LVN NCLEX REVIEW

A pregnant client with vaginal bleeding asks a nurse how the fetus is doing. Which response is best?

"I'll tell you what the monitors show." Reason: The client deserves a truthful answer and the nurse should be objective without giving opinions. Relating what the monitors show is objective and truthful. Vague answers may be misleading and aren't therapeutic

The physician prescribes acetaminophen 650 mg by mouth every 4 hours for a client with a temperature of 102°F (38.8°C) who has a feeding tube in place. The nurse has acetaminophen solution on hand containing 160 mg/5 mL. How many milliliters of solution should the nurse administer? Record your answer using one decimal place.

20.3 ml

A client with a history of heart disease is given a prescription for 4 grains of aspirin which comes in 81 mg per tablet. The client asks the nurse, "how many tablets should I take?" What is the nurse's best response? Round to the nearest whole number.

3 tablets 4 grains x 60 mg = 240 mg/81 mg = 2.96=3 tabs

A client is prescribed transcutaneous electrical nerve stimulation (TENS) for pain relief. What is the rationale for using TENS?

A client is prescribed transcutaneous electrical nerve stimulation (TENS) for pain relief. What is the rationale for using TENS? Reason: The rationale for using TENS for pain relief is to block painful stimuli traveling over small nerve fibers. Massage is used to relax tense muscles. Range-of-motion exercises are used to prevent stiffness and further loss of mobility. Elevation and repositioning are used to reduce swelling and inflammation.

At the conclusion of visiting hours, the parent of a 14-year-old adolescent scheduled for orthopedic surgery the next day hands the nurse a bottle of capsules and says, "These are for my child's allergy. Will you be sure my child takes one about 9 PM tonight?" What is the nurse's best response? 1. "I will give one capsule tonight before bedtime." 2. "I will get a prescription so that the medicine can be taken." 3. "Does your health care provider know about your child's allergy?" 4. "Did you ask your health care provider if your child should have this tonight?"

Answer: "I will get a prescription so that the medicine can be taken" Reason: Legally, a nurse cannot administer medications without a prescription from a legally licensed individual. The nurse cannot give the medication without a current health care provider's prescription

A 2-g sodium diet is prescribed for a client with stage 2 hypertension, and the nurse teaches the client the rationale for this diet. The client reports distaste for the food. The primary nurse hears the client request that the family "bring in a ham and cheese sandwich and fries." What is the most effective nursing intervention? 1. Discuss the diet with the client and family. 2. Tell the client why salty foods should not be eaten. 3. Explain the dietary restriction to the client's visitors. 4. Ask the dietitian to teach the client and family about sodium restrictions.

Answer: 1. Discuss the diet with the client and family Reason: The client and significant family members should be included in dietary teaching

After gastric surgery a client has a nasogastric tube in place. What should the nurse do when caring for this client? 1. Monitor for signs of electrolyte imbalance. 2. Change the tube at least once every 48 hours. 3. Connect the nasogastric tube to high continuous suction. 4. Assess placement by injecting 10 mL of water into the tube

Answer: 1. Monitor for signs of electrolyte imbalance Reason: Gastric secretions, which are electrolyte rich, are lost through the nasogastric tube

A client is admitted for surgery. Although not physically distressed, the client appears apprehensive and withdrawn. What is the nurse's best action? 1. Orient the client to the unit environment. 2. Have a copy of hospital regulations available. 3. Explain that that there is no reason to be concerned. 4. Reassure the client that the staff is available if the client has questions

Answer: 1. Orient the client to the unit environment Reason: Orienting the client to the hospital unit provides knowledge that may reduce the strangeness of the environment. Having a copy of hospital regulations available is part of orienting the client to the unit. This alone is not enough when orienting a client to the hospital. Explaining that that there is no reason to be concerned may be false reassurance, because no one can guarantee that there is no reason to be concerned. Reassuring the client that the staff is available to answer questions implies that staff members are available only if the client has specific questions.

your health care provider prescribed them."

Answer: 2. "They are done to identify other health risks" Reason: Certain diagnostic tests (e.g., CBC, urinalysis, chest x-ray examination) are done preoperatively to rule out the existence of health problems that may increase the risks involved with surgery. Feelings will not be dispelled by telling the client not to worry

A client is scheduled to receive conscious sedation during a colonoscopy. The client asks the nurse, "How will they 'knock me out' for this procedure?" Which answer by the nurse correctly describes the route of administration for conscious sedation? 1. "You will receive the anesthesia through a face mask." 2. "You will receive medication through an intravenous catheter." 3. "We will give you an oral medication about one hour before the procedure." 4. "The nurse anesthetist will inject the medication into the epidural space of your spine."

Answer: 2. "You will receive medication through an intravenous catheter." Reason: Conscious sedation is administered by direct intravenous (IV) injection (IV push) to dull or reduce the intensity of pain or awareness of pain during a procedure without loss of defensive reflexes. General anesthesia usually is administered via inhalation of the vapor of a volatile liquid or an anesthetic gas via a mask or endotracheal tube

A client who is to have brain surgery has a signed advance directive in the medical record. In what situation should this document be used? 1. Discharge planning is not covered by insurance. 2. Client cannot consent to his or her own surgery. 3. Postoperative complications occur that require additional treatment. 4. Client death and which client's belongings are to be given to family members

Answer: 2. Client cannot consent to his or her own surgery Reason: Advance directives allow clients to designate another person to consent to procedures if they are unable to do so. Advance directives are not related to insurance. No information suggests the client cannot consent to treatment. Directions for distribution of belongings should be stipulated in a will, not in an advance directive.

A client has been admitted with a diagnosis of intractable vomiting and can only tolerate sips of water. The initial blood work shows a sodium level of 122 mEq/L and a potassium level of 3.6 mEq/L. Based on the lab results and symptoms, what is the client experiencing? 1. Hypernatremia 2. Hyponatremia 3. Hyperkalemia 4. Hypokalemia

Answer: 2. Hyponatremia Reason: The normal range for serum sodium is 135 to 145 mEq/L, and for serum potassium it is 3.5 to 5 mEq/L. Vomiting and use of diuretics, such as furosemide (Lasix), deplete the body of sodium. Without intervention, symptoms of hyponatremia may progress to include neurological symptoms such as confusion, lethargy, seizures, and coma. Hypernatremia results when serum sodium is greater than 145 mEq/L

A client reports vomiting and diarrhea for three days. What clinical finding most accurately will indicate that the client has a fluid deficit? 1. Presence of dry skin 2. Loss of body weight 3. Decrease in blood pressure 4. Altered general appearance

Answer: 2. Loss of body weight Reason: Dehydration is measured most readily and accurately by serial assessments of body weight

A nurse is preparing to administer an oil-retention enema and understands that it works primarily by: 1. Stimulating the urge to defecate. 2. Lubricating the sigmoid colon and rectum. 3. Dissolving the feces. 4. Softening the feces

Answer: 2. Lubricating the sigmoid colon and rectum Reason: The primary purpose of an oil-retention enema is to lubricate the sigmoid colon and rectum. Secondary benefits of an oil-retention enema include stimulating the urge to defecate and softening feces. An oil-retention enema does not dissolve feces .

A client reports severe pain two days after surgery. After assessing the characteristics of the pain, which initial action should the nurse take next? 1. Encourage rest. 2. Obtain the vital signs. 3. Administer the prescribed analgesic. 4. Document the client's pain response.

Answer: 2. Obtain vital signs Reason: Immediately before administration of an analgesic, an assessment of vital signs is necessary to determine whether any contraindications to the medication exist (e.g., hypotension, respirations ≤12 breaths/min). Pain prevents both psychological and physiological rest. Before administration of an analgesic, the nurse must check the health care provider's prescription, the time of the last administration, and the client's vital signs. A complete assessment including vital signs should be done before documenting.

When monitoring fluids and electrolytes, the nurse recalls that the major cation-regulating intracellular osmolarity is: 1. Sodium 2. Potassium 3. Calcium 4. Calcitonin

Answer: 2. Potassium Reason: A decrease in serum potassium causes a decrease in the cell wall pressure gradient and results in water moving out of the cell. Besides intracellular osmolarity regulation, potassium also regulates metabolic activities, transmission and conduction of nerve impulses, cardiac conduction, and smooth and skeletal muscle contraction. Sodium is the most abundant extracellular cation that regulates serum osmolarity, as well as nerve impulse transmission and acid-base balance. Calcium is an extracellular cation necessary for bone and teeth formation, blood clotting, hormone secretion, cardiac conduction, transmission of nerve impulses, and muscle contraction. Calcitonin is a hormone secreted by the thyroid gland and works opposite of parathormone to reduce serum calcium and keep calcium in the bones. Calcitonin does not have a direct effect on intracellular osmolarity.

The physician orders intravenous fluids to be infused at 100 mL/hour. The intravenous tubing delivers 15 drops/milliliters. The nurse would infuse the solution at a flow rate of how many drops per minute to ensure that the client receives 100 mL/hour? Record your answer using a whole number. _____ gtts/min.

Answer: 25 gtt/min

A nurse assesses for hypocalcemia in a postoperative client. One of the initial signs that might be present is: 1. Headache. 2. Pallor. 3. Paresthesias. 4. Blurred vision

Answer: 3. Paresthesias Reason: Normally, calcium ions block the movement of sodium into cells. When calcium is low, this allows sodium to move freely into cells, creating increased excitability of the nervous system. Initial symptoms are paresthesias. This can lead to tetany if untreated. Headache, pallor, and blurred vision are not signs of hypocalcemia.

A client has a pressure ulcer that is full thickness with necrosis into the subcutaneous tissue down to the underlying fascia. The nurse should document the assessment finding as which stage of pressure ulcers? 1. Stage I 2. Stage II 3. Stage III 4. Stage IV

Answer: 3. Stage III Reason: A pressure ulcer that is full thickness with necrosis and ulceration into the subcutaneous tissue and down to, but not through, the underlying fascia is characteristic of a stage III pressure ulcer. A stage I pressure ulcer is defined as an area of persistent redness with no break in skin integrity. A stage II pressure ulcer is a partial thickness wound with skin loss involving the epidermis, dermis, or both

A nurse is caring for a client with pulmonary tuberculosis who is to receive several antitubercular medications. Which of the first-line antitubercular medications is associated with damage to the eighth cranial nerve? 1. Isoniazid (INH) 2. Rifampin (Rifadin) 3. Streptomycin 4. Ethambutol (Myambutol)

Answer: 3. Streptomycin Reason: Streptomycin is ototoxic and can cause damage to the eighth cranial nerve, resulting in deafness. Assessment for ringing or roaring in the ears, vertigo, and hearing acuity should be made before, during, and after treatment. Isoniazid does not affect the ear

An intravenous (IV) solution of 1000 mL 5% dextrose in water is to be infused at 125 mL/hr to correct a client's fluid imbalance. The infusion set delivers 15 drops/mL. To ensure that the solution will infuse over an eight-hour period, at how many drops per minute should the nurse set the rate of flow? Record the answer using a whole number. ______ gtts/min

Answer: 31 gtt/min

The health care provider orders 1000 mL normal saline to be infused over 8 hours for a client with a diagnosis of dehydration. The intravenous (IV) tubing delivers 15 drops per milliliter (drop factor). The nurse should administer the IV infusion at a rate of ____ gtts/minute. Record your answer using a whole number.

Answer: 31 gtt/min

What clinical finding indicates to the nurse that a client may have hypokalemia? 1. Edema 2. Muscle spasms 3. Kussmaul breathing 4. Abdominal distention

Answer: 4. Abdominal distention Reason: Hypokalemia diminishes the magnitude of the neuronal and muscle cell resting potentials. Abdominal distention results from flaccidity of intestinal and abdominal musculature. Edema is a sign of sodium excess. Muscle spasms are a sign of hypocalcemia. Kussmaul breathing is a sign of metabolic acidosis.

What response should a nurse be particularly alert for when assessing a client for side effects of long-term cortisone therapy? 1. Hypoglycemia 2. Severe anorexia 3. Anaphylactic shock 4. Behavioral changes

Answer: 4. Behavioral changes Reason: Development of mood swings and psychosis is possible during long-term therapy with glucocorticoids because of fluid and electrolyte alterations. Hypoglycemia, severe anorexia, and anaphylactic shock are not responses to long-term glucocorticoid therapy.

A nurse applies a cold pack to treat an acute musculoskeletal injury. Cold therapy decreases pain by: 1 Promoting analgesia and circulation 2 Numbing the nerves and dilating the blood vessels 3 Promoting circulation and reducing muscle spasms 4. Causing local vasoconstriction, preventing edema and muscle spasm

Answer: 4. Causing local vasoconstriction, preventing edema and muscle spasm Reason: Cold causes the blood vessels to constrict, which reduces the leakage of fluid into the tissues and prevents swelling and therefore muscle spasm. Cold therapy also may numb the nerves and surrounding tissues, thus reducing pain. Cold does promote analgesia but not circulation. It may numb nerves but does not dilate blood vessels.

The client receives a prescription for tap water enemas until clear. The nurse is aware that no more than two enemas should be given at one time to prevent the occurrence of: 1. Hypercalcemia 2. Hypocalcemia 3. Hyperkalemia 4. Hypokalemia

Answer: 4. Hypokalemia Reason: Repeated tap water enemas deplete cells and extracellular fluid of potassium and sodium resulting in hypokalemia, hyponatremia, and the potential for water intoxication. Repeated tap water enemas do not have a direct effect on hyper- or hypocalcemia. Potassium is depleted from cells and extracellular fluid and does not result in hyperkalemia.

