely accepted exam to test for the presence of tardive dyskinesia

The nurse on a psychiatric unit of the hospital refuses to agree to a patient's request to organize a party on the unit for the patient's friends. The patient becomes angry and uses abusive language toward the nurse. Which of the following statements indicates that the nurse has an understanding of the patient's behavior? 1. Allowing the patient to use abusive language will undermine the authority of the nurse. 2. Responding in kind to a patient who uses abusive language will perpetuate the behavior 3. Abusive language is one of the behaviors symptomatic of the patient's illness. 4. The nurse should model acceptable behavior and language for all patients.

3. Abusive language is one of the behaviors symptomatic of the patient's illness. - Symptoms will respond to treatment

The nurse administers morphine 6 mg IV push to a patient for post-op pain. Following administration of the drug, the nurse observes the following: BP 100/68, pulse 68, respirations 8, client sleeping quietly. Which of the following nursing actions is MOST appropriate? 1. Allow the client to sleep undisturbed 2. Administer oxygen via face mask or nasal prongs 3. Administer naloxone (Narcan) 4. Place epinephrine 1:1,000 at the bedside

3. Administer naloxone (Narcan) - IV naloxone (Narcan) should be given to reverse respiratory depression; respiratory rate of 8 is too low and necessitates a nursing action I picked 2. Administer oxygen via face mask or nasal prongs Wrong because problem is low respirations; this may be administered after medication

The nurse recognizes that the client diagnosed w/ an obsessive-compulsive ritual is attempting to achieve which of the following? 1. Control of other people 2. Increased self-esteem 3. Avoid severe level of anxiety 4. Express and manage anxiety

3. Avoid severe levels of anxiety - obsessive-compulsive rituals are an attempt to avoid or alleviate increasing levels of anxiety

The nurse cares for a post-op client diagnosed w/ type 2 diabetes controlled w/ anti hyperglycemic agents. The client asks why the physician ordered subcutaneous insulin injections after surgery. The nurse's response should be based on which of the following statements? 1. Tissue injury after surgery decreases blood sugar 2. Anesthesia acts to increase glycogen stores 3. Being NPO inhibits normal blood sugar control 4. Surgery often leads to insulin dependency

3. Being NPO inhibits normal blood sugar control - Inability to control diabetes by diet and oral agents, coupled w/ surgically induced metabolic changes, being NPO both before and after surgery, and the infusion of IV fluids

The nurse knows that cortisol is responsible for which of the following? 1. Preparing the body for "flight or fight" 2. Regulating the calcium metabolism 3. Converting proteins and fat into glucose 4. Enhancing musculoskeletal activity

3. Converting proteins and fat into glucose - Action of cortisol; is also an anti-inflammatory agent

A client has orders for cefoxitin (Mefoxin) 2g IV piggyback in 100mL 5% dextorse in water. The primary IV is 5% dextrose in lactated Ringer's and is infusing by gravity. It is MOST important for the nurse to take which of the following actions? 1. Administer the med slowly at 20 to 25 cc/h 2. Change the priarmy IV solution 3 Hang the piggyback infusion bag higher than the primary infusion bag. 4. Obtain an infusion pump prior to administration.

3. Hang the piggyback infusion bag higher than the primary infusion bag. - when using a gravity drip, piggyback fluid level needs to be higher than primary infusion I picked 4 wrong because it is unnecessary for safe infusion

The nurse is called to the room of the client 4 days after abdominal surgery. The client had been coughing and said "It felt like something gave." The nurse observes that the edges of the incision have separated, and a small loop of the bowel protrudes through the incision. The nurse should place the client in which positions? 1. Head of the bed elevated 30 degrees 2. Head of the bed tilted down 3. Head of the bed elevated 15 degrees 4. Head of the bed elevated 90 degrees.

3. Head of the bed elevated 15 degrees - low Fowler's; reduces stress on suture line, may be placed supine with hips and knees bent. I picked 1. Head of the bed elevated 30 degrees - wrong because too high, puts pressure on abdominal area Strategy: Answers are all implementations. Determine the outcome of each answer choice. Is it desired?

