NCLEX

C Vancomycin and ahminoglycosides (gentamicin, amikacin, tobramycin) are strong antibiotics that can cause nephrotoxicity and ototoxicity. The client receiving these medications simultaneously would be at an even higher risk for these adverse reactions. The nurse should monitor the client's renal function by assessing blood urea nitrogen (BUN) and creatinine levels and measuring urinary output. Increased levels of BUN and creatinine may indicate kidney damage. The health care provider should be notified before continuing these medications

A client in the intensive care unit is receiving IV vancomycin and gentamicin. The nurse should monitor for which potential complication with the administration of these medications? A. blood in nasogastric tube drainage B. decrease in red blood cell count C. increase in serum creatinine level D. onset of muscle aches and cramping

C The nurse has a medical order stating the the client should not be resuscitated. Therefore, the appropriate first action is to assess the apical pulse. Then the nurse should call the HCP. If the client's family members are present, the nurse should explain what is happening and make sure that they have support.

A client with end-stage renal disease, oxygen-dependent chronic obstructive pulmonary disease (COPD), and a Do Not Resuscitate (DNR) code status is admitted to the medical floor for COPD exacerbation. The nurse walks into the room and finds that the client is not breathing. What should the nurse do first? A. activate the code system B. call the health care provider stat C. check the apical pulse D. check the blood pressure

A The nurse will monitor for passage of normal brown stool, indicating reduction of intussusception. If this occurs, the HCP should be notified immediately to modify the plan of care and stop all plans for surgery

The nurse is caring for a 2 year old who is receiving a saline enema for treatment of intussusception. Reporting which client finding to the health care provider is most important? A. passed a normal brown stool B. passed a stool mixed with blood C. stopped crying D. vomited a third time

ABDE Option D: immunosuppression lowers the body's ability to defend against cancerous mutations

The nurse is participating in a staff presentation to review risk factors for skin cancer. Which of the following risk factors should the nurse include? Select all that apply A. family history of skin cancer B. high number of moles C. history of severe adolescent acne D. immunosuppressant medication use E. outdoor occupation

A Oxybutyin is an anticholinergic medication that is frequently used to treat overactive bladder. Common side effects include: - new-onset constipation - dry mouth - flushing - heat intolerance - blurred vision - drowsiness Decreased sweat production may lead to hyperthermia. The nurse should instruct the client to be cautious in hot weather and during physical activity

The nurse is providing discharge instructions to a client receiving oxybutyin for overactive bladder. Which client statement indicates that further teaching is required? A. "I am looking forward to our summer vacation at the beach" B. "I plan to eat more fruits and vegetables to prevent constipation" C. "I should not drive until I know how this drug affects me" D. "I will drink at least 6-8 glasses of water daily"

ABD Phenylketonuria is one of a few genetic inborn errors of metabolism. Individuals with PKU lack the enzyme required for converting the amino acid phenylalanine into the amino acid tyrosine. As unconverted phenylalanine accumulates, irreversible neurologic damage can occur

The nurse is reviewing anticipatory guidance with the parents of a 6 month old infant with phenylketonuria. Which statements by the nurse are appropriate? Select all that apply A. "a low-phenylalanine diet is required" B. "meat and dairy products should not be introduced into the diet" C. "phenylketonuria is self-limiting and usually resolves by adulthood" D. "special infant formula is required" E. "tyrosine should be removed from the diet"

A Anemia is a common complication of pregnancy, sometimes due to iron deficiency. During the second half of pregnancy, the fetus begins to store iron in preparation for extrauterine life and depletes maternal iron stores

The nurse is reviewing laboratory results for several prenatal clients. Which finding is most important to report to the health care provider? A. client at 24 weeks gestation with hemoglobin of 9 g/dL and hematocrit of 29% B. client at 26 weeks gestation whose 1-hour oral glucose challenge test result is 120 mg/dL C. client at 36 weeks gestation with blood pressure of 125/85 mm Hg and trace protein detected on urine dipstick D. client at 37 weeks gestation with a WBC count of 13,000/mm3

C Isotretinoin is an oral acne medication derived from vitamin A. Taking vitamin A supplements along with isotretinoin can cause vitamin A toxicity, which can cause increased intracranial pressure, gastrointestinal upset, liver damage, and changes in skin and nails. Therefore, clients should be instructed to avoid vitamin A supplements while taking this medication

The nurse reinforces education with a client starting isotretinoin for acne. Which statement indicates the client needs further instruction? A. "I should not donate blood while taking this medication" B. "I will stop taking my tetracycline prior to taking this medication" C. "I will take vitamin A supplements" D. "I will use condoms and birth control pills"

CDE Option A: playing dodgeball places the child at risk for joint or other injury Option B: reading a book does not provide physical activity

The summer camp nurse and parent of a 9 year old child with juvenile idiopathic arthritis (JIA) are discussing appropriate physical activities for the child. Which of the following activities should be included? Select all that apply A. dodgeball B. reading a book C. stationary bicycling D. swimming E. yoga

D Right upper quadrant or epigastric pain can be an indicator of HELLP syndrome, a severe form of preeclampsia. HELLP syndrome is often mistaken for viral gastroenteritis due to its variable and nonspecific presentation. Clients may have RUQ pain, nausea, vomiting and malaise.

When triaging 4 pregnant clients in the obstetric clinic, the nurse should alert the health care provider to see which client first? A. first trimester client reporting frequent nausea and vomiting B. second trimester client with dysuria and urinary frequency C. second trimester client with obesity reporting decrease in fetal movement D. third trimester client with right upper quadrant pain and nausea

BD Option A: continuous IV drug infusions are managed by the RN. This is especially true with drug categories such as anticoagulants, which will require titration depending on client response Option C: in this situation, the LPN is not explaining the LPN's own care to the family, but rather that provided by others on a different shift. Issues related to unit management should be handled by the charge RN Option E: initial teaching should be performed by the RN. The LPN can reinforce the RN's initial teaching

Which actions are appropriate for the registered nurse to delegate to an experienced licensed practical nurse? Select all that apply A. administer heparin continuous infusion to a client with a venous thromboembolism B. auscultate bowel sounds 2 days after repair of an inguinal hernia C. discuss concerns about last shift's care with an irate family member D. monitor flow rate and drainage in a client receiving bladder irrigation E. teach Kegel exercises after a client has a catheter removed

BCE Option A: bottle should be pointed down, away from the cleft, in order to prevent formula from flowing back into the nose area. This back flow would cause nasal regurgitation, and milk or formula may commonly escape through the nose. This is dangerous and the infant will sneeze or cough in order to clear the nose Option D: feeding should take about 20-30 minutes. The infant may be working too hard and tire out if feeding takes 45 minutes or more. In addition, the extra work of feeding will burn up calories that are needed for growth

An infant is born with a cleft palate. Which actions will promote oral intake until the defect can be repaired? Select all that apply A. angle bottle up and toward cleft B. burping the infant often C. feeding in an upright position D. feeding slowly over 45 minutes or more E. using a specialty bottle or nipple

ABCE Option D: nulliparity (no previous pregnancies) is not a risk factor for cervical cancer; however, it is a risk factor for breast cancer

The nurse is teaching about cervical cancer prevention during a women's health conference. Which of the following factors should be taught as risks for cervical cancer? Select all that apply A. human immunodeficiency virus (HIV) B. human papilloma virus (HPV) C. multiple sexual partners D. nulliparity E. sexual activity before age 18

A Pinworm is easily spread by inhaling or swallowing microscopic pinworm eggs, which can be found on contaminated food, drink, toys and linens. Once eggs are ingested, they hatch in the intestines. During the night, the female pinworm lays thousands of microscopic eggs in the skin folds around the anus, resulting in. anal itching and troubled sleep

The clinic nurse cares for a 4 year old who has been diagnosed with a pinworm infection. Which client symptom supports this diagnosis? A. anal itching that is worse at night B. intestinal bleeding with anemia C. poor appetite with weight loss D. red, scaly, blistered rings on skin

B Over-the-counter non steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen can cause cardiovascular side effects, including heart attack, stroke, high blood pressure, and heart failure from fluid retention.

During a routine office visit, the nurse documents the list of current medications of a client with a history of hypertension. Which statement by the client would cause the most concern? A. "I periodically take docusate sodium for constipation" B. "I regularly take ibuprofen for chronic low back pain" C. "I take hydrochlorothiazide to prevent swelling around my ankles" D. "I take omeprazole daily to prevent heartburn"

B Option B: the lowest effective dose of dopamine should be used as dopamine administration leads to an increased cardiac workload. Significant adverse effects include tachycardia, dysrhythmias, and myocardial ischemia. A heart rate of 120/min may indicate that the dopamine infusion needs to be reduced

In the intensive care unit, the nurse cares for a client who is being treated for hypotension with a continuous infusion of dopamine. Which assessment finding indicates that the infusion rate may need to be adjusted? A. central venous pressure is 6 mm Hg B. heart rate is 120/min C. mean arterial pressure is 78 mm Hg D. systemic vascular resistance is 900 dynes/sec/cm-5

ABD Option C: clients with pertussis infection (whooping cough) need droplet precautions Option E: influenza requires droplet precautions

The charge nurse is planning assignments for the day. Which clients will require the nursing staff to institute contact precautions? Select all that apply A. 38 year old with methicillin-resistant staphylococcus aureus B. 42 year old with clostridium difficile diarrhea C. 69 year old with pertussis infection D. 72 year old with vancomycin-resistant enterococcus E. 80 year old with influenza

C Individuals with prosthetic heart valves or prosthetic materials used to repair heart valves should receive prophylactic antibiotics prior to dental procedures to prevent infective endocarditis

The nurse should plan to teach which client about the need for prophylactic antibiotics prior to dental procedures? A. client who had a large anterior wall myocardial infarction with subsequent heart failure B. client who had a mitral valvuloplasty repair C. client with a mechanical aortic valve replacement D. client with mitral valve prolapse with regurgitation

ADE Option B: at times, formula intolerance or allergy is suspected initially when the infant first starts vomiting. However, celiac disease or gluten enteropathy is related to intolerance to gluten, a protein in barley, rye, oats and wheat (BROW). Clients with celiac disease cannot eat these foods. A 3 week old infant would only consume milk; this history would not be a factor at this time Option C: physiological hyperbilirubinemia occurs due to the newborn's immature liver that is unable to metabolize hemoglobin byproducts. This is a "normal" finding that is unrelated to pyloric stenosis

The parent of a 21 day old male infant reports that the infant is "throwing up a lot." Which assessments should the nurse make to help determine if pyloric stenosis is an issue? Select all that apply A. assess the parent's feeding technique B. check for family history of gluten enteropathy C. check for history of physiological hyperbilirubinemia D. check if the vomiting is projectile E. compare current weight to birth weight

CE Cardinal symptoms of acute cholecystitis from cholelithiasis include pain in the RUQ with referred pain to the right shoulder and scapula. Clients often report fatty food ingestion 1-3 hours before the initial onset of pain. Associated symptoms include low-grade fever, chills, nausea, vomiting and anorexia

When assessing a client with cholelithiasis and acute cholecystitis, which findings might the nurse note during the health history and physical examination? Select all that apply A. flank pain radiating to the groin B. high-protein food ingestion before the onset of pain C. low-grade fever with chills D. pain at the umbilicus E. right upper-quadrant pain radiating to the right shoulder

ABC Option D: the off-going nurse will not stay on the new shift to watch for impairment. The impaired nurse may not behave in an obvious manner while the off-going nurse is watching. Regardless of these factors, the nurse has alcohol on the breath and slurred speech; by definition there is evidence of impairment Option E: confronting the impaired nurse in a hostile manner does nothing to protect the client and offers no support to the nurse. Confrontation may be necessary if the client is in immediate danger. The off-going nurse should notify the charge nurse so that facility authorities can collaborate with the governing state board of nursing to carry out appropriate investigation, discipline, and supportive interventions. Most state nurse practice acts allow rehabilitation for a cooperative professional rather than automatic loss of license

During change-of-shift report, the nurse going off duty notes that the nurse coming on has an alcohol smell on the breath and slurred speech. What actions are most important for the nurse to take? Select all that apply A. do not continue the handoff report with the oncoming nurse B. document the incident according to facility policy C. notify the charge nurse D. say nothing but watch for impaired behavior E. tell the oncoming nurse that he/she is not fit for duty

A The richest dietary sources of iron include meat, fish, and poultry, which provide a form of iron that is easily absorbed by the body

Several children seen at a local pediatric clinic are found to have a hemoglobin level of 10-11 g/dL. Which dietary modification would most likely help increase hemoglobin levels in these clients? A. ensuring adequate intake of meat, fish, and poultry B. increasing consumption of fruits and vegetables C. prioritizing intake of milk and other dairy products D. providing orange juice fortified with vitamin D at meals

D Key preventative measures include eliminating exposure to smoke, obtaining routine immunizations to prevent infection and reducing or eliminating use of a pacifier after age 6 months

A 1 year old child who goes to day care is recovering from an episode of otitis media. Which intervention is most important for the nurse to recommend to the parents in order to prevent recurrence? A. exclusive breastfeeding B. not sending the child to day care C. preventing water from entering the ear D. smoking cessation by the parents

ACE Option A: the priority intervention for clients with elevated BLLs is preventing continued exposure. The home environment should be assessed for lead sources Option B: vacuuming spreads lead dust in the air, which increases inhalation exposure. Hard surfaces should be wet-dusted or mopped at least weekly Option C: pediatric and pregnant clients should not live in homes being renovated until the work is complete. Handwashing, especially before eating, is important to remove lead residue Option D: hot tap water dissolves lead from older pipes; therefore, cold water should be used for consumption if lead plumbing is present. Taps should be flushed for several minutes to clear out contaminated water before use Option E: clients with elevated BLLs require follow-up blood work to ensure that levels decrease

A 12 month old client has a high blood lead level of 18 mcg/dL. The nurse educates the parents about lead poisoning. Which statements made by the parent indicate that teaching is successful? Select all that apply A. "I should get our home inspected for the source of the lead" B. "I will vacuum our hard-surface floors daily" C. "I will wash my child's hands often, especially before eating" D. "we should use hot tap water for cooking" E. "we will have to return for a follow-up lead level"

C Extremely elevated BLLs can lead to permanent cognitive impairment, seizures, blindness or even death Option A: gastrointestinal bleeding is a concern for clients with iron poisoning but has no link to lead toxicity Option B: although delays in physical growth can result from chronic lead toxicity, the danger of permanent damage to the neurological system is a higher priority, particularly for young children. Growth retardation more commonly occurs with chronic anemia or pituitary disorders Option D: lead poisoning is most threatening to the kidneys and neurological system; liver injury typically does not occur. Severe liver damage is closely associated with acetaminophen overdose or Reye syndrome

A 12 month old is found to have a moderately elevated blood lead level. Which of the following is the most serious concern for this child? A. gastrointestinal bleeding B. growth retardation C. neurocognitive impairment D. severe liver injury

D During adolescence, being with a peer group is part of the process of achieving individual identity, the most important developmental task at this age. An adolescent's friends have more influence than parents, teachers or any other adults. Social relationships and activities help to provide a sense of belonging, acceptance, and approval. Having face-to-face visits and spending time with friends will help counteract feelings of isolation and loneliness during the client's recuperative period. In addition, the client is at risk for body image disturbance related to scoliosis and surgery. The client may be particularly sensitive about body image and needs understanding and acceptance from peers

A 14 year old is scheduled for surgery to treat scoliosis. The child will be hospitalized for about a week and then discharged home to recuperate for 3-4 weeks before returning to school. What is the best activity the nurse can recommend to promote age-specific growth and development during this time? A. attending selected after-school events and social activities B. keeping up with schoolwork C. reading teen magazines D. visits from friends

B Certain behaviors are common in the adolescent period, ages 11 to 20. Teenagers engage in risk-taking behaviors and want to be just like their peers. Adolescents with chronic disease may have difficulty managing their illness due to a false sense of security and the belief that nothing bad can happen to them

A 15 year old client with type 1 diabetes mellitus is admitted to the pediatric intensive care unit with a blood glucose level of 460 mg/dL. The nurse understands that which factor is contributing to this client's noncompliant behavior? A. client is depressed and wants to die B. client's psychosocial developmental stage C. lack of supervision by the client's caregivers D. limited understanding of the disease process

C During the first 3-4 months of life, it is not unusual for an infant to cry 1-3 hours a day in response to being hungry, thirsty, tired, in pain, bored, or lonely. A very young, first-time parent may not have an appreciable understanding of normal infant behavior and may perceive normal crying as excessive. It is most important for the nurse to assess the infant's pattern and quality of crying to better understand whether it is normal behavior or a sign of something more serious that requires further evaluation and treatment

A 15 year old parent brings a 4 month old infant for a well-baby checkup. The parent tells the nurse that the baby cries all the time; the parent has tried everything to keep the infant quiet but nothing works. What is the priority nursing action? A. advise the parent to give a pacifier whenever the infant cries B. ask the parent to describe what is done to "keep the baby quiet" C. assess the infant's pattern and frequency of crying D. explore the parent's support system

BCD Option A: avoid lotions and powders to prevent irritation and excess moisture Option E: the Pavlik harness is usually worn all the time, particularly during the first few weeks of treatment. Some providers may allow the harness to be removed for a short bath once a day, but it should be left in place for all other care activities, including diaper changes

A 2 month old recently diagnose with developmental dysplasia of the hip is beginning treatment with a Pavlik harness. Which instructions should the nurse provide to the parents? Select all that apply A. "apply lotion under the straps to protect the skin" B. "dress the child in a shirt and knee socks under the straps" C. "lightly massage the skin under the straps daily" D. "place the diaper under the straps" E. "remove the harness during diaper changes"

A Retinoblastoma, a unilateral or bilateral retinal tumor, is the most common childhood intraocular malignancy. It is typically diagnosed in children under age 2 and is usually first recognized when parents report a white "glow" of the pupil. Light reflecting off the tumor will cause the pupil to appear white instead of displaying the usual red reflex

A 2 year old is suspected of having retinoblastoma. The nurse recognizes which sign as being most characteristic of this disease? A. absence of red reflex B. fixed and mid-dilated pupil C. ptosis of the eye D. purulent eye discharge

D Clients taking MAOIs or other antidepressants are at increased risk for suicidal ideation, particularly children, adolescents, and young adults. The risk of suicidal thoughts can be more prevalent when starting the medication or with dose increases. Feelings of hopelessness or despair must be evaluated to assess if suicidal ideation or thoughts of self-harm are present

A 21 year old client is being evaluated in the outpatient psychiatric clinic after starting isocarboxazid 2 weeks ago. Which of the client's statements needs to be addressed first? A. "I am not sleeping well at night and would like a sleeping aid" B. "I do not know how well I will do on this restricted diet" C. "I have been having quite a bit of nausea and constipation" D. "this medicine is not working; I am so tired of being depressed"

B The straps are assessed every 1-2 weeks by the health care provider and adjusted as necessary to account for infant growth. Parents should not alter the strap placements at home as incorrect positioning can lead to damage to the nerves or vascular supply of the hip.

A 3 month old child with developmental dysplasia of the hip (DDH) is being fitted for a Pavlik harness. Which statement made by the parent indicates a need for further instruction? A. "I should leave the harness on during diaper changes" B. "I will adjust the harness straps every 3-5 days" C. "I will inspect the skin under the straps 2-3 times daily" D. "the harness should keep my baby's legs bent and spread apart"

D Symptoms of hyponatremia include irritability, lethargy, and in severe cases, hypothermia and seizure activity. Formula should be prepared per the manufacturer's instructions.

A 3 month old infant has irritability, facial edema, a 1 day history of diarrhea with adequate oral intake, and seizure activity. During assessment, the parents state that they have recently been diluting formula to save money. Which is the most likely cause of the infant's symptoms? A. hypernatremia due to diarrhea B. hypoglycemia due to dilute formula intake C. hypokalemia due to excess gastrointestinal output D. hyponatremia due to water intoxication

A Chest tube drainage > 3 mL/kg/hr for 3 consecutive hours or >5-10 mL/kg in 1 hour should be reported immediately to the health care provider

A 3 month old who weighs 8.8 lb (4 kg) has just returned to the intensive care unit after surgical repair of a congenital heart defect. Which finding by the nurse should be reported immediately to the health care provider? A. chest tube output of 50 mL in the past hour B. heart rate of 150/min C. temp of 97.5 F D. urine output of 8 mL in the past hour

C Duchenne muscular dystrophy is the most common form of childhood MD. The condition is X-linked recessive and is due to lack of a protein called dystrophin needed for muscle stabilization. There is no effective cure. Most children are wheelchair bound by adolescence and die by age 20-30 from respiratory failure. It is important to avoid floor clutter and prevent falls/injury

A 4 year old boy is diagnosed with Duchenne muscular dystrophy. Which nursing teaching is most appropriate to reinforce for this child's parents? A. increase intake of foods high in iron B. lift weights to strengthen weak muscles C. remove throw rugs from the home D. take the muscle relaxant baclofen on time

D The treatment goals are to reduce the ventricular rate to <100/min and prevent stroke. Ventricular rate control is the priority. Medications used for rate control include calcium channel blockers (diltiazem), beta blockers (metoprolol) and digoxin

A 45 year old client with atrial fibrillation has been prescribed diltiazem. Which client outcome would best indicate that the medication has had its intended effect? A. atrial fibrillation is converted to sinus rhythm B. blood pressure is 126/78 mm Hg C. no signs or symptoms of stroke D. ventricular rate decreased from 158/min to 88/min

C The child who is playing or sleeping might still be experiencing pain but is using distraction as a coping mechanism. This statement by the caregiver indicates that further teaching is needed

A 5 year old child is receiving morphine sulfate for pain. Which statement by the caregiver indicates that further teaching is necessary? A. "I will call the nurse if my child begins to act aggressively" B. "I'm concerned that my child thinks the pain is punishment" C. "my child is playing and so does not need pain medication" D. "the FACES pain scale seems to be working very well"

C Herpes zoster, or shingles, has a characteristic unilateral, linear pattern of fluid-filled blisters. Affected clients commonly report pain and itching. Herpes zoster is due to the varicella-zoster virus, which also causes chickenpox. After initial chickenpox infection in early childhood, the virus remains dormant in the sensory nerves. Reactivation occurs when the immune system is compromised, resulting in formation of lesions along the distribution of one or more such nerves.

A 59 year old client comes to the clinic due to a blistering, linear rash on the left chest. The client reports itching and pain around the rash. What is the priority question for the nurse to ask the client? A. "did the rash start after taking a new medication?" B. "have you been keeping the rash covered?" C. "have you ever had chickenpox?" D. "what have you tried to help the pain?"

C Infants and young children have a higher percentage of body water than older children and adults. As a result, they become dehydrated quickly due to fluid losses caused by vomiting and diarrhea. Signs of severe dehydration include lethargy, sunken fontanel, increased capillary refill time, increased heart rate, and increased respiratory rate. When dehydration is severe enough to affect the client's hemodynamic status or to potentiate shock, the priority is intravenous rehydration

A 6 month old infant is brought to the emergency department after experiencing vomiting and diarrhea for 4 days. Which prescription from the health care provider is the priority? A. IV acetaminophen 60 mg every 6 hours B. IV ampicillin 240 mg every 12 hours C. IV normal saline bolus 20 mL/kg over 1 hour D. IV ondansetron 2 mg every 8 hours

A This client is experiencing amnesia of undetermined origin. The cause could stem from a medical condition, substance abuse, traumatic brain injury, cognitive disorder such as dementia, or psychiatric condition such as dissociative fugue. Regardless of the diagnosis, the priority nursing action is to assess the client's physical status. This client has been wandering for 2 days and cannot recall previous locations, arriving at the present location, and the timetable involved. It is highly probable that the client is dehydrated and fatigued. It is most important to assess the client's physical needs and implement interventions to stabilize the physiologic condition before assessing psychosocial status and needs

A 60 year old client wanders away during halftime at a football game and is found 48 hours later sleeping on a park bench, 100 miles from home. The client is brought to the emergency department by the police. the client can state the name and address but has no recollection of the past 2 days. What is the priority nursing action? A. assess vital signs B. contact family members C. encourage the client to recall recent events D. perform a mental status assessment

B Establishing baseline data is essential for comparison with postoperative assessments. The nurse should pay special attention to the character and quality of peripheral pulses and renal and neurologic status. Dorsalis pedis and posterior tibial pulse sites should be marked for easy location postoperatively. A decreased or absent pulse with cool, pale, mottled, or painful extremity postoperatively can indicate embolization or graft occlusion.

A 62 year old client is scheduled for open abdominal aneurysm repair. What key assessment should be made by the nurse preoperatively? A. assess and compare blood pressure in each arm B. assess character and quality of peripheral pulses C. assess for presence or absence of hair on lower extremities D. assess for presence of bowel sounds

D Treatment of hypokalemia may require an IV infusion of potassium chloride. The infusion rate should not exceed 10 mEq/hr. Therefore, IVPB KCL must be given via an infusion pump so the rate can be regulated. Too rapid infusion can cause cardiac arrest.