1600: IV has 550 mL left in bag. What is the difference between the client's intake and output? Record the answer using a whole number. _________ mL

Answer: 495 ml Reason: Intake includes 350 mL of IV fluid, 600 mL of nasogastric intubation (NGT) feeding, and 150 mL of water via NGT, for a total intake of 1100 mL

A nurse anticipates that a hospitalized client will be transferred to a nursing home. When should the nurse begin preparing the client for the transfer? 1. At the time of admission 2. After a relative gives permission 3. When the client talks about future plans 4. As soon as the client's transfer has been approved

Answer: 1. At the time of admission Reason: Preparation of clients for discharge to their own home or to a nursing home should begin on the day of admission. The client gives permission for transfer to a nursing home. Intervention includes talking to the family members, including them in plans, and helping them understand the importance of early preparation. The client may never talk about future plans. Waiting until the client's transfer has been approved will make the adjustment more difficult than if the client had adequate preparation time.

A nurse is teaching members of a health care team how to help disabled clients stand and transfer from the bed to a chair. To protect the caregivers from injury, the nurse teaches them to lift the client by first placing their arms under the client's axillae and next: 1. Bending and then straightening their knees 2. Bending at the waist and then straightening the back 3. Placing one foot in front of the other and then leaning back 4. Placing pressure against the client's axillae and then raising their arms

Answer: 1. Bending and then straightening their knees Reason: The leg bones and muscles are used for weight bearing and are the strongest in the body. Using the knees for leverage while lifting the client shifts the stress of the transfer to the caregiver's legs. By using the strong muscles of the legs the back is protected from injury. Bending at the waist and then using the back for leverage is how many caregivers and people who must lift heavy objects sustain back injuries. The anatomical structure of the back is equipped only to bear the weight of the upper body. By leaning back, the client's weight is on the caregiver's arms, which are not equipped for heavy weight bearing. The caregiver's arms are not strong enough to lift the client. In the struggle to lift the client, the client and caregiver may be injured.

To decrease abdominal distention following a client's surgery, what actions should the nurse take? (Select all that apply.) 1. Encourage ambulation 2 . Give sips of ginger ale 3. Auscultate bowel sounds 4 . Provide a straw for drinking 5 . Offer an opioid analgesic

Answer: 1. Encourage ambulation 3. Auscultate bowel sounds Reason: Ambulation will stimulate peristalsis, increasing passage of flatus and decreasing distention. Monitoring bowel sounds is important because it provides information about peristalsis. Carbonated beverages, such as ginger ale, increase flatulence and should be avoided. Using a straw should be avoided because it causes swallowing of air, which increases flatulence. Opioids will slow peristalsis, contributing to increased distention.

A nurse is explaining the nursing process to a nursing assistant. Which step of the nursing process should include interpretation of data collected about the client? 1. Evaluation 2. Data Collection 3. Nursing interventions 4. Proposed nursing care

Answer: 1. Evaluation Reason: An actual or potential client health problem is based on the analysis and interpretation of the data previously collected during the assessment phase of the nursing process. Gathering data is included in the client's assessment. Nursing interventions are based on the earlier steps of the nursing process. The plan of care includes nursing actions to meet client needs. The needs first must be identified before nursing actions are planned.

What should the nurse consider when obtaining an informed consent from a 17-year-old adolescent? 1. If the client is allowed to give consent. 2. The client cannot make informed decisions about health care. 3. If the client is permitted to give voluntary consent when parents are not available. 4. The client probably will be unable to choose between alternatives when asked to consent.

Answer: 1. If the client is allowed to give consent. Reason: A person is legally unable to sign a consent until the age of 18 years unless the client is an emancipated minor or married. The nurse must determine the legal status of the adolescent. Although the adolescent may be capable of intelligent choices, 18 is the legal age of consent unless the client is emancipated or married. Parents or guardians are legally responsible under all circumstances unless the adolescent is an emancipated minor or married. Adolescents have the capacity to choose, but not the legal right in this situation unless they are legally emancipated or married.

A client with limited mobility is being discharged. To prevent urinary stasis and formation of renal calculi, the nurse should instruct the client to: 1. Increase oral fluid intake to 2 to 3 L per day. 2. Maintain bed rest after discharge. 3. Limit fluid intake to 1 L/day. 4. Void at least every hour.

Answer: 1. Increase oral fluid intake to 2- 3 L per day Reason: Increasing oral fluid intake to 2 to 3 L per day, if not contraindicated, will dilute urine and promote urine flow, thus preventing stasis and complications such as renal calculi. Bed rest and limited fluid intake may lead to urinary stasis and increase risk for the formation of renal calculi. Voiding at least every hour has no effect on urinary stasis and renal calculi.

A health care provider prescribes a vitamin tablet that contains vitamin B complex. What should the nurse teach the client? 1. It may turn the urine bright yellow. 2. The daily fluid intake should be increased. 3. The drug should be taken on an empty stomach. 4. It may accumulate in the body if an excessive amount is taken

Answer: 1. It may turn the urine bright yellow Reason: Bright yellow urine is an expected, insignificant side effect of vitamin B complex. There is no need to increase oral fluids

The nurse recognizes that which are important components of a neurovascular assessment? (Select all that apply.) 1. Orientation 2. Capillary refill 3. Pupillary response 4. Respiratory rate 5. Pulse and skin temperature 6. Movement and sensation

Answer: 1. Orientation 4. Respiratory Rate 5. Pulse and skin temperature Reason: A neurovascular assessment involves evaluating of nerve and blood supply to an extremity involved in an injury. The area involved may include an orthopedic and/or soft tissue injury. A correct neurovascular assessment should include evaluating of capillary refill, pulses, warmth and paresthesias, and movement and sensation. Orientation, pupillary response, and respiratory rate are components of a neurological assessment.

A nurse is obtaining a health history from the newly admitted client who has chronic pain in the knee. What should the nurse include in the pain assessment? (Select all that apply.) 1 . Pain history including location, intensity and quality of pain 2 . Client's purposeful body movement in arranging the papers on the bedside table 3. Pain pattern including precipitating and alleviating factors 4. Vital signs such as increased blood pressure and heart rate 5. The client's family statement about increases in pain with ambulation

Answer: 1. Pain history including location, intensity and quality of pain 3. Pain pattern including precipitating and alleviating factors Reason: Accurate pain assessment includes pain history with the client's identification of pain location, intensity and quality and helps the nurse to identify what pain means to the client. The pattern of pain includes time of onset, duration and recurrence of pain and it assessment helps to the nurse to anticipate and meet the needs of the client. Assessment of the precipitating factors helps the nurse to prevent the pain and determine it cause. Purposeless movements such as tossing and turning or involuntary movements such as a reflexive jerking may indicate pain. Physiological responses such as elevated blood pressure and heart rate are most likely to be absent in the client with chronic pain. Pain is subjective experience and therefore the nurse has to ask the client directly instead of accepting statement of the family members

A nurse is assisting a client to transfer from the bed to a chair. What should the nurse do to widen the client's base of support during the transfer? 1. Spread the client's feet away from each other. 2. Move the client on the count of three. 3. Instruct the client to flex the muscles of the internal girdle. 4. Stand close to the client when assisting with the move.

Answer: 1. Spread the client's feet away from each other Reason: Spreading the feet apart widens the base of support. A wide base of support lowers the center of gravity, thereby increasing stability. Counting to three does not widen the base of support. Counting to three ensures a coordinated effort on behalf of the client and nurse to affect the move, which may alleviate some of the burden borne by the nurse. Flexing the muscles of the internal girdle (contracting the gluteal muscles in the buttocks downward and the abdominal muscles upward) stabilizes the pelvis and protects the abdominal viscera when lifting, pulling, reaching, or stooping, but it does not widen the base of support. Working close to the client is not based on the principle of widening the base of support. This action brings the center of gravity close to the client being moved, permitting the muscles of the nurse's legs and arms to carry the burden of the transfer rather than the muscles of the back.

What physiological changes that occur with aging must be taken into consideration when the nurse provides care for the older adult? (Select all that apply.) 1 . Urinary urgency 2. Loss of skin elasticity 3 . Increased body warmth 4. Swallowing difficulties 5. Elevated blood pressure

Answer: 1. Urinary urgency 2. Loss of skin elasticity 4. Swallowing difficulties 5. Elevated blood pressure Reason: Weakened muscles supporting the bladder in women and enlargement of the prostate gland in men commonly cause urinary urgency and frequency in older adults. Skin elasticity decreases in older adults because of a decline in subcutaneous fat and collagen fibers, as well as thinning of the epidermis. Swallowing difficulties result from a decrease in salivary gland secretions. With aging, an increase in systolic blood pressure and a slight increase in diastolic blood pressure occur. A decrease in subcutaneous fat results in a decreased body warmth.

A client admitted to the hospital with a diagnosis of malabsorption syndrome exhibits signs of tetany. The nurse concludes that the tetany was precipitated by the inadequate absorption of which electrolyte? 1. Sodium 2. Calcium 3. Potassium 4. Phosphorus

Answer: 2. Calcium Reason: The muscle contraction-relaxation cycle requires an adequate serum calcium-phosphorus ratio

Which nursing interventions require a nurse to wear gloves? (Select all that apply.) 1 . Giving a back rub. 2. Cleaning a newborn immediately after delivery. 3. Emptying a portable wound drainage system. 4. Interviewing a client in the emergency department. 5. Obtaining the blood pressure of a client who is human immunodeficiency virus (HIV) positive

Answer: 2. Cleaning a newborn immediately after delivery 3. Emptying a portable wound drainage system Reason: Personal protective equipment (PPE) should be used because the newborn is covered with amniotic fluid and maternal blood. PPE should be used because the nurse may be exposed to blood and fluid that are contained in the portable wound drainage system. PPE is not required for a back rub

A client is admitted to the hospital for an elective surgical procedure. The client tells a nurse about the emotional stress of recently disclosing being a homosexual to family and friends. What is the nurse's first consideration when planning care? 1. Exploring the client's emotional conflict 2. Identifying personal feelings toward this client 3. Planning to discuss this with the client's family 4. Developing a rapport with the client's health care provider

Answer: 2. Identifying personal feelings toward this client Reason: Nurses must identify their own feelings and prejudices because these may affect the ability to provide objective, nonjudgmental nursing care. Exploring a client's emotional well-being can be accomplished only after the nurse works through one's own feelings. The focus should be on the client, not the family. Health team members should work together for the benefit of all clients, not just this client.

A client reports fatigue and dyspnea and appears pale. The nurse questions the client about medications currently being taken. In light of the symptoms, which medication causes the nurse to be most concerned? 1. Famotidine (Pepcid) 2. Methyldopa (Aldomet) 3. Ferrous sulfate (Feosol) 4. Levothyroxine (Synthroid)

Answer: 2. Methyldopa (Aldomet) Reason: Methyldopa is associated with acquired hemolytic anemia and should be discontinued to prevent progression and complications. Famotidine will not cause these symptoms

A client reports severe pain two days after surgery. After assessing the characteristics of the pain, which initial action should the nurse take next? 1. Encourage rest. 2. Obtain the vital signs. 3. Administer the prescribed analgesic. 4. Document the client's pain response.

Answer: 2. Obtain the vital signs Reason: Immediately before administration of an analgesic, an assessment of vital signs is necessary to determine whether any contraindications to the medication exist (e.g., hypotension, respirations ≤12 breaths/min). Pain prevents both psychological and physiological rest. Before administration of an analgesic, the nurse must check the health care provider's prescription, the time of the last administration, and the client's vital signs. A complete assessment including vital signs should be done before documenting.

A nurse provides crutch-walking instructions to a client that has a left-leg cast. The nurse should explain that weight must be placed: 1. In the axillae. 2. On the hands. 3. On the right side. 4. On the side that the client prefers

Answer: 2. On the hands Reason: Body weight should be placed on the hands and not under the arms in the axillae when a client is walking with crutches to prevent damage to the brachial plexus nerves and prevent "crutch paralysis." Placing weight in the axillae during crutch walking is incorrect. Weight during walking with two crutches should be distributed equally to both sides of the body without regard to the unaffected side or either side.

What are the desired outcomes that the nurse expects when administering a nonsteroidal antiinflammatory drug (NSAID)? (Select all that apply.) 1 . Diuresis 2 . Pain relief 3. Antipyresis 4 . Bronchodilation 5 . Anticoagulation 6 . Reduced inflammation

Answer: 2. Pain relief, 3. Antipyresis & 6. Reduced inflammation Reason: Prostaglandins accumulate at the site of an injury, causing pain

A nurse is caring for a client who has paraplegia as a result of a spinal cord injury. Which rehabilitation plan will be most effective for this client? 1. Arrangements will be made by the client and the client's family. 2. The plan is formulated and implemented early in the client's care. 3. The rehabilitation is minimal and short term because the client will return to former activities. 4. Arrangements will be made for long-term care because the client is no longer capable of self-care

Answer: 2. The plan is formulated and implemented early in the client's care. Reason: To promote optimism and facilitate smooth functioning, rehabilitation planning should begin on admission to the hospital. The client and family often are unaware of the options available in the health care system

A client has a stage III pressure ulcer. Which nursing intervention can prevent further injury by eliminating shearing force? 1. Maintain the head of the bed at 35 degrees or less. 2. With the help of another staff member, use a drawsheet when lifting the client in bed. 3. Reposition the client at least every 2 hours and support the client with pillows. 4. At least once every 8 hours, perform passive range-of-motion exercises of all extremities.

Answer: 2. With the help of another staff member, use a drawsheet when lifting the client in bed Reason: Shearing force is the pressure exerted on the skin when a debilitated client is pulled up in bed without a drawsheet, or when the client slides down in bed. With shearing, the skin adheres to the bed linens while the layers of subcutaneous tissue and bone slide in the direction of the body movements, causing a tearing of the skin. Using a drawsheet can reduce and minimize friction and shearing force. Maintaining the head of the bed at 35 degrees or less, repositioning the client at least every 2 hours and supporting with pillows, and, at least once every 8 hours, performing passive range-of-motion exercises of all extremities are all appropriate interventions to prevent further pressure injury and to promote circulation, but they are not as effective as using a drawsheet in prevention of shearing force.