A 7-year-old girl is seen in the clinic w/ a diagnosis of pituitary dwarfism. Which of the following clinical manifestations is the nurse MOST likely to observe? 1. Abnormal body proportions 2. Early sexual maturations 3. Delicate features 4. Coarse, dry skin

3. Delicate features - Appear younger than chronological age

The client taking chlorpromazine should be instructed to notify the nurse immediately. If the client experiences which sign and symptom? 1. Dry mouth and nasal stuffiness 2. Increased sensitivity to heat 3. Difficulty urinating 4. Weight gain and constipation

3. Difficulty urinating - is an anticholinergic reaction that may become a severe health problem unless treated. I picked 1. Dry mouth and nasal stuffiness - wrong because possible side effect of antipsychotic medications, but client can be instructed on measures to take at home to resolve this problem Strategy: Determine the cause of each answer choice and how it relates to chlorpromazine.

The 5-year-old child is scheduled for a lumbar puncture (LP). Which nursing action BEST prepares the child for the procedure? 1. Explain the procedure in detail 2. Show a video of the procedure 3. Do a mock run-through of the procedure 4. Answer all questions simply and honestly

3. Do a mock run-through of the procedure - excellent method to use with a child because it incorporates actually "feeling" many aspects of the procedure as they are explained. I picked 4. Answer all questions simply and honestly - wrong because child probably doesn't know enough to ask many questions Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired?

A nurse begins a therapeutic relationship with the client diagnosed with generalized anxiety disorder. It is MOST important for the nurse to obtain which information? 1. What the client's priorities are 2. How the client views self 3. In what situations the client gets anxious 4. Any family history of mental issues.

3. In what situations the client gets anxious - will provide necessary information in baseline assessment of client's anxiety I picked 1. What the client's priorities are - wrong because helpful data; priority is to determine in what situations the client becomes anxious. Strategy: Think about each answer choice.

The nurse obtains a client's temp of 103F (39.4C). The nurse knows body compensatory mechanisms include which of the following? 1. Decrease Resp rate and bradycardia 2. Normal blood pressure and pulse 3. Increased resp rate and tachycardia 4. Diaphoresis w/ cool, clammy skin

3. Increased resp rate and tachycardia - hyperthermia increases the oxygen requirements, which results in faster breathing as well as an increase in the pulse rate I picked 4 wrong because diaphoresis may occur, but the skin will be warm.

Which of the following nursing actions has the HIGHEST priority for a teenager admitted with burns to 50% of the body? 1. Counseling regarding problems of body image 2. Maintain airborne precautions 3. Maintain aseptic technique during procedures 4. Encourage peers to visit on a regular basis.

3. Maintain aseptic technique during procedures - safety is a priority for the client who is at high risk for infection I picked 1. Counseling regarding problems of body image Wrong because psychosocial, not highest priority

The nurse makes rounds on the postpartum unit. The nurse notes that a client's uterus is relaxed. The nurse should take which actions? 1. Encourage the client to drink warm oral fluids 2. Check the client's pulse and respirations 3. Massage the funds until firm 4. Put the infant to the client's breast 5. Assess the bladder for fullness 6. Continue to monitor

3. Massage the funds until firm - Massage is the first action to contract the uterus 4. Put the infant to the client's breast - Having the infant nurse will cause oxytocin to be produced which will contract the uterus. 5. Assess the bladder for fullness - A full bladder will cause the uterus to relax and needs to be emptied. Strategy: Identify all of the actions to help contract the uterus.

A client has been taking propranolol (Inderal) 40 mg BID and furosemide (Lasix) 40 mg daily for several months. Two weeks ago, the physician added verapamil (Calan) 80mg TID to the client's regimen. It is MOST important for the nurse to assess for which of the following? 1. Tachycardia 2. Diarrhea 3. Peripheral edema 4. Impotence

3. Peripheral edema - Calan is a calcium channel blocker, depresses myocardial contractility, decreases work of ventricle and oxygen demand, dilates coronary arteries; when used w/ other anti-hypertensives can cause hypotension and heart failure.

