Med Surg HESI set 1

The nurse identifies which client is at risk to develop metabolic acidosis? Select all that apply 1. (1.) A client diagnosed with type 1 diabetes mellitus. 2. (2.) A client diagnosed with salicylate toxicity. 3. (3.) A client diagnosed with bilateral bacterial pneumonia. 4. (4.) A client diagnosed with acute renal failure. 5. (5.) A client diagnosed with continuous nasogastric drainage. 6. (6.) A client diagnosed with severe diarrhea.

(1.) CORRECT - At risk for diabetic ketoacidosis (2.) CORRECT - Acidic medication (3.) At risk for respiratory acidosis (4.) CORRECT - Kidneys not able to excrete acids or absorb bases (5.) At risk for metabolic alkalosis; lose acids (6.) CORRECT - Lose base in diarrhea

The nurse presents a class on herbal medications at a community health care seminar. Which statement should be included in the class? Select all that apply 1. (1.) The potency of herbal preparations varies between manufacturers. 2. (2.) The FDA tests and regulates herbal preparations. 3. (3.) Herbal preparations are classified as dietary supplements. 4. (4.) Ma huang contains ephedra and can be dangerous for people with high blood pressure. 5. (5.) Herbal preparations are used in the treatment of immune system dysfunction.

(1.) CORRECT - read labels carefully to determine the exact amount of herbs in the preparation (2.) herbal preparations are classified as dietary supplements; adverse reactions may be reported after use (3.) CORRECT - the FDA does not research or regulate herbal preparations because they are classified as dietary supplements (4.) CORRECT - read labels carefully to determine what the herbal preparation contains (5.) label should state that the herbal preparation will "decrease inflammation or support the immune system"; label cannot say that the preparation "protects against cancer"

A client is prescribed prednisone and asks about possible adverse effects. The nurse teaches the client about which common adverse effects of prednisone? Select all that apply 1. (1.) Osteoporosis. 2. (2.) Decreased white count. 3. (3.) Low blood sugar. 4. (4.) Low serum potassium. 5. (5.) Retinal detachment. 6. (6.) Fluid retention

(1.) CORRECT-Glucocorticoids decrease bone density; calcium and vitamin D supplements or biphosphonates will decrease risk (2.) Glucocorticoids depress the immune response, but not the white cell count (3.) Glucorticoids cause hyperglycemia and glyxosuria (4.) CORRECT-Glucocorticoids cause hypokalemia and hypernatremia (5.) Glucocorticoids increase the risk of cataracts and glaucoma (6.) CORRECT-Glucocorticoids cause sodium and water retention

The nurse cares for a client with chronic renal failure who has an arteriovenous fistula in the left arm. Which of the following should be included in the care of the client? Select all that apply 1. (1.) Assess and compare blood pressure in both arms. 2. (2.) Auscultate for "whooshing" sound over the fistula. 3. (3.) Palpate for warmth and tenderness over the area of the fistula. 4. (4.) Instruct the client to avoid getting the left arm wet. 5. (5.) Instruct the client to sleep with the left arm in the dependent position. 6. (6.) Instruct the client to avoid carrying heavy objects with the left arm.

(1.) no constriction of the arm with the fistula; may damage fistula (2.) CORRECT - Bruit should be heard over the area of the fistula due to increased blood flow; if no bruit heard, notify healthcare provider (3.) CORRECT - Increased risk of infection in the fistula area; possible infection should be reported to healthcare provider (4.) fistula is internal; no risk of infection from exposure to water (5.) no weight should be placed on the extremity with the fistula (6.) CORRECT - increases the risk of fistula damage

The nurse cares for a client with a history of type 1 diabetes mellitus who has just returned to the surgical acute-care unit after a right below-knee amputation. The client's capillary blood glucose is 480 mg/dL. The postoperative orders indicate 6 units of regular insulin subcutaneously should be administered. Which of the following is the FIRST action the nurse should take? 1. Check the client records to see if insulin was given prior to surgery. 2. Administer the 6 units of regular insulin subcutaneously. 3. Administer the insulin when oral fluids are tolerated. 4. Contact the healthcare provider.

1) Assessment: outcome desired but not priority; client needs insulin coverage now 2) CORRECT - Implementation: outcome desired; sliding scale-receives predetermined amount of insulin according to glucose level; surgery and infection increase insulin needs 3) Implementation: outcome not desired; needs insulin regardless of oral intake due to elevated blood glucose 4) Implementation: outcome not desired; no reason to contact healthcare provider; order is valid and appropriate for situation

A child sustains a crushing chest injury in a car accident. In the emergency room, an endotracheal tube is inserted. Several hours later the nurse enters the client's room and finds the child in respiratory distress. It is MOST important for the nurse to take which action prior to the angiogram? 1. Observe the color of the client's fingernail beds. 2. Assess the client's blood pressure in both arms. 3. Listen to the client's breath sounds. 4. Assess for intercostal retractions.

1) Assessment: outcome desired but not priority; cyanosis is a late sign of respiratory distress; central cyanosis will occur later than peripheral cyanosis 2) Assessment: outcome not desired; priority is to assess respiratory status; blood pressure may change due to decreased arterial oxygen levels; priority is to correct underlying problem 3) CORRECT - Assessment: outcome priority; will give early and clearest indication of respiratory status, will hear changes with narrowed airways, fluid in alveoli or pneumothorax 4) Assessment: outcome desired but not priority; late indication of respiratory distress; intercostal muscles are accessory muscles

The nurse cares for the client diagnosed with lung cancer. The family states that the client has become confused and that urinary output has decreased during the previous 24 hours. Which finding MOST concerns the nurse? 1. 2+ pitting pretibial edema. 2. Sodium 128 mEq/L. 3. Weight gain of 2 kg in 24 hours. 4. Urine specific gravity 1.008.

1) Assessment: outcome desired but not priority; edema not seen with SIADH even though water is retained; needs to be monitored 2) CORRECT - Assessment: outcome desired and priority; normal sodium range is 135-145 mEq/L, dilutional hyponatremia due to SIADH; client is neurologically depressed with increased risk of seizures 3) Asssessment: outcome desired but not priority; indicates fluid retention, not as important as hyponatremia; important to watch trends in weight 4) Assessment: outcome not desired; 1.008 indicates that urine is very dilute; with SIADH, urine will have high concentration and specific gravity due to excess ADH secretion

A woman is admitted to the hospital with a diagnosis of ovarian cancer. She has been treated with surgery and chemotherapy. The client states that she has no appetite and has lost 10 lbs in the last 4 weeks. Which statement, if made by the nurse, is MOST important? 1. "Have you noticed a decrease in your energy levels lately?" 2. "Do you notice any swelling of your hands and feet?" 3. "Describe your normal daily food intake." 4. "What are your favorite foods?"

1) Assessment: outcome desired but not priority; energy level decreased with malnutrition; is also adverse effect of chemotherapy 2) Assessment: outcome desired but not priority; protein deficiency may cause peripheral edema 3) Assessment: outcome desired but not priority; more important to provide nutrition 4) CORRECT-Assessment: outcome desired and priority; offer favorite foods to deal with the "here and now"

The nurse cares for a client who returned 4 hours ago after a subtotal thyroidectomy procedure. The nurse notes that the client sounds more hoarse when speaking than he did 1 hour ago. Which of the following is the MOST appropriate action for the nurse to take? 1. Check the gag and swallow reflex. 2. Instruct the client to chew small amounts of ice chips. 3. Notify the healthcare provider. 4. Instruct the client to cough and breathe deeply every 15 minutes.

1) Assessment: outcome desired but not priority; not best test for laryngeal damage 2) Implementation: outcome not desired; will not decrease hoarseness 3) CORRECT- Implementation: outcome priority and desired; possible laryngeal damage; further assessment and possible treatment indicated; do not assume that hoarseness is caused by endotracheal tube 4) Implementation: outcome not desired; may further damage operative site

A child in a new plaster walking cast has dusky, swollen toes following assessment. Which action by the nurse is MOST appropriate? 1. Get Doppler studies to check the pulse. 2. Notify the healthcare provider. 3. Determine if the cast is dry. 4. Check the client's vital signs.