A client who is HIV positive is admitted to a surgical unit after an orthopedic procedure. The nurse should institute appropriate precautions with the awareness that HIV is highly transmissible through: (Select all that apply.) 1 . feces. 2 . blood. 3 . semen. 4 . urine. 5 . sweat. 6 . tears

Answer: 2. blood 3. semen Reason: HIV, which is the virus that causes AIDS, is transmitted through infected blood, semen, and bloody body fluids. HIV is not spread casually. Although HIV may be found in other body secretions, including feces, urine, sweat, tears, saliva, sputum, and emesis, the amount of virus is likely not sufficient enough to be transmitted.

The family of an older adult who is aphasic reports to the nurse manager that the primary nurse failed to obtain a signed consent before inserting an indwelling catheter to measure hourly output. What should the nurse manager consider before responding 1. Procedures for a client's benefit do not require a signed consent. 2. Clients who are aphasic are incapable of signing an informed consent. 3. A separate signed informed consent for routine treatments is unnecessary. 4. A specific intervention without a client's signed consent is an invasion of rights.

Answer: 3. A seperate signed informed consent for routine treatments is unnecessary Reason: This is considered a routine procedure to meet basic physiological needs and is covered by a consent signed at the time of admission. The need for consent is not negated because the procedure is beneficial. This treatment does not require special consent.

A client has undergone a subtotal thyroidectomy. The client is being transferred from the post anesthesia care unit/recovery area to the inpatient nursing unit. What emergency equipment is most important for the nurse to have available for this client? 1. A defibrillator 2. An IV infusion pump 3. A tracheostomy tray 4. An electrocardiogram (ECG) monitor

Answer: 3. A tracheostomy tray Reason: The client who has undergone a subtotal thyroidectomy is at high risk for airway occlusion resulting from postoperative edema. With this in mind, emergency airway equipment such as a tracheostomy set and intubation supplies should be immediately available to the client. A defibrillator, an IV infusion pump, and an electrocardiogram (ECG) monitor are all equipment items that should be available to all postoperative clients.

What should the nurse assess to determine whether a 75-year-old individual is meeting the developmental task associated with aging? 1. Achievement of a personal philosophy 2. Adaptation to the children leaving home 3. Attainment of a sense of worth as a person 4. Adjustment to life in an assisted-living facility

Answer: 3. Attainment of a sense of worth as a person Reason: Developing and participating in meaningful activities and satisfaction with past accomplishments increase feelings of self-worth. Achievement of a personal philosophy is a task of early adulthood. Adaptation to the children leaving home is a task of middle adulthood. Adjustment to life in an assisted-living facility is not a developmental task of older adults

A nurse discusses the philosophy of Alcoholics Anonymous (AA) with the client who has a history of alcoholism. What need must self-help groups such as AA meet to be successful? 1. Trust 2. Growth 3. Belonging 4. Independence

Answer: 3. Belonging Reason: Self-help groups are successful because they support a basic human need for acceptance. A feeling of comfort and safety and a sense of belonging may be achieved in a nonjudgmental, supportive, sharing experience with others. AA meets dependency needs rather than focusing on independence, trust, and growth.

The nurse should instruct a client with an ileal conduit to empty the collection device frequently because a full urine collection bag may: 1. Force urine to back up into the kidneys. 2. Suppress production of urine. 3. Cause the device to pull away from the skin. 4. Tear the ileal conduit.

Answer: 3. Cause the device to pull away from the skin Reason: If the device becomes full and is not emptied, it may pull away from the skin and leak urine. Urine in contact with unprotected skin will irritate and cause skin breakdown. A full urine collection bag will not cause urine to back up into the kidneys, suppress the production of urine , or tear the ileal conduit

A nurse is transcribing a practitioner's orders for a group of clients. Which order should the nurse clarify with the practitioner? 1. Discharge in am 2. Blood glucose monitoring ac and bedtime 3. Erythropoietin (Procrit) 6000 units subcutaneously TIW 4. Dalteparin (Fragmin) 5000 international units Sub-Q BID

Answer: 3. Erythropoietin (Procrit) 6000 units subcutaneously TIW Reason: "TIW", indicating three times a week is an unacceptable abbreviation . It may be mistaken for "three times a day" or "twice weekly." The abbreviation "AM" for in the morning is an acceptable abbreviation. The word "discharge" must be completely spelled out instead of just "D/C" because this may be confused with "discontinue." The use of "ac" (before meals) is an acceptable abbreviation. Bedtime must be completely spelled out instead of just "hs" because "hs" may be confused with "half strength" or "every hour." The abbreviation "Sub-Q", indicating the subcutaneous route is an acceptable abbreviation. "BID," indicating twice a day, is an acceptable abbreviation. "International units" must be completely spelled out instead of just "IU" because it may be mistaken as a four.

To minimize the side effects of the vincristine (Oncovin) that a client is receiving, what type of dietary plan does the nurse expect? 1. Low in fat 2. High in iron 3. High in fluids 4. Low in residue

Answer: 3. High in fluids Reason: A common side effect of vincristine is a paralytic ileus, which results in constipation. Preventative measures include high fiber foods and fluids that exceed minimum requirements. These will keep the stool bulky and soft, thereby promoting evacuation. Low fat, high in iron, and low in residue dietary plans will not provide the roughage and fluids needed to minimize the constipation associated with vincristine.

A nurse is preparing a community health program for senior citizens. The nurse teaches the group that the physical findings that are typical in older people include: 1. A loss of skin elasticity and a decrease in libido 2. Impaired fat digestion and increased salivary secretions 3. Increased blood pressure and decreased hormone production 4. An increase in body warmth and some swallowing difficulties

Answer: 3. Increased blood pressure and decreased hormone production Reason: With aging, narrowing of the arteries causes some increase in the systolic and diastolic blood pressures

Which age-related change should the nurse consider when formulating a plan of care for an older adult? (Select all that apply.) 1 . Difficulty in swallowing 2 . Increased sensitivity to heat 3 . Increased sensitivity to glare 4 . Diminished sensation of pain 5 . Heightened response to stimuli

Answer: 3. Increased sesitivityt to glare 4. Diminished sensation of pain Reason: Changes in the ciliary muscles, decrease in pupil size, and a more rigid pupil sphincter contribute to an increased sensitivity to glare . Diminished sensation of pain may make an older individual unaware of a serious illness, thermal extremes, or excessive pressure. There should be no interference with swallowing in older individuals. Older individuals tend to feel the cold and rarely complain of the heat. There is a decreased response to stimuli in the older individual.

The nurse is caring for a client who is on a low carbohydrate diet. With this diet, there is decreased glucose available for energy, and fat is metabolized for energy resulting in an increased production of which substance in the urine? 1. Protein 2. Glucose 3. Ketones 4. Uric acid

Answer: 3. Ketones Reason: As a result of fat metabolism, ketone bodies are formed and the kidneys attempt to decrease the excess by filtration and excretion. Excessive ketones in the blood can cause metabolic acidosis. A low carbohydrate diet does not cause increased protein, glucose, or uric acid in the urine.

A nurse is caring for a client who has a Hemovac portable wound suction device after abdominal surgery. What is the reason why the nurse empties the device when it is half full? 1. Emptying the unit is safer when it is half full. 2. Accurate measurement of drainage is facilitated. 3. Negative pressure in the unit lessens as fluid accumulates, interfering with further drainage. 4. Fluid collecting in the unit exerts positive pressure, forcing drainage back up the tubing and into the wound.

Answer: 3. Negative pressure in the unit lessens as fluid accumulates, interfering with further drainage Reason: As drainage collects and occupies space, the original level of negative pressure decreases

Which drug requires the nurse to monitor the client for signs of hyperkalemia? 1. Furosemide (Lasix) 2. Metolazone (Zaroxolyn) 3. Spironolactone (Aldactone) 4. Hydrochlorothiazide (HydroDIURIL)

Answer: 3. Spironolactone (Aldactone) Reason: Spironolactone is a potassium-sparing diuretic

A client with Addison's disease is receiving cortisone therapy. The nurse expects what clinical indicators if the client abruptly stops the medication? (Select all that apply.) 1 . Diplopia 2 . Dysphagia 3. Tachypnea 4. Bradycardia 5. Hypotension

Answer: 3. Tachypnea 5. Hypotension Reason: Tachypnea occurs with Addisonian crisis because of inadequate circulating glucocorticoids and mineralocorticoids. Inadequate circulating glucocorticoids and mineralocorticoids cause hypotension, pallor, weakness, tachycardia, and tachypnea. Double vision does not occur with Addisonian crisis. Difficulty swallowing does not occur with Addisonian crisis. Tachycardia, not bradycardia, occurs with Addisonian crisis.

A client has been instructed to stop smoking. The nurse discovers a pack of cigarettes in the client's bathrobe. What is the nurse's initial action? 1. Notify the health care provider. 2. Report this to the nurse manager. 3. Tell the client that the cigarettes were found. 4. Discard the cigarettes without commenting to the client

Answer: 3. Tell the client that the cigarettes were found Reason: Honest nurse-client relationships should be maintained so that trust can develop. Although other health care team members may need to be informed eventually, the initial action should involve only the nurse and client. Discarding the cigarettes without commenting to the client does not promote trust or communication between the client and nurse.

A nurse is providing care to a client eight hours after the client had surgery to correct an upper urinary tract obstruction. Which assessment finding should the nurse report to the charge nurse or surgeon? 1. Incisional pain 2. Absent bowel sounds 3. Urine output of 20 mL/hour 4. Serosanguineous drainage on the dressing

Answer: 3. Urine output of 20 mL/hour Reason: A urinary output of 50 mL/hr or greater is necessary to prevent stasis and consequent infections after this type of surgery. The nurse should notify the surgeon of the assessment findings, as this may indicate a urinary tract obstruction. Incisional pain, absent bowel sounds, and serosanguineous drainage are acceptable assessment findings for this client after this procedure and require continued monitoring but do not necessarily require reporting to the surgeon.

The nurse plans care for a client with a somatoform disorder based on the understanding that the disorder is: 1. A physiological response to stress. 2. A conscious defense against anxiety. 3. An intentional attempt to gain attention. 4. An unconscious means of reducing stress

Answer: 4. An unconscious means of reducing stress Reason: When emotional stress overwhelms an individual's ability to cope, the unconscious seeks to reduce stress. A conversion reaction removes the client from the stressful situation, and the conversion reaction's physical/sensory manifestation causes little or no anxiety in the individual. This lack of concern is called la belle indifference. No physiological changes are involved with this unconscious resolution of a conflict. The conversion of anxiety to physical symptoms operates on an unconscious level.

A nurse reinforces teaching a client about Coumadin (warfarin) and concludes that the teaching is effective when the client states, "I must not drink: 1. apple juice. 2. grape juice. 3. orange juice. 4. cranberry juice

Answer: 4. Cranberry juice Reason: Antioxidants in cranberry juice may inhibit the mechanism that metabolizes Coumadin, causing elevations in the international normalized ratio (INR), resulting in hemorrhage. Apple juice, grape juice, and orange juice are fine to drink.

A postoperative client says to the nurse, "My neighbor—I mean the person in the next room—sings all night and keeps me awake." The neighboring client has dementia and is awaiting transfer to a nursing home. How can the nurse best handle this situation? 1. Tell the neighboring client to stop singing. 2. Close the doors to both clients' rooms at night. 3. Give the complaining client the prescribed as needed sedative. 4. Move the neighboring client to a room at the end of the hall.

Answer: 4. Move the neighboring client to a room at the end of the hall. Reason: Moving the client who is singing away from the other clients diminishes the disturbance. A client with dementia will not remember instructions. It is unsafe to close the doors of clients' rooms because they need to be monitored. The use of a sedative should not be the initial intervention.

A nurse is reviewing a plan of care for a client who was admitted with dehydration as a result of prolonged watery diarrhea. Which prescription should the nurse question? 1. Oral psyllium (Metamucil) 2. Oral potassium supplement 3. Parenteral half normal saline 4. Parenteral albumin (Albuminar)

Answer: 4. Parenteral albumin (Albuminar) Reason: Albumin is hypertonic and will draw additional fluid from the tissues into the intravascular space. Oral psyllium will absorb the watery diarrhea, giving more bulk to the stool. An oral potassium supplement is appropriate because diarrhea causes potassium loss. Parenteral half normal saline is a hypotonic solution, which can correct dehydration.

The nurse is providing information about blood pressure to Unlicensed Assistive Personnel (UAP) and recalls that the factor that has the greatest influence on diastolic blood pressure is: 1. Renal function 2. Cardiac output 3. Oxygen saturation 4. Peripheral vascular resistance

Answer: 4. Peripheral vascular resistance Reason: Peripheral vascular resistance is the impedance of blood flow, or back pressure, by the arterioles, which is the most influential component of diastolic blood pressure. Renal function through the renin-angiotensin-aldosterone system regulates fluid balance and does influence blood pressure. Cardiac output is the determinant of systolic blood pressure. Oxygen saturation does not have a direct effect on diastolic blood pressure.

An 82-year-old retired schoolteacher is admitted to a nursing home. During the physical assessment, the nurse identifies an ocular problem common to persons at this client's developmental level, which is: 1. Tropia 2 .Myopia 3. Hyperopia 4. Presbyopia

Answer: 4. Presbyopia Reason: Presbyopia is the decreased accommodative ability of the lens that occurs with aging. Tropia (eye turn) generally occurs at birth. Myopia (nearsightedness) can occur during any developmental level or be congenital. Hyperopia (farsightedness) can occur during any developmental level or be congenital.

A nurse is taking care of a client who has severe back pain as a result of a work injury. What nursing considerations should be made when determining the client's plan of care? (Select all that apply.) 1.Ask the client what is the client's acceptable level of pain. 2 . Eliminate all activities that precipitate the pain. 3 . Administer the pain medications regularly around the clock. 4 . Use a different pain scale each time to promote patient education. 5 . Assess the client's pain every 15 minutes

Answer: 1. Ask the client what is the client's acceptable level of pain & 3. Administer the pain medications regularly around the clock Reason: The nurse works together with the client in order to determine a tolerable level of pain. Considering that the client has chronic, not acute pain, the goal of the pain management is to decrease pain to a tolerable level instead of eliminating pain completely. That is an appropriate goal for acute pain. Administration of pain medications around the clock will provide a stable level of pain medication in blood and relief of pain. Elimination of all activities that precipitate the client's pain is not possible even though the nurse will try to minimize such activities. Use of the same pain scale for assessment of the client's pain level helps to ensure consistency and accuracy in the pain assessment. Only management of acute pain such as postoperative pain requires the pain assessment at the frequent intervals.