A charge nurse is monitoring a newly licensed registered nurse. What action by the new nurse would warrant intervention by the charge nurse? A. administer hydromorphone 1 mg to a client who rates pain a 7 on a 1 to 10 scale B. notifies physician of occasional premature ventricular beats in a client with myocardial infarction C. positions a postoperative pneumonectomy client on the affected side D. prepares to administer IVPD potassium chloride via gravity infusion for a client with hypokalemia

A The priority nursing action is to rinse and reinsert the tooth in to the gingival socket and hold it in place until stabilized by a dentist. Reimplantation within 15 minutes of injury re-establishes blood supply, increasing the probability of tooth survival Option B: scrubbing the root would damage it. The tooth should be gently rinsed with sterile saline or clean, running water Option C: placing the tooth in water would lyse the cells, killing the tooth Option D: wrapping the tooth in sterile gauze would dry it out. In addition, the nurse should arrange for immediate transfer to a dentist rather than advise the parent to schedule an appointment that might not be available for days

A child is brought to the school nurse after having a permanent tooth knocked out during gym class. Which action by the nurse is appropriate? A. gently rinse the tooth with sterile saline and reinsert it into the gingival cavity B. gently scrub the root of the tooth to remove any debris, and wrap it in sterile gauze C. place the tooth in water and transport the client to the nearest emergency department D. wrap the tooth in sterile gauze and advise the parent to arrange for a dental appointment

B Option A: food and liquids are not restricted prior to an EEG except for caffeinated beverages. Cocoa contains caffeine Option C: this test is not painful as it only records brain electrical activity. Electrode gel is nonirritating to the skin Option D: a routine EEG is not performed under sedation, and so the child should remember the procedure

A child is scheduled to have an electroencephalogram (EEG). Which statement by the parent indicates understanding of the teaching? A. "I will let my child drink cocoa as usual the morning of the procedure" B. "I will wash my child's hair using shampoo the morning of the procedure" C. "my child may have scalp tenderness where the electrodes were applied" D. "my child will not remember the procedure"

C Having the child return to school immediately is the best approach for resolving school phobia and is associated with a faster recovery. If necessary, gradual exposure to the school environment can be implemented; the child can attend school for a few hours and then gradually increase the time to a full day. A gradual approach may decrease the child's sensitization to the classroom. If the child is allowed to remain out of school, the problem will only worsen, with potential deterioration of academic performance and social relationships

A child with a high level of school absenteeism has been determined to have school phobia. The school nurse should counsel the child's parent/caregiver to take which action? A. allow the child to stay home when the child seems particularly anxious B. encourage the parent/caregiver to sit in the classroom with the child C. insist on school attendance immediately, starting with a few hours a day D. return the child to school when the cause of the school phobia has been identified

C A common side effect of methylphenidate is loss of appetite with resulting weight loss. Parents and caregivers should be instructed to weigh the child with ADHD at least weekly due to the risk of temporary interruption of growth and development

A child with attention-deficit hyperactivity disorder has been taking methylphenidate for a year. What are the priority nursing assessments when the client comes to the clinic for a well-child visit? A. attention span and activity level B. dental health and mouth dryness C. height/weight and blood pressure D. progress with schoolwork and in making friends

BCE Option A: medications should not be applied to a burn until prescribed by a health care provider as they may interfere with assessment of the burned area Option D: placing ice on a burn or wrapping the area in ice can increase tissue damage and may cause hypothermia with large burns. No ice, ointments, creams, or butter should be placed on the open skin

A child's arm is burned from accidentally spilling boiling water on it, and the parent calls the clinic. The nearest emergency department is an hour away. Which instructions would be appropriate to give the parent? Select all that apply A. "apply antibiotic ointment to any open skin" B. "briefly soak the arm with cool water" C. "cover the area with a clean, dry cloth" D. "place ice on the arm to relieve pain" E. "remove clothing, if not stuck to skin, around the burn"

A Urinary tract infections are common during pregnancy due to physiologic renal system changes. Most UTIs are confined to the lower urinary tract. Symptoms include urinary frequent, dysuria, urgency, foul-smelling urine, and a sensation of bladder fullness. Diagnostic testing includes urinalysis and urine culture. Oral antibiotics are required to appropriately treat cystitis. Option A: if cystitis goes unreported or untreated, the infection may ascend to the kidneys and cause pyelonephritis. During pregnancy, pyelonephritis requires IV antibiotics and hospitalization because of the increased risk of preterm labor. Therefore, priority assessment is to rule out indicators of pyelonephritis in clients who report UTI symptoms to ensure appropriate diagnosis and treatment Option B: wiping front to back after urination may help prevent escherichia coli from contaminating the urethra. Reviewing toileting hygiene is important but doesn't to help assess current symptoms Option C: urinary frequency and nocturia are common during pregnancy. However, the nurse should not focus on the normalcy of urinary frequency since the client has reported additional symptoms Option D: pregnancy predisposes clients to UTIs. Furthermore, assessing for history of UTI does little to address the client's current symptoms

A client at 20 weeks gestation reports "running to the bathroom all the time," pain with urination, and foul-smelling urine. Which question is most important for the nurse to ask when assessing the client? A. "are you having any pain in your lower back or flank area?" B. "do you wipe from front to back after urinating?" C. "have you found that you urinate more frequently since becoming pregnant?" D. "have you had a urinary tract infection in the past?"

A Pica is the abnormal, compulsive craving for and consumption of substances normally not considered nutritionally valuable or edible. Pica is often accompanied by iron deficiency anemia due to insufficient nutritional intake or impaired iron absorption. However, the exact relationship between pica and anemia is not fully understood. The health care provider would likely order hemoglobin and hematocrit levels to screen for the presence of anemia

A client at 20 weeks gestation states that she started consuming an increased amount of cornstarch about 3 weeks ago. Based on this assessment, the nurse should anticipate that the health care provider will order which laboratory test(s)? A. hemoglobin and hematocrit levels B. human chorionic gonadotropin level C. serum folate level D. white blood cell count

BC Option A: dairy is a great source of calcium, which is essential for fetal bone development. However, dairy products should be consumed at least 2 hours before or 1 hour after iron supplements as they bind to iron and decrease absorption Option D: laxatives are not recommended during pregnancy due to the risk of dehydration and electrolyte imbalance, which can lead to uterine cramping and contractions. The client should consult with the health care provider before using any over-the-counter stool softeners or laxatives Option E: caffeine consumption in pregnancy should be limited to 200-300 mg/day. Coffee may contain 100-200 mg caffeine per cup and should therefore be consumed in moderation during pregnancy

A client at 34 weeks gestation reports constipation. The client has been taking 325 mg ferrous sulfate tid for anemia since the last appointment 4 weeks ago. Which recommendations should the nurse make for this client? Select all that apply A. decreased daily dairy intake B. increased fruit and vegetable intake C. moderate-intensity regular exercise D. one laxative twice daily for a week E. two cups of hot coffee each morning

ADE Option A: absent or decreased deep tendon reflexes are the earliest sign of magnesium toxicity. Option B: hypertension is a sign of pre-eclampsia, not of magnesium toxicity. Hydralazine and/or labetalol are used to lower blood pressure if needed Option C: urine output <30 mL/hr is a sign that magnesium toxicity may be likely, as magnesium is excreted through the urine Option D: if toxicity is not recognized early, clients can progress to respiratory depression, followed by cardiac arrest. Option E: magnesium toxicity can occur when magnesium levels are > 7 mEq/L, which causes central nervous system depression and blocks neuromuscular transmission

A client at 35 weeks gestation is admitted to the labor and delivery unit for severe pre-eclampsia. She is started on IV magnesium sulfate for seizure prophylaxis. Which of the following signs indicate that the client has developed magnesium sulfate toxicity? Select all that apply A. 0/4 patellar reflex B. blood presume of 156/84 mm Hg C. client voiding 600 mL in 8 hours D. respirations of 10/min E. serum magnesium level of 8.0 mEq/L

B Administration of IV narcotics during the peak of contractions can help decrease sedation of the fetus and subsequent newborn respiratory depression at birth. Uteroplacental blood flow is significantly reduced during contraction peaks, and administration of IV medication at this time results in less medication crossing the placental barrier. In addition, a higher concentration of medication remains in the maternal vasculature, which increases the effectiveness of pain relief

A client at 38 weeks gestation is in latent labor with ruptured membranes and is receiving an oxytocin infusion for labor augmentation. The client is requesting IV pain medication. When administering an IV narcotic during labor, which nursing action is appropriate? A. discontinue the oxytocin infusion prior to giving the medication B. give the mediation slowly during the peak of the next contraction C. hold until contractions are occurring at least every 4 minutes for an hour D. withdrawn 5 mL of lactated ringer from the IV tubing to dilute the medication

ABE Option C: as with any vaginal examination, the client may feel some pressure and discomfort during an amniotomy. However, the actual AROM procedure, or "breaking the bag of water" is painless Option D: supine positioning decreases utter-placental blood flow and fetal oxygenation. The client should be assisted to upright positions after AROM to allow for drainage of amniotic fluid and to encourage the fetal head to remain firmly applied to the cervix

A client at 41 weeks gestation is admitted to the labor and delivery unit fo labor induction. The nurse is assisting the health care provider with an amniotomy. What actions should the nurse anticipate? Select all that apply A. assessing the fetal heart rate before and after the procedure B. checking the client's temperature every 2 hours C. informing the client that she will feel a sharp pain during the procedure D. keeping the client in a supine position after the procedure E. noting the characteristics of the amniotic fluid

BDF Option B: doxycycline, a tetracycline antibiotic, is avoided in pregnancy because it can impair bone mineralization and discolor permanent teeth in the fetus Option D: isotretinoin (accutane) has a black box warning for severe birth defects. Retinoids may not be prescribed to women of childbearing age without a formal agreement to participate in iPLEDGE (a prescription tracking program) and a commitment to use two forms of contraception Option F: ACE inhibitors such as lisinopril (prinivil) have a black box warning for use in pregnancy because they can affect fetal renal function and lung development or cause fetal death

A client at 9 weeks gestation arrives at the clinic for an initial obstetric appointment. The nurse reviews the client's medical history and obtains a list of current medications. The nurse recognizes that which of the following medications should be clarified with the health care provider immediately? Select all that apply A. albuterol B. doxycycline C. insulin aspart D. isotretinoin E. levothyroxine F. lisinopril

A Individuals with agoraphobia have fear and anxiety about being in (or anticipating) certain situations or physical spaces. The fear they experience is out of proportion to any actual danger. These individuals are also highly concerned about having trouble escaping or getting help in the event of a panic attack or panic symptoms Option B: in generalized anxiety disorder, the anxiety is evident in various situations and can impact all areas of an individuals' life Option C: in social anxiety disorder, individuals fear being scrutinized, observed, or embarrassed in social or performance settings Option D: zoo phobia is fear of animals

A client comes to the community mental health clinic seeking treatment for severe anxiety associated with a recent job promotion that requires a 30 minute commute via train. The nurse recognizes that this client most likely suffers form which psychological disorder? A. agoraphobia B. generalized anxiety disorder C. social anxiety disorder D. zoophobia

ABCE Angina pectoris is defined as chest pain brought on by myocardial ischemia (decreased blood flow to the heart muscle). Any factor that increases oxygen demand or decreases oxygen supply to the cardiac muscle may cause angina. Option D: deep sleep doesn't increase oxygen demand

A client comes to the emergency department for the second time with shortness of breath and substernal pressure that radiates to the jaw. The nurse understands that angina pectoris may be precipitated by which of these factors? Select all that apply A. amphetamine use B. cigarette smoking C. cold exposure D. deep sleep E. sexual intercourse

B BNP is a peptide that causes natriuresis. B-type natriuretic peptides are made, stored, and released primarily by the ventricles. They are produced in response to stretching of the ventricles due to the increased blood volume and higher levels of extracellular fluid (fluid overload) that accompany heart failure. Elevation of BNP > 100 pg/mL helps to distinguish cardiac from respiratory causes of dyspnea.

A client comes to the emergency department with severe dyspnea and a cough. Vital signs are temperature 99.2 F; blood pressure 108/70 mm Hg; heart rate 88/min; and respirations 24/min. The client has a history of chronic obstructive pulmonary disease (COPD) and chronic heart failure. Which diagnostic test will be most useful to the nurse in determining if this is an exacerbation of heart failure? A. arterial blood gases (ABGs) B. B-type natriuretic peptide (BNP) C. cardiac enzymes D. chest x-ray

C Sexual intercourse is avoided until the inflammation is resolved, typically for the duration of treatment, approximately 3-7 days. However, sexual activity is not a significant cause of infection or reinfection of candida, and partner evaluation is not needed. Trichomoniasis, syphilis, gonorrhea, and HIV are mainly sexually transmitted; therefore, partners should be evaluated and treated

A client diagnosed with vaginal candidiasis is instructed on self-care management techniques and proper administration of the prescribed miconazole vaginal cream. Which statement by the client indicates that further teaching is needed? A. "each time I use the bathroom, I will wipe myself from the front to the back" B. "I should choose loose-fitting cotton underwear instead of nylon undergarments" C. "I will refrain from having sex until my partner is also tested and treated for the infection" D. "prior to going to bed at night, I will apply miconazole cream using the vaginal applicator"

ABE Option C: the client with MRSA or VRE is allowed to have visitors. However, these individuals will need instructors from the nursing staff about hand hygiene and the use of gloves and gowns and their disposal prior to leaving the client's room. A sign should be placed on the client's door to inform visitors about these precautions Option D: a face mask is required for droplet precautions. An N95 particulate respirator mask is required for certain airborne precautions

A client has been admitted with a catheter-associated, vancomycin-resistant enterococcal bacteremia. Which interventions should the nurse implement? Select all that apply A. keep dedicated equipment for client B. perform hand hygiene before exiting the room C. place a "no visitors" sign on the client's door D. wear a face mask when in the room E. wear an isolation gown when providing direct care

A Acute lithium toxicity presents primarily with gastrointestinal side effects such as persistent nausea and vomiting and diarrhea. Neurologic symptoms typically manifest later and include tremor, confusion, ataxia, and sluggishness. Severe toxicity results in seizures and encephalopathy

A client has been on lithium carbonate therapy for 7 days. Which of the following findings would be most important to report to the health care provider? A. diarrhea, vomiting and mild tremor B. dry mouth and mild thirst C. hyperactivity and auditory hallucinations D. lithium level of 1.3 mEq/L

B An atrioventricular pacemaker paces the right atrium and right ventricle in sequence. The ECG will have 2 pacer spikes, one before the P wave and one before the QRS complex. The P wave following the atrial pacer spike may be normal or abnormal appearing. The QRS complex following the ventricular pacer spike is typically wide and distorted. An atrioventricular pacemaker can improve synchrony between the atria and ventricles. It may be implanted in the client with bradycardia, heart block, or cardiomyopathy.

A client has just returned from the cardiac catheterization laboratory for a permanent pacemaker placement. How should the nurse document the rhythm on the client's cardiac monitor? A. atrial paced rhythm B. atrioventricular paced rhythm C. biventricular paced rhythm D. ventricular paced rhythm

C Metronidazole (flagyl) is an anti-infective drug commonly used to treat C difficile. For severe C difficile infection, oral vancomycin may be used; intravenous vancomycin is ineffective. Option A: ceftriaxone (rocephin) is a cephalosporin antibiotic; its use could cause C difficile infection Option C: fluconazole (diflucan) is a broad-spectrum antifungal agent; it is not indicated to treat C difficile Option D: pantoprazole (protonix) is a proton pump inhibitor agent; its use has been associated with development of C difficile infection

A client has nausea, abdominal cramping, and persistent mucus-like, watery diarrhea that is positive for clostridium difficile. The nurse anticipates the client will be prescribed which medication to treat this condition? A. ceftriaxone B. fluconazole C. metronidazole D. pantoprazole

CDE Radiation damages the DNA, which causes cell destruction. Radiation usually affects tissues with rapidly proliferating cells (oral mucosa, GI tract, bone marrow) first, followed by tissues with slowly proliferating cells (cartilage, bone, kidney). As a result, early manifestations of radiation damage include oral mucosal ulcerations, vomiting/diarrhea and low blood cell counts. Option A: a bitter almond smell on the client's breath is a classic sign of cyanide poisoning Option B: fever and raised skin pustules are signs/symptoms of smallpox, which is transmitted from person to person via respiratory droplets. Infection starts with fever, followed by a rash and then sharply raised pustules

A client has potential radiation contamination from a disaster. The nurse should monitor for which of the following related to this contamination? Select all that apply A. bitter almond smell on breath B. fever and raised skin pustules C. low blood cell counts D. oral mucosal ulcerations D. vomiting and diarrhea

C If a client exhibits hypotensive symptoms while receiving epidural anesthesia, the nurse should first assess blood pressure to confirm the presence of hypotension before intervening Option A: IV ondansetron may help alleviate symptoms of nausea and vomiting, but evaluation and correction of potential hypotension should be completed first Option B: if hypotension persists after initial interventions or fetal distress occurs, further measures include administering IV vasopressors and applying 8-10 L/min oxygen via face mask to increase blood flow and oxygen delivery to the fetus Option D: nausea may occur independently of hypotension due to labor pain or as a sign of complete dilation. However, this client also has lightheadedness and is receiving epidural anesthesia; hypotension is extremely common with epidural anesthesia

A client in active labor who received an epidural 20 minutes ago reports feeling nauseated and lightheaded. Which action should the nurse perform first? A. administer IV ondansetron B. apply oxygen via face mask C. obtain blood pressure D. perform vaginal examination

D The period of active labor from 8-10 cm dilation is often the most emotionally challenging phase of labor, marked by increased maternal anxiety. A mixture of mucus and pink/dark brown blood is commonly observed during transition. Nursing priorities include providing emotional support and encouragement, and coaching the client is breathing techniques

A client in labor has reached 8 cm dilation, is fully effaced, and feels an urge to push. The nurse observes thick, blood-tinged mucus during the vaginal examination. What is the nurse's best action? A. administer prescribed IV meperidine for pain relief B. encourage client to bear down with spontaneous urges to push C. place client in the lithotomy position in preparation for birth D. provide encouragement and coaching in breathing techniques

A The first sign of uterine rupture is usually abnormal fetal heart rate patterns. Other manifestations include constant abdominal pain, loss of fetal station, and sudden cessation of uterine contractions. Option B: most commonly, FHR decelerations followed by fetal bradycardia are indicative of uterine rupture. Fetal tachycardia may be caused by infection, maternal fever, or stimulant drugs. However, moderate variability is a reassuring sign predictive of adequate fetal oxygenation Option C: contractions normally grow more intense as labor progresses, and increasing anxiety and discomfort are common. However, the nurse should monitor the client for constant, severe abdominal pain, which may indicate uterine rupture Option D: the nurse should be hyper vigilant for tachysystole, which increases the risk for uterine rupture. Strong contractions every 3-4 minutes are probably indicative of a normal labor contraction pattern

A client in labor with a history of a previous cesarean birth has chosen to attempt a vaginal birth. During labor, which finding would be most concerning to the nurse? A. cessation of contractions and maternal tachycardia B. fetal tachycardia and moderate variability C. increased anxiety and discomfort with contractions D. painful, strong contractions every 3-4 minutes

ABCDE Preconception care improves pregnancy outcomes and includes folic acid supplementation; regular dental care; updated vaccinations; avoidance of alcohol, smoking and illicit drugs; and achieving a normal weight

A client indicates the desire to become pregnant. Which of the following are important preconception education topics for the nurse to provide? Select all that apply A. aim for BMI of 18.5-24.9 kg/m2 B. avoid alcohol consumption and tobacco products C. ensure daily intake of 400 mcg of folic acid D. obtain testing for rubella immunity E. schedule dental wellness appointment

ADE Myasthenia Gravis is an autoimmune disease involving a decreased number of acetylcholine receptors at the neuromuscular junction. As a result, there is fluctuating weakness of skeletal muscles, most often presented as ptosis/diplopia, bulbar signs (difficulty speaking or swallowing), and difficulty breathing. Muscles are stronger in the morning and become weaker with the day's activity as the supply of available acetylcholine is depleted. Option A: treatment includes anticholinesterase drugs that are administered before meals so that the client's ability to swallow is strongest during the meal Option B: an anticholinergic drug, such as atropine, is used for treatment in a cholinergic crisis. The need would not be anticipated during a myasthenia crisis, which is usually a result of too little medication related to noncompliance, illness, or surgery Option C: the skeletal muscles are involved in myasthenia gravis; dysfunction of the reflexes or central nervous system affects bowel and bladder control. This issue is classic with multiple sclerosis Option D: semi-solid foods are preferred over solid foods or liquids Option E: all clients with a serious chronic co-morbidity should receive the annual flu vaccine as they are more likely to have a negative outcome if the illness is contracted

A client is admitted to the hospital with an exacerbation of myasthenia graves. What are the appropriate nursing actions? Select all that apply A. administer an anti cholinesterase drug AC B. anticipate a need for an anticholinergic drug C. develop a bladder training schedule D. encourage semi-solid food consumption E. teach the necessity for annual flu vaccination

DE The cerebellum is involved in 2 major functions: coordination of voluntary movements and maintenance of balance and posture.

A client is being admitted for a potential cerebellar pathology. Which tasks should the nurse ask the client to perform to assess if cerebellar function is within the defined limits? Select all that apply A. identify the number "8" traced on the palm B. shrug the shoulders against resistance C. swallow water D. touch each finger of one hand to the hand's thumb E. walk heel-to-toe

B Mild pain, bruising, irritation or redness of the skin at the injection site is common. Do NOT rub the site with the hand. Using an ice cube on the injection site can provide relief

A client is being discharged on enoxaparin therapy following total knee replacement surgery. Which teaching instruction does the nurse include in the teaching plan? A. "eliminate green, leafy, vitamin K-rich vegetables from your diet" B. "mild bruising or redness may occur at the injection site" C. "you can take over-the-counter drugs such as ibuprofen t relieve mild discomfort" D. "you will need PT/INR assessments at regular intervals while on enoxaparin therapy"

D The case manager and social worker on the interdisciplinary team have expertise in discharge planning and health care finance. They can assess the adequacy of the discharge setting and support systems, arrange for resources at home, or discharge to an alternate setting, such as a rehabilitation facility. They can also help advocate for safe, effective discharge planning

A client is being discharged with plans to return home alone. The client cannot get up from a chair without help and is very unsteady when standing, even with a walker. The nurse expresses concern, but the primary health care provider is adamant that the client be discharged today. Which team member would be most appropriate to assist the nurse in advocating for this client? A. clinical psychologist B. occupational therapist C. physical therapist D. social worker

B Difficulty swallowing is the most important symptom to report to the HCP. A thoracic aortic aneurysm can put pressure on the esophagus and cause dysphagia. The development of this symptom may indicate that the aneurysm has increased in size and may need further diagnostic evaluation and treatment

A client is diagnosed with a small thoracic aortic aneurysm during a routine chest x-ray and follows up 6 months later with the health care provider. Which assessment data is most important for the nurse to report to the HCP? A. blood pressure of 140/86 mm Hg B. difficulty swallowing C. dry, hacking cough D. low back pain

ACD Client teaching should include the following: 1. eye care: use glasses during the day; wear a patch at night to protect the exposed eye. Use artificial tears during the day as needed to prevent excess drying of the cornea 2. oral care: chew on the unaffected side to prevent food trapping; a soft diet is recommended. Maintain good oral hygiene after every meal to prevent problems from accumulated residual food Vision, balance, consciousness, and extremity motor function are not impaired with bell's palsy

A client is diagnosed with right-sided Bell's palsy. What instructions should the nurse give this client for care at home? Select all that apply A. apply a patch to the right eye at night B. avoid driving C. chew on the left side D. maintain meticulous oral hygiene E. use a cane on the left side

ABC Clinical manifestations characteristic of moderate to severe asthma exacerbations include tachycardia, tachypnea, saturation <90% on room air, use of accessory muscles to breathe, and peak expiratory flow (PEF) <40% of predicted or best Pharmacologic treatment modalities recommended by the Global initiative for asthma to correct hypoxemia, improve ventilation, and promote bronchodilation include the following: 1. oxygen to maintain saturation >90% 2. high-dose inhaled short-acting beta agonist (albuterol) and anticholinergic agent (ipratropium) nebulizer treatments every 20 minutes 3. systemic corticosteroids (solu-medrol)

A client is having a severe asthma attack lasting over 4 hours after exposure to animal dander. On arrival, the pulse is 128/min, respirations are 36/min, pulse oximetry is 86% on room air, and the client is using accessory muscles to breathe. Lung sounds are diminished and high-pitched wheezes are present on expiration. Based on this assessment, the nurse anticipates the administration of which of the following medications? Select all that apply A. inhaled albuterol nebulizer every 20 minutes B. inhaled ipratropium nebulizer every 20 minutes C. intravenous methylprednisolone D. montelukast 10 mg by mouth STAT E. salmeterol metered-dose inhaler every 20 minutes

ABD A client who recently received chemotherapy may be immunocompromised and should be protected from infectious contacts. The med-surg nurse has the training to care for a client with immunosuppression and a broken leg. If chemotherapy needs to be administered during the hospitalization, a chemotherapy certified nurse will administer the medication. The client is not radioactive or infectious, and the nurse will not be administering or handling the chemotherapeutic agents. Therefore, it is safe for the pregnant nurse to care for the client. The injectable influenza vaccination does not contain the live influenza virus; therefore, the unlicensed assistive personnel is not infectious.