The nurse cares for a child diagnosed w/ pediculosis capitis (head lice) and is being treated w/ 1% gamma benzene hexachloride (Kwell) shampoo. The nurse should include which of the following when instructing the child's parents? 1. Continue treatment every other day for 1 week 2. Wash the child's clothing and personal belongings in soap and cool water 3. Repeat the application of the shampoo in 7-10 days 4. One treatment w/ kwell kills both

3. Repeat the application of the shampoo in 7-10 days.

The nurse cares for a client receiving a blood transfusion for approximately 30 minutes. Which of these assessments, if made by the nurse, indicates an allergic reaction? 1. Hypotension 2. Chills 3. Respiratory wheezing 4. Lower back discomfort

3. Respiratory wheezing - Allergic reaction is characterized by wheezing, urticaria (hives), facial flushing, and epiglottal edema

The client admitted with a diagnosis of metastatic cancer has been receiving chemotherapy for 3 months. The client's lab values include RBC 3.8 million/ mm3, WBC 2,000/mm, HgB 9.3 g/dL, platelets 50,000/mm3. Which nursing diagnosis is MOST appropriate for this client? 1. Decreased cardiac output 2. Ineffective thermoregulation 3. Risk for injury 4. Ineffective airway clearance

3. Risk for injury - due to low platelet count, normal platelets 150,000-400,000/mm3, decrease causes problems with blood clotting Strategy: Determine how each answer choice relates to the lab values.

The nurse cares for the child diagnosed with a fractured right femur. The child is in balanced suspension traction with a Thomas splint and Pearson attachment. When the nurse checks the client, the nurse finds the weights on the floor, and the child's feet touching the foot of the bed. Which action by the nurse is MOST appropriate? 1. Release the traction weights and reposition the child in bed. 2. Pull on the traction weights while two nurse's aides pull the child up in bed. 3. Steady the traction and ask the child to bend the left leg and push up in bed. 4. Assess the child's right left for proper position and alignment.

3. Steady the traction and ask the child to bend the left leg and push up in bed. - permits patient to reposition self and re-establish pull of traction weights. I picked 2. Pull on the traction weights while two nurse's aides pull the child up in bed. - wrong because pulling on traction weights would alter proper pull on fracture. Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? No. Determine the outcome of each answer choice.

The nurse cares for a client after cataract surgery. The nurse should intervene if which of the following is observed? 1. Client is in the supine position 2. The head of the bed is elevated 30 degrees 3. The client is lying on the right side 4. An eye shield is over the right eye.

3. The client is lying on the right side. - client should not be positioned w/ operative side in a dependent position or against the bed.

Which of the following would be MOST important for the rehab nurse to assess during a new client's admission? 1. The client's expectation of family members 2. The client's understanding of available support services 3. The client's personal goals for rehab 4. The client's past experiences in the hospital.

3. The client's personal goals for rehab - It is important for the nurse to understand what the client expects from the rehab program for future success.

The nurse cares for the client hospitalized with an acute asthma attack. The nurse is MOST concerned if which finding is observed? 1. The client becomes more diaphoretic 2. The client's respirations increase from 14 to 16 per minute 3. The client's pulse increases from 86 to 100 per minute 4. The client shows increasing pallor.

3. The client's pulse increases from 86 to 100 per minute - pulse increase is due to decrease in oxygenation of tissues I picked 4. The client shows increasing pallor - wrong because subjective symptom, unreliable indicator of deterioration of status Strategy: "MOST concerned" indicates a complication

The nurse prepares an older client for an intravenous pyelogram (IVP). The client asks the nurse to explain the reason why the procedure is performed. The nurse's response should be based on which of the following? 1. The healthcare provider is able to directly observe the renal pelvis 2. An IVP assesses glomerular filtration rate 3. The health care provider is able to examine the urinary tract by x-ray 4. Medication is injected into the urinary system

3. The health care provider is able to examine the urinary tract by x-ray - X-rays of entire urinary tract taken, evaluates kidney function

The nurse performs screening at the local senior citizens' facility. The nurse is MOST concerned if which finding is observed? 1. A 69-year-old client has a slightly elevated systolic blood pressure. 2. The nurse has difficulty palpating an apical pulse on a 74-year-old client. 3. The nurse auscultates an S3 ventricular gallop on a 78-year-old client. 4. An 81-year-old man has a temp of 98.2F (36.7C)

3. The nurse auscultates an S3 ventricular gallop on a 78-year-old client. - ventricular gallop is the earliest sign of HF I picked 2. The nurse has difficulty palpating an apical pulse on a 74-year-old client. - wrong because it's a usual finding for the older adult Strategy: Determine how each assessment relates to an older adult.