The nurse assesses an edematous client and recalls that edema occurs in what extracellular fluid compartment? 1. Interstitial 2. Intercellular 3. Intravascular 4. Intracellular

Answer: 1. Interstitial Reason: Edema is defined as the accumulation of fluid in the interstitial spaces. The incorrect answer options occur in other compartments: intercellular means between or among cells

An arterial blood gas report indicates the client's pH is 7.25, PCO2 is 35 mm Hg, and HCO3 is 20 mEq/L. Which disturbance should the nurse identify based on these results? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

Answer: 1. Metabolic acidosis Reason: A low pH and low bicarbonate level are consistent with metabolic acidosis. The pH indicates acidosis. The CO2 concentration is within normal limits, which is inconsistent with respiratory acidosis

repeat several times."

Answer: 2. "Inhale deeply through the spirometer, hold it as long as possible, and slowly exhale." Reason: The correct procedure to maximize use of an incentive spirometer is to exhale completely, then take a slow, deep breath through the spirometer, and hold it as long as possible. This procedure will maximize inspiratory function by expanding the lungs. The client should practice using the incentive spirometer before surgery. Answer options 1 and 4 are completely inaccurate procedures for using an incentive spirometer. Option 3 is partially correct but does not state to use the incentive spirometer. When teaching clients, it is important to provide exact step-by-step instructions, thus not leaving out any critical points.

When suctioning a client with a tracheostomy, an important safety measure for the nurse is to: 1. Hyperventilate the client with room air prior to suctioning. 2. Apply suction only as the catheter is being withdrawn. 3. Insert the catheter until the cough reflex is stimulated. 4. Remove the inner cannula before inserting the suction catheter.

Answer: 2. Apply suction only as the catheter is being withdrawn Reason: Use of suction upon withdrawal of a suction catheter reduces unnecessary removal of oxygen. In addition, suction should be applied intermittently during the withdrawal procedure to prevent hypoxia. A sterile catheter is used to prevent infection, and the catheter should only be inserted approximately 1 to 2 cm past the end of the trach tube to prevent tissue trauma. Hyperventilating a client before suctioning should always be with oxygen, not room air. Inserting the catheter until the cough reflex is stimulated frequently occurs and does help to mobilize secretions but is not a safety measure. Removal of the inner cannula before inserting the suction catheter is not necessary.

What clinical finding does a nurse anticipate when admitting a client with an extracellular fluid volume excess? 1. Rapid, thready pulse 2. Distended jugular veins 3. Elevated hematocrit level 4. Increased serum sodium level

Answer: 2. Distended jugular veins Reason: Because of fluid overload in the intravascular space, the neck veins become visibly distended. Rapid, thready pulse and elevated hematocrit level occur with a fluid deficit. If sodium causes fluid retention, its concentration is unchanged

A client is admitted with metabolic acidosis. The nurse considers that two body systems interact with the bicarbonate buffer system to preserve healthy body fluid pH. What two body systems should the nurse assess for compensatory changes? 1. Skeletal and nervous 2. Circulatory and urinary 3. Respiratory and urinary 4. Muscular and endocrine

Answer: 3. Respiratory and Urinary Reason: Increased respirations blow off carbon dioxide (CO2 ), which decreases the hydrogen ion concentration and the pH increases (less acidity). Decreased respirations result in CO2 buildup, which increases hydrogen ion concentration and the pH falls (more acidity). The kidneys either conserve or excrete bicarbonate and hydrogen ions, which helps to adjust the body's pH . The buffering capacity of the renal system is greater than that of the pulmonary system, but the pulmonary system is quicker to respond. Skeletal and nervous systems do not maintain the pH, nor do muscular and endocrine systems. Although the circulatory system carries fluids and electrolytes to the kidneys, it does not interact with the urinary system to regulate plasma pH.

The health care provider orders 1000 mL normal saline to be infused over 8 hours for a client with a diagnosis of dehydration. The intravenous (IV) tubing delivers 15 drops per milliliter (drop factor). The nurse should administer the IV infusion at a rate of ____ gtts/minute. Record your answer using a whole number.

Answer: 31 gtt/min

A nurse is caring for an elderly client with dementia who has developed dehydration as a result of vomiting and diarrhea. Which assessment best reflects the fluid balance of this client? 1. Skin turgor 2. Intake and output results 3. Client's report about fluid intake 4. Blood lab results

Answer: 4. Blood Lab results Reason: Blood lab results provide objective data about fluid and electrolyte status as well as about hemoglobin and hematocrit. Intake and output results provide data only about fluid balance but don't present comprehensive picture of the client's fluid and electrolyte status and therefore are not the best answer. Skin turgor is not a reliable indicator of hydration status for the elderly client because it is generally decreased with age. The client's report about fluid intake is a subjective data in general and not reliable because this client has dementia and therefore has memory problems.

What does a nurse consider the most significant influence on many clients' perception of pain when interpreting findings from a pain assessment? 1 Age and sex 2 Physical and physiological status 3 Intelligence and economic status 4 Previous experience and cultural values

Answer: 4. Previous experience and cultural values Reason: Interpretation of pain sensations is highly individual and is based on past experiences, which include cultural values. Age and sex affect pain perception only indirectly because they generally account for past experience to some degree. Overall physical condition may affect the ability to cope with stress

While receiving a preoperative enema, a client starts to cry and says, "I'm sorry you have to do this messy thing for me." What is the nurse's best response? 1. "I don't mind it." 2. "You seem upset." 3. "This is part of my job." 4. "Nurses get used to this."

Answer: 2. "You seem upset" Reason: The nurse should identify clues to a client's anxiety and encourage verbalization of feelings. Saying it is part of the job focuses on the task rather than on the client's feelings. Saying "I don't mind it" or "Nurses get used to this" negate the client's feelings and present a negative connotation

A client is scheduled for a transurethral resection of the prostate (TURP). Which statement made by the client most indicates the need for further preoperative teaching? 1. "My urine will be red after surgery." 2. "I will have a catheter after surgery." 3. "My incision will probably be painful." 4. "I will need to drink a lot after surgery."

Answer: 3. "My incision will probably be painful" Reason: The TURP procedure is performed by insertion of a scope device into the urethra to reach the prostate from within the urinary tract. No incision is made to reach the prostate, therefore the client statement about an incision being painful after surgery warrants further evaluating and teaching by the nurse. The client is demonstrating correct knowledge about the TURP procedure by stating that after surgery his urine will be red, he will have a catheter, and he will need to increase fluid intake.

The nurse should place the client in which position to obtain the most accurate reading of jugular vein distention? 1. Upright at 90 degrees 2. Supine position 3. Raised to 45 degrees 4. Raised to 10 degrees

Answer: 3. Raised to 45 degrees Reason: Jugular vein pressure is measured with a centimeter ruler to obtain the vertical distance between the sternal angle and the point of highest pulsation. This procedure is most accurate when the head of the bed is elevated between 30 and 45 degrees. The internal and external jugular veins should be inspected while the client is gradually elevated from a supine position to an upright 30-45 degrees. Jugular vein distention cannot accurately be assessed if the client is supine, at 90 degrees or 10 degrees.

The nurse is teaching a client how to administer subcutaneous (subQ) insulin injections. Which injection site would be appropriate for the client to use?

Anterior aspect of the thigh Reason: SubQ injection sites, which are relatively distant from bones and major blood vessels, include the lateral aspects of the upper arm, the anterior aspects of the thigh, and the abdomen. The deltoid, rectus femoris, and vastus lateralis are I.M. injection sites

For the past 24 hours, a client with dry skin and dry mucous membranes has had a urine output of 600 ml and a fluid intake of 800 ml. The client's urine is dark amber. These findings indicate which nursing diagnosis?

Deficient fluid volume Reason: Dark, concentrated urine, dry mucous membranes, and a urine output of less than 30 ml/hour (720 ml/24 hours) are symptoms of dehydration or Deficient fluid volume. Decreased urine output is related to fluid volume deficit, not Impaired urinary elimination. Nothing in the scenario suggests a nutritional problem. If a fluid volume excess were present, manifestations would most likely include signs of fluid overload such as edema

The nurse is examining a client with suspected peritonitis. What nursing intervention does the nurse use to elicit rebound tenderness?

Press the affected area firmly with one hand, release pressure quickly, and note any tenderness on release Reason: The nurse elicits rebound tenderness by pressing the affected area firmly with one hand, releasing pressure quickly, and noting any tenderness on release. The other options aren't used to elicit rebound tenderness

The nurse distinguishes that which assessment data will most influence a client in crisis?

Previous coping skills Reason: Coping is the process by which a person deals with problems using cognitive and noncognitive components. Cognitive responses come from learned skills

A nursing faculty is preparing a lecture on the foundation of nursing knowledge. Which framework for nursing education and clinical practice would faculty include in the lecture?

Theoretical and conceptual models Reason: Theoretical and conceptual models of nursing provide the foundation for all nursing knowledge. They also direct nursing practice based on the concepts of health, person, environment, and nursing. Scientific breakthroughs, technological advances, and medical practices may affect nursing but aren't frameworks for nursing education and practice

A client with cirrhosis is jaundiced and edematous. He's experiencing severe itching and dryness. Which intervention is best to help the client?

Use alcohol-free body lotion. Reason: Alcohol-free body lotion applied to the skin is best to help relieve dryness and is absorbed without oiliness. Mitts may help keep the client from scratching his skin open. Baby oil doesn't allow excretions through the skin and may block pores. Soap dries out the skin.

A client is admitted to the hospital with an exacerbation of chronic systemic lupus erythematosus (SLE). The client gets angry when the call bell isn't immediately answered. What would be the most appropriate response for the nurse? a) "You seem angry." b) "Calm down. You know that stress can make your symptoms worse." c) "Would you like to talk about the problem with the nursing supervisor?" d) "I can see you're angry. I'll come back when you've calmed down."

a) "You seem angry." Reason: Verbalizing the observed behavior is a therapeutic communication technique in which the nurse acknowledges what the client is feeling. Although stress can exacerbate the symptoms of SLE, telling the client to calm down doesn't acknowledge his feelings. Offering to get the nursing supervisor doesn't acknowledge the client's feelings either. Leaving the client implies that the nurse has no interest in what the client has said

A client comes to the emergency department with the complaint of chest pain. After an electrocardiogram shows an irregular heart rate of 166 beats/minute, the client is admitted to the intensive care unit. Which nursing diagnosis is the priority? a) Anxiety related to the fear death b) Impaired physical mobility related to complete bed rest c) Social isolation related to restricted family visits d) Deficient knowledge related to emergency interventions

a) Anxiety related to the fear death Reason: Anxiety related to the fear of death is a priority nursing diagnosis. Anxiety can adversely affect the client's heart rate and rhythm by stimulating the autonomic nervous system. The threat of death is an immediate and real concern for the client. The other nursing diagnoses are valid, but they aren't the priority in this situation

A client who was brought to the emergency department after a motor vehicle crash is complaining of abdominal pain. Peritoneal lavage is a diagnostic tool used to detect abdominal injuries. Which finding is a contraindication for peritoneal lavage? a) Distended bladder b) History of abdominal surgery c) Unconscious client d) Allergy to radiopaque dye

a) Distended bladder Reason: A distended bladder is an absolute contraindication for peritoneal lavage. An indwelling urinary catheter should be inserted before the procedure. Peritoneal lavage can be especially useful in an unconscious client with suspected abdominal injuries because the client is unable to report pain. History of abdominal surgery isn't a contraindication to this procedure. Peritoneal lavage involves the instillation and withdrawal of fluid from the abdominal cavity and doesn't require radiopaque dye

Which nursing action takes priority when admitting a client with right lower lobe pneumonia? a) Elevate the head of the bed 45 to 90 degrees. b) Auscultate the chest for adventitious sounds. c) Notify the physician of the client's admission. d) Obtain a sputum specimen for culture.

a) Elevate the head of the bed 45 to 90 degrees. Reason: Clients with pneumonia breathe easier in Fowler's or semi-Fowler's position because gravity facilitates diaphragmatic movement and lung expansion. The other actions are important but don't take priority

What is one disadvantage of using the rectal route for drug administration? a) It can result in incomplete drug absorption. b) It can cause orthostatic hypotension. c) It can cause rectal tears. d) It can cause hypersensitivity to the drug.

a) It can result in incomplete drug absorption. Reason: Incomplete drug absorption is a disadvantage of rectal drug administration. The drug itself, not the way in which it is administered, may cause orthostatic hypotension or hypersensitivity reactions. If inserted properly, drugs won't cause rectal tears

A nurse is administering xylometazoline nose drops to a client. Which technique is correct? a) Lie client flat on bed with head tipped back, hold bottle over nares, and deposit drops. b) Hold the dropper against the side of the nose to allow the medication to flow into the nare. c) Tip the client's head back and hold bottle over the nares to deposit drops. d) Have the client sit upright, tip the head to the side, and instill the drops.

a) Lie client flat on bed with head tipped back, hold bottle over nares, and deposit drops. Reason: The aim is to get the liquid to spread over the entire inside surface of the nose, including the upper surface. To install, have the client lay on a bed with his or her head tipped back

A LPN/LVN working in a community health center is reinforcing family needs during a disaster planning drill. What should be included in the family preparedness drill? Select all that apply. a) Prepare a package of vital records b) Plan where to park the family c) Establish a place to meet in an emergency d) Plan to transport pets to the shelter e) Have extra medications and food items for dietary requirements

a) Prepare a package of vital records c) Establish a place to meet in an emergency e) Have extra medications and food items for dietary requirements Reason: A plan for parking the vehicle is not a concern during disaster

While providing care to a married female client, the nurse notes multiple blue, purple, and yellow ecchymotic areas on her arms and trunk. When the nurse asks how she got these bruises, the client responds, "I tripped." What actions should the nurse take? Select all that apply. a) Provide the client with telephone numbers of local shelters and safe houses. b) Document the client's statement and complete a body map indicating the size, color, shape, location, and type of injuries. c) Assist the client in developing a safety plan for times of increased violence. d) Tell the client that she needs to leave the abusive situation as soon as possible. e) Contact the local authorities to report suspicions of abuse. f) Call the client's husband to arrange a meeting to discuss the situation.

a) Provide the client with telephone numbers of local shelters and safe houses. b) Document the client's statement and complete a body map indicating the size, color, shape, location, and type of injuries. c) Assist the client in developing a safety plan for times of increased violence. Reason: The nurse should objectively document her assessment findings. A detailed description of physical findings of abuse in the medical record is essential if legal action is pursued. All women suspected of being abuse victims should be counseled on a safety plan, which consists of recognizing escalating violence within the family, formulating a plan to exit quickly, and knowing the telephone numbers of local shelters and safe houses. The nurse should not report this suspicion of abuse because the client is a competent adult who has the right to self-determination. Contacting the client's husband without her consent violates confidentiality. The nurse should respond to the client in a nonthreatening manner that promotes trust, rather than ordering her to break off her relationship

this is normal and will subside." d) "You can be flexible with scheduling your albuterol treatments."

b) "You should take your pulse before and after treatment

A 2-year-old returns from surgery after a bowel resection as a result of Hirschsprung disease. A temporary colostomy is in place. Which immediate postoperative nursing intervention would have priority? a) Suction the nasopharynx frequently to remove secretions. b) Auscultate lung sounds. c) Irrigate the colostomy with 100 mL of normal saline solution. d) Change the surgical dressing.

b) Auscultate lung sounds. Reason: The immediate nursing intervention after bowel resection surgery is to evaluate pulmonary function. The surgical dressing shouldn't require changing right away. Suctioning should be performed only if the client can't maintain a patent airway. Colostomy irrigation isn't warranted.