A client is hospitalized for a broken leg. The client has a history of breast cancer and is receiving outpatient chemotherapy; the last infusion was about a week ago. Which staff members can safely care for this client? Select all that apply A. nurse floated form another medical-surgical floor B. nurse who is 24 weeks pregnant C. nurse with erythematous rash and honey-color crusts on the hand D. unlicensed assistive personnel who just received the yearly injectable flu vaccination E. unlicensed assistive personnel with a cold

BE Option A: apical pulse is a central pulse and does not indicate adequacy of peripheral tissue perfusion Option C: lung sounds indicate the adequacy of ventilation and gas exchange, not peripheral tissue perfusion Option D: pupillary response is an indicator of cerebral function, not peripheral tissue perfusion

A client is in suspected shock state from major trauma. Which parameters best indicate the adequacy of peripheral perfusion? Select all that apply A. apical pulse B. capillary refill C. lung sounds D. pupillary response E. skin color and temperature

A Although rare, serious adverse drug reactions such as retinal toxicity and visual disturbances can occur with hydroxychloroquine. Therefore, clients are instructed to undergo regular ophthalmologic examination every 6-12 months

A client is prescribed long-term pharmacologic therapy with hydroxychloroquine to treat systemic lupus erythematous. Which intervention related to the drug's adverse effects should the nurse include in the teaching plan? A. have an ophthalmologic examination every 6 months B. take the medication on an empty stomach C. take vitamin D and calcium supplements D. wear a medialert bracelet

C Metabolic acidosis is due to an increase in the production or retention of acid or the depletion of bicarbonate via the kidneys or gastrointestinal tract. In metabolic acidosis, there is a decrease in pH and HCO3. Acidosis damages cells, causing them to release intracellular contents. Hyperkalemia frequently occurs with acidosis, putting the client at risk for cardiac arrhythmias. Depending on the cause and severity of acidosis, the client can exhibit altered mental status and tachypnea. Management focuses on treating the underlying cause and administering IV sodium bicarbonate to correct the imbalance. Arterial blood gas pH 7.39, HCO3 24 mEq/L and serum potassium 3.8 mEq/L are within normal limits, indicating the sodium bicarbonate has effectively corrected acidosis

A client is receiving IV sodium bicarbonate for acute metabolic acidosis. Which of these laboratory values would best indicate that the sodium bicarbonate has been effective? A. serum pH 7.32, HCO3 26 mEq/L, potassium 4.9 mEq/L B. serum pH 7.34, HCO3 21 mEq/L, potassium 5.1 mEq/L C. serum pH 7.39, HCO3 24 mEq/L, potassium 3.8 mEq/L D. serum pH 7.41, HCO3 18 mEq/L, potassium 4.3 mEq/L

DE Depending on the institution and HCP, a therapeutic aPTT level for a client being heparinized is somewhere between 46-70 seconds (1.5-2 x the baseline value). An aPTT of 140 seconds is too long and this client is showing signs of bleeding. The nurse should stop the heparin infusion, notify the HCP and review administration guidelines for possible administration of protamine (reversal agent for heparin). Option A: continuing the heparin infusion will put the client at risk for a severe bleeding episode Option B: vitamin K is the reversal agent for warfarin Option C: there is not reason to redraw blood for laboratory workup at this time as the abnormal aPTT result is consistent with the client's bleeding. Laboratory studies may need to be redone within 1 hour of stopping the infusion or giving a reversal agent

A client is receiving a continuous heparin infusion and the most recent aPTT is 140 seconds. The nurse notices blood oozing at the surgical incision and IV insertion sites. What interventions should the nurse implement? Select all that apply A. continue heparin infusion and recheck aPTT in 6 hours B. prepare to administer vitamin K C. redraw blood for laboratory tests D. review guidelines for administration of protamine E. stop infusion of heparin and notify the health care provider

CDE

A client is receiving several adjunctive professional therapies while rehabilitating after a stroke. Which client statements indicate an understanding of the services? Select all that apply A. "occupational therapy will help me learn how to properly use my walker" B. "physical therapy will help me learn how to dress myself again" C. "social services can help me find resources for affording my medications" D. "speech therapy will teach me how to eat my meals properly" E. "wound care will teach me how to properly dress this wound on my knee"

C This client is symptomatic from insufficiency perfusion. The nurse's priority is to use transcutaneous pacemaker pads to normalize the heart rate, stabilize blood pressure, and adequately perfuse organs until the permanent pacemaker is repaired or replaced.

A client with a permanent pacemaker with continuous telemetry calls the nurse and reports feeling lightheaded and dizzy. The client's blood pressure is 75/55 mm Hg. What is the nurse's priority action? A. administer atropine 0.5 mg IV B. administer dopamine 5 mcg/kg/min IV C. initiate transcutaneous pacing D. notify the health care provider

ABD Option C: if the procedure is just a diagnostic study, the client often goes home the same day. Hospitalization for 1-3 days may be required if angioplasty or stent placement is performed Option E: general anesthesia is not used during coronary angiography. Sedating medications are given during the procedure

A client is scheduled for a coronary arteriogram procedure. Which information should the nurse provide to the client prior to the procedure? Select all that apply A. client may be required to lie flat for several hours following the procedure B. client may feel warm or flushed when contrast dye is injected during the procedure C. client should expect to stay in the hospital for 1-3 days following the procedure D. client should not eat or drink anything for 6-12 hours before the procedure E. client will receive general anesthesia and will not be awake during the procedure

A Options B, C and D: rationalization, regression, displacement, sublimation and reaction formation are not the primary defense mechanisms used by the client. The client displays no symptoms of depression. Rationalization: using excuses to explain away threatening circumstances Displacement: transferring thoughts and feelings toward one person or object onto another person or object. Regression: returning to a previous level of development Introjection: taking on the qualities or attitudes of others without thought or examination Reaction formation: behaving in a manner or expressing a feeling opposite of one's true feelings. Repression: keeping unacceptable thoughts or traumatic events buried in the unconcsious Sublimation: transforming unacceptable thoughts to needs into acceptable actions

A client recently admitted to an inpatient unit for treatment of alcoholism says to the nurse, "I only came here to get away from my nagging spouse. Sometimes I think my spouse is the one who should be here. I can stop drinking any time I want." The nurse recognizes that the client is exhibiting which of the following defense mechanisms? A. denial and projection B. rationalization and depression C. regression and displacement D. sublimation and reaction formation

B The therapeutic serum phenytoin range is 10-20 mcg/mL. In the presence of an elevated phenytoin level, the nurse anticipates that the health care provider will prescribe a decreased daily dose

A client was prescribed phenytoin (100 mg PO 3 times a day) a month ago. Today, the client has a serum phenytoin level of 32 mcg/mL. The nurse notifies the health care provider and expects which prescription? A. continue phenytoin as prescribed B. decreased phenytoin daily dose C. increase phenytoin daily dose D. repeat serum phenytoin level in 2 hours

A The low pressure alarm could signal hypotension. The nurse's first action should be to check the client for evidence of hypotension and the cause. Arterial lines carry the risk of hemorrhage and are most likely to occur at connection sites of the tubing and catheter. A client can lose a large amount of arterial blood in a short period of time. The nurse should verify that these connections are tight on admission of the client to the ICU

A client who is 2 hours post aortic valve replacement is in the intensive care unit. The low pressure alarm for the client's radial arterial line sounds. Which action should the nurse take first? A. check for bleeding at tube connection sites B. perform a fast flush of the arterial line system C. re-level the transducer to the phlebostatic axis D. zero and re-balance the monitor and system

ADE Clinical manifestations are lower-quadrant abdominal pain on one side, mild to moderate vaginal bleeding and missed or delayed menses. Signs of subsequent hypovolemic shock from ruptured ectopic pregnancy include dizziness, hypotension, and tachycardia. Free intraperitoneal blood pooling under the diaphragm can cause referred shoulder pain. Peritoneal signs may develop subsequently Option B & C: distended jugular veins and lung crackles indicate volume overload. The main risk with ectopic pregnancy is hypovolemic shock. Jugular veins would be flat in hypovolemic shock

A client who is being evaluated for suspected ectopic pregnancy reports sudden-onset, severe, right lower abdominal pain and dizziness. Which additional assessment findings will the nurse anticipate if the client is experiencing a ruptured ectopic pregnancy? Select all that apply A. blood pressure 82/64 mm Hg B. crackles on auscultation C. distended jugular veins D. pulse 120/min E. shoulder pain

A Clients with burns have increased metabolism and calorie requirements that must be met for healing to occur. The nutrition needed for healing increases proportionally with the percentage of burned tissue. Therefore, providing proper nutrition as soon as possible is the highest priority

A client who suffered a burn injury has received fluid resuscitation and is now digressing, indicating the end of the emergency phase. Which prescription is the highest priority at this time? A. administer enteral feedings at the return of bowel sounds B. assist the client in activities of daily living as tolerated C. contact the client's religious advisor for spiritual support D. educate the client's family about dressings and medications

D This client is experiencing the symptoms of a panic attack and should not be left alone. The priority nursing action is to stay with the client to ensure the client's safety and offer support.

A client who was suddenly overwhelmed with an intense. fear that something terrible was going to happen is brought to the emergency department by the spouse after they were out to dinner. The client is not shaking, hyperventilating and having heart palpitations. What is the priority nursing action? A. encourage the client to perform deep breathing exercises B. explore possible reasons for the episode C. place the client in a private room and tell the client to relax D. remain in the room with the client

A A plan of care should be developed collaboratively, informed by the client's knowledge, beliefs and preferences and the expertise and evidence-based recommendations of HCPs Option B: this response is based on the idea of the nurse and HCP being in control, but it fails to include the client in the decision-making team Option C: this statement provides a rationale for the client to remain in the hospital, but it does not address the client's concerns about going into withdrawal Option D: this response is based on the idea of client autonomy, but it does not propose a solution to the problem

A client with a 10 year history of methadone use for chronic leg pain is being treated with azithromycin for pneumonia. On the third hospital day, both medications are discontinued as the QT interval on EKG has lengthened, increasing arrhythmia risk. The client wants to be discharged against medical advice to return home and take the client's own medications to prevent going into withdrawal without the methadone. Which is the most appropriate nursing response? A. "I will ask the HCP to come talk with us so that we can develop a plan to prevent withdrawal while reducing your risk of heart problems" B. "I will talk with the HCP about your concerns, but in the meantime its important that you stay here" C. "its important that you stay in the hospital so that we can treat you quickly if you have problems" D. "you have the right to make your own decisions, but you are at high risk of having heart problems if you go home right now"

D Autonomic dysreflexia is an acute, life-threatening response to noxious stimuli, which clients with spinal cord injuries above T6 are unable to feel. Signs and symptoms include hypertension, bradycardia, a pounding headache, diaphoresis, and nausea. It is essential that the nurse assess for and remove noxious stimuli to prevent a stroke. Noxious stimuli may include: - bladder distention - fecal impaction - tight clothing Option A & B: hypertension, headache and nausea due to uncontrolled sympathetic activity will resolve once the cause is identified and removed Option C: lowering the head of the bed would increase blood pressure. The head of the bed should be raised to lower the blood pressure.

A client with a C3 spinal cord injury has a headache and nausea. The client's blood pressure is 170/100 mm Hg. How should the nurse respond initially? A. administer PRN analgesic medication B. administer PRN antihypertensive medication C. lower the head of the bed D. palpate the client's bladder

A It is important to lower the blood pressure slowly, as too rapid a drop may cause decreased perfusion to the brain, heart and kidneys. This may result in stroke, renal failure or MI. The initial goal is usually to decrease the MAP by no more than 25% or to maintain MAP at 110-115 mm Hg. The pressure can then be lowered further over a period of 24 hours. MAP is calculated by adding the systolic blood pressure and double the diastolic blood pressure and then diving the resulting value by 3.

A client with a blood pressure of 250/145 mm Hg is admitted for hypertensive crisis. The health care provider prescribes a continuous IV infusion of nitroprusside sodium. Which of these is the priority goal in initial management of hypertensive crisis? A. decrease mean arterial pressure by no more than 25% B. keep blood pressure at or below 120/80 mm Hg C. maintain heart rate of 60-100/min D. maintain urine output of at least 30 mL/hrIt is

C A diagnosis of schizophrenia with catatonia can be made if the clinic features meet the criteria for a diagnosis of schizophrenia and include at least 2 of the following: - immobility - remaining mute - bizarre postures - extreme negativism Clients with catatonic schizophrenia are unable to meet their basic needs for adequate fluid and food intake and are at high risk for dehydration and malnutrition.

A client with a diagnosis of schizophrenia with catatonia has recently been admitted to the psychiatric unit. Which of the following is the priority nursing diagnosis? A. impaired social interaction B. impaired verbal communication C. risk for deficient fluid volume D. risk for impaired skin integrity

ABCD Option E: side-to-side repositioning of the client in buck traction can cause injury. Side-to-side position changes cause the affected leg to be adducted or abducted, which, when paired with the force of traction, can increase spasm and pain and contribute to neuromuscular and orthopedic compromise

A client with a hip fracture is placed in Buck traction. Which activities are appropriate for the nurse to include in the client's plan of care? Select all that apply A. assess for skin breakdown of the limb in traction B. ensure adequate pain relief C. keep the limb in a neutral position D. perform frequent neuromuscular checks on the limb in traction E. reposition the client and use a wedge pillow

A Lactulose is a syrup like liquid that decreases intestinal ammonia absorption in clients with liver disease and hepatic encephalopathy. Hepatic encephalopathy occurs when the failing liver does not adequately detoxify ammonia in the body, leading to changes in mental status and death if not adequately and promptly treated. The lactulose dosing frequently should be adjusted to ensure 2-3 soft stools per day with no confusion or lethargy

A client with a history of cirrhosis has a new prescription for lactulose 30 mL four times a day. What does the nurse explain to the client about this medication? A. it will decrease intestinal absorption of ammonia B. it will facilitate diuresis of excess fluid C. it will promote renal excretion of bilirubin D. it will reduce portal pressure contributing to esophageal varices

A Most clients with heart failure are prescribed a loop diuretic to reduce fluid retention. If the client has signs and symptoms of excessive fluid accumulation, the nurse will need to assess the situation by asking the client about dietary and fluid intake, adherence to prescribed medications, and the presence of any other associated symptoms. If the client is stable, the nurse may anticipate the need to increase the dosage of the prescribed loop diuretic

A client with a history of heart failure calls the clinic and reports a 3 lb weight gain over the past 2 days and increased ankle swelling. The nurse reviews the client's medications and anticipate the immediate need for dosage adjustment of which medication? A. bumetanide B. candesartan C. carvedilol D. isosorbide

D The priority for a client with a mandibular fracture whose teeth have been wired together is maintaining a patent airway. If the client begins to choke on oral secretions, the nurse should immediately attempt to clear the airway by suctioning via the oral or nasopharyngeal route. If this intervention is ineffective, cutting the wires may be necessary

A client with a mandibular fracture who has the upper and lower teeth wired together begins to choke on excessive oral secretions. What is the nurse's immediate action? A. cut the wires B. elevate the head of the bed C. notify the health care provider D. suction the mouth and oropharynx

A Ethambutol is used in combination with other anti tubercular drugs to treat active tuberculosis. The client must have baseline and periodic eye examinations during therapy as optic neuritis is a potentially reversible adverse effect. The client is instructed to report signs of decreased visual acuity and loss of color discrimination

A client with active pulmonary tuberculosis is prescribed 4-drug therapy with ethambutol. The community health nurse instructs the client to notify the health care provider immediately if which adverse effect associated with ethambutol occurs? A. blurred vision B. dark-colored urine C. difficulty hearing D. yellow skin

ACD Option B: low-grade fever develops as part of systemic inflammation. OA is typically a noninflammatory, nonsystemic disorder. Occasional OA inflammation is limited to affected joints Option E: serum rheumatoid factor is positive in clients with systemic rheumatoid arthritis. No diagnostic laboratory tests or biomarkers exist for OA

A client with advanced osteoarthritis is admitted for right total knee arthroplasty. Which characteristic manifestations does the nurse expect to assess in this client? Select all that apply A. crepitus with joint movement B. low-grade fever C. morning stiffness lasting 10 to 15 minutes D. pain exacerbated by weight-bearing activities E. positive serum rheumatoid factor

A Options B & D: this client already developed syncope and angina and is at high risk for sudden death with exertion Option C: the client should restrict activity. The incidence of sudden death is high in this population, and it is therefore prudent to decrease the strain on the heart while awaiting surgery

A client with aortic stenosis is scheduled for surgery in 2 weeks. The client reports episodes of angina and passing out twice at home. Which would be the best response by the nurse to explain the appropriate activity for this client at this time? A. "avoid strenuous activity before the surgery" B. "continue to exercise, even if angina occurs. It will strengthen your heart muscles" C. "take short walks 3 times a day" D. "there are no activity restrictions unless angina occurs"

CDE Option A: paracentesis is an invasive procedure requiring delivery of informed consent by the health care provider. The HCP explains the benefits and risks of the procedure. The nurse's role is to witness informed consent and verify that is has occurred Option B: NPO status is not required for paracentesis, which is often performed at the bedside or in an HCP's office using only a local anesthetic

A client with ascites due to cirrhosis has increasing shortness of breath and abdominal pain. The health care provider requests that the nurse prepare the client for a paracentesis. Which nursing actions would the nurse implement prior to the procedure? Select all that apply A. educate client about the procedure and obtain informed consent B. initiate NPO status 6 hours prior to the procedure C. obtain baseline vital signs, abdominal circumference, and weight D. place client in high fowler position or as upright as possible E. request that the client empty the bladder

A Option B: continuing to assign the client's stated preferred nurse with reinforce the manipulative behavior and the need to cling to one person. Option C: simply telling the client about staff competency will not facilitate behavior change. The client is engaging in this behavior as a protection against abandonment. Option D: it is important to reinforce unit rules and the consequences of inappropriate behaviors. However, this is not the best action to address the client's attempt to manipulate the staff.

A client with borderline personality disorder says to the nurse, "you're the only one I trust around here. The others don't know what they are doing and they don't care about anyone except themselves. I only want to talk with you." What is the priority action for the client's nursing care plan? A. assign different staff members to care for the client each day B. continue assigning the client's stated preferred nurse to care for the client C. frequently reassure the client that all staff members are competent in their jobs D. reinforce unit rules and consequences of inappropriate behaviors

B Two groups of commonly used drugs, nonsteroidal anti-inflammatory drugs and beta-adrenergic antagonists (beta blockers), have the potential to cause problems for clients with asthma. Ibuprofen (Motrin) and aspirin are common over-the-counter anti-inflammatory drugs that are effective in relieving pain, discomfort and fever. About 10-20% of asthmatics are sensitive to these medications and can experience severe bronchospasm after ingestion. This is prevalent in clients with nasal polyposis

A client with bronchial asthma and sinusitis has increased wheezing and decreased peak flow readings. During the admission interview, the nurse reconciles the medications and notes that which of the following over-the-counter medications taken by the client could be contributing to increased asthma symptoms? A. guaifenesin 600 mg orally twice a day as needed B. ibuprofen 400 mg orally every 6 hours for pain as needed C. loratadine 1 tablet orally every day as needed D. vitamin D 2,000 units orally every day

D Option A: pericarditis causes pain on inspiration, not expiration. This pleuritic-type pain also increases with coughing. Option B: the supine or lying-down position worsens with pericarditis pain Option C: the pursed-lip breathing technique helps to decreased shortness of breath by preventing airway collapse, promoting carbon dioxide elimination, and reducing air trapping in clients with chronic obstructive pulmonary disease

A client with chest pain is diagnosed with acute pericarditis by the health care provider. The nurse explains that the pain will improve with which of the following? A. coughing and deep breathing B. left lateral position C. pursed-lip breathing D. sitting up and leaning forward

D The client with kidney disease is at risk for both hyperkalemia and hyperphosphatemia due to reduced glomerular filtration rate. Untreated hyperkalemia may cause life-threatening cardiac arrhythmias. Sodium polystyrene sulfonate can be used to treat hyperkalemia. It works in the gastrointestinal tract to trade sodium for potassium, thereby eliminating excess potassium through the stool and reducing the serum potassium level

A client with chronic kidney disease has blood laboratory values as shown. The nurse administers sodium polystyrene sulfonate by mouth per the health care provider's prescription. The nurse evaluates that the therapy is effective when which value is noted on the follow-up results? A. calcium 7.4 mg/dL B. creatinine 4.0 mg/dL C. phosphorus 3.9 mg/dL D. potassium 4.9 mEq/L

C Option A: tablets are heat and light sensitive. They should be kept in a dark bottle and capped tightly. An opened bottle should be discarded after 6 months Option B: concurrent use of erectile dysfunction drugs (sildenafil, tadalafil, vardenafil) or alpha blockers (terazosin, tamsulosin) is contraindicated due to potentially fatal hypotension Option D: headache and flushing are common side effects of NTG due to systemic vasodilation and do no warrant medication discontinuation

A client with coronary artery disease and stable angina is being discharged home on sublingual nitroglycerin (NTG). The nurse has completed discharge teaching related to this medication. Which statement by the client indicates that the teaching has been effective? A. "I can keep a few pills in a plastic bag in my pocket in case I need them while im out" B. "I can still take this with my vardenafil prescription" C. "I can take up to 3 pills in a 15 minute period if I am experiencing chest pain" D. "I should stop taking the pills if I experience a headache"

C Nonsteroidal anti-inflammatory drugs are common medications used for their analgesic, antipyretic, and anti-inflammatory properties. However, the use of NSAIDs increases the risk of thrombotic events in clients with cardiovascular disease, especially with long-term use.

A client with coronary artery disease is being seen in the clinic for a follow-up examination. During medication reconciliation, the nurse identifies which reported medication as requiring further investigation? A. 10 mg isosorbide dinitrate twice daily B. 20 mg atorvastatin once daily C. 500 mg naproxen twice daily D. 2,000 mg fish oil once daily

B Duloxetine is a serotonin-norepinephrine reuptake inhibitor that has both antidepressant and pain-relieving effects. It is used to relieve chronic pain that interferes with normal sleep patterns in clients with FM. With the restoration of normal sleep patterns, fatigue often improves as well.

A client with fibromyalgia refuses to take the prescribed drug duloxetine. When the nurse asks why, the client response, "because I'm not depressed!" What is the nurse's most appropriate response? A. "depression is common with fibromyalgia, but a low dose of this drug can prevent it" B. "it can relieve your chronic pain and help you sleep better at night" C. "it helps to relieve the adverse effects of your other prescribed drugs" D. "you have the right to refuse. I will notify your health care provider"

C Option A: 0.45% sodium chloride is a hypotonic solution. Giving hypotonic saline would provide more free water than sodium, thereby worsening fluid overload and hyponatremia Option B: the client's calcium is within normal limits and does not need replacement Option D: sodium polystyrene sulfonate is a medication used to treat hyperkalemia that works by exchanging sodium for potassium across the mucous membranes of the bowel and then excreting potassium via stool. Sodium polystyrene sulfonate is not indicated if potassium is within normal limits

A client with heart failure has gained 5 lb (2.26 kg) over the last 3 days. The nurse reviews the client's blood laboratory results. Based on this information, what medication administration does the nurse anticipate? A. 0.45% sodium chloride IV B. calcium gluconate C. furosemide D. sodium polystyrene sulfonate

D Hypomagnesemia (normal: 1.5-2.5 mEq/L) causes a prolonged QT interval that increases the client's susceptibility to ventricular tachycardia. Torsades de pointes is a type of polymorphic ventricular tachycardia coupled with a prolonged QT interval; it is a lethal cardiac arrhythmia that leads to decreased cardiac output and can develop quickly into ventricular fibrillation

A client with heart failure is started on furosemide. The laboratory results are shown in the exhibit. The nurse is most concerned about which condition? A. atrial fibrillation B. atrial flutter C. mobitz II D. torsades de pointes

B Vancomycin can cause nephrotoxicity, which occurs most often in clients who already have some degree of renal impairment. Serum creatinine levels should be monitored daily during IV vancomycin treatment to look for an increase in level over a few days. If an increasing trend is identified, the nurse should consult with the health care provider and/or pharmacist before administering the dose

A client with methicillin-resistant Staphylococcus aureus (MRSA) bacteremia has been receiving IV vancomycin for the last 3 days. Which blood test trend is most important for the nurse to review when preparing to administer this medication? A. blood cultures B. creatinine levels C. magnesium levels D. white blood cell count

C Option A: clients should be taught to begin or maintain an exercise program, preferably aerobic exercise, to achieve optimal health Option B: although MVP may place the client at an increased risk for infective endocarditis, there is no clinical evidence to support the need for prophylactic antibiotics prior to dental procedures Option D: there is no need for a medical alert bracelet. MVP is usually a benign condition

A client with mitral valve prolapse (MVP) has been experiencing occasional palpitations, lightheadedness, and dizziness. The health care provider prescribes a beta blocker. What additional teaching should the nurse include for this client? A. avoid aerobic exercise B. ensure you receive antibiotics prior to dental work C. stay well hydrated and avoid caffeine D. wear a medical alert bracelet

A The nurse should encourage clients to discuss concerns with the HCP; in general, if a client can walk 1 block or climb 2 flights of stairs without symptoms, the client can resume sexual activity safely. Option B: the use of erectile agents is contraindicated if the client is consuming any form of nitrates Option C: resumption of sexual activity depends on the emotional readiness of the client and the client's partner and on the HCP's assessment of recovery. In general, it is safe to resume sexual activity 7-10 days after an uncomplicated MI Option D: the client may participate in cardiac rehabilitation, but this should not impact the ability to engage in sexual activity, especially if the client remains asymptomatic

A client with myocardial infarction (MI) underwent successful revascularization with stent placement, is now chest pain free, and will be attending cardiac rehabilitation as an outpatient. The client is embarrassed to talk to the health care provider about resuming sexual relations after an MI. What teaching should the nurse initiate with this client? A. if the client is able to climb 2 flights of stairs without symptoms, the client may be ready for sexual activity if approved by the HCP B. inform the client that medications such as sildenafil to tadalafil are available as prescriptions from the HCP C. it will be 6 months before the heart is healthy enough for sexual activity D. the client will be ready for sexual activity after completion of cardiac rehabilitation

B Auditory hallucinations are the most common type of hallucination and are typically experienced by individuals with a diagnosis of schizophrenia, bipolar disorder, or other psychotic illness. Individuals with auditory hallucinations have reported that increasing the amount of external sound (watching TV or listening to music through headphones) makes it easier to ignore internal sounds from the hallucinations.