The nurse cares for the client admitted with a diagnosis of myocardial infarction (MI) 36 hours ago. An appropriate nursing diagnosis is "Alteration in cardiac output" related to which team? 1. Mitral valve collapse 2. Endocarditis 3. Ventricular dysrhythmias 4. Hypertensive crisis

3. Ventricular dysrhythmias - most common complication following a myocardial infarction is dysrhythmia, with ventricular types being the most serious. I picked 1. Mitral valve collapse - wrong because not the most common occurrence Strategy: Think about each answer choice

The 20-year-old primipara attends a class for women who plan to breast feed. To prepare for breast feeding, the nurse should encourage the woman to perform which implementation? 1. Apply moisturizer to the breasts every day after bathing 2. Expose the breasts to air every day for 20 minutes. 3. Wash breasts with water only 4. Massage the breasts to increase circulation twice daily.

3. Wash breasts with water only - soap avoided to prevent drying I picked 4. Massage the breasts to increase circulation twice daily. - wrong because could cause breast tissues to become tender. Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired?

The nurse prepares a patient for a cesarean section. The patient says that she had major surgery several years ago and asks if she will receive a similar "shot" before surgery. The nurse's response should be based on an understanding that the preoperative medication given before a cesarean section? 1. contains a lower overall dosage of medication than is given before general surgery. 2. contains lower amounts of sedatives and hypnotics than are given before general surgery. 3. contains lower amounts of narcotics than are given before general surgery. 4. contains medications similiar in type and dosages to those given before general surgery.

3. contains lower amounts of narcotics than are given before general surgery. - decreased so that less narcotic crosses the placental barrier, causing respiratory depression in the infant. I picked 4. contains medications similiar in type and dosages to those given before general surgery. Wrong because dosages of narcotics are reduced Strategy: Think about the action of the medications

The nurse cares for a client who has had an above-knee-amputation (AKA) w/ an immediate prosthetic fitting. It is MOST important for the nurse to take which of the following actions? 1. Assess drainage from Penrose drain 2. Observe dressing for signs of excessive bleeding 3. Elevate the stump for no less than 40 hours 4. Provide cast care on the affected extremity

4. Provide cast care on the affected extremity - cast applied to provide uniform compression, prevent pain and contractures. I picked 1 wrong because drains not usually used with amputations

The client is returned to the room following an appendectomy. The nurse notices a large amount of serosangulineous drainage on the dressing. It is MOST important for the nurse to obtain an answer to which question? 1. "Were there any intraoperative complications?" 2. "Has the dressing been changed?" 3. "Why didn't the recovery room nurse report any drainage?" 4. "Was a tissue drain placed during surgery?"

4. "Was a tissue drain placed during surgery?" - drain is frequently placed during surgery to prevent accumulation in wound, dressing should be reinforced Strategy: Determine how each answer choice relates to an appendectomy.

The client has surgery for cancer of the colon, and a colostomy is established. Before discharge, the client tells the nurse that swimming will no longer be allowed. Which response by the nurse is correct? 1. "You should begin looking for other areas of interest." 2. "You will have to wear a watertight dressing over the stoma." 3. "You cannot go into water that covers the stoma area." 4. "You may resume all previous activities."

4. "You may resume all previous activities." - all activities that the client participated in before the colostomy may be resumed after appropriate healing of the stoma or incisions Strategy: Determine the outcome of each answer choice. Is it desired?