1) Assessment: outcome desired but not priority; question stem tells you that assessment has been done; changes in pulse, color, sensation should be reported immediately to the healthcare provider 2) CORRECT - Implementation: outcome priority and desired; diminished pulses indicates change in circulation 3) Assessment: outcome desired but not priority; should report changes in circulation 4) Assessment: outcome not desired; symptoms suggest changes in circulation to extremity; more important to report change in distal circulation

Based on the nurse's knowledge of the goal of diuretic therapy for a client with heart failure, which assessment BEST indicates that the client's condition is improving? 1. The client's weight has decreased 2 pounds. 2. The client's systolic blood pressure has decreased. 3. The client has fewer crackles heard during auscultation. 4. The client's urinary output has increased.

1) Assessment: outcome expected but not priority; could be due to changes in appetite, no time frame given in question 2) Assessment: outcome expected but not priority; could be due to other causes such as change in position 3) CORRECT- Assessment: outcome priority; reason for diuretics; diuretic reduces alveolar edema and pulmonary venous pressure 4) Assessment: outcome expected but not priority; will increase due to diuretic but may not change heart failure

The nurse cares for a client with Addison's disease who is taking 20 mg hydrocortisone (Cortef) daily. Which statement by the client requires an intervention by the nurse? 1. "I will need to have my blood sugar levels checked while on this medication." 2. "I may have episodes of low blood pressure while taking this medication." 3. "I need to weigh myself twice a week and keep a record of my weight." 4. "I should notify my health care provider if I am running a fever."

1) Assessment: outcome expected; glucocorticoids can increase serum glucose levels 2) CORRECT- Assessment: outcome not expected; hypertension due to sodium and water retention expected 3) Assessment: outcome expected; weight gain due to sodium and water retention expected 4) Implementation: outcome desired; glucocorticoids have immunosuppressant effect; client at high risk for infection

The nurse supervises care of clients on a postoperative surgical unit. Which of the following requires an immediate intervention by the nurse? 1. The nursing assistive personnel (NAP) obtains vital signs on a client who had a bowel resection 24 hours ago. 2. The NAP assists a client who had an above-the-knee amputation apply an elastic bandage to the residual limb. 3. The NAP assists a client who had a stroke 3 days ago with feeding. 4. The NAP assists a client who had a laparoscopic cholecystectomy 6 hours ago ambulate.

1) Assessment: outcome expected; within NAP scope of practice; principles of delegation should be followed 2) Implementation: outcome desired; within NAP scope of practice 3) CORRECT-Implementation: outcome not desired; client requires assessment and evaluation; may have problems with gag and swallow reflex 4) Implementation: outcome desired; within NAP scope of practice; stable client; principles of delegation should be followed

The nurse cares for the client diagnosed with type 2 diabetes. The client is scheduled for a renal computed tomography scan with contrast media at 10 a.m. The nurse is MOST concerned if the client makes which statement? 1. "My blood sugar was 124 mg/dL this morning." 2. "I drank a glass of water at midnight." 3. "Sometimes I get dizzy when I first get out of bed." 4. "I took my metformin (Glucophage ER) at 6 A.M. this morning."

1) Assessment: outcome not desired but not priority; further assessment needed 2) Implementation: outcome not a problem; NPO for 8 hours prior to scan 3) Assessment: outcome not desired but not priority; possible orthostatic hypotension; further assessment needed 4) Correct - Implementation: outcome not desired and priority; metformin should be held for 48 hours prior to tomography with contrast media; risk lactic acidosis with potential renal damage

The nurse cares for an 80-year-old client taking medication for the treatment of hypertension and heart failure. Which action is MOST important for the nurse to take? 1. Check the client's blood pressure and heart rate immediately after ambulation. 2. Instruct the client to use a walker at all times during ambulation. 3. Encourage the client to walk with the feet as close together as possible. 4. Instruct the client to sit on the edge of the bed for 3 to 5 minutes before arising.

1) Assessment: outcome not desired; blood pressure and heart rate should be assessed prior to ambulation; more important to assess for shortness of breath and activity tolerance 2) Implementation: outcome not desired; avoid soft-soled shoes; remove barriers; orthostatic precautions are priority; no indication in the question that a walker is needed 3) Implementation: outcome not desired; should have wide-based gait to distribute center of gravity; may be unsafe ambulation 4) CORRECT-Implementation: outcome desired and priority; elderly have decreased cerebral perfusion; antihypertensives and medications used to treat heart failure cause vasodilation

The home care nurse is visiting a client terminally ill with pancreatic cancer who wishes to die at home. Which question, if asked by the nurse, is MOST appropriate? 1. "Are you sure you want to die at home?" 2. "Where will you put the hospital bed?" 3. "Would you like your minister to visit you?" 4. "Who will take care of you?"

1) Assessment: outcome not desired; psychosocial, yes-no question, non-therapeutic 2) Assessment: outcome desired but not priority; important to obtain the needed equipment, but is very specific 3) Assessment: outcome not priority; passing the buck, yes-no question, non-therapeutic 4) CORRECT- Assessment: outcome desired and priority; physical need, meet basic needs first before psychosocial

The nurse is caring for an elderly client receiving total parenteral nutrition (TPN) due to malnutrition. Which observation, if made by the nurse, indicates that the client is improving? 1. The client gains 8 lbs in one week. 2. The client's edema decreases. 3. The client's hemoglobin increases. 4. The client's output is greater than the intake.

1) Assessment: outcome not expected; indicates fluid retention 2) CORRECT- Assessment: outcome expected; edema is manifestation of malnutrition; decreased serum protein levels cause fluid to move into interstitial space 3) Assessment: outcome not expected; hemoglobin may increase with increased iron levels 4) Assessment: outcome not expected; TPN can cause hyperosmolar diuresis due to hyperglycemia, complication of TPN

The nurse cares for the client with a client controlled analgesia (PCA) pump. The nurse determines that the client has pressed the button 11 times and received 6 doses of morphine during the last hour. Which is the MOST appropriate action for the nurse to take? 1. Assess the patency of the PCA IV tubing. 2. Determine the client's understanding of the PCA pump function. 3. Obtain an order to begin a PCA infusion of fentanyl. 4. Ask the client to describe the pain.

1) Assessment: outcome not priority but may be appropriate; if tubing is obstructed, alarm is activated 2) Assessment: outcome may be appropriate but not priority; more important to determine pain level, description of the pain, region and radiation of the pain, and relieving factors 3) Implementation: outcome not desired; more important to assess severity of pain and pain relief first 4) CORRECT - Assessment: outcome priority; must validate that client is in pain before implementation

An LPN/LVN informs the nurse that aspirin 325 mg was given to a client even though 80 mg aspirin had been ordered once daily. The LPN/LVN asks the nurse if it is necessary to complete a medication-error form since "no harm was done." Which statement, if made by the nurse, is BEST? 1. "What do you mean, "no harm was done"? 2. "A medication-error form must be completed whenever the wrong preparation of a medication is given." 3. "I will call the health care provider and ask what should be done to deal with this error." 4. "It is not necessary to complete an incident report with over-the-counter medications."

1) Assessment: outcome not priority; assessment of client must be done by nurse; question is not necessary 2) CORRECT-Implementation: outcome desired; contains full description of situation, error committed, condition of client, remedial steps taken; medication error form must be completed for all variances 3) Implementation: outcome not desired; it is a nursing responsibility; health care provider should be informed 4) Implementation: outcome not desired; always complete form for any medication error

The nurse prepares to administer gentamicin (Garamycin) to the 65-year-old client. Which is the MOST important action for the nurse to take prior to administration of the medication? 1. Request a daily hemoglobin and hematocrit test. 2. Monitor the serum BUN and creatinine. 3. Request a highly-sensitive C-reactive protein (hs-CRP) test. 4. Monitor the erythrocyte sedimentation rate (ESR).

1) Assessment: outcome not priority; may cause anemia, but not usually seen 2) CORRECT - Assessment: outcome priority; nephrotoxic; will see proteinuria, oliguria, hematuria, thirst, increased BUN, decreased creatine clearance 3) Assessment: outcome not priority; will be increased in inflammation and rheumatoid arthritis 4) Assessment: outcome not priority; will be increased with any inflammatory process

The nurse cares for the client in the recovery room after a knee surgery procedure. The client has an oral airway in place. Which is the BEST indicator that the oral airway can be removed? 1. The client has a forceful cough during repositioning. 2. The client tries to chew on the oral airway.. 3. The client tries to push the airway out with his tongue. 4. The client is able to swallow.