A client with schizophrenia has been hospitalized for a week and placed on an antipsychotic medication. The client tells the nurse of hearing multiple voices all day long arguing about whether the client is a good or bad person. The client says, "everyone tells me that the voices are not real, but they are driving me crazy." What is the best action by the nurse? A. give the client a book to read B. provide earphones and a DVD player and have the client sing along with the music C. tell the client that the voices will go away when the medication starts to work D. tell the client to ignore the voices

A Clonzapine is a atypical antipsychotic medication used to treat schizophrenia that has not responded to standard, more traditional treatment. Clozapine is associated with a risk for agranulocytosis (a potentially fatal blood disorder causing a dangerously low WBC count) and is therefore used only in clients with treatment-resistant schizophrenia

A client with schizophrenia is started on clozapine. Which periodic measurements take priority in this client? A. complete blood count and absolute neutrophil count B. ECG and blood pressure C. fasting blood glucose and fasting lipid panel D. height, weight and waist circumference

B The nurse should discuss the need to perform good oral hygiene with a soft-bristle toothbrush and to visit the dentist regularly as phenytoin can cause gingival hyperplasia, especially in high doses. Folic acid supplementation can also reduce this side effect

A client with seizure disorder is prescribed a moderately high dose of phenytoin. Which teaching topic should the nurse discuss with this client? A. diet high in iron B. good oral care and dental follow-up C. shaving with an electric razor D. use of sunglasses for eye protection

ADE Option B: bounding pulses may be present during fluid overload or hypertension. They may also be present with anxiety or fear. The client with possible tamponade will have evidence of decreased cardiac output and is more likely to have weak, thready pulses. Option C: decreased breath sounds on the left side are not specific to the development of cardiac tamponade. Decreased breath sounds could indicate conditions such as atelectasis, pleural effusion, or pneumothorax

A client with suspected moderate to large pericardial effusion is admitted for monitoring. The nurse performs a head-to-toe assessment. Which of these findings indicate likely cardiac tamponade and require immediate intervention? Select all that apply A. blood pressure of 90/70 mm Hg B. bounding peripheral pulses C. decreased breath sounds on left side D. distant heart tones E. jugular venous distension

D NPH can be safely mixed with short-acting (regular) and rapid acting (lispro, aspart) insulins in one syringe. To prepare: 1. inject the NPH insulin vial with 20 units of air without inverting the vial or passing the needle into the solution 2. inject 6 units of air into the regular insulin vial and withdraw the dose, leaving no air bubble 3. draw NPH, totaling 26 units in one syringe. Any overdraw of NPH into the syringe will necessitate wasting the total quantity

A client with type 1 diabetes has a prescription for 20 units of NPH insulin daily at 7:30 AM and regular insulin before meals, based on a sliding scale. At 7:00 AM, the client's blood glucose level is 220 mg/dL, and the client's breakfast tray has arrived. What action should the nurse take? A. administer 20 units of NPH insulin now and then 6 units of regular insulin after the morning meal B. administer 26 units of insulin: 20 units of NPH insulin and 6 units of regular insulin in 2 separate injections C. administer 26 units of insulin: 20 units of NPH mixed with 6 units of regular insulin in the same syringe, drawing up the NPH into the syringe first D. administer 26 units of insulin: 20 units of NPH mixed with 6 units of regular insulin in the same syringe, drawing up the regular insulin first

B CSII therapy delivers the insulin more accurately than injections, so the client experiences fewer swings in blood glucose levels and hypoglycemic episodes, as compared with the administration of insulin using a needle and syringe, or pen

A client with type I diabetes mellitus is prescribed an insulin pump. The nurse reinforces the diabetic educator's teaching regarding transitioning from multiple daily injections to continuous subcutaneous insulin infusion therapy. Which statement indicates that the client understands the advantages of using this therapy? A. "I won't need a bolus dose of insulin before my meals anymore" B. "im glad my blood sugars won't go way up and way down, like they did before" C. "im so glad I dont have to stick my finger 4 times a day to test my sugar anymore" D. "it'll finally be easier for me to lose some weight"

C Central-acting alpha2 agonists decrease the sympathetic response from the brainstem to the peripheral vessels, resulting in decreased peripheral vascular resistance and vasodilation. Clonidine is a highly potent antihypertensive. Abrupt discontinuation can result in serious rebound hypertension due to the rapid surge of catecholamine secretion that was suppressed during therapy. Clonidine should be tapered over 2-4 days. Abrupt withdrawal of beta blockers can also result in rebound hypertension and in precipitation of angina, myocardial infarction or sudden death

A client with uncontrolled hypertension is prescribed clonidine. What instruction is most important for the clinic nurse to give this client? A. avoid consuming high-sodium foods B. change positions slowly to prevent dizziness C. don't stop taking this medication abruptly D. use an oral moisturizer to relieve dry mouth

ADE Neonatal abstinence syndrome or opioid withdrawal results from maternal, habitual use of illicit drugs during pregnancy and begins within days or weeks after birth. Option B: meconium ileus is a classic finding in clients with cystic fibrosis. Floppy muscle tone is typical of clients with trisomy 21 Option C: microcephaly and cleft palate are manifestations of early prenatal exposure to teratogenic agents and are not associated with NAS. Limited evidence has shown that opioids are generally not teratogenic

A client without prenatal care gives birth to a newborn at term gestation. The client denies opioid or other illicit drug use during pregnancy. When monitoring the newborn, which of the following signs would indicate neonatal abstinence syndrome to the nurse? Select all that apply A. irritability and restlessness B. meconium ileus and floppy muscle tone C. microcephaly and cleft palate D. nasal congestion and frequent sneezing E. poor feeding and loose stools

BCE Option A: perineal hygiene is performed using soap and water only every shift and as needed. Routine use of antiseptic cleansers is not shown to prevent infection and may lead to development of drug-resistant bacteria Option D: routine irrigation with antimicrobial solution or systemic administration of antimicrobials is not recommended for routine catheter care and infection prevention

A comatose client in the intensive care unit has an indwelling urinary catheter. Which action(s) should the nurse implement to reduce the incidence of catheter-associated urinary tract infections? Select all that apply A. cleanse periurethral area with antiseptics every shift B. ensure each client has a separate container to empty collection bag C. keep catheter bag below the level of the bladder D. routinely irrigate the catheter with antimicrobial solution E. use sterile technique when collecting a urine specimen

A Before surgical repair, the priority is decreasing the risk of aortic rupture by maintaining a normal pressure in the aorta. Administering IV beta blocker medication helps achieve this by lowering the heart rate and blood pressure, which are often elevated with aortic dissection

A critical care nurse is caring for a newly admitted client with acute aortic dissection. Which prescription should the nurse prioritize while awaiting surgical revision of the client's aortic dissection? A. administer IV labetalol to maintain blood pressure within prescribed parameters B. initiate and maintain strict bed rest and a low=stimulation environment C. monitor bilateral lower extremity peripheral pulse strength D. prepare the client's consent form for surgical repair of the aorta

CDE Options A & B: when the infection ascends to the kidneys (pyelonephritis), clients become very ill. They develop nausea, vomiting, fever with chills, and flank pain.

A female client comes to the clinic with a suspected lower urinary tract infection; urinalysis confirms a diagnosis of cystitis. Which symptoms reported by the client would be most consistent with this condition? Select all that apply A. chills and vomiting B. flank pain C. painful urination D. urinary frequency E. urinary urgency

B Float nurse assignments should be made on the basis of what is within the knowledge and skill of the generalist nurse. The float nurse can safely care for the client whose BP is controlled by oral medication, and has the knowledge and skill to assess vital signs

A float nurse from labor and delivery is assigned to the cardiac care unit. Which client is most appropriate for the charge nurse to assign to the float nurse? A. client 3 days following a myocardial infarction who is on 6 L of oxygen and reports nausea B. client admitted for hypertensive crisis with blood pressure of 154/92 mm Hg on amlodipine PO C. client with a demand pacemaker set at 70/min who has a ventricular rate of 65/min D. client with angina at rest who has normal troponin levels and normal sinus rhythm on ECG

A Retinal detachment is a separation of the retina from the posterior wall of the eye that may occur following head trauma. Permanent blindness may result without intervention. Signs of retinal detachment include perception of lightning flashes or floaters and a curtain-like or gnats/hairnet/cobweb effect throughout the visual field Option B: loss of memory about the accident, or retrograde amnesia, is commonly reported after mild head injuries. The client should be monitored for decreased level of consciousness or alterations in mental status, which may indicate intracranial bleeding Option C: headache is expected after mild head injury and is not innately concerning except if the pain acutely worsens or is not relieved by over-the-counter analgesics Option D: a bleeding tongue laceration may occur when the force of the trauma causes the client to accidentally bite the tongue. Oozing blood, although disturbing to the client, does not pose an immediate threat

A football player is brought to the emergency department after a helmet-to-helmet collision without loss of consciousness or signs of external trauma. Which clinical finding warrants immediate intervention? A. hairnet-like effect across vision B. loss of memory about the collision C. temporal headache D. tongue laceration oozing blood

B Oxytocin is a uterotonic medication used for labor induction/augmentation. A common adverse effect of oxytocin is uterine tachysystole (ie, >5 contractions in 10 minutes averaged over 30 minutes). If not corrected, uterine tachysystole can lead to reduced placental blood flow, impaired fetal oxygenation, and abnormal fetal heart rate patterns If non reassuring FHR patterns (eg, late decelerations, fetal tachycardia, bradycardia) occur, the nurse should stop oxytocin immediately to decrease uterine stimulation and increase blood flow to the fetus. Simply decreasing the dose is inappropriate

A graduate nurse is caring for a client at 39 weeks gestation who is receiving an oxytocin infusion. Oxytocin is infusing at 20 mU/min. Based on the electronic fetal monitoring strip, which action by the graduate nurse would cause the registered nurse to intervene? A. administers oxygen by face mask at 10 L/min B. decreases oxytocin to 10 mU/min C. notifies the health care provider D. repositions the client in left lateral position

D Hypokalemia is a common, adverse effect of potassium-wasting diuretics that may cause muscle cramps, weakness, or paresthesia. Unmanaged hypokalemia can lead to lethal cardiac dysrhythmias and paralysis. Therefore, the nurse should immediately notify the health care provider of symptoms of hypokalemia

A home health nurse visits a client 2 weeks after the client is discharged from treatment for an acute myocardial infarction and heart failure. After a review of the home medications, which symptom reported by the client is most concerning to the nurse? A. bruising easily, especially on the arms B. fatigue C. feeling depressed D. muscle cramps in the legs

A Refeeding syndrome is a potentially lethal complication of nutritional replenishment in significantly malnourished clients and can occur with oral, enteral, or parenteral feedings. After a period of starvation, carbohydrate-rich nutrition (glucose) stimulates insulin production along with a shift of electrolytes from the blood into tissue cells for anabolism. The key signs of refeeding syndrome are rapid declines in phosphorus, potassium, and/or magnesium (mnemonic PPM.

A homeless man known to have chronic alcoholism and who has not eaten for 8 days is undergoing nutritional rehabilitation via oral and enteral feedings. Which of the following findings would indicate that the client is developing refeeding syndrome? A. phosphorus 2.0 mg/dL, potassium 2.9 mEq/L, magnesium 1.0 mEq/L B. phosphorus 4.0 mg/dL, potassium 3.5 mEq/L, magnesium 2.0 mEq/L C. random blood glucose 60 mg/dL, sodium 120 mEq/dL, calcium 7.0 mg/dL D. random blood glucose 100 mg/dL, sodium 140 mEq/dL, calcium 10.0 mg/dL

B Umbilical cord prolapse may occur after rupture of membranes if the presenting fetal part is not firmly applied to the cervix. Cord compression caused by a prolapse cord will produce abrupt fetal heart rate deceleration, fetal bradycardia and disruption of fetal oxygen supply. The priority action is to inspect the vaginal area and perform a sterile vaginal examination to assess for a prolapsed cord. If a prolapsed cord is visualized or palpated, the nurse should then manually elevate the presenting fetal part off the umbilical cord, leave the hand in place and call for help

A laboring client with epidural anesthesia experiences spontaneous rupture of membranes, immediately followed by an abrupt change in the fetal heart rate. The nurse knows that considering the probable cause of the change in fetal heart rate, which action should be taken first? A. administer IV fluid bolus B. assess for umbilical cord prolapse C. notify the health care provider D. reposition client to alternate side

D A pudendal nerve block infiltrates local anesthesia into the areas surrounding the pudendal nerves that innervate the lower vagina, perineum and vulva. When birth is imminent, a pudendal block provides the best pain relief with the least maternal/newborn side effects and could be administered quickly by the health care provider. It does not relieve contraction pain but does relieve perineal pressure when administered in the late second stage of labor

A laboring client, gravida 3 para 2, is admitted to the labor unit reporting severe perineal pressure and urgently requesting pain relief. The client's cervix is 10 cm dilated and 100% effaced, with the fetal head at 0 station. Which pain management technique is most appropriate for this client's report of perineal pressure? A. epidural anesthesia B. hydrotherapy C. IV narcotics D. pudendal nerve block

D When walking with a client who is legally blind, the nurse uses the sighted-guide technique by walking slightly ahead of the client with the client holding the nurse's elbow. The nurse should describe the environment while ambulating the client

A legally blind client is being prepared to ambulate 1 day after an appendectomy. What is the most appropriate action by the nurse? A. arrange for the client's service dog to come to the health care facility as soon as possible B. described the environment in detail so the client can ambulate safely with a cane C. instruct the unlicensed assistive personnel to walk beside the client and lead by the hand D. walk slightly ahead of the client with the client's hand resting on the nurse's elbow

A Option B: advance directives are determined ahead of time to guide decision making at the time of the event. The client can indicate a desire to make a change, and the original decision should be honored. This client could be experiencing hypoxia and thus not thinking as clearly as when the advance directives were made. Asking about changes could imply that he should make a change, which is not true. The original decision should be honored; however, the client can indicate a desire to make a change Option C: the client's advance directives take legal precedence over the spouse's wishes. The spouse is consulted when there are no advance directives or durable power of attorney for health care Option D: advance directives include living wills with written directives on how to handle situations. A medical power of attorney is used in situations not covered by the written directives. This client has indicated his wishes. A durable power of attorney for health care is used only when clients have not expressed wishes or cannot speak for themselves

A male client has terminal metastatic disease. He arrives at the emergency department with respirations of 6/min and an advance directive indicating to withhold resuscitative efforts. What should the nurse's response be? A. apply oxygen at 2 L by nasal cannula B. ask the client if he wants to change his mind C. ask the spouse what she wants done D. determine who has medical power of attorney

A Asthma is a chronic inflammatory disease of the lungs in genetically susceptible children. Frequent cough, especially at night, is the warning signal that the child's airway is very sensitive to stimuli; it may be the only sign in "silent" asthma. Common triggers include indoor contaminants (tobacco smoke, pet dander, cockroach feces), outdoor contaminants (air pollution), and allergic disease (hay fever, food allergies)

A mother reports to the pediatric nurse that her 3 year old child coughs at night and at times until he vomits. The symptoms have not improved over the past 2 months despite multiple over-the-counter cough medications. What should the nurse explore related to a possible etiology? A. ask about exposure to triggers such as pet dander B. assess for the presence of a butterfly rash C. history of intolerance to wheat food products D. palpate for an abdominal mass from pyloric stenosis

A Trisomy 18 is a life-threatening chromosomal abnormality that affects multiple organ systems. Many fetuses affected by this condition die in utero. Of the newborns that survive birth, half will die in the first week of life and most do not make it to the first birthday. Before withdrawal of ventilator support, it is appropriate for the nurse to request a collaborative meeting between the health care providers and the palliative care team to help the parents understand their child's condition as well as make decisions about interventions and the potential need for end-of-life care.

A newborn diagnosed with trisomy 18 (Edwards syndrome) is on ventilator support. The client's parents have repeatedly asked when their child will be able to breathe without the ventilator. Which action by the nurse is appropriate? A. facilitate a meeting between the health care providers, palliative care team, and parents to discuss care plan B. notify the parents of the newborn's genetic test results and provide information to read about trisomy 18 C. provide the parents with information about various options for curative medical treatment for their child D. share with the parents that many newborns with trisomy 18 live long enough to go home with their families

CD Drugs commonly associated with orthostatic hypotension include: 1. most antihypertensive medications, particularly sympathetic blockers such as beta blockers and alpha blockers 2. antipsychotic medications and antidepressants 3. volume-depleting medications such as diuretics 4. vasodilator medications 5. narcotics

A newly admitted client describes symptoms of dizziness and feeling faint on standing. The client has a of type 2 diabetes, coronary artery disease and bipolar disorder. Which medications may be contributing to the client's symptoms? Select all that apply A. atorvastatin B. metformin C. metoprolol D. olanzapine E. omeprazole

D Clients with schizophrenia often become anxious when around other individuals and will seek to be alone to relieve anxiety. Impaired social and interpersonal functioning are common negative symptoms of schizophrenia. These are more difficult to treat than the positive symptoms and contribute to a poor quality of life. Asking where the client is going is non therapeutic as it requires an explanation fo the client's actions. Following this client out the door could increase the client's anxiety. Directing this client to come back to the room is placing a demand that may be unrealistic and does not help develop a sense of trust.

A newly admitted client with schizophrenia has been exhibiting severe social withdrawal, odd mannerisms, and regressive behavior. The client is sitting alone in the room when the nurse enters, says "good morning," and proceeds to sit down next to the client. Without responding, the client stands up and starts to leave. Which of the following actions is best for the nurse to take? A. ask where the client is going B. immediately follow the client out the door C. in a loud voice, direct the client to come back to the room D. remain silent and allow the client to leave

ADE Option B: true labor contractions will not lessen or dissipate with comfort measures and may intensify with walking or activity. Braxton Hicks contraptions are irregular contractions that occur throughout pregnancy, and they do not result in cervical change Option C: mucoid vaginal discharge that is blood-tinged or brownish is a common finding in the days preceding onset of labor; however, it is not a definitive sign that true labor has started

A nulliparous client asks about being in "real" labor. The nurse should teach that which signs are most indicative of true labor? Select all that apply A. contractions that increase in frequency B. contractions that lessen after resting C. increased blood-tinged, mucoid vaginal discharge D. pain in lower back that moves to lower abdomen E. progressive cervical effacement and dilation

A Option A: if bleeding occurs, the nurse applies direct manual pressure to the vessel puncture site to achieve hemostasis and keep the client hemodynamically stable

A nurse cares for a client after cardiac catheterization. During assessment of the groin site, the nurse notices that the dressing is saturated with blood and a small trickle leaks down the client's leg. What should the nurse do first? A. apply direct manual pressure at and above the skin puncture site B. call the health care provider to report active bleeding C. check the peripheral pulse distal to the catheterization site D. place a new pressure dressing over the catheterization site

B Local organ procurement services are notified for every client death, per hospital protocol. If the client is deemed appropriate as a donor, then OPS collaborate with hospital staff in approaching the client's family about organ donation

A nurse cares for a client on life support who has been declared brain dead. Which intervention is appropriate at this time? A. ask the family members about their plans for the funeral service B. call the local organ procurement services representative C. discontinue nursing care and provide postmortem care D. remove life support as requested by the spouse and family

ABDE Option C: high fowler position may worsen respiratory distress caused by air embolism by promoting displacement of venous air emboli into pulmonary circulation

A nurse caring for a client with a central venous catheter (CVC) enters the client's room and notes that the CVC is dislodged and lying in the client's bed linens. The client appears cyanotic and is tachypneic and diaphoretic. Which of the following actions by the nurse are appropriate? Select all that apply A. administer oxygen via non-rebreather mask B. apply an occlusive dressing over the insertion site C. assist the client to high fowler position D. monitor vital signs and respiratory effort E. notify the health care provider

ACE Option B: ignoring acts of lateral violence will perpetuate the bullying Option D: the chain of command should be followed when reporting incidents of lateral violence. If the immediate supervisor takes no action, the employee can move up the chain

A nurse educator is developing materials for a hospital-wide campaign about zero tolerance for lateral violence and bullying among staff. Which actions will the nurse educator include in teaching about what staff members should do if they experience workplace violence? Select all that apply A. document the interactions with the bully B. ignore the bully's comments, remarks and allegations C. observe interactions between the bully and other colleagues D. report the violent incidents to the hospital administrator E. tell the bully you will not tolerate the unprofessional behavior

D Lithium is a mood stabilizer most often used to treat bipolar affective disorders. It has a very narrow therapeutic serum range of 0.6-1.2 mEq/L. Levels > 1.5 mEq/L are considered toxic. Lithium is cleared renal. Even a mild change in kidney function can cause serious lithium toxicity. Therefore, drugs that decrease renal blood flow should be avoided. Acetaminophen would be a better choice for pain relief

A nurse has completed teaching a client who is being discharged on lithium for a bipolar disorder. Which statement by the client indicates a need for further teaching? A. "I need to drink 1-2 liters of fluid daily" B. "I need to have my blood levels checked periodically" C. "I should not limit my sodium intake" D. "I should use ibuprofen for pain relief"

C Weigh gain slows during the toddler years with an average yearly weight gain of 4-6 lb. By age 30 months, current weight should be approximately 4 times greater than birth weight. A toddler weighing 6 times the initial birth weight requires further evaluation. Family nutrition and meal habits should be discussed

A nurse in a pediatric clinic is performing a physical examination of a 30 month old child. Which finding requires further evaluation? A. bladder and bowel control achieved B. chest circumference is greater than abdominal circumference C. current weight is 6 times greater than birth weight D. head circumference increased by 1 in. in the past year

BDE Option A: keep wounds open immediately after a water bath or whirlpool treatment and allow them to dry before applying loose, nonadherent, sterile dressings Option C: do not massage, rub or squeeze the area involved. Injured tissue is easily damaged

A nurse in the emergency department is caring for a homeless client just brought in with frostbite to the fingers and toes. The client is experiencing numbness, and assessment shows mottled skin. Which interventions should be included in the client's plan of care? Select all that apply A. apply occlusive dressings after rewarming B. elevated affected extremities after rewarming C. massage the areas to increase circulation D. provide adequate analgesia E. provide continuous warm water soaks

D Option A: a fish-like vaginal odor is often caused by bacterial vaginosis, an overgrowth of vaginal bacterial flora. This condition is not usually serious and is treated with oral or vaginal antibiotics. Option B: heavy menstrual bleeding is a common disadvantage of having an intrauterine device. If the client cannot tolerate heavy bleeding or if excessive bleeding results in anemia, another form of birth control should be considered Option C: reports of painful intercourse are not unusual in clients with endometriosis. Disease management and pain control should be discussed

A nurse in the gynecology clinic is reviewing client histories. Which report would be most concerning to the nurse? A. 25 year old client who reports fish-like vaginal odor for the past month B. 30 year old client with intrauterine device who reports heavy bleeding with menses C. 40 year old client with endometriosis who reports persistent pain during intercourse D. 60 year old client who reports bloating and pelvic pressure for the past 2 months

D Hypotension, tachycardia and low central venous pressure may indicate hypovolemic shock. Central venous pressure is a measurement of right ventricular preload and reflects the client's fluid volume status. The client is at risk for fluid volume losses. This client should be treated with isotonic fluids to restore adequate fluid volume status. IV boluses of isotonic fluids increase intravascular volume, which increases blood pressure and end-organ perfusion

A nurse in the intensive care unit is caring for a client in the immediate postoperative period following abdominal surgery. The nurse receives several prescriptions. Which prescription should the nurse initiate first? A. acetaminophen 1000 mg IVPB every 8 hours B. cefazolin 2 g IVPB once, now C. norepinephrine 0.02-2.0 mcg/kg/min titrated IV D. normal saline 2 L via rapid IV bolus

A The bishop score is a system for the assessment and rating of cervical favorability and the readiness for induction of labor. The cervix is scored (0-3) on consistency, position, dilation, effacement, and station of the fetal presenting part. A higher bishop score indicates an increased likelihood of successful induction that results in vaginal birth. For nulliparous women, a score of ≥6-8 usually indicates that induction will be successful Option B: a cervix that is firm and posterior is associated with a low bishop score, which reflect a low likelihood of successful labor induction Option C: a history of precipitous labor may indicate that the client will again experience precipitous labor once labor is established. However, such a history is not an independent predictor of successful induction Option D: a reactive non stress test indicates that the fetus is well oxygenated and established fetal well-being. It does not provide information about the likely success or failure of labor induction

A nurse is admitting a client at 42 weeks gestation to the labor and delivery unit for induction of labor. What is a predictor of a successful induction? A. bishop score of 10 B. firm and posterior cervix C. history of precipitous labor D. reactive non stress test

C Strabismus (crossed eyes) is a disorder involving misalignment of the eyes caused by a congenital defect or acquired weakness of an eye muscle. One eye may appear deviated inward or outward. One common treatment is to strengthen the muscles of the weaker eye by wearing a patch over the stronger eye or using special corrective lenses

A nurse is caring for a 2 year old with a new diagnosis of strabismus. Which intervention should the nurse anticipate? A. eye drops in the abnormal eye B. measurement of intraocular pressure C. patching the stronger eye D. correction with laser surgery

B Trismus (inability to open the mouth due to a tonic contraction of the muscles used for chewing) may indicate a more serious complication of tonsillitis, a peritonsillar or retropharyngeal abscess. Other features include a "hot potato" or muffled voice, pooling of saliva, and deviation of the uvula to one side. This abscess can occlude the airway, making it a medical emergency. Surgical intervention is often required. In the meantime, maintaining and adequate airway is essential

A nurse is caring for a 6 year old client with tonsillitis. Which further assessment finding requires immediate intervention? A. dry mucous membranes B. presence of trismus C. pulling at the ears D. sandpaper-like skin rash

A Although most clients recover spontaneously within days, severe hypertension is an anticipated complication that must be identified early. Monitoring and control of blood pressure are most important as they prevent further progression of kidney injury and development of hypertensive encephalopathy or pulmonary edema

A nurse is caring for a child with acute glomerulonephritis. Frequent monitoring of which of the following is a priority? A. blood pressure B. hematuria C. intake and output D. peripheral edema

ABCD Toxic epidermal necrolysis is an acute skin disorder, most commonly associated with a medication reaction, that results in widespread erythema, blistering, epidermal shedding, keratoconjunctivitis, and skin erosion. It is a severe form of Stevens-Johnson syndrome. The major cause of death related to toxic epidermal necrolysis is sepsis; therefore, infection prevention is critical.