The nurse leads a parenting class for a group of expectant mothers. The nurse should advise that the breast-feeding mother should increase her daily caloric intake by how many calories? 1. 200 2. 300 3. 400 4. 500

4. 500 - Milk production requires an increase of 500 calories/day

A client diagnosed w/ biopolar disorder is in a manic phase w/ combative behavior. Which of the following is the INITIAL priority nursing action? 1. Provide adequate hygiene and nutrition 2. Decrease environmental stimuli 3. Slowly involve client in unit activities 4. Admin and monitor sedative and mood-stabilizing meds

4. Admin and monitor sedative and mood-stabilizing meds - is the most important to gain control w/ a physically aggressive client in manic phase; client has significant sympathetic nervous system stimulation and will require psychopharmacologic intervention w/ both sedative meds and mood-stabilizing agents.

A client w/ clear lung sounds and unlabored breathing receives aminophylline IV. Which of the following is the MOSt appropriate nursing action if the client's IV infiltrates? 1. Apply warm soaks to the infiltration site, start a new IV, and continue IV meds 2. Wait 2 hours, reassess the client, and restart the IV if the client has wheezing or labored breathing 3. Restart the IV and continue the previous med schedule 4. Call the physician and recommend the IV meds be changed to PO.

4. Call the physician and recommend the IV meds be changed to PO. - before a new IV is started on this client, physician should be called and PO meds recommended.

The nurse cares for clients in a drug rehab facility. Which of the following complications of IV drug abuse is the nurse MOST likely to observe? 1. Jaundice 2. Rash 3. Bruising 4. Cellulitis

4. Cellulitis - Most narcotic addicts do not inject sterile purified material w/ aseptic techniques; cellulitis is a common complication because of skin popping or using an infected drug apparatus.

The nurse cares for patients on the pediatric unit. The mother of a 2-year-old who is one day post-op tells the nurse, "My child is so restless and overactive." The nurse should take which of the following actions? 1. Direct the LPN/LVN to obtain the child's vital signs 2. Ask the mother if the child's sutures are still intact 3. Tell the nursing assistant to take the child for a walk 4. Check to see when the child last received pain med

4. Check to see when the child last received pain med - young children typically become restless and overactive if in pain; grimacing, clenching teeth, rocking, and aggressive behavior may also be observed

The nurse cares for clients in the medical clinic. A nursing assessment of a client w/ a hiatal hernia is MOST likely to reveal which of the following? 1. A bulge in the LRQ 2. Pain at the umbilicus radiating down into the groin 3. A burning sensation in the midepigastric area each day before lunch 4. Complaints of awakening at night w/ heartburn

4. Complaints of awakening at night w/ heartburn -classic symptoms of hiatal hernia associated w/ reflux

The nurse cares for clients on the neurology. What is the MOST appropriate action for the nurse to take after noting that a client suddenly developed a fixed and dilated pupil? 1. Reassess in 5 minutes 2. Check the client's visual acuity 3. Lower the head of the client's bed 4. Contact the physician.

4. Contact the physician. - implementation; fixed and dilated pupil represents a neurological emergency. I picked 2. Check the client's visual acuity Wrong because assessment; has symptoms of increased intracranial pressure (ICP) Strategy: Answers are a mix of assessments and implementations. Is this situation that requires assessment or validation? No. Determine the outcome of the implementations.

The nurse cares for a client admitted w/ a diagnosis of CVA and facial paralysis. Nursing care should be planned to prevent which of the following complications? 1. Inability to talk 2. Loss of gag reflex 3. Inability to open the affected eye 4. Corneal abrasion

4. Corneal abrasion - Client will be unable to close eye voluntarily; when facial nerve (cranial nerve VII) is affected, the lacrimal gland will no longer supply secretions that protect eye.

The nurse cares for the client diagnosed with Cushing's syndrome. Which nursing action is the priority? 1. Implement measures to prevent skin breakdown. 2. Plan measures to prevent infections. 3. Teach the client signs and symptoms of hyperglycemia. 4. Instigate measures to prevent fluid overload.

4. Instigate measures to prevent fluid overload. - respirations are the first priority; clients with Cushing's syndrome are prone to fluid overload and CHF due to sodium and water retention I picked 2. Plan measures to prevent infections. wrong because clients are susceptible to skin breakdown and infections Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?