1) Assessment: outcome not priority; may cough due to irritation of the airway; does not reflect client responsiveness 2) CORRECT - Assessment: outcome priority; client is alert and able to maintain his own airway 3) Assessment: outcome not priority; client needs to be responsive before airway is removed; may be a reflexive action 4) Assessment: outcome not priority; client will be able to swallow before he is responsive

The nurse is caring for an elderly client admitted for type 1 diabetes mellitus. The nurse notes that the client appears to have difficulty understanding what is said. Which of the following actions, if taken by the nurse, is MOST appropriate? 1. Ask the client if cotton-tipped applicators are used for ear cleaning. 2. Perform the Weber hearing test. 3. Check the client's ear canals for cerumen. 4. Use facial expressions and speak in a high frequency tone of voice.

1) Assessment: outcome not priority; most common cause is cerumen in elderly 2) Assessment: outcome not priority; cerumen most likely cause 3) CORRECT- Assessment: outcome priority; physical, ear wax becomes drier in elderly; can block ear canal and cause decreased hearing 4) Implementation: outcome not priority; nonverbal cues useful when speaking to hearing-impaired; need low tones; high frequency tones are problem for elderly

A client is scheduled for transfer to another hospital. Which observation, if made by the nurse, would require an IMMEDIATE intervention? 1. Lactated Ringer's infusing IV into the client's left forearm is 400 mL behind schedule. 2. The client's nasogastric tube is draining a moderate amount of green liquid. 3. The client's blood pressure has changed from 140/80 to 150/88 in the last hour. 4. The client's SaO2 is 88%.

1) Assessment: outcome not priority; needs to be investigated 2) Assessment: outcome not priority; no indication of a problem 3) Assessment: outcome not priority; still the same range 4) CORRECT- Assessment: outcome priority; decreased oxygenation level; needs further assessment

A 56-year-old man is scheduled for an MRI (magnetic resonance imaging). His history indicates that he suffered an injury during the Vietnam War. Which question is MOST important for the nurse to ask the client? 1. Where was your injury? 2. When were you wounded? 3. Did your injury involve shrapnel? 4. Were you exposed to chemical warfare?

1) Assessment: outcome not priority; not significant for MRI 2) Assessment: outcome not priority; not significant for MRI 3) CORRECT- Assessment: outcome desired and priority; MRI contraindicated with metal prosthesis or implanted metal 4) Assessment: outcome not priority; defoliant used in war, not significant for MRI

A client is admitted to the hospital with a diagnosis of chronic bronchitis. Which action should the nurse take FIRST? 1. Weigh the client. 2. Place cardiac telemetry leads. 3. Place pulse oximetry on finger. 4. Obtain a sputum specimen

1) Assessment: outcome not priority; right heart failure and weight gain seen with chronic bronchitis; priority is to assess oxygenation 2) Assessment: outcome not priority; dysrhythmias occur due to right heart failure; priority is oxygenation 3) CORRECT-Assessment: outcome desired; priority is to establish oxygenation status 4) Assessment: outcome not priority; common reason for worsening status is respiratory infection; more important to establish respiratory status first

A client had a right kidney transplant 1 week ago. Which symptom, if experienced by the client, indicates to the nurse that the client is experiencing rejection? 1. The client complains of generalized muscle weakness. 2. The client complains of diffuse pain over the right abdomen. 3. The client gets up twice each night to void. 4. The client has lost 3 pounds.

1) Assessment: outcome not priority; seen with electrolyte imbalance, not rejection 2) CORRECT-Assessment: outcome priority and expected with kidney rejection; tenderness over kidney is sign of rejection 3) Assessment: outcome not expected; oliguria is seen with rejection due to failing kidney 4) Assessment: outcome not expected; edema and weight gain are seen with rejection

A client is brought to the clinic by the spouse. The client's lab results are Na+ 156 mEq/L, Cl- 100 mEq/L, K+ 4.0 mEq/L, BUN 86 mg/dL, glucose 100 mg/dL. Which is the MOST appropriate action for the nurse to take? 1. Assess for muscle weakness and dysrhythmias. 2. Assess for confusion and tachycardia. 3. Check for peripheral edema and lung crackles. 4. Determine if muscular twitching and muscle weakness are present.

1) Assessment: outcome not priority; symptoms of hypokalemia 2) CORRECT-Assessment: outcome priority; elevated Na+ and elevated BUN, other values are normal; elevated Na+ and BUN seen with dehydration 3) Assessment: outcome not priority; symptoms of fluid volume overload 4) Assessment: outcome not priority; symptoms of hyponatremia; hypernatremia seen with dehydration

During a paracentesis, 1500 mL of fluid is removed from a client. Which action should the nurse take IMMEDIATELY following the procedure? 1. Measure the client's abdominal girth. 2. Weigh the client. 3. Assess the client's level of pain. 4. Check the client's blood pressure.

1) Assessment: outcome not priority; will decrease in size 2) Assessment: outcome not priority; will lose weight 3) Assessment: outcome not priority; not most important 4) CORRECT- Assessment: outcome priority; complication of procedure is hypotension (hypovolemic shock due to fluid shift); also check for tachycardia, oliguria, pallor

The nurse plans care for a client admitted with fever, vomiting, and diarrhea. Which laboratory value demonstrates an improvement in the client's condition? 1. Specific gravity of urine 1.020 and hematocrit 42%. 2. Specific gravity of urine 1.039 and hematocrit 50%. 3. Specific gravity of urine 1.010 and hematocrit 52%. 4. Specific gravity of urine 1.030 and hematocrit 35%.

1) CORRECT - Assessment: outcome expected; normal specific gravity of urine, normal hematocrit; specific gravity and hematocrit increase with dehydration 2) Assessment: outcome not expected; increased specific gravity of urine, increased hematocrit; suggests ongoing fluid volume deficit 3) Assessment: outcome not expected; decreased specific gravity of urine, increased hematocrit; does not indicate improvement 4) Assessment: outcome not expected; increased specific gravity of urine, decreased hematocrit; does not indicate improvement

A nursing order, "Increase fluid intake" is written for a client diagnosed with dehydration. Which finding BEST indicates improving fluid status? 1. Urinary output of 1,500 mL in 24 hours. 2. Serum hematocrit 52%. 3. Oral fluid intake of 900 mL in 24 hours. 4. Blood pressure of 100/82.

1) CORRECT - Assessment: outcome priority; increased amounts of antidiuretic hormone secreted; urine output decreased and concentrated 2) Assessment: outcome not priority; indicates that blood is hemoconcentrated 3) Assessment: outcome not priority; normal intake is 1,500 mL in 24 hours 4) Assessment: outcome not priority; normal BP is 120/80

The nurse prepares to assign a client requiring a capillary blood glucose test to a newly hired nursing assistive personnel. Which action should the nurse take FIRST? 1. "Show me how you check a capillary glucose level." 2. "How many of these glucose checks have you done in the past?" 3. "Would you like for me to go with you when you do the glucose test?" 4. "Was this procedure covered during your nursing assistive personnel class?"

1) CORRECT - Assessment: outcome priority; must evaluate competency of the UAP; nurse is accountable for UAP's actions during delegation process 2) Assessment: outcome not priority; number of procedures done is not as important as demonstrated competency 3) Assessment: outcome not priority; nurse should be able to delegate procedure if UAP is competent 4) Assessment: outcome not priority; obtaining a capillary glucose sample is within UAP scope of practice

The nurse cares for a client during a 24-hour urine specimen collection. Several hours later, the client tells the nurse that she has started to menstruate. Which action by the nurse is MOST appropriate? 1. Inform the health care provider that the client is menstruating. 2. Send the urine collected prior to the onset of the client's menstruation to the lab. 3. Insert an indwelling bladder catheter during the remainder of the collection period. 4. Request a separate urine collection container from the laboratory to be used during the remainder of the urine collection period.