A nurse is caring for a client admitted to the intensive care unit for toxic epidermal necrolysis. Which interventions should be included in this client's care plan? Select all that apply A. administer prescribed eye lubricants on schedule B. apply sterile, moist dressings and ointments to denuded areas of skin C. implement reverse isolation precautions and strict aseptic technique D. keep room temperature warm to prevent shivering E. provide gentle massage as needed to relieve pain

D Hyperemesis gravidarum is characterized by severe, persistent nausea and vomiting during pregnancy that usually leads to considerable weight loss, fluid and electrolyte imbalances, and nutritional deficiencies. Clients with HG may require hospitalization for IV fluid replacement and antiemetic therapy Routine laboratory assessment for HG includes urinalysis dipstick testing to monitor the client's health status. Expected findings include an elevated urine specific gravity and ketonuria. Urine specific gravity increases when urine is concentrated due to dehydration, and ketones are a by-product of the fat breakdown that occurs in starvation states

A nurse is caring for a client at 12 weeks gestation who is admitted for hyperemesis gravidarum. Which clinical manifestation should the nurse expect? A. abdominal pain and low-grade fever B. blood pressure ≥140/90 mm Hg C. high urine protein level D. moderate to high urine ketones

ABD Option A: administer IM antenatal glucocorticoids to stimulate fetal lung maturation and promote surfactant development Option B: administer antibiotics to prevent group B streptococcus infection in the newborn if preterm birth occurs Option C: artificial rupture of membranes, or amniotomy, is performed to augment labor or assess amniotic fluid in clients who are at term gestation. For clients in PTL, the goal is to prolong pregnancy if possible. Therefore, AROM is contraindicated Option D: initiate an IV magnesium sulfate infusion for fetal neuroprotection if at <32 weeks gestation Option E: clients with suspected PTL should be placed on continuous fetal monitoring to assess for increasing frequency and duration of contractions and to evaluate fetal tolerance of labor. Continuous fetal monitoring is also required if the client is receiving a magnesium sulfate infusion

A nurse is caring for a client at 30 weeks gestation who is admitted for preterm labor. Which of the following interventions should the nurse anticipate? Select all that apply A. administering IM betamethasone B. administering penicillin via IV piggyback C. assisting with artificial rupture of membranes D. initiating IV magnesium sulfate E. obtaining fetal heart tones once per shift

D A vaginal hematoma is formed when trauma to the tissues of the perineum occurs during delivery. Vaginal hematoma are more likely to occur following a forceps- or vacuum-assisted birth or an episiotomy. The client reports persistent, severe vaginal pain or a feeling of fullness. If the client had epidural anesthesia, pain may not be felt until the effects have worn off. Vaginal bleeding is unchanged. The uterus is firm and at the midline on palpation. If the hematoma is large, the hemoglobin level and vital signs can change significantly. In a client with epidural analgesia, a change in vital signs may be an important indicator of hematoma Option A: cervical lacerations should be suspect if the uterine funds is firm and midline on palpation despite continued vaginal bleeding. The bleeding can be minimal to frank hemorrhage. Sever pain or a feeling of fullness is not associated with cervical lacerations Option B: complete inversion of the uterus presents with a large, red mass protruding from the introitus Option C: uterine atony presents with a boggy uterus on palpation and an increase in vaginal bleeding

A nurse is caring for a client following a forceps-assisted vaginal birth. The client reports severe vaginal pain and fullness. On assessment, the nurse notices a firm, midline uterine funds. Lochia rubra is light. Which diagnosis should the nurse anticipate? A. cervical lacerations B. inversion of the uterus C. uterine atony D. vaginal hematoma

ADE Option B: the nurse should encourage family members to name the infant, which helps them identify the child as part of the family. The staff should refer to the infant by name during care Option C: the nurse or primary health care provider should call the designated organ procurement organization, according to facility protocol. Discussions surrounding organ donation are best performed by trained personnel

A nurse is caring for a client following delivery of a stillborn infant. Which actions should the nurse take? Select all that apply A. ask the parents if they would like to help bathe the infant B. discourage the parents from naming the infant C. discuss the importance of organ donation with the parents D. encourage the parents and family members to hold the infant E. offer to obtain handprints, footprints, and photographs of the infant

D Option A: the client may need pain medication, but this response does not answer the initial question. The nurse should first answer the client's question and then assess if pain medication is necessary. Option B: before calling the HCP for an increase in dosage, the nurse should assess the clients pain level and if pain medication has been effective. However, this should be done after answering the client's question. Option C: The client needs to move, cough, breathe deeply, splint the chest, and use the incentive spirometer. However, the client is asking the nurse a question that should be addressed before reinforcing these teachings.

A nurse is caring for a client on the first day postop after having minimally invasive direct coronary artery bypass (MIDCAB) grafting. The client thought that this surgery was supposed to have a much easier recovery and asks the nurse why it is so painful to take deep breaths. What is the best response by the nurse? A. "I am sorry you have so much pain. I'll go get your pain medication right now" B. "let me call the health care provider to see if we can increase the dose of your pain medicine" C. "take deep breaths while splinting your chest with a pillow, and use your incentive spirometer every 2 hours. This will help your recovery" D. "the overall recovery time is expected to be shorter, but initial postop pain can actually be higher with MIDCAB because the incisions are made between the ribs"

ACE Option B: palliative care is not limited to the last 6 months of life and can begin immediately after diagnosis of terminal disease Option D: the main difference between palliative care and hospice is that clients receiving palliative care can receive concurrent curative treatment. Hospice care is only started once the client decide to forego curative treatment

A nurse is caring for a client who is meeting with the palliative care team. After the meeting, the client's family asks for clarification about palliative care. Which statements about palliative care are accurate? Select all that apply A. palliative care focuses on quality of life and can be provided at any time B. palliative care is only possible with a terminal diagnosis of ≤6 months C. palliative care is provided by a multidisciplinary team D. palliative care is another term for hospice care E. palliative care provides relief from symptoms associated with chronic illness

A Antidepressants can cause suicidal ideation and behaviors, especially during the initial few weeks of therapy. This risk is even higher for young adults (age 18-24). The nurse must assess for this adverse effect and alert the provider

A nurse is caring for a client with a diagnosis of fibromyalgia. During care, the client reports having suicidal thoughts. What currently prescribed medication should the nurse question in regard to this new finding? A. amitriptyline B. celecoxib C. cyclobenzaprine D. hydrocodone

ABD Option C: the nurse should initiate droplet precautions for clients with meningococcal meningitis that require the nurse to wear a mask when caring for the client (not the client to wear a mask). The client wears a mask only if being transported outside the room Option E: a negative-pressure airflow room is appropriate for a client requiring airborne precautions

A nurse is caring for a school-age client with fever, somnolence, and a skin rash from suspected meningococcal meningitis. Which of the following interventions should the nurse plan to implement for this client? Select all that apply A. elevate head of bed at 30 degrees B. implement seizure precautions C. keep a mask on the client at all times D. minimize environmental stimuli E. place client in a room with negative-pressure air flow

D Option A: adult protective services would be notified when abuse or neglect is suspected. In the hospital setting, a social worker should be contacted to do a detailed assessment of the situation before adult protective services is notified Option B: the physical therapist should be consulted when there is concern about the client's ability to function safely in the home environment Option C: the physician would not be the most appropriate person to appoint when a detailed assessment of the home living situation needs to be conducted. However, the physician should be notified if a social worker is assigned to assess the home living situation

A nurse is caring for an older adult client admitted for failure to thrive and a history of recent falls and weight loss. The client lives in the child's home, but the nurse is questioning the safety of the home. The nurse needs to assess the appropriateness of the living situation and arrange for an alternate living situation or additional support if needed. It is most appropriate for the nurse to consult with which interdisciplinary team member during the assessment? A. adult protective services B. physical therapist C. physician D. social worker

D Clients should apply chilled, fresh cabbage leaves to both breasts, replacing with fresh leaves after they wilt. The mechanism of action is unclear but may be related to the cool temperature or to phytoestrogens from the leaves Option A: heat application increases blood flow and worsens engorgement. Although running warm water over the breasts may make milk leak and temporarily relieve pressure, more milk is produced later, which is counterproductive in a client who has chosen not to breastfeed Option B & C: breastfeeding is a supply-and-demand process. Massaging the breasts or manually expressing milk stimulates milk production, which exacerbates engorgement if the client is not breastfeeding

A nurse is caring or a postpartum client who has chosen to exclusively formula feed her newborn for medical reasons and is experiencing breast engorgement. What should the nurse teach regarding relief of breast engorgement? A. apply heat frequently to both breasts for 15-20 minutes B. manually express milk several times a day C. massage breasts from the base to the nipple 3 or 4 times a day D. use chilled, fresh cabbage leaves on breasts throughout the day

C Clients with IE usually have fever for several days during the initial stages of antibiotic therapy. By the time they are discharged, fever subsides or becomes occasional and low-grade. Option A: a client who has had IE is at risk for reoccurrence. This client should receive prophylactic antibiotics for certain high-risk procedures. Option B: IE causes the formation of vegetations of valve and endocardial surfaces. Embolization to various organ sites can occur. Slurred speech could indicate that embolization has caused a possible stroke Option D: IE can require IV antibiotics for up to 4-6 weeks. The client may be discharged home once hemodynamically stable, and a home health nurse will come to administer the antibiotics through the client's PICC line

A nurse is discharging a client who has been hospitalized with streptococcal infective endocarditis. Which statement by the client would indicate a need for further teaching? A. "I may need prophylactic antibiotics before dental work from now on" B. "I should call my heart care provider or 911 right away if I notice my speech is slurred" C. "I shouldn't be concerned if I continue to have a fever at home" D. "I will expect a home health nurse to give me IV antibiotics for several more weeks"

D Option A: adding potassium to a diet, especially when substituting it for sodium, can decrease blood pressure and fluid retention Option B: tracking the level of fluid retention with daily weigh-ins is the easiest way for clients and health care providers to monitor the effects of medication on congestive heart failure Option C: physical activity is very important in preserving cardiac function

A nurse is discussing discharge education with a client after his fifth hospitalization for pulmonary edema caused by his congestive heart failure. Which of the following statements indicates that further teaching is required? A. "I should supplement my potassium intake" B. "I should weigh myself daily" C. "moderate exercise may be helpful in my condition" D. "potato chips are an acceptable snack in moderation"

CE Option A: never over dilute or over concentrate formula. Dilution reduces necessary calories, vitamins, and minerals, which hinders growth and development. Overconcentration results in intake of excessive proteins and minerals beyond the excretory ability of the infant's immature kidneys Option B: never microwave formula as it causes "hot spots" in the milk that can burn the infant's mouth Option D: any formula in a bottle left over after feeding should be discarded because the infant's saliva has mixed with it, which can foster bacterial growth

A nurse is evaluating a client's understanding about infant formula preparation. Which of the following client statements indicate proper understanding? Select all that apply A. "I can add extra water to powdered formula if it seems that my baby wants to feed longer" B. "I can heat formula in the microwave for less than 1 minute" C. "I must wash the top of concentrated formula cans before opening" D. "leftover milk in the bottle may be refrigerated and used at a later feeding" E. "unused, prepared formula should be kept in the refrigerator and discarded after 48 hours"

ACD To prevent sunburn, instruct clients to avoid sun exposure from 10 AM to 4 PM, wear protective clothing, use sunscreen properly (daily application; minimum SPF of 15-30; 15-30 minutes before going outside; reapplication when wet and every 2 hours), and avoid non-solar exposure to ultraviolet radiation

A nurse is making a presentation on skin cancer prevention with special focus on melanoma at a community health forum. Which statements should the nurse include? Select all that apply A. "apply a broad-spectrum sunscreen before and during outdoor sports" B. "apply sunscreen a few minutes before starting outdoor activities" C. "reapply sunscreen after swimming, even if waterproof sunscreen was used earlier" D. "serious sunburns can occur even on overcast days" E. "use tanning beds for ≤ 15 minutes for a base tan that is less likely to burn"

BCE Shoulder dystocia is an unpredictable obstetrical emergency that occurs during vaginal birth when the fetal head delivers but the anterior shoulder becomes wedged behind or under the mother's symphysis pubis. Should dystocia lasting ≥5 minutes is correlated with almost certain fetal asphyxia resulting from prolonged compression of the umbilical cord. Minimizing the time it takes to deliver the fetal body is essential for reducing adverse outcomes. Options A & D: fundal pressure and the use of forceps or a vacuum to facilitate birth are contraindicate because they may further wedge the fetal shoulder into the maternal symphysis pubis and increase the risk for neurological complications in the newborn

A nurse is participating in an obstetrical emergency situation in which the health care provider announces shoulder dystocia. Which of the following interventions should the assisting nurse implement? Select all that apply A. assist maternal pushing efforts by applying fundal pressure during each contraction B. document the time the fetal head was born C. flex the client's legs back against the abdomen and apply downward pressure above the symphysis pubis D. prepare for a forceps-assisted birth E. request additional assistance from other nurses immediately

AC Option A: checking for residual volume is not an appropriate intervention because the Salem sump is attached to continuous suction for decompression and is not being used to administer enteral feeding Option C: the air vent (blue pigtail) must remain open as it provides a continuous flow of atmospheric air through the drainage tube at its distal end (to prevent excessive suction force). This prevents damage to the gastric mucosa. If gastric content refluxes, 10-20 mL of air can be injected into the air vent. However, the air vent is kept above the level of the client's stomach to prevent reflux.

A nurse is precepting a new graduate nurse who is caring for a client with a paralytic ileum and a Salem sump tube attached to continuous suction. The preceptor should intervene when the graduate nurse performs which interventions? Select all that apply A. checks for residual every 4 hours B. places client in semi-fowler's position C. plugs the air vent if gastric content refluxes D. provides mouth care every 4 hours E. turns off suction when auscultating bowel sounds

C Herbal preparations are not regulated by governmental agencies and are generally classified as food or dietary supplements. Manufacturers are therefore able to avoid the scientific scrutiny exercised when prescription drugs are readied for the market. Saw palmetto is one such herbal preparation, and clients most often use it to treat benign prostatic hyperplasia

A nurse is preparing an educational presentation on herbal supplements for the local community center. Saw palmetto is one herbal medicine being discussed. Which audience participants would find this information beneficial? A. clients diagnosed with heart failure B. clients experiencing major depressive disorder C. elderly clients with benign prostatic hyperplasia D. perimenopausal clients experiencing hot flashes

BCDE Option A: family members are usually notified by the health care provider. Most likely they will ask questions that the UAP would be unable to answer. This task would not be appropriate for delegation

A nurse is preparing to perform postmortem care on a client who recently died from metastatic cancer. No family members were present at the time of death. What interventions can be delegated to experienced unlicensed assistive personnel? Select all that apply A. notifying the family of the client's death B. placing dentures in the client's mouth C. positioning a pillow beneath the client's head D. transporting the client to the morgue E. washing the client's body

ABCD Option E: educate clients with HIV to always use synthetic barriers (condoms) during sex to reduce the risk of transmitting HIV and being infected with additional HIV strains or other sexually transmitted infections

A nurse is reinforcing teaching with a client newly diagnosed with human immunodeficiency virus (HIV) about actions to prevent complications. Which of the following statements indicate that the teaching was effective? Select all that apply A. "I should ask for my steak to be cooked thoroughly with no pink" B. "I should receive the influenza vaccine every year" C. "I will ask my roommate to change the cat litter box for me" D. "if I travel to a developing country, I will use bottled water when brushing my teeth" E. "if my HIV viral load is undetectable, I do not need to wear condoms"

A Nephrotic syndrome is a collection of symptoms resulting from various causes of glomerular injury. The 4 classic manifestations of nephrotic syndrome are: 1. massive proteinuria 2. hypoalbuminemia 3. edema 4. hyperlipidemia Option B: ascites and edema are often associated with liver disease. However, these symptoms result from fluid shifts related to hypoalbuminemia in nephrotic syndrome Option C: lipid levels (normal total cholesterol <200 mg/dL) can increase with nephrotic syndrome as the liver produces increased lipids and proteins to compensate for protein loss Option D: although low serum albumin could result from malnutrition, hypoalbuminemia in nephrotic syndrome is related to massive proteinuria

A nurse is reviewing the laboratory values for a 3 year old with nephrotic syndrome. The nurse interprets the results to most clearly reflect which physiologic process related to nephrotic syndrome? A. glomerular injury B. hepatic impairment C. inherited hypercholesterolemia D. malnutrition

ABCD Option E: Tet spells occur more often during stressful situations or on waking, so sleep should not be interrupted whenever possible

A nurse is teaching the parents of an infant with tetralogy of Fallot. Which of the following actions should the nurse include to reduce the incidence of hypercyanotic spells? Select all that apply A. encourage smaller, frequent feedings B. offer a pacifier when the infant begins to cry C. promote a quiet period upon waking in the morning D. swaddle the infant during procedures E. turn the infant frequently during sleep

C Children who develop Reyes syndrome often have had a recent viral infection, especially varicella (chicken pox) or influenza. Reye syndrome increases if aspirin therapy is used to treat the fever associated with varicella or influenza

A nurse on a pediatric unit is admitting a school-aged child with suspected Reyes syndrome. Which information obtained during the history taking is most consistent with this condition? A. no history of varicella vaccine administration B. recent exposure to bats C. recent influenza infection D. recent use of acetaminophen for fever

ABE Option C: this is an appropriate activity when working with an adolescent. Adolescents are often very concerned with outward changes that may occur as a result of illness or surgery Option D: this is an appropriate activity when working with school-age children after they have grasped the concept of time. Toddlers have not yet reached this level of cognition

A nurse on a pediatric unit is reviewing interventions for a toddler with a practical nurse who will be caring for this child. Which of the following are appropriate activities to minimize the effect of hospitalization on a toddler? Select all that apply A. integrate preferred snack foods in the day's routine B. plan quiet play prior to usual nap time C. point out body changes that may occur D. post a daily schedule by the child's bed E. provide 1 or 2 options when choosing toys

C Monoamine oxidase inhibitors (MAOIs) [eg. selegiline] interact with many medications, including many antidepressants. Concurrent use of MAOIs with selective serotonin reuptake inhibitors (SSRIs) [eg. escitalopram {lexapro}] may precipitate life-threatening adverse reactions

A nurse on the behavioral health unit is reviewing medication prescriptions for 4 clients. Which combination of medications does the nurse question? A. a client with anxiety prescribed escitalopram and alprazolam B. a client with bipolar disorder prescribed risperidone and lithium C. a client with depression prescribed escitalopram and selegiline D. a client with depression prescribed sertraline and zolpidem

D SIADH is often caused by the ectopic production of ADH by a malignant lung tumor. Increased ADH leads to increased water reabsorption and intravascular volume, which results in dilutional hyponatremia. Severe neurologic dysfunction can occur when serum sodium drops below 120 mEq/L. Therefore, hyponatremia is the highest priority to report as it poses the greatest threat to survival.

A nurse reviews the most current serum laboratory results for assigned clients. Which result is the highest priority to report to the health care provider? A. albumin of 3.0 g/dL (30 g/L) in a client with chronic hepatitis B. B-type natriuretic peptide of 400 pg/mL (300 pmol/L) in a client with heart failure C. magnesium of 1.7 mEq/L (0.85 mmol/L) in a client with alcohol withdrawal D. sodium of 120 mEq/L (120 mol/L) in a client with small cell lung cancer

AD Option B: leafy-green vegetables contain a high amount of vitamin K, which may lower a client's INR and make it difficult to maintain a therapeutic INR. Clients do not have to avoid consumption of leafy-green vegetables, but they should eat a consistent quantity and have their INR checked periodically Option C: a therapeutic INR for most conditions is 2-3 but can be up to 3.5 for heart valve disease. However, it is never between 4 and 5 Option E: clients should call their health care provider if they miss or forget to take a warfarin dose. Double dosing is contraindicated

A nurse teaches a client who is being discharged on warfarin for atrial fibrillation. Which client statements indicate that teaching has been effective? Select all that apply A. "antibiotics can affect my INR value" B. "I am going to eat more leafy greens" C. "I will shoot for my INR value to be between 4 and 5" D. "I will take warfarin at the same time daily" E. "if I miss a dose, I can double it on the following day"

B Serotonin can be increased by the addition or high doses of serotonergic medication, or by some herbal medications, placing clients at risk for serotonin syndrome. Symptoms may include mental status changes, autonomic dysregulation, and neuromuscular hyperactivity. The nurse should call this client back to investigate the symptoms further.