The middle-aged adult is seen in the emergency department for reports of severe right-flank pain. The client is 20 pounds overweight, lives a sedentary lifestyle, and was treated for renal calculi 4 years ago. Which action, if performed by the nurse, is MOST important? 1. Ensure that the client has nothing to eat or drink 2. Obtain a "clean-catch" urine specimen for analysis 3. Provide warm packs to relieve discomfort 4. Measure and strain the client's urine

4. Measure and strain the client's urine - will document passage of stone and allow composition to be analyzed I picked 2. Obtain a "clean-catch" urine specimen for analysis - not most important, used to identify infection Strategy: "MOST important" indicates discrimination is required to answer the question.

The nurse knows which of the following mood-altering drugs is most often associated w/ an increased risk for HIV infection related to IV drug use? 1. Benzodiazepines 2. Marijuana 3. Barbiturates 4. Narcotics

4. Narcotics - Narcotics are most often used IV

The nurse plans care for the elderly client with dementia. Which action is a priority for the nurse? 1. Encourage dependency with activities of daily living 2. Provide flexibility in schedules due to confusion 3. Limit reminiscing due to poor memory. 4. Speak slowly in a face-to-face position.

4. Speak slowly in a face-to-face position. - is most effective when communicating with an elderly client I picked 3. Limit reminiscing due to poor memory. - wrong because reminiscence and life reviews help client resume progression through grief process associated with disappointing life events, and increases self-esteem Strategy: The topic of the question is unstated. Read the answer choices for clues

The nurse cares for a client diagnosed w/ type 1 diabetes complaining of decreased vision. The client asks the nurse what caused the visual changes. The nurse's response is based on which of the following? 1. The client's decreased vision is caused by bleeding into the inner ocular chamber of the eye. 2. The client's decreased vision is caused by gradual separation of the retina from the base of the eye 3. The client's decreased vision is caused by an increase in the size of vessels in the back of the eye. 4. The client's decreased vision is caused by gradual destruction and degeneration of the retina.

4. The client's decreased vision is caused by gradual destruction and degeneration of the retina. - Gradual destruction occurs because of deterioration of the retinal vessels.

While scheduling the administration of bromocriptine, which nursing action has the HIGHEST priority? 1. The medication should be taken once a day for 6 weeks. 2. The medication should be taken with orange juice 3. The medication should be taken in the morning and at bedtime 4. The medication should be taken with meals.

4. The medication should be taken with meals. - will decrease GI upset Strategy: Answers are implementations. Determine the outcome of each answer. Is it desired?

The nursing team consists of an RN, two LPN/LVNs, and a nursing assistive personal (NAP). The Rn should care for which client? 1. The infant 2 days ago post-op after repair of cleft lip requiring a tube feeding 2. The preschool child 3 days post-op after surgical removal of Wilms tumor requiring a bath 3. The school-aged child diagnosed with osteomyelitis requiring a dressing change 4. The teenager with a head injury, Glasgow coma scale is 5, requiring personal care.

4. The teenager with a head injury, Glasgow coma scale is 5, requiring personal care. - Glasgow coma scale of 5 indicates coma, client requires frequent assessment. Strategy: RN care for clients who require assessment, teaching, and nursing judgment.

Prior to a caesarean delivery, the client is treated for abrupt placenta. The nurse cares for the client during the postpartum period. Which symptom is suggestive of disseminated intravascular coagulation (DIC)? 1. The client's vital signs are: BP 90/58, temp 101.0F (38.3C), pulse 112/min, rest 18/min 2. The client's lab results are Hgb 13 g/dL, HCT 40%, WBC 7,000/mm3 3. The client is nauseated, lethargic, and has vomited three times 4. There is oozing blood from the venipuncture site and abdominal incision.

4. There is oozing blood from the venipuncture site and abdominal incision. - DIC is an acquired clotting disorder from overstimulation, prolonged oozing from sites of minor trauma first symptom. I picked 1. The client's vital signs are: BP 90/58, temp 101.0F (38.3C), pulse 112/min, rest 18/min Wrong because may indicate hemorrhage or sepsis Strategy: Determine how each answer choice relates to DIC.