1) CORRECT - Implementation: outcome desired; menstruation may last several days to a week; protein and red cells may alter the results of the urinalysis 2) Implementation: outcome not desired; all urine must be collected for accuracy 3) Implementation: outcome not desired; invasive procedure should be avoided if possible 4) Implementation: outcome not desired; would change the results of the 24-hour urine sample; all urine must be collected for accuracy

A client returns to the unit following a thyroidectomy. Which assessment finding requires an intervention by the nurse? 1. The client makes noises when breathing. 2. The client reports pain at the surgical site. 3. The client asks for liquids to drink. 4. The client is sleepy from anesthesia.

1) CORRECT- Assessment: outcome not expected and priority; sign of tracheal compression caused by hemorrhage or edema 2) Assessment: outcome expected; use analgesics, semi-Fowler's position 3) Assessment: outcome expected; NPO status prior to surgery 4) Assessment: outcome expected

The home care nurse visits a client who had a traditional cholecystectomy 10 days ago. The client returned to the healthcare provider to have the T-tube removed 2 days ago. It is MOST important for the nurse to take which action? 1. Observe the color of the client's urine and stool. 2. Ask the client to describe the quality and quantity of pain she is experiencing. 3. Instruct the client to avoid fatty foods for 6 weeks. 4. Listen to bowel sounds.

1) CORRECT- Assessment: outcome priority; clay-colored stools and dark urine indicate that bile is draining into liver 2) Assessment: outcome not priority; psychosocial, not as important as assessing color of urine and stool 3) Implementation: outcome desired but not priority; should eat balanced diet and avoid high-fat foods 4) Assessment: outcome not priority; more important to assess urine and stools

A client with an 8-year history of ulcerative colitis is admitted to the hospital with severe abdominal cramping and diarrhea. The client has experienced 18 to 20 stools a day for the last 4 days. The nurse is MOST concerned by which finding? 1. The client's diastolic blood pressure decreases 20 mm when the client rises to a standing position. 2. The client's urinary specific gravity is 1.020. 3. The client has lost 3 pounds since her last admission. 4. The client appears pale and thin.

1) CORRECT- Assessment: outcome priority; indicates fluid volume deficit, check blood pressure supine, sitting and standing; other symptoms include concentrated urine and weak, rapid pulse 2) Assessment: outcome not priority; normal 1.010-1.030 3) Assessment: outcome not priority; don't know when client was last hospitalized 4) Assessment: outcome not priority; more concerned about fluid volume deficit

The nurse teaches a client about foods and beverages that may be consumed on a low- sodium diet. Which beverage, if selected by the client, indicates an understanding of the instructions? 1. Lemonade. 2. Skim milk. 3. Ginger ale. 4. Tomato juice.

1) CORRECT- Implementation: outcome desired; 1 cup = 2 mg Na+ 2) Implementation: outcome not desired; 1 cup = 125 mg; high Na+ in milk products 3) Implementation: outcome not desired; 1 cup = 60 mg; high Na+ in carbonated beverages 4) Implementation: outcome not desired; 1 cup = 500 mg; extremely high Na+

The nurse teaches a client with a spinal cord injury how to perform self-catheterization at home. Which statement, if made by the client, indicates that teaching has been successful? 1. "I will keep the catheter in a plastic bag." 2. "I will catheterize myself every 2 hours." 3. "I will wear sterile gloves." 4. "I will wash the perineum with alcohol prior to catheterizing myself."

1) CORRECT- Implementation: outcome desired; after use, catheter is soaked in solution of Betadine, bleach, or hydrogen peroxide, then dried and stored in a towel or bag; clean procedure in the home 2) Implementation: outcome not desired; done every 6-8 hours 3) Implementation: outcome not desired; clean procedure in the home, less risk of contamination 4) Implementation: outcome not desired; wash with soap and water

The health care provider (HCP) provider orders hydralazine 25 mg IM on call for a client before surgery. The LPN/LVN administers hydroxyzine 25 mg IM to the client. Which of the following is the MOST appropriate action for the nurse to take? 1. Document "Hydralazine 25 mg ordered; hydroxyzine 25 mg given; HCP notified; blood pressure 130/84; pulse 86; respiration 12." 2. Document "Hydroxyzine 25 mg given; hydralazine 25 mg ordered; HCP notified; vital signs stable." 3. Document "Hydroxyzine 25 mg mistakenly given; hydralazine 25 mg ordered." 4. Document "Hydroxyzine 25 mg given; incident report completed."

1) CORRECT- Implementation: outcome desired; objective; indicates nurse has monitored client 2) Implementation: outcome not desired; not best; contains judgment 3) Implementation: outcome not desired; incomplete; subjective 4) Implementation: outcome not desired; incident report not part of legal record

A woman is admitted to the hospital complaining of diarrhea and vomiting for 3 days. The blood pressure is 90/60, apical heart rate 96, and respiratory rate 22 with shallow respirations. Laboratory results include Na+ 147 mEq/L, K+ 5.6 mEq/L, hematocrit 52%, hemoglobin 14 g/dL. The client is receiving 5% dextrose in 0.45% normal saline with K+ 20 mEq at 125 mL/hr. Prior to calling the healthcare provider, it is MOST important for the nurse to take which of these actions? 1. Change IV fluids to 5% dextrose in 0.45% normal saline. 2. Increase IV flow rate to 150 mL/hour. 3. Check the hourly urine output. 4. Observe the client for muscle weakness.

1) CORRECT- Implementation: outcome desired; potassium removed due to hyperkalemia; hypotonic solution used to correct dehydration 2) Implementation: outcome not desired; will increase serum potassium 3) Assessment: outcome not priority; client is dehydrated; intervention required 4) Assessment: outcome not priority; lab values indicate hyperkalemia

In preparation for a total laryngectomy, the nurse teaches a client how to support his neck after surgery. Which of the following demonstrations by the client indicates to the nurse that teaching is successful? 1. The client raises the elbows and places the hands behind the neck. 2. The client places one hand on the forehead and the other hand on the back of the head. 3. The client covers the ears with both hands and presses firmly. 4. The client grasps the chin with one hand and places the other hand on the forehead.

1) CORRECT- Implementation: outcome desired; prevents stress on suture line; supports head; use folded towel when mobile 2) Implementation: outcome not desired; no support for neck 3) Implementation: outcome not desired; no support for neck 4) Implementation: outcome not desired

Levodopa (L-Dopa) is prescribed for a 61-year-old woman. Which statement, if made by the client to the nurse, would indicate that the client needs further instruction? 1. "While I take this medication, I should eat a high-protein diet." 2. "I should change positions slowly at first so I don't get dizzy." 3. "If I have muscle twitching, I should report it to my health care provider." 4. "I should check with my health care provider before taking any over-the-counter medications."

1) CORRECT- Implementation: outcome not desired; take with low-protein diet to decrease GI upset 2) Implementation: outcome desired; true; orthostatic hypotension is common with Parkinson's disease 3) Implementation: outcome desired; true; blepharospasms (twitching eyelid) are early signs of overdosage 4) Implementation: outcome desired; true; multivitamins can reverse actions, especially vitamin B6

The home care nurse makes an initial visit to an 80-year-old client. The client's daughter states that her mother has a history of colon cancer and has been restless and confused for about a week. It is MOST important for the nurse to obtain an answer to which question? 1. "What medication is your mother taking?" 2. "Is there a family history of diabetes?" 3. "Describe your mother's usual diet." 4. "Does your mother complain of difficulty urinating?"

1) CORRECT-Assessment: outcome desired and priority; confusion can be caused by drug toxicity and polypharmacy; decreased renal function may increase risk 2) Assessment: outcome desired but not priority; hypoglycemia may be a factor 3) Assessment: outcome desired but not priority; is a good open-ended question 4) Assessment: outcome desired but not priority; not most important; urinary tract infections cause acute confusion in elderly

A man is returned to his room in stable condition after a transurethral prostatectomy (TURP). He has continuous bladder irrigation through a 3-way urinary drainage catheter with a 30-mL balloon tip. Tension has been applied to the catheter. The client reports that he feels pressure in his bladder and rectum, and feels as though he has to urinate. Which action should the nurse take FIRST? 1. Check the patency of the catheter. 2. Assess residual urine volume using bladder ultrasonography. 3. Assess the amount of drainage in the urinary drainage bag. 4. Decrease the tension on the catheter.