A nurse working at a mental health clinic is reviewing four messages from clients requesting a same-day appointment. Which client does the nurse prioritize to call back first? A. a client who experienced a panic attack for the first time in 6 months after a minor car accident yesterday and is requesting a refill for alprazolam B. a client who is experiencing a fever and diarrhea 2 days after the health care provider increased the sertraline dose C. a client taking phenelzine who is concerned about food medication interactions and is requesting a list of foods to avoid D. a client who has attention-deficit hyperactivity disorder and is experiencing insomnia and irritability 2 days after starting methylphenidate

D Immediately after exposure to poison ivy, the client should be instructed to thoroughly wash the area to remove the oily resin, which is responsible for causing the rash that follows in 12-48 hours

A parent calls the nursing triage line during the evening. The parent says that a 7 year old was found playing in an area with poison ivy and asks what to do. Which is the most important instruction to give the parent? A. apply cool, wet compresses for itching B. apply topical cortisone ointment to the area C. discourage the child from scratching the area D. wash the skin where the contact occurred

B This fetal heart rate strip shows 2 accelerations and moderate variability. An acceleration of the fetal heart rate of at least 15/min above the baseline lasting for at least 15 seconds is a reassuring finding most often indicating fetal movement. Moderate variability refers to fluctuations in the baseline heart rate between 6-25/min. It is considered normal and indicates that the fetus is healthy and has adequate oxygenation and normal function of the autonomic nervous system. No immediate intervention is needed

A pregnant client admitted for induction of labor is receiving an oxytocin infusion. The baseline fetal heart rate is 140/min and the strip is shown in the exhibit. What is the nurse's best course of action? A. apply oxygen 10 L/min face mask B. continue to monitor the client C. discontinue oxytocin infusion D. notify the health care provider

ABCD Digital vaginal examinations are contraindicated in the presence of vaginal bleeding of unknown origin. When placenta previa is present, manual manipulation of the cervix can damage placental blood vessels, causing subsequent bleeding that can progress to hemorrhage. Clients with placenta previa are on pelvic rest

A pregnant client arrives in the labor and delivery unit with mild contractions and brisk, painless vaginal bleeding. The client received no prenatal care and reports being "about 7-8 months." Which actions should the nurse anticipate? Select all that apply A. blood draw for type and screen B. electronic fetal monitoring C. initiation of 2 large-bore IV catheters D. pad counts to assess bleeding E. vaginal examination for cervical dilation

AD Pregnant women have suppressed immune systems and are at increased risk for illness and subsequent complications. Some viruses can cause birth defects if contracted during pregnancy. Inactivated vaccines contain a "killed" version of the virus and pose no risk of causing illness from the vaccine. Some vaccines contain a weakened live virus and pose a slight theoretical risk of contraction the illness from the vaccine. For this reason, women should not receive live virus vaccines during pregnancy or become pregnant within 4 weeks of receiving such a vaccine The tetanus, diphtheria, and pertussis (Tdap) vaccine is recommended for all pregnant women between the beginning of the 27th and the end of the 36th week of gestation as it provides the newborn with passive immunity against pertussis (whooping cough) During influenza season (October-march), it is safe and recommended for pregnant women to receive the injectable inactivated influenza vaccine regardless of trimester The influenza nasal spray, measles, mumps and rubella vaccine and varicella vaccine contain live virus and are contraindicated in pregnancy

A pregnant client at 30 weeks gestation comes to the prenatal clinic. Which vaccines may be administered safely at this prenatal visit? Select all that apply A. influenza injection B. influenza nasal spray C. measles, mumps, rubella D. tetanus, diphtheria, and pertussis E. varicella

D During stabilization of a pregnant client after trauma, uterine displacement is the first step to address supine hypotension and promote blood circulation to the fetus. The client should be tilted laterally while strapped on the backboard to promote venous return and protect the client from further potential spinal injury

A pregnant client at 39 weeks gestation is brought to the emergency department in stable condition following a motor vehicle collision. The client, who is secured supine on a backboard, suddenly becomes pale with a blood pressure of 88/50 mm Hg. Which action should the nurse take first? A. administer normal saline fluid bolus B. ask about any prenatal complications C. initiate fetal heart rate monitoring D. tilt the backboard to one side

D The enlarging pregnant uterus should be just above the symphysis pubis at approximately 12 weeks gestation. At 16 weeks gestation, the funds is roughly halfway between the symphysis pubis and the umbilicus. It reaches the umbilicus at 20-22 weeks gestation and approaches the diploid process around 36 weeks gestation.

A pregnant client comes in for a routine first prenatal examination. According to the last menstrual period, the estimated gestational age is 12 weeks. Where would the nurse expect to palpate the uterine fundus in this client? A. 12 cm above the umbilicus B. at the level of the umbilicus C. halfway between the symphysis pubis and the umbilicus D. just above the symphysis pubis

ABCE Most routine nursing tasks in a stable client can be delegated to a licensed practical nurse (LPN). Routine ostomy care is an appropriate task for delegation to an LPN. The LPN may administer bolus or continuous tube feedings to a stable client. In addition, most medication administration is suitable for delegation to an LPN. However, advanced medication administration (IV meds) must be performed by a registered nurse (RN).

A registered nurse (RN), licensed practical nurse (LPN), and unlicensed assistive personnel are working on the unit. A client who is about to be discharged home with tube feedings needs care. Which responsibilities should the RN delegate to the LPN? select all that apply A. cleaning the skin surrounding the gastrostomy tube stoma B. crushing and administering metoprolol through the gastrostomy tube C. programming the feeding pump to administer a prescribed bolus feeding D. teaching the client about home enteral feeding and gastrostomy tube care E. weighing the client using the bed scale

AD Options B & E: the registered nurse is responsible for developing the pain management care plan, which includes assessing subjective characteristics of pain, performing initial client and caregiver teaching, including discharge instructions and evaluating the effectiveness of the care plan Option C: the RN should delegate vital sign measurement to the unlicensed assistive personnel. Although vital sign measurement is within the LPN's scope of practice, delegating this task to UAP is a more effective use of resources. The RN should provide instructions regarding timing of vital sign measurement and is responsible for evaluating the client's vital signs

A registered nurse, a licensed practical nurse, and unlicensed assistive personnel are caring for a client who is 1 day postoperative gastric bypass surgery. Which pain management related tasks should the RN delegate to the LPN? Select all that apply A. administering oral pain medication B. assessing characteristics of pain C. measuring vital signs before and after analgesic administration D. monitoring pain level using a numeric scale E. providing discharge teaching about pain management

A Option B: back blows and chest thrusts are appropriate interventions for a choking infant under age 1. Older children require abdominal thrusts to clear an obstructed airway.

A school nurse observes a 3 year old begin to choke and turn blue while eating lunch. What should be the nurse's initial action? A. abdominal thrusts B. back blows and chest thrusts C. blind sweep of the child's mouth D. call 911 for an ambulance

BEF Options A & D: avoid douching and using feminine perineal products, as they can alter the vaginal pH and normal flora, increasing the risk for infection. Take showers instead of baths as bath products and bacteria in bath water can irritate the urethra and increase the risk of infection Option C: avoid spermicidal contraceptive jelly as it can suppress the production of protective vaginal flora. Discontinue diaphragm use temporarily; a diaphragm increases pressure on the urethra and bladder neck, which may inhibit complete bladder emptying

A sexually active female client has had 3 urinary tract infections in 12 months. Which instructions should the nurse include in teaching the client how to prevent UTI recurrence? Select all that apply A. douche with a water and vinegar solution after intercourse B. increase daily intake of fluids C. use a spermicidal contraceptive jelly D. use fragrance-free perineal deodorant products E. void immediately after intercourse F. wear underwear with a cotton crotch

D Ferrous sulfate is an oral iron supplement prescribed to prevent or treat iron deficiency anemia, which occurs when the body lacks sufficient iron, an essential mineral in the formation of new RBCs. Low iron levels may result from malabsorption, insufficient intake, increased requirements, or blood loss. The nurse should avoid administering calcium supplements or antacids with or within 1 hour of ferrous sulfate because calcium decreases iron absorption Option A: taking an iron supplement increases the client's risk for constipation. instructing the client to increase fluid intake during therapy may help prevent hard stools Option B & C: taking an iron supplement with vitamin C further enhances duodenal acidity and increases absorption. An acid-rich environment enhances iron absorption, so oral supplements should be taken 1 hour before or 2 hours after meals

A student nurse is caring for a client with iron deficiency anemia who is newly prescribed ferrous sulfate. Which action by the student nurse requires the supervising nurse to intervene? A. encourages the client to drink extra fluids while taking ferrous sulfate B. offers the client orange juice for administration of ferrous sulfate C. plans to administer ferrous sulfate one hour before breakfast D. prepares to administer a prescribed calcium supplement with ferrous sulfate

B A normal blood glucose range for an infant is 40-60 mg/dL within the first 24 hours after delivery. A blood glucose level <40 mg/dL indicates hypoglycemia. Symptoms of hypoglycemia include jitters, cyanosis, tremors, pallor, poor feeding, retractions, lethargy, low oxygen saturation, and seizures. This infant with borderline-low glucose level is symptomatic and should be assessed first Option A: a normal respiratory rate for an infant is 30-60/min. This infant is currently stable Option C: it is normal to auscultate crackles in an infant during the first hour of life. This is because fluid is still being pushed out of and absorbed by the lungs. This infant is currently stable Option D: a normal temperature range for an infant is 97.7-99.7 F. This infant is currently stable

After receiving the shift report, the nurse should assess which infant first? A. an infant born 6 hours ago after 38 weeks gestation who has a respiratory rate of 52/min B. an infant born 12 hours ago who is jittery and has a blood glucose level of 40 mg/dL C. an infant with bilateral crackles who was delivered vaginally 30 minutes ago D. an infant wrapped in a warm blanket 15 minutes ago due to temperature 97.7 F

C This client with advanced chronic obstructive pulmonary disease is approaching the end of life. The client has expressed the desire to avoid further tests, treatments, and hospitalizations. The goals of care should be consistent with the client's wishes and emphasize comfort and quality of life. Palliative care is appropriate for clients who wish to focus on quality of life and symptom management rather than life-prolonging treatments

An 84 year old client with oxygen-dependent chronic obstructive pulmonary disease is admitted with an exacerbation and steady weight loss. The client has been in the hospital 4 times over the last several months and is "tired of being poked and prodded." Which topic would be most important for the nurse to discuss with this client's health care team? A. need for discharge to a skilled nursing facility B. nutritional consult with instructions on a high-calorie diet C. option of palliative care D. physical therapy prescriptions to promote activity

A Beneficence is the ethical principle of doing good. It involves helping to meet the client's emotional needs through understanding (including their family). This can involve withholding information at times. Option B: this is a true statement but it is being given abruptly to the family without support or gradual adjustment. It might be so distressing that they cannot travel to the hospital safely Option C: this is not a true statement and violates the principle of veracity. It will do nothing to help the family and might even cause them alarm that a nurse there is not informed about what is going on with their child Option D: although this is an option, it does nothing to deal with the situation and the family's needs adequately. It also "passes the buck" to another provider, and even though this provider can speak to them, the nurse should deal with the family's immediate needs at this point. Once they arrive, the health care provider is usually the one to tell family members about the client's prognosis

An adolescent client is brought to the emergency department after being in a serious motor vehicle crash. The client is undergoing cardiopulmonary resuscitation. The nurse calls the family to inform them to come to the hospital and a family member asks how the client is doing. Which is an example of the ethical principle of beneficence when responding to the client's family? A. "he is critically ill and we are caring for his needs" B. "his heart has stopped and we are attempting to revive him" C. "I don't know how he is doing but you need to come" D. "I will have the health care provider talk to you once you arrive"

BCE Option A: giving false reassurance is non therapeutic communication as it implies that there in no cause for concern and provides no specific information about this client's condition. Option D: asking judgmental questions is nontherapeutic as it may cause the client's parents to be defensive, thereby hampering communication.

An adolescent client is brought to the emergency department by the parents after being found making superficial cuts along the side of an arm with a razor blade. There are several minor cuts in various stages of healing on the client's forearms. Which statements are appropriate for the nurse to make to the client's parents? Select all that apply A. "Everything is going to be alright" B. "tell me about when you started noticing this behavior" C. "we have the bleeding under control" D. "why didn't you bring your child in sooner?" E. "you must be very upset after seeing this"

A Antibiotic treatment is inappropriate for a viral infection

An adolescent client with a sore throat is diagnosed with infectious mononucleosis. Which comment by the caregiver would alert the nurse that additional instruction is necessary? A. "I need to go to the pharmacy to pick up an antibiotic prescription" B. "it is acceptable for my child to have ibuprofen for discomfort or fever" C. "my child will be on bed rest with few activities for the next 2 weeks" D. "participation in soccer practice will not be allowed for the next month"

ABCE Option A: hypotension (systolic BP < 90 mm Hg or mean arterial pressure < 65 mm Hg) in a client with infection may indicate septic shock. Option B: prolonged capillary refill time > 3-4 seconds in adults indicates inadequate tissue perfusion. Option C: fever or hypothermia (>100.4 F; <96.8F) either fever or low body temp is found in sepsis and septic shock Option D: clients with septic shock typically develop decreased urine output (ie <0.5 mL/kg/hr) due to inadequate organ perfusion

An adult client with bacterial pneumonia becomes increasingly disoriented and somnolent. Which assessment findings indicate that the client may be in septic shock? Select all that apply A. blood pressure 80/50 mm Hg B. capillary refill of 5 seconds C. temperature of 96.4 F D. urine output of 125 mL/hr E. WBC count of 26,000/mm3

C Option A: telling family members that a nurse is busy is not a helpful response. Option B: although calling clergy members may be appropriate, it may take several hours for them to arrive. Option D: family members who ask the nurse to stay for a few minutes may have question or need emotional support. In such cases, it in not helpful for the nurse to decline.

An elderly client at the end of life is visited by family members. One begins to cry and asks the nurse, "Will you please stay for a few minutes?" The nurse has other clients to care for as well. Which statement by the nurse is the most helpful? A. "I am busy right now but can stay for a few minutes" B. "I can call the clergy to come sit with you" C. "I can stay and sit with you if you would like" D. "I don't think I should interrupt your family time"

B In a healthy client, an induration > 15 mm indicates a positive TST; this means that the client was exposed to TB, developed antibodies to the disease, and has a TB infection. Additional tests are needed to determine if the client has latent TB infection or active TB disease. Clients with latent TB infection are asymptomatic and cannot transmit the microorganism to others

An elderly client has a 17-mm induration after a tuberculin skin test. Based on this result, which statement is most accurate? A. the client has a false-positive reaction due to advanced age B. the client has a tuberculosis infection C. the client has active TB disease D. the client must be isolated immediately

B Hematocrit is the percentage of red blood cells in a volume of whole blood. Hct and hemoglobin values are related (approx 3x hgb = hct). When one value is decreased, the other is also. This client likely has hemoglobin of 7 g/dL. Hgb is a component of the RBC that carries oxygen to the body's tissues. A decrease in Hgb decreases oxygen-carrying capacity and transport to tissues. RBCs may be 100% saturated with oxygen at rest, but desaturation may occur with increased activity and oxygen demand in the presence of decreased hct and hgb NORMALS: - hemoglobin: 13.2-17.3 for males; 11.7-15.5 for females

An elderly client reports shortness of breath with activity for the past 2 weeks. The nurse reviews the admission laboratory results and identifies which value as the most likely cause of the clients symptoms? A. brain natriuretic peptide 70 pg/mL B. hematocrit 21% C. leukocytes 3,500/mm3 D. platelets 105,000/mm3

B Sundowning refers to the increased confusion experiences by an individual with dementia; it occurs at night, when lighting is inadequate or when the client is excessively fatigued. Wandering is a common associated behavior. A client with mild-to-moderate dementia may need frequent reality reorientation to promote appropriate behaviors. However, with advanced dementia, reality orientation may not be effective and might cause the client to feel anxious, leading to inappropriate behaviors and aggression. In this situation, validation therapy is more appropriate and involves recognizing and exploring the client's feelings and concerns but not reinforcing or arguing with any incorrect perceptions

An elderly client with dementia frequently exhibits sundowning behavior while living in a community-based residential facility. When the nurse finds the client wandering at night, which of the following statements is most appropriate? A. "don't you know its not morning yet?" B. "its time to get back to bed now" C. "you might fall if you wander in the dark" D. "you should not leave your room without assistance"

C Procedure for measurement of orthostatic BP: 1. have the client lie down for at least 5 minutes 2. measure BP and HR 3. have the client stand 4. repeat BP and HR measurements after standing at 1- and 3-minute intervals A drop in systolic BP of ≥20 mm Hg or in diastolic BP of ≥10 mm Hg, or experiencing lightheadedness or dizziness is considered abnormal

An experienced nurse is mentoring a new registered nurse (RN) on the telemetry unit. The new RN is measuring orthostatic blood pressure (BP) for a client. Which situation would warrant intervention by the experienced nurse? A. nurse has client lie supine for 5-10 minutes prior to starting procedure B. nurse interprets a decrease in systolic BP by 10 mm Hg as a normal finding C. nurse starts by measuring BP and heart rate (HR) with the client standing D. nurse takes BP and HR after standing at 1- and 3-minute intervals

AE Option B: Some clients who have suffered a cerebrovascular accident are also left with visual impairment such as hemianopsia; in this condition, a person sees only a portion of the visual field from each eye. A client with a right-sided CVA may have left-sided hemianopsia. Having the client turn their head during a meal will help the client see everything on the plate. Option E: using a straw for drinking liquids might cause increased swallowing difficulty and choking. Controlling liquid intake through a straw is more difficult than drinking straight from a cup or glass

An unlicensed assistive personnel (UAP) is aiding a client recovering from a right-sided cerebrovascular accident with resulting mild oropharyngeal dysphagia. The client has been placed on a dysphagia diet. Which actions require intervention by the registered nurse? Select all that apply A. the UAP adds milk to mashed potatoes to make them thinner B. the UAP encourages the client to occasionally turn the head to the left C. the UAP helps the client sit in an upright position D. the UAP places food on the strong side of the client's mouth E. the UAP puts a straw in a fruit smoothie to prevent spilling

B The nurse should be assertive and deal with the issue directly now. The nurse is using an "I" statement; the nurse is not attacking the UAP's character but is focusing only on the task at hand, which the UAP can perform. The request should be given as a directive, not as an option. Putting the request in the scope of a universal goal on which everyone can agree, such as quality care, makes it harder for the UAP to refuse. It is also helpful to say please/thank you and to stand and wait expectantly until the UAP starts the requested action

Client call lights come on while the unlicensed assistive personnel (UAP) sits at a desk and reads a magazine. When the nurse asks the UAP to answer the lights, the UAP says, "those aren't my clients." What is the best response by the nurse? A. "would you mind answering the lights anyway?" B. "I need you to answer the lights because we want to provide good client care" C. say nothing and answer the lights, but write up a disciplinary action D. tell the UAP that this is unacceptable and speak to the nurse manager

D Option A: eczema is a skin rash caused by an immune disorder that is often triggered by an allergy. Itching is common, but the rash is not contagious Option B: oral candidiasis, or thrush, often occurs after a course of antibiotics or corticosteroids or can occur in infants with immature immune systems. An infant who is breastfed can transfer candidiasis to the mother's breast. There is also a small risk of transmission when infants place pacifiers or toys in their mouths and subsequently transfer these items to another child's mouth. However, oral candidiasis is significantly less contagious than tinea corporis Option C: psoriasis is a chronic autoimmune disease that most often affects the skin by causing dry, scaly, red rashes. Psoriasis is not contagious

For which client is it most important for the nurse to provide teaching on ways to prevent the spread of the condition? A. client with eczema on upper torso B. client with oral candidiasis C. client with psoriasis on hands D. client with tinea corporis

D Hypokalemia often occurs with resolution of acidosis and administration of IV insulin, which shifts potassium from the intravascular to the intracellular space. Therefore, potassium is administered even when the client is normokalemic to prevent hypokalemia and subsequent life-threatening arrhythmias

In the intensive care unit, the nurse cares for a client who has been admitted with diabetic keto acidosis. The client is on a continuous infusion of regular insulin at 5 units/hr via IV pump. Which action should the nurse expect to implement? A. check serum BUN and creatinine levels every hour B. discontinue insulin infusion when blood glucose is <350 mg/dL C. increase insulin infusion rate when blood glucose level decreases D. initiate potassium IV when serum potassium is 3.5-5.0 mEq/L

ABC Option D: gingival hyperplasia or hypertrophy is a known side effect of phenytoin (dilantin) and is not a reason to stop the drug. Vigorous dental hygiene beginning within 10 days of initiation of phenytoin therapy can help control it. Signs and symptoms that require discontinuation include toxic levels or phenytoin hypersensitivity syndrome Option E: warfarin (Coumadin) is used to prolong clotting so that the desired result is a "therapeutic" range rather than the client's "normal" control value when not on the drug. Therapeutic range is considered roughly 1.5-2.5 times the control, but up to 3-4 times the control in high-risk situations such as an artificial heart valve

In which scenarios should the nurse hold the prescribed medication and question its administration? Select all that apply A. client on IV heparin and the platelet count is 50,000/mm3 B. client on newly prescribed lisinopril and is at 8 weeks gestation C. client on nitroglycerin patch for heart failure and blood pressure is 84/56 mm Hg D. client on phenytoin for epilepsy and the nurse notes gingival hyperplasia E. client on warfarin and prothrombin time/International Normalized Ratio is 1.5 times control value

D Severely immunocompromised children generally should not receive live vaccines (varicella-zoster, measles-mumps-rubella, rotavirus, yellow fever). Passive immunization may be the only option for children with severe immunosuppression or those unable to mount an antibody immune response

Several 12-month-old infants are brought to the clinic for routine immunizations. Which situation would be most important for the nurse to clarify with the provider before administering the vaccination? A. haemophilus influenza type b vaccine for client allergic to penicillin B. hepatitis A vaccine for a client with a "cold" and temperature of 99.0 F C. pneumococcal vaccine for client with local swelling after last immunization D. varicella-zoster vaccine for client recently diagnosed with leukemia

B Shingles lesions that are open may transmit the infection by both air and contact. The client with disseminated shingles that are not crusted over will require contact precautions, airborne precautions, and a negative airflow room to prevent transmission of the infection to others in the hospital.

The charge nurse is notified that a client is being admitted with a diagnosis of active shingles with a disseminated rash. Which room assignment is most appropriate for this client? A. a private room with contact and droplet precautions B. a private room with negative airflow and contact and airborne precautions C. a private room with positive airflow and airborne precautions D. a semi-private 2-bed room with standard precautions

ABD Option C: case managers typically do not provide direct client care. Medication reconciliation should be done between the primary nurse directly caring for the client and the HCP Option E: case managers often make daily rounds to the nursing department to review documentation in the client's chart but do not necessarily visit the client personally

The charge nurse on the cardiac floor is orienting a new graduate nurse. The charge nurse describes various roles of the interdisciplinary team. In which situations would the nurse "case manager" be consulted? Select all that apply A. facilitating communication between health care providers B. obtaining health information from the client's nursing home C. reconciliation of home medications D. referral for home health after discharge E. visiting the client daily while hospitalized

D The best option is room 4 with the client who has severe epistaxis and decreased platelet count as this does not place the immediate post-operative client at increased risk for infection

The charge nurse on the medical surgical unit must assign a room for an immediate post-operative nephrectomy client. Which room assignment is the best option for this client? A. room 1 - client with diabetes and chronic kidney disease who is on hemodialysis and has a serum glucose level of 265 mg/dL B. room 2 - client with chronic HIV infection and overwhelming fatigue who has a CD4+ cell count of 200/mm3 C. room 3 - client with cellulitis of the leg due to a spider bite who has a WBC count of 13,000/mm3 D. room 4 - client with severe epistaxis due to a traumatic nasal fracture who has a platelet count of 85,000/mm3

A The charge nurse should assign the most stable and predictable client to the LPN. The client who needs to have a urinary catheter reinserted is within the scope of practice for the LPN. The other clients need nursing interventions that require independent nursing knowledge, skill, and judgment such as assessment, client teaching, and evaluation of care.