When attempting to dislodge a foreign object from an infant's airway, the rescuer should initiate five back blows followed by what intervention? a) A blind sweep of the airway b) Five chest thrusts c) Five abdominal thrusts d) Five ventilations

b) Five chest thrusts Reason: To dislodge a foreign object from an infant's airway, the rescuer should support the child's head, keeping it lower than the trunk. The infant should then be placed supine on the rescuer's thigh. Next, five quick thrusts should be administered in rapid succession in the same location as external chest compressions used in cardiopulmonary resuscitation. Back blows and chest compressions should be continued until the object is dislodged. A blind sweep of the airway should never be performed on children. Abdominal thrusts are recommended for children over age 1. Ventilations would be useless because the airway is obstructed.

A client on an inpatient psychiatric unit at a community mental health center is pacing the hallway and appears agitated. When a nurse approaches, the client says loudly, "Leave me alone." Which response by the nurse would be best? a) Say "okay" and walk away. b) Say, "You sound upset. I'd like to help." c) Summon help in case the client becomes aggressive. d) Say nothing and pace with the client.

b) Say, "You sound upset. I'd like to help." Reason: Telling the client on an inpatient psychiatric unit at a community mental health center that he sounds upset and that the nurse would like to help demonstrates concern and encourages the client to discuss his feelings. Given the likelihood of an increase in anxiety level, the client shouldn't be left alone. Summoning help would probably escalate the client's anxiety. Saying nothing and pacing with the client doesn't acknowledge the client's emotional state.

A nurse is caring for a client who's unconscious. In which position should the nurse place the client? a) Prone with his knees sharply flexed b) Side-lying with the head of the bed elevated c) Flat on his back with his head turned to the side d) Trendelenburg position with his body in straight alignment

b) Side-lying with the head of the bed elevated Reason: Positioning the unconscious client on his side, with the head of the bed elevated, reduces the risk of airway occlusion by the tongue and aids the drainage of secretions. The other positions place the unconscious client at risk for aspiration.

The nurse is caring for four clients on a medical surgical unit. Which interaction between the nurse and a client is the best example of the nurse using the ethical principle of fidelity? a) A client on a hospice unit asked the nurse, "Am I going to die?" The nurse said no. b) The client asked for information regarding a new medication. The nurse provided written instructions. c) The nurse states returning in 10 minutes with medication for the client but forgot to return by the end of the shift. d) The client refused pain medication and the nurse documented that the client refused.

b) The client asked for information regarding a new medication. The nurse provided written instructions. Reason: Fidelity refers to faithfulness to agreement. The nurse forgetting to return is not fidelity. Returning to the client with the said information, even in printed form, is fidelity. The nurse was faithful to the agreement between the nurse and the client. The client refusing pain medication and the nurse documenting it signifies autonomy. A client in a hospice facility is there to die with dignity and free of pain. The nurse saying no to the question about death is against the ethical principle of veracity. If the nurse did not know, the client should be told that.

Before preparing a client for surgery, a nurse assists in developing a teaching plan. What's the primary purpose of preoperative teaching? a) To explain the risks and obtain informed consent b) To reduce the risk of postoperative complications c) To determine if the client is psychologically ready for surgery d) To express concerns to the client about the surgery

b) To reduce the risk of postoperative complications Reason: Preoperative teaching helps reduce the risk of postoperative complications by telling the client what to expect and providing an opportunity to practice before surgery any postoperative activities that may be required, such as breathing and leg exercises. The physician, not the nurse, is responsible for determining the client's psychological readiness. It's inappropriate for the nurse to express personal concerns about surgery to a client. The physician should describe alternative treatments and explain the risks of surgery to the client when obtaining informed consent

A nurse is teaching a client how to use transcutaneous electrical nerve stimulation (TENS) to manage pain. Which client statement indicates an accurate understanding of its use? a) "It's okay to increase the unit's amplitude as rapidly as needed." b) "I'll leave the TENS unit on while I take a shower." c) "If I have a headache, nausea, or unpleasant sensations, I'll use my troubleshooting techniques." d) "I should clean the unit every 24 hours by soaking it in water for 5 to 10 minutes."

c) "If I have a headache, nausea, or unpleasant sensations, I'll use my troubleshooting techniques." Reason: By identifying symptoms that require troubleshooting, the client demonstrates that teaching has been effective. The client should remove the TENS unit before bathing or showering to prevent electrical shock. The client should increase the amplitude slowly to reach the necessary level without exceeding it. The client should clean the unit like any other small electrical appliance and avoid submerging it in water to prevent damage.

An elderly client with Alzheimer disease begins supplemental feedings through a gastrostomy tube to provide adequate calorie intake. What should the nurse be most concerned about with this client? a) Constipation b) Hypoglycemia c) Aspiration d) Fluid volume excess

c) Aspiration Reason: Of the options listed, aspiration is the most serious potential complication of tube feedings. Dehydration, not fluid volume excess, is a concern because of decreased free water intake. Hyperglycemia, not hypoglycemia, is a complication secondary to carbohydrate load of enteral feeding solutions. Constipation is a problem, but it usually isn't a serious one. The client would most likely experience diarrhea

A bed-confined client with an indwelling catheter informs the nurse of having discomfort in the lower abdomen. What is the first action by the nurse? a) Irrigate the catheter. b) Remove the catheter and reinsert another. c) Check to see if the catheter is kinked. d) Obtain a urine specimen to see if the client has a urinary tract infection.

c) Check to see if the catheter is kinked. Reason: The catheter should be checked for kinks. The catheter may have become occluded while lying in the bed or underneath the client's legs. There is no indication that the catheter should be removed and reinserted

A client with coronary artery disease reports intermittent chest pain that occurs with exertion. The physician prescribes sublingual nitroglycerin. When teaching the client about nitroglycerin administration, the nurse should include which instruction? a) "Make sure you replace your nitroglycerin tablets every 6 months to ensure potency." b) "Leave two nitroglycerin tablets on the bedside table to take if chest pain occurs at night." c) "When you experience chest pain, take one tablet every 30 minutes until the pain is relieved." d) "Take nitroglycerin with caution because it may cause dizziness."

d) "Take nitroglycerin with caution because it may cause dizziness." Reason: The client should use caution when taking nitroglycerin because it commonly causes orthostatic hypotension and dizziness. To ensure potency, the client should store nitroglycerin in a tightly closed container in a cool, dark place. The client shouldn't leave nitroglycerin tablets open on the bedside table. The client should replace the tablets every 3 months. The client should take a sublingual nitroglycerin tablet at the onset of chest pain and repeat the dose every 5 to 10 minutes, for up to three doses. If this doesn't relieve chest pain, the client should seek immediate medical attention.

The nurse is admitting a patient who is a suspected victim of domestic abuse. Which action(s) should the nurse take? Select all that apply. a) Refer the patient to a substance abuse program. b) Consult with social services for temporary assistance. c) Question the patient regarding barriers to leaving the situation. d) Assess the patient's readiness to leave. e) Assess the patient's knowledge of available resources.

d) Assess the patient's readiness to leave. e) Assess the patient's knowledge of available resources. Reason: Victims of domestic violence must be assessed for their readiness to leave the perpetrator and their knowledge of the resources available to them. Nurses can then provide the victims with information and options to enable them to leave when they are ready. Regarding the other answer options: The reasons that victims stay in the relationship are complex and can be explored at a later time, and the use of drugs or alcohol is irrelevant

A nurse is caring for a client who had a stroke. Which nursing intervention can help prevent contractures in the client's lower legs? a) Apply slippers to the feet. b) Keep the heels off the mattress. c) Turn the client every 2 hours. d) Attach braces or splints to each foot and leg.

d) Attach braces or splints to each foot and leg. Reason: Attaching a brace or a splint to each foot and leg prevents footdrop (a lower leg contracture) by supporting the feet in proper alignment in the client who has had a stroke. Slippers can't prevent footdrop because they're too soft to support the ankle joints. Turning the client every 2 hours and keeping the heels off the mattress prevent skin breakdown, not contractures.

An unlicensed assistive personnel (UAP) is observed leaving the room of a client in isolation. The nurse recognizes the UAP is following proper technique when he or she removes which protective equipment first? a) Mask b) Cap c) Gown d) Gloves

d) Gloves Reason: When leaving an isolation room, the health care practitioner should remove the gloves first because they're considered the most contaminated. Removing other protective equipment before removing the gloves and washing hands could cause contamination of the hair and uniform and promote pathogen transmission

A nurse is teaching a client with pernicious anemia who requires vitamin B12 replacement therapy. Which statement indicates that the client understands the treatment program? a) "I'll need only daily injections of vitamin B12 until my blood count improves." b) "I'll take a vitamin B12 tablet once each month for life." c) "I'll take one vitamin B12 tablet every morning for 2 weeks." d) "I'll need an injection of vitamin B12 every month for life."

d) I'll need an injection of vitamin B12 every month for life." Reason: In pernicious anemia, the gastric mucosa doesn't secrete intrinsic factor, a protein necessary for vitamin B12 absorption. Without intrinsic factor, vitamin B12 replacements taken orally aren't absorbed

In which position does the nurse place the client when administering an intramuscular (I.M.) injection into a client's left vastus lateralis muscle? a) Lying on the right side b) Lying on the stomach c) Lying on the left side d) Lying supine

d) Lying supine Reason: To administer an I.M. injection into the vastus lateralis muscle, the nurse should position the client lying flat on the back (supine) or sitting upright to allow access to the muscle in the thigh. Lying on the stomach would allow access to the ventrogluteal or dorsogluteal site. Lying on the left or right side would allow access to the ventrogluteal site

Before clients can learn, they must believe that they need to learn the information. The nurse recognizes that this is an example of which learning principle? a) Initiative b) Maturation c) Motivation d) Relevance

d) Relevance Reason: Clients are more receptive and ready to learn if they believe that information being presented is real and relevant to them

A school nurse is examining a student at an elementary school. Which finding would lead the nurse to suspect impetigo? a) Red spots with a blue base found on the buccal membranes b) Small, red lesions on the trunk and in the skinfolds c) A discrete, pink-red, maculopapular rash that starts on the head and progresses down the body d) Vesicular lesions that ooze, forming crusts on the face and extremities

d) Vesicular lesions that ooze, forming crusts on the face and extremities Reason: Impetigo starts as papulovesicular lesions surrounded by redness. The lesions become purulent and begin to ooze, forming crusts. Impetigo occurs most often on the face and extremities. Small, red lesions on the trunk and in the skinfolds are characteristic of scarlet fever. A discrete, pink-red, maculopapular rash that starts on the face and progresses down to the trunk and extremities is characteristic of rubella (German measles). Red spots with a blue base found on the buccal membranes, known as Koplik spots, are characteristic of measles (rubeola).

Two days after undergoing a total abdominal hysterectomy, a client complains of left calf pain, and venography reveals deep vein thrombosis (DVT). When checking this client, the nurse is most likely to detect: a) loss of hair on the lower portion of the left leg. b) pallor and coolness of the left foot. c) a decrease in the left pedal pulse. d) left calf circumference 1" (2.5 cm) larger than the right.

d) left calf circumference 1" (2.5 cm) larger than the right. Reason: Signs of DVT include inflammation and edema in the affected extremity, causing its circumference to exceed that of the opposite extremity. Pallor, coolness, decreased pulse, and hair loss in an extremity signal interrupted arterial blood flow, which doesn't occur in DVT

The home health nurse is completing the admission paperwork for a new client diagnosed with osteomyelitits who will be receiving home service intravenous therapy for the next month. The client is 32 years old and happily married. Which of the following findings will warrant further investigation? Select all that apply. a) The client voices concerns about recovering quickly so that she might return back to work in the next month. b) The client is talkative about her spouse and children. c) The client reports having many hobbies and interests outside of the home. d) The client spends a great deal of time reflecting back on her teen years. e) The client talks repeatedly about her death.

e) The client talks repeatedly about her death. d) The client spends a great deal of time reflecting back on her teen years. Reason: At age 32, the client is in the middle adult stage of life. Her repeated discussions about death and reflections back on life aren't appropriate or expected for this stage of development and should be investigated further. An interest in civic responsibilities and the establishment of hobbies is expected. During this developmental period, the greatest concern typically relates to establishing gainful employment and significant relationships. This is being demonstrated by the client's willingness to discuss her spouse and children

After intentionally taking an overdose of hydrocodone, a client is admitted to the emergency department. Activated charcoal is prescribed. Before administering the drug, the nurse should ensure that the client:

has audible bowel sounds. Reason: Activated charcoal binds to the ingested drug and is eliminated in the stool. Therefore, the client should have audible bowel sounds before the drug is given. Being able to follow commands isn't required

The nurse is caring for a 40-year-old client admitted with an acute myocardial infarction. Which behavior by the client indicates adult cognitive development?