1) CORRECT-Assessment: outcome priority; catheter may be blocked or client may be having bladder spasms 2) Assessment: outcome not priority; need to check patency of tubing first 3) Assessment: outcome not priority; more important to look for obstruction in tubing 4) Implementation: outcome not desired; decrease in traction against bladder neck could cause bleeding; is a healthcare provider order and should not be changed

On the third day after a thyroidectomy, the nurse notes that the client has developed tremors. Which of the following is the MOST appropriate action for the nurse to take? 1. Check the client's calcium level. 2. Check the client's glucose level. 3. Check the client's potassium level. 4. Check the client's sodium level.

1) CORRECT-Assessment: outcome priority; parathyroid gland may be injured, causing hormone levels to decrease; causes decrease in blood calcium; early signs include tingling of fingers, toes, lips 2) Assessment: outcome desired but not priority; blood glucose below 50 mg/dL; symptoms include sweating, trembling, anxiety, hunger, weakness 3) Assessment: outcome desired but not priority; K+ below 3.5 mEq/L; symptoms include fatigue, vomiting, muscle weakness, dysrhythmias 4) Assessment: outcome desired but not priority; if Na+ below 135 mEq/L; symptoms include muscle cramps, lethargy, hemiparesis (paralysis of one side of body)

The nurse makes a follow-up phone call to the family of an infant receiving treatment for watery diarrhea after 7 days of amoxicillin (Amoxil) therapy. The nurse knows teaching is successful if the family makes which statement? 1. "We wear a fresh pair of clean gloves with each diaper change." 2. "We are not allowing our other children to be in the same room with the baby." 3. The grandmother wears a mask when changing the baby's diaper. 4. The mother wears an apron when changing the baby's diaper.

1) CORRECT-Implementation: outcome desired; contact precautions; Clostridium difficile infection may develop after antibiotic treatment 2) Implementation: outcome not desired; unnecessary; should use stool and enteric precautions 3) Implementation: outcome not desired; mask unnecessary; used for airborne infection 4) Implementation: outcome not desired; need to use contact precautions, gown only if soiling likely

The nurse teaches a client who is lactose-intolerant about some alternative ways to maintain an adequate diet that includes calcium. The nurse will suggest the client include which food items in the diet? 1. Tofu and green leafy vegetables. 2. Beef and tomato salad. 3. Cottage cheese and yogurt. 4. Custard and mashed potatoes.

1) CORRECT-Implementation: outcome desired; good sources of calcium 2) Implementation: outcome not desired; contain no calcium 3) Implementation: outcome not desired; contain lactose 4) Implementation: outcome not desired; made with milk; contain lactose

The nurse assesses the IV site before administering vancomycin. The nurse notes that the area around the IV infusion site is pale and feels cool. Which INITIAL action will the nurse perform? 1. Remove the intravenous catheter and elevate the arm on 1 or 2 pillows. 2. Begin the vancomycin infusion and reassess the infusion site in 15 minutes. 3. Withhold the vancomycin infusion and notify the healthcare provider. 4. Apply warm, moist compresses to the infusion site for 30 minutes and then administer the medication.

1) CORRECT-Implementation: outcome desired; possible infiltration; high risk of tissue damage and thrombophlebitis during vancomycin administration 2) Implementation: outcome not desired; priority is to discontinue infusion and prevent harm to client 3) Implementation: outcome not desired; medication should be given; no need to notify healthcare provider 4) Implementation: outcome not desired; warmth indicated for thrombophlebitis, not infiltration

The husband of an elderly client who is incontinent asks the nurse whether his wife will have to wear diapers. Which response, if made by the nurse, is MOST appropriate? 1. "Let's discuss your specific concerns about your wife." 2. "Have you tried any type of incontinence pads in the past?" 3. "Let's wait and see if incontinence pads are necessary." 4. "There are many brands of adult diapers available for you to try."

1) CORRECT-Outcome desired; open-ended; client can verbalize concerns 2) Outcome not priority; need to address husband's immediate concerns; is "yes/no" answer 3) Outcome not desired; need to deal with the "here and now" 4) Outcome not desired; non-therapeutic; dismisses concerns

The home health nurse is planning client visits for the day. Which of the following clients should the nurse see FIRST? 1. A 70-year-old diabetic with fasting blood glucose readings of 240-260 mg/dL for 1 week. 2. A 65-year-old discharged from the hospital 2 days ago following coronary artery bypass graft surgery (CABG). 3. A 55-year-old with congestive heart failure who gained 3 lbs in the last 24 hours. 4. A 40-year-old with metastatic breast cancer complaining of pain unrelieved by pain medication.

1) Follow-up required, but not priority; see second 2) Will require assessment and teaching, but no immediate care indicated; see third 3) CORRECT-Rapid weight gain indicates fluid retention, which could exacerbate CHF; see first 4) Stable client; pain control will be addressed but not first; see last

A 60-year-old male client awakens frightened and agitated. He climbs out of bed, removes his indwelling urinary drainage catheter, and runs down the hall screaming. Which of the following is the FIRST action the nurse should take? 1. Notify the healthcare provider. 2. Restrain the client. 3. Replace the urinary catheter. 4. Check for injuries.

1) Implementation: outcome desired but not priority; assessment needed 2) Implementation: outcome not desired; restraint is last resort; needs reorientation 3) Implementation: outcome desired but not priority 4) CORRECT- Assessment: outcome desired and priority; will guide further assessment and interventions; will gather needed information to tell health care provider

A 39-year-old man is admitted with a diagnosis of Acquired Immune Deficiency Syndrome (AIDS). His lab results are hemoglobin 9.3 g/dL, hematocrit 25%, platelets 50,000/mm3, white cell count 1,500/mm3. Which order will should the nurse implement FIRST? 1. "Infuse 2 units of packed red cells." 2. "High-protein, high-carbohydrate diet as tolerated." 3. "Administer 2 units platelets." 4. "Place the client on neutropenic precautions."

1) Implementation: outcome desired but not priority; given when hemoglobin is down to 8 g/dL 2) Implementation: outcome desired but lower priority 3) Implementation: outcome desired but lower priority; risk of spontaneous bleeding when platelets 20,000/mm3 or below 4) CORRECT- Implementation: outcome desired and high priority; at risk for acquiring life-threatening infection due to leukopenia

The home care nurse observes an elderly woman on a low-sodium diet eating a dill pickle that her son gave her with lunch. Which response by the nurse is MOST appropriate? 1. "Giving your mother salty food will only make her condition worse." 2. "Didn't your mother tell you she's on a low-sodium diet?" 3. "Tell me what you know about your mother's diet." 4. "Let's make an appointment for you to meet with a dietician."

1) Implementation: outcome desired but not priority; non-therapeutic; closed statement 2) Assessment: outcome not desired; "yes/no" question; non-therapeutic 3) CORRECT-Assessment: outcome desired; teaching opportunity; includes family in teaching 4) Implementation: outcome not desired; "passing the buck"

The nurse reviews room assignments for 4 clients admitted to the unit. The nurse should question which room assignment? 1. A child with chickenpox placed in a private room at the end of the hall. 2. A child with meningitis placed in a private room across from the nurses' station. 3. A client with cellulitis of the right leg placed in a semi-private room with a client diagnosed with type 1 diabetes. 4. A client with essential hypertension placed in a semi-private room with a client who has pancreatitis.

1) Implementation: outcome desired; communicable disease, appropriate room placemen 2) Implementation: outcome desired; communicable disease, requires frequent assessment; client at risk for seizures 3) CORRECT- Implementation: outcome not desired; don't put a client with infection (cellulitis) with a client who is at risk for infection 4) Implementation: outcome desired; appropriate placement, no cross-contamination

The nurse instructs a client on 100 mg losartan (Cozaar) and 25 mg hydrochlorothiazide (Hyzaar 100-25) tablets to be taken once daily. Which statement requires an intervention by the nurse? 1. "I will eat more fresh fruits while taking this medication." 2. "I should call my health care provider if I develop swelling of my lips." 3. "I can take this medication with or without food." 4. "I understand that I may develop a dry cough while taking this medication."