The charge nurse on the telemetry unit is making client assignments. Which client is appropriate to assign to the licensed practical nurse (LPN)? A. client 2 days after aortic valve surgery who needs a urinary catheter reinserted due to inability to void B. client being discharged after deep vein thrombosis who needs teaching on how to self administer enoxaparin injections C. client who has just been admitted to the telemetry unit from the emergency department with a rule out myocardial infarction D. client with a nitroglycerin infusion with prescription to titrate to keep systolic blood pressure < 150 mm Hg; currently at 110/62 mm Hg

ABD

The charge nurse supervising a graduate nurse would need to intervene when the nurse violates health information privacy laws with which action? Select all that apply A. accesses the medical record of a client not currently assigned, but previously care for, to assess client improvement B. advises a client's transport technician, "this client has metastatic breast cancer and must be moved very carefully due to fragile bones" C. asks a client quietly, "when were you diagnosed with diabetes?" during admission assessment in a semiprivate room with the privacy curtain in place between beds D. explains the results of a client's diagnostic testing to the unit clerk who is organizing paperwork to be included in the client's medical record E. writes a client's last name on a whiteboard hanging in the nurses' station on which scheduled procedures are logged

D An RN is appropriately assigned to the client who is most unstable. Following this client's orthopedic surgery, the nurse must perform frequent neuromuscular, pain, drain, wound and respiratory assessments; assess for potential risk factors and provide emotional support as well. Good critical thinking skills are needed to develop, implement, and evaluate an appropriate plan of care for this client Option A: administration of blood is not within the scope of the LPN's practice Option B: a student nurse may not be able to administer medications independently and/or would require close supervision by either nursing faculty or an RN preceptor. The student nurse may not be able to provide adequate pain relief in a timely manner. The nurse who assesses the pain should administer the medication and evaluate the response Option C: a postoperative client requires thorough education and evaluation prior to discharge. This level of client education should be performed by an RN; an LPN may reinforce prior teaching completed by an RN but is not able to provide initial teaching or evaluate learning outcomes

The charge registered nurse (RN) on a medical-surgical unit is responsible for making assignments. Which assignment made by the RN is most appropriate? A. an LPN assigned to a client receiving blood transfusions B. a student nurse assigned to a client who requires frequent intravenous pain medication C. an LPN assigned to a client 2 days postoperative appendectomy scheduled to be discharged today D. an RN assigned to a client 1 day postoperative repair of a compound fracture

A Systolic blood pressure should remain at 80 mm Hg or above to adequately perfuse the kidneys. Administration of fluids is a priority to ensure adequate kidney and other organ perfusion

The client is brought to the emergency department after falling off o roof and landing on his back. A T1 spinal fracture is diagnosed. The client's blood pressure is 74/40 mm Hg, pulse is 50/min, and skin is pink and dry. What nursing action is a priority? A. administer IV normal saline B. determine if urinary occult blood is present C. perform a neurological assessment D. verify that there is no stool impaction

BDE Option B: clients with previous allergic reaction to IV contrast may require premedication or another contrast medium Option D: iodine-containing contrast can cause kidney injury, although this risk can be reduced with adequate hydration. However, clients with renal impairment should not receive IV contrast unless absolutely necessary Option E: metformin with IV iodine contrast increases the risk for lactic acidosis. Metformin is usually discontinued 24-48 hours before exposure and restarted after 48 hours, when stable renal function is confirmed

The client is scheduled to have a cardiac catheterization. Which findings will cause the nurse to question the safety of the test proceeding? Select all that apply A. elevated C-reactive protein level B. history of previous reaction to IV contrast C. prolonged PR interval on electrocardiogram D. serum creatinine of 2.5 mg/dL E. took metformin today for type 2 diabetes

D Use of a pacifier or them sucking prior to eruption of the permanent teeth does not tend to cause dental issues such as teeth misalignment or malocclusion

The clinic nurse is asked by the mother of a 15-month-old, "I am worried about my child's thumb sucking and its effects on tooth alignment. What should I do?" What is the nurse's best response? A. "as long as your child's thumb sucking stops by age 2-3 years when all of the primary teeth have erupted, there is little concern" B. "because your child already has teeth, it is important to implement a plan to stop the thumb sucking as soon as possible" C. "newer research shows that thumb sucking has little effect on a child's teeth" D. "the risk for misaligned teeth occurs when thumb sucking persists after eruption of permanent teeth"

C Infants born at preterm gestation have less time in utero to accumulate iron. Preterm infants typically deplete iron stores by age 2-3 months and require additional iron supplementation. Therefore, a 3 month old infant born at preterm gestation who is exclusively receiving breastmilk is most at risk for anemia

The clinic nurse is caring for several clients during well-child visits. The nurse should recognize which client as being the most at risk for anemia? A. 1-month-old infant born at term gestation who exclusively breastfeeds B. 2-month-old infant born at preterm gestation who exclusively receives iron-fortified formula C. 3-month-old infant born at preterm gestation who is exclusively bottle-fed with breastmilk D. 6-month-old infant born at term gestation who breastfeeds and eats iron-fortified infant cereal

C Clostridium botulinum spores in honey or soil can colonize an infant's immature gastrointestinal system and release a toxin that causes botulism, a rare but serious illness. The toxin attacks the neuromuscular system, causing progressive muscle paralysis that can potentially lead to respiratory failure and death. Initial manifestations may include constipation, generalized weakness, difficulty feeding and decreased gag reflex

The clinic nurse is interviewing the parents of a 6 month old client about the infant's die. Which statement by the parents is most concerning? A. "because apples are healthy, we make apple pie and feed small, soft bites to our baby" B. "if our baby refuses to finish foods, we continue to offer small bites, so food isn't wasted" C. "infant oatmeal sweetened with fresh honey is our baby's favorite breakfast" D. "we found that the food in TV dinners can be easily pureed and is convenient"

B A holter monitor continuously records client's electrocardiogram rhythm for 24-48 hours. Electrodes are placed on the client's chest and a portable reading unit is kept with the client. At the end of the prescribed period, the client returns the unit to the health care provider's office. The data can be recalled, printed and analyzed for any abnormalities Option A: the data are not generally transmitted over the phone. The client simply takes the monitor back to the HCP's office Option C: patient should engage in normal activities to stimulate conditions that may produce symptoms that the monitor can record Option D: instructions include no bathing or showering during the test period

The clinic nurse is providing instructions to a client who will be wearing a Holter monitor for the next 24 hours. Which instructions are important to review with the client? A. how to transmit the readings over the phone B. keep a diary of activities and any symptoms experienced C. refrain from exercising while wearing the monitor D. the monitor may be removed only when bathing

B Hydrocephalus is an increase in intracranial pressure that results from obstruction of cerebrospinal fluid flow. Increased ICP can progress to brain damage and death. Signs of increased ICP in children include bulging fontanelles, increasing head circumference and sunset eyes. Sunset eyes occur with periaquedutal structures are compressed from increased ICP, paralyzing the upward gaze. This is a late sign of increased ICP that requires timely treatment and is the priority

The clinic nurse performs assessments on four infants. The nurse should alert the health care provider to see which client first? A. 3 month old whose posterior occiput appears flattened B. 4 month old who has sclera visible about the iris (sunset eyes) C. 6 month old who has vomited twice and has had 8 wet diapers in the last 24 hours D. 9 month old whose toes fan out and big toe dorsiflexes when plantar surface is stroked

ABE Options C & D: discarding stuffed animals is not required. Nonwashable belongings can be sealed in plastic bags for ≥3 days because scabies mites can survive away from skin for only 2-3 days. Fumigation of living areas is not necessary

The clinic nurse provides teaching for the parent of a child diagnosed with scabies. Which instructions should the nurse include in the teaching plan? Select all that apply A. all persons in close contact with the child need treatment B. apply the permethrin cream to all skin surfaces C. discard the child's stuffed animals D. fumigate all living ares in the home E. wash the child's clothing and bedding in hot water

BCD Options A & D: Pneumonia and annual influenza vaccinations are recommended for those with SLE as they are more susceptible to infections. These individuals should avoid contact with sick people and report fever to their health care provider Option B: Both physical and emotional stress exacerbate SLE. Therefore, clients should follow a healthy lifestyle. Balanced exercise with alternating periods of rest is recommended Option C: sunlight is known to worsen the rash of SLE and should be avoided when possible. Protective clothing and sunscreen application are recommended during periods of sun exposure Option E: The rash of SLE should be cleansed only with mild soap. Harsh soap and chemicals should be avoided. The rash is not due to bacterial infection.

The clinic nurse reinforces teaching to a client with systemic lupus erythematosus. Which instructions will the nurse include? Select all that apply A. avoid annual influenza vaccination B. avoid situations that cause physical and emotional stress C. avoid sun exposure and ultraviolet light when possible D. notify the health care provider if you have a fever E. use antibiotic soap to cleanse skin rashes

D Growth hormone replacement is an option for children who are not growing according to accepted standards. The treatment should begin as soon as delays are noted and continue until bone growth begins to cease despite replacement therapy. Replacement is administered via subcutaneous injections Option A: growth hormone replacement does not guarantee that a child will grow at a rate equal to peers. Treated children often remain shorter than their peers Option B: replacement therapy is not continued throughout a child's life. It is stopped when bone growth begins to cease or when the child, parents, and provider make the decision Option C: replacement therapy is most successful when treatment begins early, as soon as growth delays are noted

The clinic nurse reviews teaching provided to the parent of a child being considered for growth hormone replacement therapy at home. Which statement by the parent indicates that teaching has been effective? A. "treatment will be considered a success when my child grows at a rate equal to peers" B. "treatment will be required throughout my child's life" C. "treatment will begin when my child becomes an adolescent" D. "treatment will require a daily injection under my child's skin"

D TNF inhibitor drugs block the action of TNF, a mediator that triggers a cell-mediated inflammatory response in the body. These drugs reduce the manifestations of rheumatoid arthritis and slow the progression of joint damage by inhibiting the inflammatory process. The medication causes immunosuppression and increased susceptibility for infection and malignancies.

The clinic nurse reviews the medical record of a client who was prescribed etanercept, a tumor necrosis factor (TNF) inhibitor. Which test result is most important for the nurse to check before initiating this treatment? A. c-reactive protein B. prothrombin time C. serum LDL cholesterol D. tuberculin skin test

CDE Codependent behaviors are those that allow the codependent person to maintain control by fulfilling the needs of the addict first. Behaviors such as keeping the addiction secret, suffering physical or psychological abuse from the addict, not allowing the addict to suffer the consequences of actions, and making excuses for the addict's habit are hallmarks of codependency. If the addict isn't happy, the codependent person will try to make the addict happy. Codependent persons will focus all their attention on others at the expense of their own sense of self. Codependent spouses, friends, and family members keep the client from focusing on treatment; this behavior is counterproductive to both themselves and the client.

The clinic nurse speaks with the spouse of a client being treated for alcohol use disorder. Which statements by the spouse indicate codependence? Select all that apply A. "I am focusing on my new hobby and my friends in the book club" B. "I left and didn't awaken my spouse, who went back to sleep after turning off the alarm clock" C. "I try to get up early and keep the children from being too loud in the mornings" D. "if I didn't get so stressed about my job, my spouse wouldn't drink so much" E. "when my spouse was sick, I called and rescheduled clients so my spouse could rest"

BD Option A: children with hemophilia should avoid aspirin and non steroidal anti-inflammatory drugs due to the risk of bleeding. Acetaminophen is recommended for pain relief Options C & E: firm pressure should be held on the site without rubbing or massaging due to the risk of bleeding and hematoma formation. Superficial bleeding can be controlled using ice packs, which promote vasoconstriction. Applying a warm compress would cause vasodilation and prolong bleeding

The clinic nurse supervises a student nurse who is preparing to administer routine vaccinations to a child diagnosed with hemophilia. Which instructions should the clinic nurse provide to the student? Select all that apply A. administer ibuprofen for pain relief B. administer vaccines via the subcutaneous route C. apply a warm compress to the injection site D. hold firm pressure on the site for 5 minutes E. massage the injection site to disperse the medication

C To prepare a client for bronchoscopy, the nurse must be able to perform basic assessment skills, such as assessing vital signs, lung sounds, ability to swallow, and gag reflex; maintain nothing-by-mouth status; prepare a checklist before the procedure; and monitor for respiratory difficulty after the procedure. Because these are skills a graduate nurse possesses, this is an appropriate assignment

The clinical coordinator registered nurse (RN) on a surgical unit makes assignments for the staff of RN, licensed practical nurse, and graduate nurse. Which assignment is most appropriate for a new graduate nurse? A. a 36 year old client with postoperative venous thromboembolism who is to be started on the institution's intravenous heparin therapy protocol this morning B. a 56 year old client with newly diagnosed cancer, scheduled for a total laryngectomy this morning, who is now refusing therapy C. a 68 year old client with multiple sclerosis, 2 days postoperative open cholecystectomy with recurrent mucous plugs, who is scheduled for a bronchoscopy this morning D. an 80 year old client, 3 days postoperative colectomy with peritonitis, who was mentally alert before and develops new-onset confusion this morning

ACE Option B: pithing sensation is an expected finding with narcotic use, especially in opioid-naïve clients. It can be managed with an antihistamine Option D: occasional premature ventricular contractions are a common, insignificant finding in most adults. The client should have cardiac monitoring in the setting of methadone use/overdose as there is a risk of QT interval prolongation

The emergency department nurse is caring for a client who has recently been prescribed methadone for chronic severe back pain. The client ingested extra tablets tonight because the pain returned. Which assessment findings during discharge require the client to be monitored longer in the hospital setting? Select all that apply A. client falls asleep while the nurse is talking B. client frequently scratches due to pruritis C. client has third emesis since taking medication D. monitor reveals one premature ventricular contraction E. pulse oximeter shows oxygen saturation is 90%

ABD Misoprostol, a prostaglandin E1, is a cervical ripening agent. Cervical ripening is a process that normally occurs before the onset of labor in which the cervix softens and becomes more pliable so the dilation and effacement can occur more easily during contractions. Mechanical or pharmacologic cervical ripening methods stimulate this process and increase the client's probability of achieving a vaginal birth Misoprostol is contraindicated if: - the client is receiving another uterotonic simultaneously (oxytocin) - the client has a history of uterine surgery (cesarean birth) due to an increased risk of uterine rupture at the surgical scar site - the client has an abnormal fetal heart rate pattern or uterine tachysystole (>5 contractions in 10 min) Option C: a client with this cervical examination would especially benefit from cervical ripening because it may reduce the amount of oxytocin required later in the labor induction process Option E: the health care provider prescribes misoprostol orally or vaginally for labor induction. Rectal administration is only appropriate during PPH

The graduate nurse is admitting a client for labor induction who is prescribed misoprostol for cervical ripening. Before misoprostol is administered, which of the following statements by the GN should be concerning to the supervising nurse? Select all that apply A. "IV oxytocin and misoprostol may be administered at the same time" B. "the client has had two prior cesarean births" C. "the client's cervical examination is 0 cm, 25% effaced, -3 station" D. "the client's contraction pattern is currently 6 contractions in 10 minutes" E. "the prescribed oral route of administration is appropriate"

B The only adequate prenatal treatment is IM penicillin injection. Expected outcomes include resolution of maternal infection and prevention or treatment of fetal infection. If a pregnant client has a penicillin allergy, the nurse should anticipate penicillin desensitization so that adequate treatment can be provided

The graduate nurse is caring for a client at 20 weeks gestation with secondary syphilis. The client reports an allergic reaction to penicillin as a child but does not know what kind of reaction occurred. When discussing the client's potential treatment plan with the precasting nurse, which statement by the GN indicates an appropriate understanding? A. "doxycycline is an acceptable alternative to penicillin for treatment of syphilis during pregnancy" B. "the client will require penicillin desensitization to receive appropriate treatment" C. "the newborn can be treated after birth if antepartum treatment is contraindicated" D. "treatment is only effective if provided during the primary stage of syphilis"

C Rh immune globulin prevents antibody formation by suppressing the maternal immune response and is effective only if the client has never developed antibodies to the Rh antigen. The nurse should verify that the client is not Rh sensitized by checking for a negative antibody screen and then proceeding with administration of Rh immune globulin. A positive maternal antibody screen would require further clarification from the health care provider

The graduate nurse receives report on a postpartum client with an Rh-negative blood type. Which statement by the GN regarding the Rh immune globulin injection requires the preceptor to provide further teaching? A. "additional doses of Rh immune globulin may be required if excessive fetomaternal hemorrhage is suspected" B. "I should administer Rh immune globulin to the client within 72 hours after birth" C. "if the maternal antibody screen is negative, I will hold Rh immune globulin and contact the health care provider" D. "Rh immune globulin is not required if the newborn's blood type is Rh negative"

C Tricyclic antidepressants are commonly used for neuropathic pain. Side effects are especially common in elderly patients. Due to the increase risk of falling, the priority nursing action is to teach the client to get up slowly from the bed or a sitting position Options A, B & D: these are important instructions but not priority ones

The health care provider has prescribed amitriptyline 25 mg orally every morning for an elderly client with recent herpes zoster infection (shingles) and severe postherpetic neuralgia. What is the priority nursing action? A. encourage increased fluid intake B. provide frequent rest periods C. teach the client to get up slowly from the bed or a sitting position D. tell the client to wear sunglasses when outdoors

D Calcium and vitamin D are essential for bone strength. Calcium carbonate has the most available elemental calcium of OTC products and is inexpensive; it is therefore the preferred calcium supplement for most clients with osteoporosis. Calcium absorption is impaired when taken in excess of 500 mg per dose. Therefore, most clients should take supplements in divided doses. These should be taken within an hour of meals as food increases calcium absorption. Constipation is a frequent side effect of calcium supplements, so clients should be advised to take appropriate precautions

The health care provider has told a client to take over-the-counter supplemental calcium carbonate 1000 mg/day for treatment of osteoporosis. Which instruction should the clinic nurse give the client? A. monthly calcium levels will need to be drawn B. stop vitamin D supplements when taking calcium C. take calcium at bedtime D. take calcium in divided doses with food

B An SBFT examines the anatomy and function of the small intestine using x-ray images taken in succession. Barium is ingested, and x-ray images are taken every 15-60 minutes to visualize the barium as it passes through the small intestine Option A: black, tarry stools are not an expected symptom of an SBFT; this is indicative of gastrointestinal bleeding and should be reported immediately to an HCP Option C: an endoscope is not used to complete an SBFT Option D: clients should refrain from eating 8 hours prior to the examination. Polyethylene glycol is prescribed as a bowel preparation for a colonoscopy, not an SBFT

The health care provider orders a small bowel follow-through for a client. Which instructions should the nurse include when teaching the client about this test? A. "after the test, you may notice your stools are tarry black for a few days" B. "during the test, a series of x-rays will be taken to assess the function of the small bowel" C. "the HCP will use an endoscope to visualize your small bowel" D. "your examination is scheduled for 8:00 AM. Please drink all of the polyethylene glycol by midnight"

C Phenazopyridine hydrochloride is a urinary analgesic prescribed to relieve the pain and burning associated with a urinary tract infection. The urine will turn bright red-orange while on this medication; other body fluids can be discolored as well. Because staining of underwear, clothing, bedding, and contact lenses can occur, the nurse should suggest that the client use sanitary napkins and wear eyeglasses while taking the medication. Phenazopyridine hydrochloride provides symptomatic relief but no antibiotic action, and so it is important that the client take a full course of antibiotics

The health care provider prescribes phenazopyridine hydrochloride for a client with a urinary tract infection. What would the office nurse teach the client to expect while taking this medication? A. constipation B. difficulty sleeping C. discoloration of urine D. dry mouth

D Trials have found greater reduction in total and LDL cholesterol when statins are taken in the evening or at bedtime as opposed to during the day

The health care provider prescribes simvastatin for a client with hyperlipidemia. The nurse instructs the client to take this medication in which manner? A. at noon with a meal B. in the morning on an empty stomach C. in the morning with breakfast D. with the evening meal

C Characteristic symptoms of rotator cuff injury usually include shoulder pain and weakness. Severe pain when the arm is abducted between 60 and 120 degrees is characteristic.

The health care provider suspects a rotator cuff injury in a client who is an avid tennis player. The nurse would most likely assess which of the following? A. complete stiffness of the shoulder joint B. paresthesia over the first 3 1/2 fingers C. shoulder pain with arm abduction D. tenderness over the lateral epicondyle

C New onset of dependent edema of the feet could represent congestive heart failure. This is an urgent medical condition that needs prompt evaluation for characteristic signs and treatment Option A: loss of short-term memory could be an early sign of dementia. It is important to assess clients' mental status to ensure safety in their homes. Further intervention is required, but this condition is not life-threatening Option B: a painful red area on the buttocks represents the beginning stages of a pressure injury. Although not emergent, this does require further intervention. It is important to recognize pressure injuries early and start treatment promptly before they progress to advanced stages. Advanced pressure injuries are more difficult to treat and heal slower in the elderly Option D: strong, foul smelling urine is likely due to a urinary tract infection. This does require treatment to prevent further complications but is not a priority over suspected heart failure. Urinary tract infections can cause fever with confusion in the elderly.

The home care nurse visits the house of an elderly client. Which assessment finding requires immediate attention? A. the client cannot remember what was done yesterday B. the client has a painful red area on the buttocks C. the client has new dependent edema of the feet D. the client has strong, foul smelling urine

B Option A: it is important to assess the client's social support system, but it is not the priority assessment. Option C: this is not the priority assessment; it is more important to determine if the client is thinking about suicide or has a plan. Option D: this is a leading question and implies what the answer should be.

The home health aide reports to the nurse care manager that the client has been trying to give away possessions. When the nurse asks the client about this behavior, the client says, "with my spouse dead, there's no reason for me to go on." What is the best priority response by the nurse? A. do you have any friends in the building? B. have you had any thoughts of hurting yourself? C. tell me more about how you're feeling D. you're not thinking of killing yourself, are you?

ACDE Option B: use of the words "excessive" and "suspicious" to describe the child's bruising conveys judgment. This may cause the caregiver to become defensive and limit the nurse's ability to establish trust and find the source of the abuse

The home health nurse assesses a child and suspects that the child is being abused. Which of the following questions are appropriate for the nurse to ask the caregiver? Select all that apply A. "how would you describe your child's usual behavior at home?" B. "these bruises seem excessive and suspicious. How did they happen?" C. "what forms of discipline do you use with your child?" D. "when you are stressed, what coping mechanisms do you use?" E. "who watches your child when you are at work?"

D Adalimumab is a tumor necrosis factor inhibitor, a biologic disease-modifying anti rheumatic drug classified as a monoclonal antibody. its major adverse effects are similar to those of other TNF inhibitor drugs. An elevated white blood cell count in this client can indicate underlying infection and should be reported immediately

The home health nurse reviews the laboratory results for 4 clients. Which laboratory value is most important for the nurse to report to the health care provider? A. client with clostridium difficile infection receiving metronidazole has a white blood cell count of 15,000/mm3 B. client with liver cirrhosis has an International Normalized Ratio of 1.5 C. client with mild asthma exacerbation receiving prednisone has a blood glucose of 250 mg/dL D. client with rheumatoid arthritis taking adalimumab has a white blood cell count of 14,000/mm3

A Option A: positioning the chin slightly downward toward the neck (chin-tuck) when swallowing can be effective in some clients with dysphagia due to its facilitating closure of the epiglottis to help prevent tracheal aspiration

The home health nurse teaches an elderly client with dysphagia some strategies to help limit repeated hospitalizations for aspiration pneumonia. Which statement indicates that the client needs further teaching? A. "I have to remember to raise my chin slightly upward when I swallow" B. "I have to remember to swallow 2 times before taking another bite of food" C. "I should avoid taking over-the-counter cold medications when i'm sick" D. "I should sit upright for at least 30-40 minutes after I eat"

ACDE Manifestations of digoxin toxicity include: - visual symptoms - gastrointestinal symptoms (anorexia, nausea, vomiting, abdominal pain) - neurologic manifestations (lethargy, fatigue, weakness, confusion) Option B: there is no need to routinely check blood pressure before taking digoxin as it does not affect blood pressure. Clients should check their pulse prior to administration

The home health nurse visits a client with atrial fibrillation who is newly prescribed digoxin 0.25 mg orally on even-numbered days. Which of the following client statements show that teaching has been effective? Select all that apply A. "I need to call the health care provider if I have trouble reading" B. "I need to check my blood pressure before taking my medicine" C. "I should call the HCP if I develop nausea and vomiting" D. "I should check my heart rate prior to taking this medication" E. "I will call the HCP if I feel dizzy and lightheaded"

C In addition to performing frequent pain assessments, the nurse should assess the client's ability to cope with labor by asking about the client's comfort and perceptions of labor, as well as monitoring for nonverbal cues of ineffective coping

The labor and delivery nurse is caring for a Japanese client who has declined epidural anesthesia. The client has been very stoic and quiet throughout labor. Which nursing action represents the most appropriate care for this client? A. complete hourly pain assessments using a numeric pain scale B. document that the client appears to be experiencing minimal pain C. monitor for nonverbal signs of ineffective coping with labor D. recognize that the client's stoicism is ineffective coping with labor

ABDE Option C: dissociation and memory gaps are protective mechanism. Forcing the client to hear or attempt to recall memories may result in distress and regression. Allow clients to recall memories at their own pace

The mental health nurse is planning care for a client newly admitted with dissociative identify disorder. Which interventions will the nurse include? Select all that apply A. develop a trusting relationship with each of the alternate identities B. encourage the client to journal about feelings and dissociation triggers C. explain to the client in detail the events of missing memories and lost time D. listen for expressions of self-harm from the alternate identities E. teach grounding techniques such as deep breathing to hinder dissociation

ABD The standard vaccine schedule for a 12 month old includes Him, PCV, MMR, varicella, and hep A. HIV-positive children who are asymptomatic and not extremely immunocompromised can receive the appropriate age-specific immunizations as recommended However, live vaccine preparations (MMR, varicella) are contraindicated in the presence of marked immunosuppression, as determine by CD4 lymphocyte percentages and/or counts. An individual with a CD4 lymphocyte percentage <15% is considered to be severely immunocompromised

The most recent laboratory results for a 12 month old who is HIV-positive show a CD4 lymphocyte count of 500/mm3 and a CD4 lymphocyte percentage of 10%. The nurse anticipates administering which immunizations? Select all that apply A. haemophilus influenzae type b (Hib) B. hepatitis A (Hep A) C. measles, mumps, rubella (MMR) D. pneumococcal conjugate vaccine (PCV) E. varicella

ADE Option B: only the health care provider can adjust the pins Option C: the nurse should avoid grabbing the device frame when moving or positioning the client, as this may cause the screws to loosen or alter device alignment

The new graduate nurse provides care for a client with a halo external fixation device. Which actions by the new nurse are appropriate? Select all that apply A. cleans around the pin sites using sterile water B. gently tightens the device screws if they become loose C. holds the frame of the device when logrolling the client D. places a small pillow under the head when client is supine E. uses a blow dryer on the cool setting to dry the vest when wet

A Valproic acid (depakote) is an anticonvulsant that is also prescribed for bipolar disorder; therefore, it would prevent the therapeutic effect of ECT. Any prescribed anticonvulsants should be discontinued prior to ECT

The new nurse is providing teaching to a client scheduled for electroconvulsive therapy (ECT). What information given by the new nurse would cause the charge nurse to intervene? A. "be sure to take your valproic acid prior to the procedure" B. "do not drive during the course of ECT treatment" C. "temporary confusion is common immediately after treatment" D. "you should avoid eating 8 hours prior to the procedure"

D Sickle cell crisis is managed with IV hydration, frequent IV pain medication, and as-needed blood transfusion. Many orthopedic clients require medication with opioids to control pain, IV fluids, and blood transfusion (blood loss with surgery/trauma). The float nurse is familiar with the policies and procedures for pain assessment and administering opioid medications, which should be the same on non-specialty units within the same facility.

The night charge nurse is making assignments for the next shift. Which client is most appropriate to assign to a nurse with less than a year of experience who is floated from the orthopedic unit to the medical unit? A. client newly admitted for an evolving ischemic stroke B. client newly diagnosed with diabetes mellitus who needs insulin administration teaching C. client with exacerbation of chronic obstructive pulmonary disease (COPD) with a new tracheostomy D. client with sickle cell crisis who requires frequent intravenous (IV) opioid medication for pain

BCDE Assessment of deep tendon reflexes is appropriate with magnesium sulfate administration. Manifestations of hypermagnesemia include lethargy, nausea, vomiting, and decreased deep tendon reflexes.