Generates new levels of awareness Reason: Adults ages 31 to 45 generate new levels of awareness. Having perceptions based on reality and assuming responsibility for actions indicate socialization development — not cognitive development. Demonstrating maximum ability to solve problems and learning new skills occur in young adults ages 20 to 30

The licensed practical nurse is admitting a client to the medical-surgical floor. She asks the client if he has an advance directive. The client responds by saying, "I don't know what you mean." How should the nurse respond?

"An advance directive is a document that states your wishes about health care." Reason: An advance directive is a written document that states a client's health care wishes should certain conditions occur. The document includes wishes regarding withdrawing treatment, resuscitation measures, life support, and end-of-life care. The other answer options might be included in a last will and testament

A nurse is caring for a terminally ill client. Place the following five stages of death and dying described by Elisabeth Kübler-Ross in the order in which they occur

Denial and isolation Anger Bargaining Depression Acceptance

A client has a nursing diagnosis of Risk for injury related to adverse effects of potassium-wasting diuretics. What is a correctly written client outcome for this nursing diagnosis?

"Before discharge, the client correctly identifies three potassium-rich food sources." Reason: A client outcome must be measurable, objective, concise, realistic for the client, and attainable through nursing management. For each client outcome, the nurse should include only one client behavior, should express that behavior in terms of client expectations, and should indicate a time frame. Knowing the importance of consuming potassium-rich foods and knowing which foods are high in potassium aren't measurable. Understanding all complications isn't measurable or specific to the nursing diagnosis listed

A 2-year-old male child is admitted through the emergency department with a suspected diagnosis of Hirschsprung disease (aganglionic megacolon). The child's mother asks about treatment of the disease. What would be an appropriate response from the nurse?

"He'll have a temporary colostomy

A 10-year-old male with sickle cell anemia continues to wet the bed at night. He feels frustrated about this and is too embarrassed to sleep over at a friend's house. Which statement from the nurse would be most appropriate?

"We can try a bladder training program." Reason: About half of all children with sickle cell anemia have problems with enuresis because the kidneys are damaged and can no longer concentrate urine. Bladder training programs may improve the situation. Restricting fluids in someone with sickle cell anemia can lead to a vasoocclusive crisis. Suggesting that friends sleep over at the child's house doesn't show an understanding of his feelings

A client who sustained a head injury in a motor vehicle accident is prescribed phenytoin liquid to prevent seizures. The client is unable to take anything by mouth and has a feeding tube in place for enteral feedings. Which intervention by the nurse is most appropriate when administering phenytoin to this client?

Administering the phenytoin 2 hours before or 2 hours after beginning the tube feedings Reason: Enteral nutrition therapy may reduce orally administered phenytoin concentrations. Therefore, the nurse should give phenytoin 2 hours before starting enteral feeding or 2 hours after stopping enteral feeding. It isn't necessary to have the dose administered I.V. Bleeding complications can occur if the client is receiving warfarin in conjunction with phenytoin, but there's nothing in this scenario to indicate that the client is receiving warfarin

The physician orders an intramuscular (I.M.) injection for a client. The nurse knows which factor may affect the drug absorption rate from an I.M. injection site?

Blood flow to the injection site Reason: Blood flow to the I.M. injection site affects the drug absorption rate. Muscle tone and strength have no effect on drug absorption. The amount of body fat at the injection site may help determine the size of the needle and the technique used to localize the site

A client who suffered a head injury is in a rehabilitation center receiving 30 mL of aluminum hydroxide through a nasogastric tube every 4 hours because of his increased risk for a stress ulcer. Which potential adverse effect should the nurse monitor for with this client?

Constipation Reason: Constipation is a potential adverse effect of antacids that contain aluminum. Urine retention, nausea, and vomiting aren't adverse effects of aluminum hydroxide. Diarrhea occurs with the use of magnesium-containing antacids

A nurse is explaining how to measure blood pressure in a client who has lymphedema in both arms and requires blood pressure measurement using a thigh cuff. In reference to the client's baseline arm blood pressure, what information would the nurse expect to find when utilizing the thigh?

Higher systolic blood pressure reading Reason: Systolic readings in the thigh may be 10 to 40 mm Hg higher than in the arm. Diastolic readings are the same in the arm and thigh.

A female client who recently had a colostomy expresses concerns about her sexual relationship with her husband. Which intervention is the most appropriate?

Inviting a client with a similar experience to speak with the client Reason: Having someone who has had a similar surgery and concerns speak to the client would be beneficial. The client is coping normally and doesn't need professional help via psychiatrist or sex therapist at this time. Discussing the concerns with the client's husband doesn't address the client's needs

A nurse is caring for a client who was admitted with an acute head injury. The client has stabilized and is ready to begin rehabilitation. When transferring the client from his bed to a chair, what should the nurse do to ensure client safety?

Lock the brakes on the bed Reason: Locking the wheels of the bed (and wheelchair, if one is used) helps to prevent the bed (and chair) from sliding away, thus preventing injuries. The side rail on the side of the bed where the nurse is standing should be lowered to facilitate the transfer. Positioning the chair alongside the bed, rather than 2 feet away, helps the client to pivot into the chair. The nurse should place shoes or slippers with nonskid soles on the client's feet to help prevent slipping during the transfer

Which aspect of drug therapy is most important when planning nursing care for an elderly client?

Noncompliance Reason: Noncompliance in older clients is so prevalent that most nurses consider it a top priority when planning nursing care. An undesired drug action is a factor that can make it harder for the client to remain compliant, but the issue of compliance is a higher priority overall. Elderly clients commonly require reduced drug dosages

When auscultating a client's abdomen, the nurse detects high-pitched gurgles over the lower right quadrant. Based on this finding, how would the nurse describe this to the client?

Nothing abnormal Reason: High-pitched gurgles are a normal finding. Decreased bowel motility causes two or three bowel sounds per minute

A nurse discovers that a stat dose of potassium chloride that was prescribed by the physician was never administered. Which action should the nurse take

Notify the charge nurse so she can notify the physician of the missed dose. Reason: An error was made that needs to be addressed by notifying the charge nurse. The charge nurse should then notify the physician to determine if the medication is still appropriate for the client, and then request the medication from the pharmacy if it's still needed. The physician might order a potassium level to see if the dose is sufficient for the client. It isn't appropriate to ask the client if the medication is still needed. After the charge nurse and physician have been notified, the nurse should document the incident according to facility policy

What is the first action that a nurse should take after accidentally failing to administer an ordered medication?

Notify the prescriber, nursing supervisor, and pharmacist. Reason: When a nurse has accidentally omitted an ordered medication, she should first notify the prescriber, nursing supervisor, and pharmacist. She should then document the omission and the reason in the client's chart and, depending on facility policy, write an incident report. The nurse shouldn't give an extra dose at the next scheduled time because adverse reactions or toxicity could occur

A client admitted to the hospital with a suspected diagnosis of hepatitis B is jaundiced and complains of weakness. Which intervention should the nurse include in the client's care plan

Rest periods after small, frequent meals Reason: Rest periods and small, frequent meals are necessary for clients suspected of having hepatitis B and complaining of weakness. A diet high in protein is recommended to enhance the recovery of injured liver cells. The client is likely to need some guidance in menu selection. Choices can be made from high-protein foods. Regular exercise is too draining for a client with hepatitis B

The nurse is preparing to boost a client up in bed. She instructs the client to use the overbed trapeze. Which risk factor for pressure ulcer development is the nurse reducing by instructing the client to move in this manner?

Shearing forces Reason: Using a trapeze reduces shearing forces (opposing forces that cause layers of skin to move over each other, stretching and tearing capillaries and, eventually, resulting in necrosis), which increase the risk of pressure ulcer development. They can occur as clients slide down in bed or when they're pulled up in bed. To reduce shearing forces, the nurse should instruct the client to use an overbed trapeze, place a draw sheet under the client to move the client up in bed, and keep the head of the bed no higher than 30 degrees. The risks of friction, impaired circulation, and localized pressure aren't decreased with trapeze use

A female client taking antidepressant medication complains to the nurse that she has a decreased desire for sex, which is causing significant marital stress. Which response by the nurse would be the most appropriate? a) "What are your thoughts on how you should handle this?" b) "Doesn't your husband understand the importance of your medication?" c) "Have you discussed this with your physician?" d) "Don't stop taking the medication."

a) "What are your thoughts on how you should handle this?" Reason: Encouraging the client to verbalize her thoughts will help her to problem-solve. Telling her not to stop taking the medication is too directive and doesn't encourage exploration on the part of the client. Asking the client if her husband understands the importance of taking the medication conveys negative judgment. Asking if the client has discussed the issue with her physician might be appropriate, but it may also give the impression that the nurse doesn't want to discuss the problem with the client.

The nurse is assessing the psychosocial status of a postpartum client. Which statement indicates that the mother is likely to have a successful parent-neonate attachment? a) "My previous experience was so awesome!" b) "I want to lie skin to skin with my baby for as long as possible after delivery." c) "Bonding is important to my baby's development." d) "I want to bond with my baby right away."

b) "I want to lie skin to skin with my baby for as long as possible after delivery." Reason: Sustained parent-neonate contact immediately after delivery is most likely to promote parent-neonate attachment. The first period of neonatal reactivity, which occurs during the first hour after delivery, is the ideal time for behavior that promotes attachment, such as touching, holding, talking, examining, and breast-feeding. Although parental desire to bond and understanding of the importance of bonding can contribute to parent-neonate attachment, early contact is a prerequisite. A previous positive childbirth experience may enhance parent-neonate attachment but is less crucial than sustained contact immediately after delivery

The nurse is caring for a client who underwent internal fixation of the right hip. Before administering the client's warfarin, the nurse checks the laboratory report for the client's International Normalized Ratio (INR) results. Which of the following indicates the therapeutic range for this client? a) 1.0 to 2.0 b) 2.0 to 3.0 c) 1.5 to 2.0 d) 3.0 to 4.0

b) 2.0 to 3.0 Reason: Recent guidelines recommend an INR of 2.0 to 3.0 for clients without mechanical prosthetic heart valves who are receiving warfarin therapy. For clients with mechanical prosthetic heart valves, an INR of 2.5 to 3.5 is suggested. An INR below 2.0 is subtherapeutic with warfarin therapy. An INR above 3.0 in a client without a prosthetic valve indicates the need to reduce the warfarin dose.

A client had a laxative prescribed that acts by causing stool to absorb water and swell. Which term describes this type of laxative? a) Emollient b) Bulk-forming c) Stimulant d) Lubricant

b) Bulk-forming Reason: Bulk-forming laxatives cause stool to absorb water and swell. Emollients lubricate stool; lubricants soften stool, making it easier to pass. Stimulants promote peristalsis by irritating the intestinal mucosa or stimulating nerve endings in the intestinal wall

The emergency department nurse obtains laboratory test results for a newly admitted client. Which result should she report to the physician immediately? a) Alanine aminotransferase level of 45 IU/L b) Cardiac troponin I level of 3.0 mcg/L c) Alkaline phosphatase level of 70 IU/ml d) Creatinine level of 1.1 mg/dl

b) Cardiac troponin I level of 3.0 mcg/L Reason: The nurse should immediately report the cardiac troponin I level of 3.0 mcg/L, which indicates cardiac damage. The alanine aminotransferase, alkaline phosphatase, and creatinine levels are within normal limits and don't require reporting

A nurse is preparing to administer oral doxycycline to a client. What is the nurse's appropriate action? a) Administer with an antacid. b) Administer with food. c) Administer with milk. d) Administer with full glass of water.

d) Administer with full glass of water. Reason: Doxycycline should be given with a full glass of water on an empty stomach. It should not be taken with milk or within 2 hours of antacid administration.

Vasodilation or vasoconstriction produced by an external cause will interfere with an accurate assessment of a client with peripheral vascular disease (PVD). Therefore, the nurse should:

keep the client warm Reason: The nurse should keep the client covered and expose only the portion of the client's body that is being assessed. The nurse should also keep the client warm by maintaining the room temperature between 68° F and 74° F (20° to 23.3° C). Extreme temperatures aren't good for clients with PVD because the valves in their arteries and veins are already insufficient and exposing them to vast changes in temperature could influence the client's response. A room temperature of 78° F may be too warm for some clients and too cool for others. Keeping the client uncovered would lead to chilling. Matching the room temperature with the client's body temperature is inappropriate

An adult client who is receiving warfarin asks the nurse if there is anything to worry about while on this medication. What are the nurse's best responses? Select all that apply.

• Do not increase your intake of green leafy vegetables. • Use a soft toothbrush for cleaning your teeth. • You will need to have your blood drawn for laboratory examination frequently. Reason: Green leafy vegetables contain vitamin K, which can act as an antidote for warfarin. A soft toothbrush will not injure the gums and lead to bleeding. Aspirin will increase the risk of bleeding and should not be used with warfarin. Blood work is needed frequently to monitor the PT level and to titrate warfarin to prevent bleeding. An antibiotic may be needed for dental work, but this has nothing to do with warfarin. A client on warfarin who needs dental work must notify the dentist and may need to stop the medication before dental surgery

A nurse is caring for a client with otosclerosis who's scheduled for stapedectomy. The client asks the nurse when his hearing will improve. Which response by the nurse is most appropriate?