1) Implementation: outcome desired; hydrochlorothiazide is potassium-wasting diuretic 2) Implementation: outcome desired; angiotensin receptor blockers (ARBs) may cause angioedema 3) Implementation: outcome desired; may be taken with or without food 4) CORRECT- Implementation: outcome not expected; dry, nonproductive cough may occur with angiotensin-converting enzyme inhibitors (ACE inhibitors), not ARBs

The nurse cares for a client who had a Roux-en-Y gastric bypass procedure 4 hours ago. The client's vital signs are blood pressure 92/68, apical heart rate 112 per minute, and respiratory rate 22 per minute. Which order should the nurse question? 1. 0.9% sodium chloride water infusion at 150 mL/hour. 2. Epinephrine (Adrenalin) 1 mg bolus intravenously. 3. Monitor urinary output hourly for 24 hours. 4. 50 mL 25% albumin (human) 50 mL intravenously.

1) Implementation: outcome desired; is isotonic; will replace lost blood volume 2) CORRECT-Implementation: outcome not desired; effect is vasoconstriction with further decrease of blood flow to vital organs; used to treat anaphylactic shock 3) Implementation: outcome desired; measuring urinary output meaures renal perfusion; appropriate activity 4) Implementation: outcome desired; is a crystalloid; will expand plasma volume rapidly; must carefully monitor response

An elderly woman is being seen by the home care nurse following a partial gastrectomy for cancer. Which statement, if made by the client, requires further teaching? 1. "The healthcare provider told me to come in once a month for vitamin B12 injections." 2. "I eat frequently throughout the day." 3. "I do not eat concentrated sweets." 4. "I drink several glasses of iced tea with my meals."

1) Implementation: outcome desired; required monthly to prevent pernicious anemia 2) Implementation: outcome desired; small, frequent feeding prevents dumping syndrome 3) Implementation: outcome desired; prevents dumping syndrome 4) CORRECT-Implementation: outcome not desired; drinking fluids with meals causes stomach content to empty too rapidly into the jejunum

The nurse teaches a client about how to care for an ileostomy. Which comment, if made by the client to the nurse, indicates further teaching is needed? 1. "The skin around the stoma should be cleaned with warm water and thoroughly dried." 2. "The appliance should fit snugly around the ileostomy opening." 3. "I should take polyethylene glycol (MiraLax) with a large glass of water." 4. "I will continue to take a daily multi-vitamin."

1) Implementation: outcome desired; standard of care for ileostomy 2) Implementation: outcome desired; ileostomy drainage is liquid and very alkaline; great risk of skin irritation 3) CORRECT - Implementation: outcome not desired; osmotic laxative and is contraindicated; avoid enteric-coated or capsule medication, which may not be absorbed through GI tract 4) Implementation: outcome desired; inform healthcare provider and pharmacist about ileostomy

The nurse instructs a client about include digoxin (Lanoxin), furosemide (Lasix), spironolactone (Aldactone), and a low-sodium diet. Which statement by the client indicates the need for further instruction? 1. "I should weigh myself every morning and call the health care provider if I gain more than a couple of pounds in a few days." 2. "I should call the health care provider immediately if I start to feel nauseated or have difficulty breathing with normal activities." 3. "I plan to use salt substitutes now that I have to limit my sodium intake." 4. "I should read food and nonprescription medication labels to check the ingredients."

1) Implementation: outcome desired; would indicate fluid retention 2) Implementation: outcome desired; symptoms of digitalis toxicity, CHF 3) CORRECT - Implementation: outcome not desired; salt substitutes contain potassium; spironolactone is a potassium-sparing diuretic 4) Implementation: outcome desired; some medications may contain sodium and potassium

The nurse prepares to administer the initial dose of oral enalapril (Vasotec) 20 mg in the morning. Which medication should the nurse question giving to the client? 1. 20 mg oral escitalopram (Celexa) in the morning. 2. 40 mg oral furosemide (Lasix) in the morning. 3. 300 mg of oral gabapentin (Neurontin) twice daily. 4. 10 mg zolpidem (Ambien) at bedtime.

1) Implementation: outcome not a problem; no interaction with ACE inhibitors; is an SSRI antidepressant 2) CORRECT - Implementation: outcome potential problem; may promote significant diuresis; first dose of ACE inhibitors increases risk of "first dose" phenomenon due to vasodilation; combination of vasodilation and diuresis increases risk of orthostatic hypotension 3) Implementation: outcome not a problem; no interaction; gabapentin classified as antiseizure medication; off-label use for neuropathic pain 4) Implementation: outcome not a problem; is a hypnotic; no interaction with ACE inhibitors

The home care nurse instructs the daughter of a client diagnosed with congestive heart failure. The daughter states her father is taking digoxin (Lanoxin) 0.25 mg and the healthcare provider just prescribed furosemide (Lasix) 40 mg. Which statement, if made by the daughter to the nurse, indicates teaching is successful? 1. "I'm glad that Dad doesn't have to change his diet." 2. "Dad is going to have to eat more cottage cheese and add some more salt to his diet." 3. "Dad must increase his intake of cheese and yogurt." 4. "I should encourage Dad to eat more fresh fruits and vegetables."

1) Implementation: outcome not desired; Lasix is a potassium-wasting diuretic, hypokalemia may precipitate digitalis toxicity 2) Implementation: outcome not desired; high in sodium, would increase fluid retention 3) Implementation: outcome not desired; high in calcium, no indication to increase calcium in the diet; dairy products are high in sodium 4) CORRECT-Implementation: outcome desired; good source of potassium, decreased potassium can predispose to digitalis toxicity

The nursing team consists of two RNs, one LPN/LVN, and one nursing assistive personnel. The nurse should consider the assignment appropriate if the LPN/LVN is required to complete which task? 1. Ambulate a client 8 hours after a thoracotomy. 2. Give an enema to a client prior to a colonoscopy. 3. Complete a bed bath for a client with burns on the arms and legs. 4. Perform a dressing change on a client 3 days after a cholecystectomy.

1) Implementation: outcome not desired; RN needs to frequently assess and evaluate 2) Implementation: outcome not desired; standard, unchanging procedure, assign to assistive personnel 3) Implementation: outcome not desired: high risk of infection and sepsis, RN can do thorough assessment during bath 4) CORRECT- Implementation: outcome desired; stable client with an expected outcome

The nurse feeds the client in a chair when the client suddenly begins to choke on food. The client is conscious but unable to speak. Which action is MOST appropriate for the nurse to take? 1. Encourage the client to cough and breathe deeply. 2. Leave the client in the chair and apply vigorous abdominal or chest thrusts from behind. 3. Return the client to the bed and apply vigorous abdominal or chest thrusts while straddling the client's thighs. 4. Apply several vigorous back blows until the food dislodges.

1) Implementation: outcome not desired; can't inhale, can't exert enough pressure 2) CORRECT-Implementation: outcome desired; abdominal thrust maneuver appropriate when client not moving air 3) Implementation: outcome not desired; no time to do this 4) Implementation: outcome not desired; could cause increased problems; food could migrate further into respiratory tract

The nurse supervises the distribution of meal trays on a medical unit. Which tray will should be given to a client who has requested a kosher diet? 1. Cheeseburger, sliced tomato, french fries, and a milkshake. 2. Pork chops, applesauce, baked potato, and ginger ale. 3. Shrimp salad, sliced avocado, bread, and coffee. 4. Fruit salad, cottage cheese, crackers, and tea.

1) Implementation: outcome not desired; cannot eat dairy and meat at the same meal; eat dairy 6 hours after meat meal 2) Implementation: outcome not desired; cannot eat pork products (bacon, ham, animal shortening, gelatin or foods containing gelatin, e.g., marshmallows) 3) Implementation: outcome not desired; cannot eat shellfish or scavenger fish; fish must have scales 4) CORRECT- Implementation: outcome desired; kosher diet follows Jewish law; no meat or poultry at the same meal as dairy, or using the same utensils; no pork products; no scavenger fish

The nurse reviews medications with a 35-year-old female. The client takes 200 mg carbamazepine (Tegretol) orally twice daily. The client asks the nurse about future pregnancies. Which statement by the nurse is MOST appropriate? 1. "If you take 5 mg folic acid daily while trying to conceive, you should be able to get pregnant." 2. "It is recommended that you take carbamazepine suspension instead of the tablets when trying to get pregnant." 3. "You should contact your health care provider and discuss your concerns about pregnancy." 4. "If you avoid drinking grapefruit juice, there should be no problem with conception."

1) Implementation: outcome not desired; carbamazepine and valproic acid increase risk of birth defects; daily folic acid decreases risk of neural tube defects if taken during pregnancy; folic acid will not increase fertility 2) Implementation: outcome not desired; possible birth defects due to action of the medication; route of administration does not matter 3) CORRECT - Implementation: outcome desired; carbamazepine may be teratogenic; the health care provider should discuss risks and benefits with client 4) Implementation: outcome not desired; grapefruit juice can increase serum levels of carbamazepine as much as 40%

A femoral angiogram is scheduled for a client. It is MOST important for the nurse to take which action prior to the angiogram? 1. Clean and shave the catheter insertion-site area. 2. Locate and note the presence of peripheral pulses. 3. Encourage the client to increase oral fluid intake. 4. Teach coughing and deep-breathing exercises.

1) Implementation: outcome not desired; cleansing may be done according to facility policy; shaving may not be recommended due to possible abrasions and increased risk of infection 2) CORRECT - Assessment: outcome desired and priority; pulse location may be marked according to facility policy; important to get baseline assessment of color, motion, temperature and sensitivity of extremities as well as strength and equality of pulses 3) Implementation: outcome not desired; NPO 8 hours prior to test; dye may cause possible nausea; fluid intake should be increased after procedure to clear dye and reduce risk of renal toxicity 4) Implementation: outcome desired but not highest priority; not at greatly increased risk for atelectasis

The nurse teaches the client how to perform a colostomy irrigation. During the teaching, the client states, "I can't do this." Which response, if made by the nurse, is BEST? 1. "Sure you can do this. You just need to have more practice." 2. "I'll do it for you this time, but you must perform the irrigation the next time." 3. "You seem to be frustrated. What are your specific concerns?" 4. "Most of the other clients learn this without any difficulty. Let's try it again."

1) Implementation: outcome not desired; false reassurance; need to assess first 2) Implementation: outcome not desired; fosters dependence 3) CORRECT-Implementation: outcome not desired; reflects feelings; allows nurse to assess 4) Implementation: outcome not desired; implies deficiency in the client

At 7 A.M., the nurse administers 10 mg glipizide (Glucotrol XL) to a 75-year-old client. At 11 A.M., the nurse notes that the client is drowsy, pale, and has cold, clammy skin. Which is the INITIAL action the nurse will take? 1. Administer 1 mg glucagon subcutaneously. 2. Give the client 1 cup of fruit juice to drink. 3. Determine if the client ate breakfast. 4. Notify the healthcare provider.

1) Implementation: outcome not desired; glucagon used with severe hypoglycemia or when client cannot take oral fluids 2) CORRECT-Implementation: outcome desired; symptoms of moderate hypoglycemia; client can drink juice 3) Assessment: outcome desired but not priority; more important to increase blood glucose level 4) Implementation: outcome desired but not priority; should take action to correct hypoglycemia first

The nurse cares for a client diagnosed with Crohn's disease. The nurse instructs the client about diet. Which menu selection indicates to the nurse that teaching is effective? 1. Cheeseburger on a whole-wheat bun, french fries, and an apple. 2. Tomato soup, saltines, and a slice of unfrosted angel food cake. 3. Baked cod, biscuit without butter, fruit roll-up. 4. Macaroni and cheese, coleslaw, 2 macaroon cookies.

1) Implementation: outcome not desired; high-fat, high-protein, high-residue; high-residue contraindicated 2) Implementation: outcome not desired; low-fat, low-protein, low-residue 3) CORRECT - Implementation: outcome desired; low-fat, high-protein, low-residue, nonirritating, high in calories, minerals 4) Implementation: outcome not desired; high-fat, low-protein, high-residue; may cause diarrhea

A unit of packed cells is ordered for a client who has an intravenous infusion of dextrose 5% in water in progress. Which of the following is the MOST important action for the nurse to take? 1. Connect the packed red blood cells to the dextrose infusion. 2. Remove the dextrose infusion and replace it with the packed red cells. 3. Start a separate infusion of normal saline and use a "Y" connector to infuse the blood. 4. Start an infusion of lactated Ringer's solution and use a "Y" connector to infuse the blood.

1) Implementation: outcome not desired; incompatible; will cause hypertonic hemolysis (clumping) 2) Implementation: outcome not desired; always start with normal saline (0.9% NaCl) 3) CORRECT- Implementation: outcome desired; isotonic solution; "Y" tubing allows for addition of saline to blood cells and provides access for saline flush if transfusion is interrupted 4) Start an infusion of lactated Ringer's solution and use a "Y" connector to infuse the blood.

The nurse cares for a client diagnosed with Alzheimer's disease. The client is confused and incontinent of urine. What is the MOST important action for the nurse to take? 1. Insert an indwelling urinary drainage catheter. 2. Perform intermittent catheterization every 4 hours. 3. Offer the bedpan to the client every 2 hours. 4. Assist the client to a bedside commode every 2 hours.

1) Implementation: outcome not desired; increases risk of infection; catheter-related infections are most common hospital-acquired infection 2) Implementation: outcome not desired; increases chance of infection 3) Implementation: outcome appropriate but not priority; does not keep client independent and active 4) CORRECT - Implementation: outcome desired; keeps client active and independent

A client with a history of gastroesophageal reflux disease reports difficulty sleeping at night. Which of the following is a PRIORITY action for the nurse to take? 1. Instruct the client to drink 8 ounces of milk at bedtime. 2. Advise the client to use 2 pillows at night. 3. Instruct the client to limit fat intake during the day. 4. Advise the client to lie down after the evening meal.

1) Implementation: outcome not desired; increasing stomach volume at bedtime may increase symptoms 2) CORRECT- Implementation: outcome desired; gravity will prevent reflux of stomach contents into esophagus 3) Implementation: outcome not desired; caffeine and spicy foods should be limited 4) Implementation: outcome not desired; lying down will increase reflux of gastric contents

The nurse cares for the client immediately after an ileostomy procedure. Which is the best INITIAL action for the nurse to take during client teaching? 1. Schedule the teaching demonstrations during family visits. 2. Encourage the client to discuss any concerns and to ask questions. 3. Show a video demonstrating ileostomy care. 4. Perform care for the ileostomy until the client is able to do it herself.

1) Implementation: outcome not desired; must assess client's readiness to learn first 2) CORRECT - Assessment: outcome desired; ventilate feelings and assess readiness to learn 3) Implementation: outcome not desired; needs to be ready to learn 4) Implementation: outcome not desired; won't assist in adjustment

The home care nurse cares for a client who is diagnosed with hypertension and mild depression. The client's daughter states that her mother has been falling frequently. WWhich response by the nurse is BEST? 1. "Let's get your mother a walker." 2. "Do you think it's time to put your mother in a nursing home?" 3. "When does your mother fall?" 4. "Does your mother seem to be more confused lately?"

1) Implementation: outcome not desired; need to assess first 2) Assessment: outcome not priority; "yes/no" question; doesn't help determine the problem 3) CORRECT - Assessment: outcome priority; nurse needs to determine what the problem is before implementing; recent history of falling is most important contributor to increased risk of falls 4) Assessment: outcome not priority; "yes/no" question is non-therapeutic; need to assess; may be a contributing factor

A pregnant woman receives an epidural anesthetic. After administration of the epidural anesthetic, the client's blood pressure changes from 120/84 to 94/50. Which action by the nurse is MOST appropriate? 1. Place the client flat on her back. 2. Elevate the head of the bed 30 degrees. 3. Place the client on her left side with her legs flexed. 4. Place the client supine with the foot of the bed elevated.

1) Implementation: outcome not desired; no increase in venous return 2) Implementation: outcome not desired; will decrease venous return 3) CORRECT - Implementation: outcome desired; will increase venous return and cardiac output; fetal pressure on inferior vena cava reduced 4) Implementation: outcome not desired; elevation of legs will increase venous return, but fetal pressure on vena cava will prevent blood return to heart

The nurse discusses an appropriate diet with a client diagnosed with iron-deficiency anemia. Which meal, if selected by the client, indicates to the nurse, that teaching is effective? 1. Spaghetti with a sauce of ground beef, cheese, and garlic bread. 2. Baked sausage casserole with rice and sliced tomato. 3. Frankfurter, baked beans, and chopped cabbage salad. 4. Lamb chop, baked potato, and tossed green salad.