"It might take as long as 6 weeks for your hearing to improve." Reason: After stapedectomy, hearing improvement can take as long as 6 weeks to occur. Hearing might initially worsen after surgery because of swelling and fluid accumulation in the ear. The client might not notice any improvement in the first 2 weeks after surgery

The nurse is preparing to provide contraceptive counseling for a young client. What should the nurse plan to do first? a) Perform a complete physical assessment of the client. b) Explore her own personal beliefs and feelings about contraception. c) Help determine the most appropriate contraceptive method for the client. d) Obtain a thorough health history from the client.

b) Explore her own personal beliefs and feelings about contraception. Reason: The nurse must first explore her own personal beliefs and feelings about contraception to detect biases

A nurse is caring for a client with multiple myeloma. What is a sign that a client with multiple myeloma isn't coping well with his prognosis? a) He shows concern about his family during his treatment. b) He avoids any conversation concerning his health. c) He becomes tearful when discussing his condition. d) He asks questions about his prognosis.

b) He avoids any conversation concerning his health. Reason: A client with multiple myeloma who avoids conversation may be denying his condition, which can interfere with treatment. Crying is a normal response to his disease. Asking questions about his prognosis is a normal coping response, as is showing concern for his family.

A client is admitted to the inpatient unit of a mental health center with a diagnosis of paranoid schizophrenia. He's shouting that the government of France is trying to assassinate him. Which response by the nurse would be most appropriate? a) "I don't think this is true. You are safe here, but you must feel frightened by this." b) "A foreign government is trying to kill you? Please tell me more about it." c) "You're wrong. Nobody is trying to kill you." d) "I think you're wrong. France is a friendly country and an ally of the United States. Their government wouldn't try to kill you."

a) "I don't think this is true. You are safe here, but you must feel frightened by this." Reason: The nurse's responses should focus on reality while acknowledging the client's feelings. Telling the client that he is safe but must feel frightened is appropriate. Arguing with the client or denying his belief isn't therapeutic. Arguing can also inhibit development of a trusting relationship. Continuing to talk about delusions may aggravate the client's psychosis. Asking the client if a foreign government is trying to kill him may increase his anxiety level and can reinforce his delusions.

A client has a prescription for a low-fat diet. When reviewing the client's food diary, which food items would the nurse suggest the client to eliminate from the diet? Select all that apply. a) Milk chocolate b) cream cheese c) broiled haddock d) beef sausage e) broccoli

a) Milk chocolate b) Cream cheese d) Beef sausage Reason: Creamed cheese, processed meats (beef sausage), and chocolate are high in fats. Fruits and vegetables (broccoli) and broiled haddock are low in fats.

The nurse is reviewing the medication administration record (MAR) in preparation for medication administration. Which of the following orders should the nurse question?

acetaminophen 650 mg PO as needed Reason: The acetaminophen order does not have a time frame and therefore is not safe. The way the order is written can cause a client to overdose. All the other prescriptions have all the required information for accurate medication administration.

A client is prescribed misoprostol (Cytotec) for treatment of a gastric ulcer. The nurse should be alert for which common dose-related adverse reaction? a) Nausea b) Diarrhea c) Bloating d) Vomiting

b) Diarrhea Reason: Misoprostol commonly causes diarrhea. This reaction is usually dose-related. Nausea and vomiting are adverse reactions that might be associated with misoprostol administration, but they're uncommon. Bloating isn't an adverse reaction to misoprostol.

and restlessness. Which action should the nurse take first? a) Calculate the client's fluid balance. b) Place the client in high Fowler position. c) Notify the physician. d) Check the client's blood pressure.

b) Place the client in high Fowler position. Reason: High Fowler position position can help reduce venous return to the heart and also decrease lung congestion. Checking the client's blood pressure is important but doesn't take top priority. Calculating the client's fluid balance wouldn't be an immediate priority in an emergency. The physician should be notified after the client has been repositioned and evaluated

A nurse is caring for a mother whose infant has died. The mother tells the nurse that she's angry at God for taking away her child. She has vowed never again to go to church or pray. Which nursing diagnosis is most appropriate? a) Powerlessness b) Spiritual distress c) Ineffective coping d) Ineffective denial

b) Spiritual distress Reason: The mother's expression of anger toward God is an indication of spiritual distress. Expressions of anger are a normal part of the grieving process and don't indicate ineffective coping. Although the mother may indeed be experiencing feelings of powerlessness, this diagnosis isn't the most accurate one given the evaluation data. The mother shows no signs of denial.

A female client who had pelvic surgery 2 weeks ago is readmitted to the facility with a warm, tender, reddened area on her right calf. Which of the following contributing factors would the nurse recognize as most important? a) Recent pelvic surgery b) An active daily walking program c) History of increased aspirin use d) A history of diabetes

a) Recent pelvic surgery Reason: The client shows signs of deep vein thrombosis (DVT). The pelvic area is rich in blood supply, and thrombophlebitis of the deep veins is associated with pelvic surgery. Aspirin, an antiplatelet agent, and an active walking program help decrease the client's risk of DVT. In general, diabetes is a contributing factor associated with peripheral vascular disease

A nurse is planning care for a client with Ménière disease. Which nursing diagnosis takes highest priority? a) Risk for injury related to vertigo b) Imbalanced nutrition related to nausea and vomiting c) Acute pain related to Ménière disease d) Risk for deficient fluid volume related to vomiting

a) Risk for injury related to vertigo Reason: Vertigo, the hallmark finding in Ménière disease, is a severe rotational whirling sensation that typically causes the client to fall when attempting to stand or walk. Because client safety is paramount, the nursing diagnosis of Risk for injury related to vertigo takes priority. Ménière disease doesn't cause pain. Although nausea and vomiting can lead to inadequate nutrition and fluid loss, these problems aren't as important as client safety

The nurse is collecting data on a 47-year-old client who has come to the physician's office for his annual physical. The nurse should keep in mind that one of the first physical signs of aging is: a) failing eyesight, especially close vision. b) having more frequent aches and pains. c) accepting limitations while developing assets. d) increasing loss of muscle tone.

a) failing eyesight, especially close vision. Reason: Failing eyesight, especially close vision, is one of the first signs of aging in middle life (ages 46 to 64). More frequent aches and pains begin in the early late years (ages 65 to 79). Increasing loss of muscle tone occurs in later years (ages 80 and older). Accepting limitations while developing assets is an example of socialization development that occurs in adulthood (ages 31 to 45)

A client begins taking haloperidol. After a few days, he experiences severe tonic contractures of muscles in the neck, mouth, and tongue. The nurse should recognize this as: a) akathisia. b) psychotic symptoms. c) dystonia. d) parkinsonism.

c) dystonia Reason: These symptoms describe dystonia, which commonly occurs after a few days of treatment with haloperidol. The symptoms may be confused with psychotic symptoms and misdiagnosed. Parkinsonism results in muscle rigidity, shuffling gait, stooped posture, flat-faced affect, tremors, and drooling. Signs and symptoms of akathisia are restlessness, pacing, and inability to sit still

A nurse is caring for a client with advanced cancer. After reading the nursing note below, determine the nurse's next intervention. Progress notes: 1/7/10, 1545 Pt. states, "The doctor says my chemotherapy isn't working anymore. They can only treat my symptoms now. I don't want to die in the hospital, I want to be in my own bed." R. Daly, RN a) Tell the client that only in the hospital can he receive adequate pain relief. b) Reread the Patient's Bill of Rights to the client. c) Call the client's spouse to discuss the client's statements. d) Explain the use of an advance directive to express the client's wishes.

d) Explain the use of an advance directive to express the client's wishes. Reason: An advance directive is a legal document used as a guideline for life-sustaining medical care of a client with an advanced disease or disability who can no longer indicate his own wishes. This document can include a living will, which instructs the health care provider to administer no life-sustaining treatment, and a durable power of attorney for health care, which names another person to act on the client's behalf for medical decisions if the client can't act for himself. The Patient's Bill of Rights doesn't specifically address the client's wishes regarding future care. Calling the spouse is a breach of the client's right to confidentiality. Stating that only a hospital can provide adequate pain relief in a terminal situation demonstrates inadequate knowledge of the resources available in the community through hospice and home care agencies in collaboration with the client's health care provider

A licensed practical nurse (LPN/LVN) is working with the RN in verifying a heparin IV infusion rate. The prescribed dose is 400 units of heparin per hour. The heparin is in a solution of 5,000 units/100 mL NS. How many milliliters per hour should the pump be set?

8 ml/hr

A nurse is caring for a client who's receiving a lumbar epidural anesthetic block to control labor pain. What should the nurse do to prevent hypotension?

Ensure adequate hydration before the anesthetic is administered Reason: For the client in a state of relative hypovolemia, administering I.V. fluids before the epidural anesthetic is given may prevent hypotension. An epidural anesthetic may lead to hypotension because blocking the sympathetic fibers in the epidural space reduces peripheral resistance. Ephedrine may be administered after an epidural block if a client becomes hypotensive and shows evidence of cardiovascular decompensation

A geriatric client has experienced several adverse drug reactions. What does the nurse recognize that this client may benefit from? a) Increased drug doses at longer intervals b) Frequent visits to the physician c) Reduced drug dosages d) Nursing home placement

c) Reduced drug dosages Reason: Older clients commonly have diminished hepatic and renal function that reduces drug metabolism and excretion. Adverse reactions tend to be related to blood level; therefore, the client may benefit from reduced drug dosages. Adverse drug reactions aren't a cause for nursing home placement. Increased drug doses at longer intervals may increase adverse reactions rather than decrease them. Although frequent visits to the physician may benefit the client, the visits themselves won't alter how the drug reacts in the client's body.

The infection control nurse is making rounds to ensure that airborne precautions are being observed while caring for clients with tuberculosis. Which action by the staff nurse requires further education? a) The nurse double-bags respiratory secretions. b) The nurse dons a surgical isolation mask when entering the client's room. c) The client's meals are served on disposable trays. d) The nurse gathers disposable client care items.

b) The nurse dons a surgical isolation mask when entering the client's room. Reason: When entering the room of a client with tuberculosis, the nurse should wear an N95 particulate respirator mask because surgical isolation masks allow turbide bacilli to pass through. All trash and waste should be disposed of as infectious waste. All client care items and meal trays should be disposable

A student nurse is preparing a care plan using the nursing diagnosis: risk for situational low self-esteem related to intervention by social services as evidenced by poor eye contact, flat affect, and behavioral changes for a child entering the foster care system. Which action(s) by the foster parents indicate that the teaching interventions to improve self-esteem were successful? Select all that apply. a) The parents established a critical environment for behavior to enhance situational understanding. b) The parents sought opportunities to provide honest praise. c) The parents used physical discipline when necessary to reinforce rules. d) The parents developed a written plan describing consistent limits on good and bad behavior. e) The parents maintained inconsistent boundaries to challenge decision-making.

b) The parents sought opportunities to provide honest praise. d) The parents developed a written plan describing consistent limits on good and bad behavior. Reason: Teaching interventions are successful as demonstrated by the following answer choices: a structured lifestyle with consistent limits demonstrates acceptance and caring and provides a sense of security, and honest praise for good behavior promotes self-esteem. On the other hand, a critical environment erodes a person's esteem; inconsistent boundaries lead to feelings of insecurity and lack of concern; and physical discipline and false praise can decrease one's self-esteem.

A client reports abdominal pain. When examining this client, when should the nurse collect data? a) The symptomatic quadrant first b) The symptomatic quadrant last c) Any quadrant first d) The symptomatic quadrant either second or third

b) The symptomatic quadrant last Reason: The nurse should systematically collect data on all areas of the abdomen, if time and the client's condition permit, concluding with the symptomatic area. Otherwise, the nurse may elicit pain in the symptomatic area, causing the muscles in other areas to tighten. This tightening would interfere with further data collection

The nurse must apply an elastic bandage to a client's ankle and calf. She should apply the bandage beginning at the client's: a) ankle. b) foot. c) lower thigh. d) knee.

b) foot. Reason: An elastic bandage should be applied from the distal area to the proximal area. This method promotes venous return. In this case, the nurse should begin applying the bandage at the client's foot. Beginning at the ankle, lower thigh, or knee doesn't promote venous return

The nurse is trying to establish rapport with a newly admitted client. Which statements will facilitate effective communication? Select all that apply. a) "Why are you crying?" b) "Tell me about your treatment so far." c) "What did your physician tell you about your need for hospitalization?" d) "Everything will be all right." e) "Did you take your medicine yesterday?"

c) "What did your physician tell you about your need for hospitalization?" b) "Tell me about your treatment so far Reason: Giving advice, providing false reassurance, and asking the client why he or she is crying is judgmental, all of which block rather than promote effective communication with a client. Asking open-ended questions and using leading questions promote effective communication

The nurse is teaching a client how to administer subcutaneous (subQ) insulin injections. Which appropriate sites would the nurse advise the client to use? Select all that apply. a) Anterior aspect of the thigh b) Rectus femoris c) Abdomen d) Vastus lateralis e) Deltoid

c) Abdomen a) Anterior aspect of the thigh Reason: SubQ injection sites, which are relatively distant from bones and major blood vessels, include the lateral aspects of the upper arm, the anterior aspects of the thigh, and the abdomen. The deltoid, rectus femoris, and vastus lateralis are I.M. injection sites

The nurse educator is presenting an in-service on pediatric assessments. Why should the educator instruct nursing staff to inspect first and then auscultate when collecting data on a pediatric clients? a) Because the nurse's touch may frighten the child b) Because the nurse's hand or stethoscope may feel cold, making the child recoil c) Because the child may cry as data collection proceeds, making auscultation difficult d) Because the nurse's touch may calm the child

c) Because the child may cry as data collection proceeds, making auscultation difficult Reason: Because other data collection procedures may make the child cry, the nurse should auscultate the child's lungs immediately after inspection. Crying increases the respiratory rate and creates noise that interferes with clear auscultation

Which of the following outcome criteria would be most appropriate for the client with a nursing diagnosis of Ineffective airway clearance? a) Presence of congestion on X-ray b) Continued use of oxygen when necessary c) Breath sounds clear on auscultation d) Respiratory rate of 24 breaths/minute

c) Breath sounds clear on auscultation Reason: The expected outcome for a client with Ineffective airway clearance is for the lungs to sound clear on auscultation. Congestion on X-ray, continued use of and need for oxygen, and a respiratory rate of 24 breaths/minute indicate that the client is still experiencing airway problems

Which term describes a clinical judgment that an individual, family, or community is more vulnerable to develop a certain problem than others in the same or similar situation? a) Actual nursing diagnosis b) Syndrome nursing diagnosis c) Risk nursing diagnosis d) Health promotion nursing diagnosis

c) Risk nursing diagnosis Reason: Risk nursing diagnosis refers to the vulnerability of a client, family, or community to health problems. An actual nursing diagnosis describes a human response to a health problem being manifested. Syndrome nursing diagnosis describes a cluster of nursing diagnoses that are addressed together through similar interventions. A health promotion nursing diagnosis is a diagnostic statement describing the human response to levels of wellness in an individual, family, or community that have a potential for enhancement to a higher state.

The nurse is administering two drugs concomitantly to a client. Which interaction, recognized by the nurse, occurs when two drugs with the same qualitative effects produce a response when given together that is greater than the response either drug produces when given alone? a) Hyporeactivity b) Tolerance c) Synergism d) Antagonism

c) Synergism Reason: Synergism, or a synergistic effect, occurs when two drugs with the same qualitative effects produce a response when given together greater than either drug produces when given alone. Tolerance is a decreased response or decreased sensitivity of the receptor to a drug. Antagonism occurs when the combined response to two drugs given together is less than the response either drug produces when given alone. Hyporeactivity is a less-than-usual response to a normal drug dose

A nurse is caring for a client who was admitted to the emergency department after a motor vehicle collision. Under the law, informed consent before treatment must be obtained unless which circumstance exists? a) The client asks the nurse to give substituted consent. b) The client refuses to give informed consent. c) The client is in an emergency situation. d) The client is mentally ill.

c) The client is in an emergency situation. Reason: The law doesn't require informed consent in an emergency situation when the client is unable to give consent and no next of kin is present. A mentally competent client may refuse or revoke consent at any time. The client may also refuse treatment. Even though a client who has been declared mentally incompetent can't give informed consent, mental illness doesn't by itself indicate that the client is incompetent to give informed consent. Although the nurse may act as a client advocate, the nurse can never give substituted consent.

The nurse prepares to measure a client's blood pressure. What correct procedure for measuring blood pressure would the nurse utilize? a) Wrapping the cuff around the limb, with the uninflated bladder covering about one-fourth of the limb circumference b) Using a bladder that is 6" (15 cm) long c) Wrapping the cuff around the limb, with the uninflated bladder covering about three-fourths of the limb circumference d) Measuring the arm about 2" (5 cm) above the antecubital space

c) Wrapping the cuff around the limb, with the uninflated bladder covering about three-fourths of the limb circumference Reason: When measuring blood pressure, the nurse should place the cuff 1" (2.5 cm) above the brachial pulse and then wrap the cuff around the client's arm or leg with the bladder uninflated; the bladder should cover approximately three-fourths (not one-fourth) of the limb circumference. Bladder size is chosen according to the size of the extremity.

The nurse is collecting data on a client who appears to miss portions of what is being asked by the nurse. The client's family member tells the nurse that the client has a hearing aid, but will not wear it. The client states, "It worked when I first got it, but now it's a nuisance because I can't hear anything with it." The nurse asks which question to gain a better understanding of the client's concern? a) "Have you notified the medical equipment place where you got the hearing aid?" b) "Let's look at having your hearing aid refitted." c) "You have not given it a chance to work. You must wear it all the time." d) "Have you checked the battery to make sure it works?"

d) "Have you checked the battery to make sure it works?" Reason: The client stated the hearing aid no longer works, so the nurse needs to determine if there is a problem; asking about the battery is appropriate. Before contacting the medical equipment company, the client should check the battery first. Even if the hearing aid is ill-fitted, it still should work, so the battery needs to be checked. The hearing aid was working, so the client did give it an opportunity to work.

A client with nephritis is taking the diuretic furosemide as prescribed. Which client statement indicates an accurate understanding of teaching about furosemide? a) "I'll avoid consuming magnesium-rich foods." b) "I'll take furosemide at night so it works first thing in the morning." c) "I'll watch for and report signs of hypercalcemia." d) "I'll eat such foods as apricots, dates, and citrus fruits."

d) "I'll eat such foods as apricots, dates, and citrus fruits." Reason: Because furosemide is a potassium-wasting diuretic, the client should eat potassium-rich foods, such as apricots, dates, and citrus fruits, to prevent potassium depletion. The client may also consume magnesium-rich foods as desired. The client should watch for signs of adverse reactions to furosemide, such as hypocalcemia (not hypercalcemia). If furosemide is prescribed once daily, it should be taken in the morning; taking the medication at night causes frequent awakening because of the need to urinate

A 57-year-old client reports experiencing leg pain whenever he walks several blocks. The client has type 1 diabetes and has smoked two packs of cigarettes per day for the past 40 years. The physician diagnoses intermittent claudication. The nurse should provide which instruction about long-term care to the client? a) "See the physician if the symptoms bother you." b) "Consider cutting down on your smoking." c) "Reduce your exercise level." d) "Practice meticulous foot care."

d) "Practice meticulous foot care." Reason: Intermittent claudication and other chronic peripheral vascular diseases reduce oxygenation to the feet, making them susceptible to injury and poor healing; therefore, meticulous foot care is essential. The nurse should teach the client to bathe his feet in warm water, dry them thoroughly, cut his toenails straight across, wear well-fitting shoes, and avoid taking medication unless cleared by the physician. The client should stop smoking, not just cut down, because nicotine is a vasoconstrictor. Daily walking benefits the client with intermittent claudication. The client should see the physician regularly, not just when he's bothered by symptoms

A first-term nursing student is preparing to use a stethoscope to auscultate a client's chest. The nursing instructor asks the student to explain the working of the stethoscope. Which statement, provided by the student, about a stethoscope with a bell and diaphragm is true? a) "The diaphragm detects low-pitched sounds best." b) "The bell detects high-pitched sounds best." c) "The bell detects thrills best." d) "The diaphragm detects high-pitched sounds best."

d) "The diaphragm detects high-pitched sounds best." Reason: The diaphragm of a stethoscope detects high-pitched sounds best; the bell detects low-pitched sounds best. Palpation detects thrills best.

A client with type 1 diabetes who's in the second trimester of pregnancy is consuming a 2,400-calorie American Diabetes Association diet divided into three meals and several snacks. Her breakfast meal plan consists of these exchanges: 3 breads, 1 meat, 1 fruit, 1 milk, and 2 fats. Which menu would best comply with the meal plan? a) 2 bagels (½ bagel per exchange), 1 cup cooked grits, 3 eggs, 1 banana, 1 cup whole milk, 3 tsp margarine b) 3 breadsticks, 2 oz ham, 30 grapes (15 grapes per exchange), and 2 tsp margarine c) 4 breadsticks, 1 oz ham, 1 small apple, 2 bacon slices, and 1 cup low-fat yogurt d) 1 English muffin, ½ cup cooked grits, 1 egg, ½ banana, 1 cup skim milk, and 2 tsp margarine

d) 1 English muffin, ½ cup cooked grits, 1 egg, ½ banana, 1 cup skim milk, and 2 tsp margarine Reason: The first menu is best for the pregnant client with type 1 diabetes and includes the following exchanges: 3 breads (2 halves of the English muffin plus ½ cup cooked grits), 1 meat (1 egg), 1 fruit (½ banana), 1 milk (1 cup skim milk), and 2 fats (2 tsp margarine). The second menu exceeds the bread, meat, and fat exchanges. The third menu exceeds the bread exchanges. The fourth menu exceeds the meat and fruit exchanges.

The nurse receives a call from the laboratory with some lab values. Which lab value represents the highest priority for the nurse? a) Potassium level of 3.5 milliequivalent b) Magnesium level of 2.2 milligrams/dl c) Sodium level of 148 milliequivalent d) Calcium level of 32 milligrams/dl

d) Calcium level of 32 milligrams/dl Reason: A calcium level of 32 mg is a critical value and requires immediate intervention. A level of 3.5 meq is a normal value for potassium. The sodium level of 148 is within the normal range. The magnesium level of 2.2 mg is normal.

A client is prescribed acetaminophen by mouth every 4 hours as needed for headache. Which factor in the client's medical history would cause the nurse to question this order? a) Bleeding disorder b) Allergy to salicylates c) Duodenal ulcer d) Cirrhosis

d) Cirrhosis Reason: Acetaminophen can cause liver failure, so the nurse should question its use in a client with a history of cirrhosis. An order for aspirin should be questioned in a client with a history of duodenal ulcer, salicylate allergy, or bleeding disorder

A newly hired nurse is reviewing a health care practitioner's orders. Which of the following would the nurse expect that must be included in a medication order? Select all that apply. a) Client's allergies b) Possible adverse reactions c) Drug class d) Client's full name e) Physician's signature

d) Client's full name e) Physician's signature Reason: The physician's signature must be included in a medication order. Other components of a medication order include the client's full name, drug name, dosage form, dose amount, administration route, time schedule, and the date and time of the order. The drug class and possible adverse reactions aren't components of a medication order. Client allergies should be recorded in the client's chart, not on the medication order

What elements must be proven by a client's attorney in the case of a professional negligence action? a) Duty, breach of duty, and damages b) Duty, damages, and causation c) Breach of duty, damages, and causation d) Duty, breach of duty, damages, and causation

d) Duty, breach of duty, damages, and causation Reason: Any professional negligence action must meet certain demands in order to be considered negligence and result in legal action. They're commonly known as the four D's: duty of the health care professional to provide care to the person making the claim, a dereliction (breach) of that duty, damages resulting from that breach of duty, and evidence that damages were directly due to negligence (causation)

A client who has recently had surgery for prostate cancer expresses to the nurse feelings of anger toward God, his church, and the clergy. Which nursing intervention is appropriate for this client? a) Invite the client's clergyman to visit. b) Avoid discussions about religious beliefs and practices. c) Ignore the client's spiritual distress. d) Encourage the client to discuss concerns with a clergy member.

d) Encourage the client to discuss concerns with a clergy member. Reason: Encouraging the client who is spiritually distressed following cancer surgery to discuss his concerns with a clergy member is an appropriate intervention. The nurse should also encourage the client to discuss his religious beliefs and practices. Ignoring the client's spiritual distress doesn't build a therapeutic relationship with the client. The nurse shouldn't invite a clergyman to visit the client, unless the client specifically asks to see that member of the clergy

A nurse observes a medical student walk into a client's room and begin questioning her about her current health status. The client appears reluctant to respond. How should the nurse intervene? a) Stay with the client until the medical student finishes his questions. b) Encourage the client to cooperate with the medical student. c) Tell the client that the only way for the medical student to learn is for clients to cooperate with him. d) Explain to the client that she has the right to refuse to answer questions asked by the medical student.

d) Explain to the client that she has the right to refuse to answer questions asked by the medical student. Reason: The client has the right to confidentiality about her health information. She may refuse to share her information if she wishes. The nurse can stay with the client until the medical student finishes his questioning if the client agrees to answer questions. Encouraging the client to cooperate with the medical student violates the client's rights. Telling the client that the only way for the medical student to learn is for her to cooperate is inappropriate and also violates the client's rights.

A nurse is preparing to perform an abdominal assessment. Which sequence would the nurse follow to effectively perform an abdominal examination on a client? a) Inspection, auscultation, palpation, and percussion b) Inspection, percussion, palpation, and auscultation c) Inspection, palpation, percussion, and auscultation d) Inspection, auscultation, percussion, and palpation

d) Inspection, auscultation, percussion, and palpation Reason: The correct sequence for abdominal assessment is inspection, auscultation, percussion, and palpation because this sequence prevents altering bowel sounds with palpation before auscultation. The correct sequence for all other assessments is inspection, palpation, percussion, and auscultation.

A nurse works in a mental health facility that uses a therapeutic community (milieu) approach to client care. Which statement describes the nurse's role in this facility? a) Distinctly separate from the psychiatrist b) Supervisor more than counselor c) Primary caregiver d) Member of the milieu

d) Member of the milieu Reason: In a therapeutic community, everything focuses on the client's treatment. Staff and clients work together as a team or member of the milieu. The nurse wouldn't be a primary caregiver, but would work with the psychiatrist. The nurse's role could be that of supervisor as well as counselor.

The nurse is caring for a client with celiac disease. How should the nurse evaluate the effectiveness of nutritional therapy? a) Measure blood urea nitrogen and serum creatinine levels. b) Measure intake and output. c) Monitor vital signs every 4 hours. d) Monitor the appearance, size, and number of stools.

d) Monitor the appearance, size, and number of stools. Reason: When a client with celiac disease is placed on a gluten-free diet, fat, bulky, foul-smelling stools should be eliminated. This indicates that the disease is controlled and the client is using nutrients effectively. Taking vital signs, measuring blood urea nitrogen and serum creatinine levels, and measuring intake and output don't provide an indication of the effectiveness of diet therapy

Which statement is correct about the diagnosis of somatoform disorders? a) The somatic complaints are limited to one organ system. b) They're physical conditions with organic pathologic causes. c) The event preceding the physical illness occurred recently. d) They're disorders that occur in the absence of organic findings.

d) They're disorders that occur in the absence of organic findings. Reason: The essential feature of somatoform disorders is a physical or somatic complaint without any demonstrable organic findings to account for the complaint. There are no known physiological mechanisms to explain the findings. Somatic complaints aren't limited to one organ system. The diagnostic criteria for somatoform disorders state that the client has a history of many physical complaints beginning before age 30 that occur over several years