1) Implementation: outcome not desired; only beef is a good source 2) Implementation: outcome not desired; only sausage is good source 3) Implementation: outcome not desired; low in iron 4) CORRECT-Implementation: outcome desired; contains 24-30 mg; vitamin C from potato and salad enhance iron availability

The nurse in the outclient surgery unit prepares a 4-year-old child for surgery. It is MOST important for the nurse to make which of these statements? 1. "Your parents are going to leave a half hour before the surgery." 2. "You're going to talk with some other children who had this surgery." 3. "If you have this surgery, your parents will buy you a new toy." 4. "Take this doll and show me where the operation will be done."

1) Implementation: outcome not desired; parents are encouraged to remain with child 2) Implementation: outcome not desired; appropriate only for school-aged and adolescent children 3) Implementation: outcome not desired; not appropriate 4) CORRECT - Implementation: outcome desired; encourage expression of feelings (e.g., anger); fear mutilation; allow child to play with models of equipment

The nurse cares for a client being maintained on a ventilator. The client suddenly becomes distressed and agitated. Which of the following is the MOST appropriate action for the nurse to take? 1. Obtain an order for a tranquilizer. 2. Restrain the client. 3. Check the last arterial blood gas result. 4. Assess the client's breathing pattern in relation to the ventilator.

1) Implementation: outcome not desired; priority is to determine cause of distress 2) Implementation: outcome not desired; physical restraints are a last resort 3) Incorrect. A current ABG is needed to make any type of decision. 4) CORRECT-Assessment: outcome desired and priority; is client "fighting" the ventilator; symptoms of respiratory distress include restlessness, agitation, apprehension, irritability, pallor, use of accessory muscles, increased pulse; check airway, vital signs, and ABGs

The healthcare provider orders furosemide (Lasix) and spironolactone (Aldactone). Prior to administering Lasix and Aldactone, the nurse determines that the client's potassium level is 3.2 mEq/L. Which is the MOST important action for the nurse to take? 1. Hold the furosemide and spironolactone. 2. Administer only the spironolactone. 3. Administer only the furosemide. 4. Administer the furosemide and spironolactone.

1) Implementation: outcome not desired; should give Aldactone, K+-sparing diuretic 2) CORRECT- Implementation: outcome desired; K+-sparing diuretic; should contact health care provider about serum potassium 3) Implementation: outcome not desired; will lose more potassium 4) Implementation: outcome not desired; will lose more potassium

The nurse performs dietary teaching for a client taking lithium carbonate (Lithonate). Which snack, if selected by the client, indicates that teaching is effective? 1. Four carrot sticks. 2. 8 oz of ice tea. 3. A whole banana. 4. 12 oz of lemonade.

1) Implementation: outcome not desired; should provide increased fluid intake 2) Implementation: outcome not desired; contains caffeine, which is a natural diuretic and stimulant; should avoid fluids containing caffeine 3) Implementation: outcome not desired; should provide increased fluid intake 4) CORRECT-Implementation: outcome desired; provides for increased fluid intake; lithium can cause nephrogenic diabetes insipidus; those on lithium experience thirst and polyuria; need 2,500-3,000 mL/day with adequate salt intake

The nurse describes to a male client how to collect a clean-catch urine for culture and sensitivity. Which explanation, if made by the nurse, is MOST accurate? 1. "The urinary meatus is cleansed with an antiseptic solution, and then a urinary drainage catheter is inserted to obtain urine." 2. "You will be asked to empty your bladder one half-hour before the test; you will then be asked to void into a container." 3. "Before voiding, the urinary meatus is cleansed with an antiseptic solution; urine is then voided into a sterile container; the container must not touch the penis." 4. "You must void a few drops of urine, and then stop; then void the remaining urine into a clean container which should be immediately covered."

1) Implementation: outcome not desired; unnecessary to use catheter 2) This is the procedure for a double void specimen and the question is for a clean catch specimen. 3) CORRECT-Implementation: outcome desired; a culture and sensitivity urinalysis is a sterile specimen 4) Implementation: outcome not desired; need sterile container

The nurse cares for clients on an acute-care surgical area. Which client should the nurse see FIRST? 1. The LPN/LVN reports that a client who had a thoracotomy 2 days ago has clots in the chest drainage system. 2. The nursing assistive personnel reports that a client who had a thyroidectomy 24 hours ago refuses to ambulate 30 minutes after receiving hydrocodone (Vicoden). 3. The family of a client who had a small bowel resection 48 hours ago reports the client is more confused than yesterday. 4. A client who had an ileostomy 3 days ago complains of "aching legs."

1) Not priority; further assessment required; see second 2) Not priority; may be safety issue; further assessment needed; see last 3) CORRECT-Priority; may have decreased cerebral blood flow or oxygenation; see first 4) Not priority; client is at risk for thrombophlebitis; further assessment and evaluation needed; see third

A nurse is presented with a group of clients in the emergency room. The nurse knows that which of the following clients needs immediate attention? 1. A child who is bleeding from a facial injury. 2. A middle-aged client with midsternal chest pain. 3. A middle-aged client in respiratory distress. 4. An infant who has been vomiting for 8 hours.

1) Not usually life-threatening 2) Could be angina; see second 3) CORRECT-Most unstable client; check airway, breathing (ABCs) 4) Potential for dehydration; needs further assessment; should not see first

The nursing team consists of one RN, one LPN/LVN and two nursing assistive personnel (NAPs). Which assignment is MOST appropriate for the LPN/LVN? 1. A 38-year-old client diagnosed with Guillain-Barré syndrome receiving plasmapheresis therapy. 2. A 72-year-old client admitted yesterday with a 10-day history of oral antibiotic therapy and a 24-hour history of watery diarrhea. 3. A 78-year-old client diagnosed with a thrombotic cerebrovascular accident 5 days ago. 4. A 86-year-old client just admitted with malaise, a productive cough, and WBC 17,000 mm3.

1) Outcome not desired; requires frequent assessment of neuromuscular function and monitoring response to therapy 2) Outcome not desired; elderly clients are at risk for clostridium difficile infection due to antibiotic therapy; client would need frequent assessment and evaluation 3) CORRECT - Outcome desired; LPN/LVN can care for stable clients with expected outcomes; nothing in question indicates instability; as cerebral edema resolves, the condition will improve 4) Outcome: not desired; client requires frequent assessment and evaluation; WBC indicates possible infection

A nurse is performing triage in the emergency department. Which of the following clients should the nurse see FIRST? 1. A client with an open fracture of the left femur. BP 110/60, P 86, R 20, T 99.2° F (37.3° C). 2. A client complaining of a "crushing" headache. BP 160/ 100, P 76, R 18, T 98.4° F (36.9° C). 3. A client with burns on the face, chest, and hands. BP 120/80, P 100, R 24, T 98.8° F (37° C). 4. A client with type 1 diabetes. Blood sugar 480 mg/dL. BP 100/60, P 100, R 26, T 99.4° F (37.4° C).

1) See last; most stable client 2) See second; unstable client; cardiovascular; requires further assessment and antihypertensive medication 3) CORRECT-See first; unstable client; upper airway injury possibly due to inhalation injury 4) See third; vital signs consistent with dehydration, rapid respiration is Kussmaul's and expected

The client is receiving an IV infusion of heparin. The bag contains 25,000 units of heparin in 500 mL of 5% dextrose in water. The heparin is to be infused at 1200 units per hour. At what rate should the nurse set the infusion pump? Calculate and record the rate in milliliters. Calculate and record the answer in the box.

24 mL

A client receives an IV heparin infusion at 22 mL/hr through an infusion pump. The IV bag contains 25,000 units of heparin in 500 mL of 5% dextrose in water. How many units of heparin is the client receiving during an 8-hour shift? Calculate and record the answer in the box.

Correct Response: 8800 units 50 units heparin/1 mL 50 units x 22 = 1100 units per hour 1100 units x 8 = 8800 units heparin