The nurse administers IV vancomycin to a client with a methicillin-resistant staphylococcus aureus infection. Which nursing actions are most appropriate? Select all that apply A. assess client for lethargy and decreased deep tendon reflexes B. assess skin for flushing and red rash on face and torso C. infuse medication over at least 60 minutes D. monitor blood pressure during infusion E. observe IV site every 30 minutes for pain, redness, and swelling

C Option C: the desired therapeutic effect of lactulose is the production of 2-3 soft bowel movements each day; therefore, the dose is titrated until the therapeutic effect is achieved. This therapeutic dose should not be held but instead should be maintained until the desired outcomes are reached.

The nurse administers lactulose to a client diagnosed with cirrhosis and hepatic encephalopathy. Which nursing action is inappropriate when administering this medication? A. assess mental status and orientation B. give on an empty stomach for rapid effect C. hold if 3 soft stools occur in a day D. mix with fruit juice to improve flavor

A Infants with underlying infection and increased intracranial pressure will be very irritable and have fever and a high-pitched cry. Other signs of increased ICP include changes in pupillary reaction, sunset eyes, dilated scalp veins, poor feeding, vomiting, and bulging fontanelles. The 3 month old needs to be seen first due to the potential for bacterial meningitis. If bacterial meningitis is suspected, droplet precautions should be initiated and the infant should be treated with antibiotics immediately

The nurse assesses 4 children in the clinic. Which assessment finding requires the nurse's priority action? A. a 3 month old with fever, vomiting, high-pitched cry, and irritability B. 9 month old with diarrhea who is refusing fluids and cries without ears C. an 11 month old with cold symptoms and an abdominal breathing pattern D. an 18 month old who cries when the caregiver leaves

C Infant growth is fast paced during the first year of life, with birth weight doubling by age 6 months and tripling by age 12 months. Options A & B: at birth, the infant has non-ossified membranes called fontanelles; these "soft spots" lie between the bones of the cranium. The 2 most noticeable are the anterior and posterior fontanelles, which are soft and non-fused. Fontanelles should be flat, but slight pulsations noted in the anterior fontanelle are normal as is temporary bulging when the infant cries, coughs or is lying down. The posterior fontanelle fuses by age 2 months and the anterior fontanelle fuses by age 18 months Option D: this assessment shows tripling of the birth weight by age 12 months, a normal finding

The nurse assesses 4 infants. Which assessment finding would require follow-up by the health care provider? A. 3 week old whose anterior fontanelle bulges with crying B. 4 week old whose posterior fontanelle is soft C. 6 month old with birth weight of 7 lb 3 oz who now weighs 12 lb D. 12 month old with birth weight of 6 lb 4 oz who now weighs 20 lb

A Peritonitis is characterized by fever, abdominal rigidity, guarding, and rebound tenderness. This condition can be fatal if it is not treated quickly. Option B: absence of tears in a painful procedure during which the client is crying is a sign of dehydration. This is very common in clients with intussusception and should be treated. IV fluids should be started, and the client's hydration status (vital signs, mucus membranes, capillary refill) should be assessed frequently Option C: a classic sign of intussusception is blood-streaked mucous stool, sometimes referred to as "currant jelly-like" stool. This is expected with intussusception. Treatment is an enema of either air or barium to unfold the intestine. Option D: a "sausage-shaped" right-sided mass is commonly felt on palpation in clients with intussusception. This is an expected finding for this condition

The nurse assesses a child with intussusception. Which assessment findings require priority intervention? A. abdominal rigidity with guarding B. absence of tears in crying child with IV start C. blood-streaked mucous stool in diaper D. sausage-shaped right-sided mass on palpation

B Option A: monitoring vital signs would be the step after ensuring IV access, administering normal saline, and notifying the HCP Option C: the nurse should ensure continued IV access before notifying the HCP. The HCP will likely prescribe IV medications to treat the transfusion reaction, so a patent IV is critical Option D: mislabeling blood and administering the wrong blood type are the most common causes of a transfusion reaction. However, maintaining IV access takes priority over investigating a potential clinical error

The nurse assesses a client 5 minutes after initiating a blood transfusion. The client has shortness of breath, itching, and chills. The nurse immediately turns off the transfusion and disconnects the tubing at the catheter hub. What action should the nurse take next? A. check vital signs B. maintain IV access with normal saline C. notify the health care provider D. recheck identification labels and numbers

D Clients who are vegan are at risk for deficiency of vitamin B12, which is primarily supplied by animal products. Chronic Vitamin B12 deficiency may precipitate megaloblastic anemia and neurological symptoms across the entire nervous system, from peripheral nerves to the spinal cord and brain.

The nurse assesses a client who has followed a vegan diet for several years. Which client statement indicates a potential nutritional deficiency? A. "I have had some visual disturbances while driving at night" B. "I have had trouble falling asleep over the past few months" C. "scaly patches of skin are developing on my elbows and knees" D. "sometimes my hands and feet get a tingling sensation"

B Option A: first degree (superficial) burns are dry with blanchable redness They usually damage the epidermis only Option C & D: third-degree (full-thickness) burns are dry and inelastic with waxy white, leathery, or charred black color. They destroy the dermis and may involve subcutaneous tissue. Fourth-degree (full-thickness) burns have the same appearance as third-degree burns, with additional involvement of fascia, muscle, and/or bone tissue. Due to nerve damage, pain is not the major feature, unlike with second-degree burns

The nurse assesses a client with a burn on the arm and finds that the area is red, moist, and covered in shiny, fluid-filled vesicles. Which burn stage does the nurse document? A. first degree B. second degree C. third degree D. fourth degree

A Symptoms of UTI are often similar to those of BPH; however, burning sensation with urination and cloudy/foul smelling urine are specific UTI symptoms that require further assessment and treatment. Option B & D: dribbling after urination and nocturne are expected findings with BPH Option C: finasteride is a medication that inhibits further growth of the prostate. Appreciable differences in prostate size are noticed only after several months of therapy. Missing three doses would not cause immediate or long-term adverse effects

The nurse assesses a client with benign prostatic hyperplasia. Which client statement requires further assessment? A. "I have a burning sensation when I urinate" B. "I have been having some dribbling after I finish urinating" C. "I missed 3 days of finasteride while on a trip last week" D. "I was awakened 3 times last night by the need to urinate"

B Congenital dermal melanocytosis (Mongolian spots) is a benign discoloration of the skin most often seen in newborns of ethnicities with darker skin tones. Mongolian spots are usually bluish gray and fade over the first 1-2 years of life. Because they are easily misidentified as bruises, it is important for the nurse to measure and document the area for reference during future health care assessments

The nurse assesses a newborn with skin discoloration in the lumbar area, as shown in the picture. What would be an appropriate action for the nurse to complete? A. assess the infant's hemoglobin, hematocrit, and platelet levels B. measure and document the size and location of the markings C. notify the health care provider of the markings immediately D. review the delivery record for evidence of a traumatic birth

A Option B: to ensure an accurate score in the verbal response category, the nurse must differentiate if the client is confused (eg, answers "1955" when asked the year) or if a client uses inappropriate words Option C: to ensure an accurate eye opening score, the nurse must determine whether the client's eyes open spontaneously or if a stimulus is needed Option D: a social, verbal client is not necessarily oriented. The nurse must assess orientation by specifically asking clients to state their name, the time, and their location

The nurse assesses several clients using the Glasgow Coma Scale. Which scenario best demonstrates a correct application of this scale? A. the nurse applies pressure to the nail bed, and the client tries to push the nurse's hand away. The nurse scores motor response as "localization of pain" B. the nurse asks the client what day it is and the client says "banana." The nurse scores verbal response as "confused" C. the nurse speaks with the client and then the client's eyes open. The nurse scores eye opening as "spontaneous" D. the nurse walks in the room and the client states "hi honey, how are you?" The nurse scores verbal response as "oriented"

ADE

The nurse assessing a 2 year old should expect the child to be able to perform which actions? A. build a tower with blocks B. draw a square C. hop on one foot D. say own name E. walk without help

ACDE Option B: before a heel stick is performed, a warm (not cold) pack should be applied to help facilitate blood flow to the area. Although a cold pack is a non pharmacological pain management technique, it causes vasoconstriction and impedes blood flow, which may result in a need to apply pressure to obtain blood or to perform multiple heel sticks

The nurse assists with a staff education conference about appropriate non pharmacological pain management interventions for newborns and infants. Which of the following strategies should be included in the presentation? Select all that apply A. administer an oral sucrose solution to a newborn during a circumcision procedure B. apply a cold pack to a newborn's heel 30 minutes before performing a heel stick C. assist the parent to hold a newborn skin-to-skin during an immunization injection D. offer a pacifier to an infant while performing venipuncture E. swaddle an infant while leaving one arm unwrapped during an IV dressing change

B Preschoolers enjoy play that enables them to imitate others and be dramatic. They have rich imaginations and enjoy make-believe. Through playing with objects such as dolls or puppets, preschoolers can often process fears and anxieties that are difficult for them to express

The nurse cares for a 4 year old who is on long term, strict bed rest. Which toy is most appropriate to provide diversion and minimize developmental delays? A. board games B. puppets C. soap bubbles D. stacking and nesting toys

BDE SIADH is an endocrine condition in which antidiuretic hormone overproduction leads to water retention, increased total body water, and dilutional hyponatremia (low serum sodium). Hyponatremia can cause confusion, seizures, or other neurologic complications. It is important for the nurse to anticipate these problems and institute seizure precautions. SIADH treatment includes: - fluid restriction to <1000 mL/day - oral salt tablets to increase serum sodium - hypertonic saline during the first few hours for clients with markedly decreased serum sodium and severe neurologic manifestations - vasopressin receptor antagonists Option A: normal saline fluid bolus would worsen the hyponatremia as the client already has excess fluid volume. Symptoms are caused by a low sodium level. If the sodium level must be raised, the client will need hypertonic saline or salt tablets as these contain mainly sodium and little free fluid

The nurse cares for a client admitted to the hospital due to confusion. The client has a nonmetastatic lung mass and a diagnosis of syndrome of inappropriate antidiuretic hormone (SIADH). Which action(s) should the nurse expect to implement? Select all that apply A. fluid bolus (normal saline) B. fluid restriction C. salt restriction in the diet D. seizure precautions E. strict record of fluid intake and output

C Adequate urine output (at least 30 mL/hr, or 0.5 mL/kg/hr) depends on adequate renal perfusion and is the greatest indicator that fluid resuscitation therapy has effectively restored tissue perfusion. Option A: although stable vital signs indicate client improvement, urine output is the greatest indicator of adequate fluid resuscitation Option B: a decrease in serum potassium from 5.7 mEq/L to 5.0 mEq/L indicates that hyperkalemia is resolving but is not an indicator of tissue perfusion Option D: rapid increase in weight indicates that fluid shifts continue to occur and the kidneys are not eliminating properly. This could be a sign of fluid overload

The nurse cares for a client admitted with severe burns who is now on fluid resuscitation therapy. Which assessment findings would best indicate that fluid resuscitation has been successful? A. heart rate 89/min; blood pressure 99/52 mm Hg B. potassium decreased from 5.7 mEq/L to 5.0 mEq/L C. urine output 31 mL/hr, respirations 20/min D. weight gain of 2.2 lbs in last 8 hours and palpable pulses

A Postpoartum hemorrhage due to uterine atony is exacerbated by conditions that cause over distention of the uterus. Methylergonovine is contraindicated for clients with high blood pressure because the primary mechanism of action is vasoconstriction. If administered to a hypertensive client, it can lead to further blood pressure elevation, seizure, or stroke

The nurse cares for a client who gave birth an hour ago to a 9 lb newborn. The client's loch is heavy with large clots, and the fungus remains boggy after fundal massage and an oxytocin bolus. Which prescription from the health care provider should the nurse question? A. administer 0.2 mg methylergonovine IM B. adminsier 800 mcg misoprostol rectally C. collect a hemoglobin and hematocrit STAT D. initiate second IV line with 18 gauge needle

ABD Manifestations of graft leakage include ecchymosis of the groin, penis, scrotum or perineum; increased abdominal girth; tachycardia; weak or absent peripheral pulses; decreasing hematocrit and hemoglobin; increased pain in the pelvis, back or groin; and decreased urinary output. Option C: urinary output would be decreased due to inadequate perfusion to the kidney if a newly placed graft were leaking, causing hypotension. Option E: increased thirst and appetite loss are not signs of graft leakage

The nurse cares for a client who had an abdominal aortic aneurysm repair 6 hours ago. Which assessment findings would indicate possible graft leakage and require a report to the primary care provider? Select all that apply A. ecchymosis of the scrotum B. increased abdominal girth C. increased urinary output D. report of groin pain E. report of increased thirst and appetite loss

B Use of therapeutic communication allows the nurse to determine client needs and strengthens the nurse-client relationship, which is instrumental in helping the client cope with difficult information

The nurse cares for a client who just had surgical excision and biopsy of a tumor. The biopsy results show that the tumor is malignant, but the client has not yet been informed by the health care provider. The client asks the nurse, "am I going to die?" Which statement by the nurse is appropriate? A. "I know how anxious you must be. Watching some television might help you relax" B. "tell me more about your thoughts and feelings regarding this situation" C. "the biopsy result shows that you have cancer, but many cancers are treatable" D. "waiting for test results can be stressful. I am sorry I cannot tell you more"

BCD Option A: stimulation increases oxygen metabolism within the brain, increasing the risk for irreversible brain damage in increased ICP. Limit performing interventions unless absolutely necessary and avoid performing interventions in clusters Option E: the nurse should suction a maximum of 10 seconds and only as necessary to remove secretions. Prolonged suctioning increases ICP

The nurse cares for an intubated client on mechanical ventilation with worsening cerebral edema from increased intracranial pressure. Which nursing interventions help reduce ICP? Select all that apply A. clustering as many interventions as possible when providing care B. hyperventilating before suctioning C. maintaining a quiet, dark environment D. maintaining the head in a neutral midline position E. suctioning for 30 seconds to remove endotracheal tube secretions at regular intervals

B The alveoli in the affected lobes become blocked with purulent fluid, which impairs ventilation. However, these alveoli continue to receive perfusion from the pulmonary artery, resulting in poorly oxygenated or deoxygenated blood. Blood flow in the lungs is partially influenced by gravity, meaning that blood flows in higher volumes to dependent parts of the lung. Therefore, a client with left lobar pneumonia should be positioned in right lateral position with the unaffected lung down to increase blood flow to the lung most capable of oxygenating blood

The nurse caring for a client with left lobar pneumonia responds to an alarm from the continuous pulse oximeter. The client is short of breath with an oxygen saturation of 78%. After applying oxygen, the nurse should place the client in which position to improve oxygenation? A. left lateral B. right lateral C. supine D. trendelenburg

B Option A: isosorbide has actions identical to nitroglycerin and can cause hypotension. It should be held when the systolic blood pressure is <90 mm Hg. Option C: insulin is given to control diabetes. A "normal" fasting glucose level indicates that eh dosing is correct and should be given to continue control of blood glucose. Option D: the effect of warfarin is monitored by the INR. The therapeutic range of INR is 2-3. This result indicates that the current dosing is achieving the desired effect.

The nurse completes the following drug administrations. Which would require an incident report? A. client with chronic stable angina and blood pressure of 84/52 mm Hg; isosorbide mononitrate held B. client with depression stopped phenelzine yesterday; escitalopram given today C. client with diabetes and morning glucose of 90 mg/dL; the daily NPH insulin 20 units given at 8:00 AM D. client with pulmonary embolism and International Normalized Ratio (INR) of 2.5; warfarin given

C When a client switched from a tricyclic antidepressant to a monoamine oxidase inhibitor, a drug-free period of at least 2 weeks should elapse between the tapered discontinuation of the TCA and the initiation of the MAOI. This timing is based on the half-life value and allows for the first medication to leave the system Without a washout period, the client could experience hypertensive crisis. If the TCA is withdrawn abruptly, the client may experience a discontinuation syndrome

The nurse develops a teaching care plan for the client with a prescription to change antidepressant medications from imipramine to phenelzine. Which instruction is appropriate to include in the teaching? A. continue avoiding foods high in tyramine until the imipramine withdrawal period is over B. skip the nighttime dose of imipramine and start the phenelzine the next morning C. taper down the imipramine, then discontinue for 2 weeks before starting phenelzine D. taper down the imipramine while gradually increasing the phenelzine

BCDE Option A: optimal female fertility is achieved at a BMI of 18.5-24.9 kg/m2; a BMI of 22 kg/m2 is within this normal range

The nurse educates a group of clients in the infertility clinic about risk factors contributing to infertility. Which factors should the nurse include in the teaching? Select all that apply A. BMI of 22 kg/m2 B. endometriosis C. maternal age >35 D. polycystic ovarian syndrome E. recurrent chlamydial infections

D The goal during anticoagulation therapy is a PTT 1.5-2 times the normal reference range of 25-35 seconds. A PTT of 127 seconds is much too prolonged, and spontaneous bleeding could occur Option A: clients with COPD typically have elevated PaCO2 levels secondary to air trapping Option B: clients with heart failure are expected to have elevated brain natriuretic peptide levels. The nurse should compare BNP levels with those from the previous day Option C: a normal WBC count is 4,000-11,000/mm3. A WBC count of 13,000/mm3 is elevated but would be expected in a client with an infection

The nurse evaluates morning laboratory results for several clients who were admitted 24 hours earlier. Which laboratory report requires priority follow up? A. client with chronic obstructive pulmonary disease who has a PaCO2 of 52 mm Hg B. client with heart failure who has a brain natriuretic peptide level of 800 pg/mL C. client with infected pressure ulcer who has a white blood cell count of 13,000/mm3 D. client with pulmonary embolism who has a partial thromboplastin time of 127 seconds

A Hypospadias is a congenital defect in which the urethral opening is on the underside of the penis. Except in very mild cases, the condition is typically corrected around age 6-12 months by surgically redirecting the urethra to the penis tip. Circumcision is delayed so the foreskin can be used to reconstruct the urethra. If not corrected, clients may have toilet-training difficulties, more frequent urinary tract infections and inability to achieve erections later in life Postoperatively, the client will have a catheter or stent to maintain latency while the new meatus heals. Urinary output is an important indication of urethral potency. Fluids are encouraged, and the hourly output is documented. Absence of urinary output for over an hour indicates that a kink or obstruction may have occurred and requires immediate follow up

The nurse has assessed 4 children. Which finding requires immediate follow-up with the health care provider? A. child who had a surgical repair of hypospadias earlier today with no urinary output in the past two hours B. child who is awaiting a neurological consult for suspected absence seizures and is sleeping soundly C. child who returned from a bronchoscopy an hour ago and coughed up a scant amount of blood-tinged sputum D. child with gastroenteritis, serum sodium of 131 mEq/L, and temperature of 100 F

ABC The DASH diet focuses on elimination or reduction of foods and beverages high in sodium, sugar, cholesterol, and trans or saturated fats, which all contribute to increased blood pressure. Option D: limiting milk intake is unnecessary; however, the nurse may need to educate the client about choosing low-fat or skin milk over whole milk Option E: taking the salt shaker off the table may be a good first step in reducing sodium intake. However, it will not be enough as salt is found in many foods.

The nurse has just completed discharge teaching for a client recently diagnosed with hypertension. Which of the following statements by the client indicate understanding of the Dietary Approaches to Stop Hypertension (DASH) diet? Select all that apply A. "I need to eat less red meat and more fresh vegetables" B. "I'll limit drinking soda to only one at a time as an occasional treat" C. "I'm going to replace potato chips with fruit during meals and snacking" D. "I'm really going to miss drinking as much milk as I normally do" E. "taking the salt shaker off the table should be enough to reduce my sodium intake"

BCD Option B: pancreatic enzyme secretion, needed for digestion and absorption of nutrients, is also impaired because thick secretions block pancreatic ducts. Therefore, the client needs supplemental enzymes with all meals and snacks Option C: sweat gland abnormalities prevent sodium and chloride reabsorption, causing increased salt loss, dehydration and hyponatremia during times of significant perspiration. Therefore, parents should increase the child's salt intake and fluids during hot weather, exercise or fever Option D: The client also requires multiple vitamins and a diet high in carbohydrates, protein and fat to help meet nutritional requirements for growth

The nurse has provided teaching about home care to the parent of a 10 year old with cystic fibrosis. Which of the following statements by the parent indicates that teaching has been effective? Select all that apply A. "chest physiotherapy is administered only if respiratory symptoms worsen" B. "I will give my child pancreatic enzymes with all meals and snacks" C. "I will increase my child's salt intake during hot weather" D. "our child will need a high-carbohydrate, high-protein diet" E. "we will limit our child's participation in sports activities"

B In clients with poorly controlled diabetes, the fetus experiences hyperglycemia and produces excess insulin. To compensate, the fetus increases metabolic activity and oxygen consumption. Fetal erythropoietin production subsequently increases to produce additional red blood cells, which are needed to transport oxygen to tissues. This increased production of red blood cells leads to polycythemia, and increased circulatory viscosity Option A: delayed meconium passage may be a sign of cystic fibrosis or Hirschsprung disease Option C: yawning, sneezing and a high-pitched cry are features of neonatal abstinence syndrome due to a history of maternal substance abuse Option D: a smooth philtrum, thin upper lip, and short palpebral tissues are classic facial features of infants with fetal alcohol syndrome

The nurse has received report for a term newborn after a vaginal birth. Maternal history includes diagnosis of gestational diabetes at 25 weeks gestation and poorly controlled blood glucose during pregnancy. When assessing the newborn, which findings should the nurse most likely expect? A. delayed meconium passage B. elevated hematocrit level C. shrill cry and frequent yawning D. smooth philtrum and thin upper lip

B Ventricular septal defect is a congenital abnormality in which a septal opening between the ventricles causes left-to-right shunting, leading to excess blood flow to the lungs. This places the client at risk for congestive heart failure and pulmonary hypertension. Clinical manifestations of VSD include a systolic murmur auscultated near the sternal border at the third or fourth intercostal spaces, and hallmark CHF signs. The client is currently showing signs of increased respiratory exertion and requires further assessment for CHF

The nurse has received report on 4 pediatric clients on a telemetry unit. Which client should the nurse assess first? A. adolescent client with coarctation of the aorta and diminished femoral pulses B. infant client with ventricular septal defect with reported grunting during feeding C. newborn client with patent ductus arteriosus and a loud machinery-like systolic murmur D. preschool client with tetralogy of Fallot who has finger clubbing and irritability

D The infant with irritability may be exhibiting signs of hypoxia. The nurse should see this client first

The nurse has received repot on the following pediatric clients. Which action should the nurse perform first? A. administer water enema to the 2 year old with intussusception who has severe abdominal pain B. call the health care provider about the 4 year old with leukemia who has a low grade fever C. measure head circumference of the 3 month old with ventriculoperitoneal shunt placement D. suction the 3 month old with bronchiolitis who is irritable and scheduled for a feeding

ABC Option D: elevated estrogen levels make blood hypercoagulable. However, elevated estrogen levels are more likely to form thrombi in veins than in arteries due to lower venous pressure and slower blood flow Option E: unlike chronic venous insufficiency, in which vessels ineffectively return blood from the feet to the central circulation, standing is not a risk factor for PAD, as standing facilitates blood flow by gravity to the lower extremities

The nurse identifies which risk factors as contributing to the development of peripheral artery disease? Select all that apply A. cigarette smoking B. diabetes mellitus C. hyperlipidemia D. oral contraceptive use E. prolonged standing

BD Options A, C & E: a 24 month old should be able to build a tower of 6 or 7 blocks, call self by name, and use a doorknob to open a door

The nurse in a clinic is obtaining a developmental history of an 18-month-old during a well-child visit. Which activities should the child be able to perform? Select all that apply A. calls self by name B. goes up stairs while holding a hand C. stacks 6 blocks in a tower D. turns 2 pages in a book at a time E. twists doorknob to open doors

D Thyroid storm is a life-threatening condition that can occur in uncontrolled hyperthyroidism or Graves' disease when a stressful incident, such as the client's motor vehicle accident, triggers a sudden surge of thyroid hormone. Manifestations of thyroid storm include a rapid onset of fever, tachycardia, and elevated blood pressure. The client often feels anxious, tremulous, or restless. Confusion and psychosis can occur, as seizures and coma. Rapid treatment is necessary

The nurse in the emergency department is caring for a client recently diagnosed with Graves' disease who was admitted following a motor vehicle accident. The nurse notes the vital signs shown in the exhibit. The nurse alerts the primary health care provider that the client may be experiencing which condition? A. hypertensive crisis B. malignant hyperthermia C. serotonin syndrome D. thyroid storm

C Gentle, continuous bubbling in the suction control chamber of a chest tube drainage unit indicates that suction is present and the unit is functioning appropriately. The nurse should document that finding and continue to monitor

The nurse in the intensive care unit is caring for a client who is postoperative from a cardiac surgery. The client has a mediastinal chest tube. During assessment, the nurse notes bubbling in the suction control chamber. Which nursing action is appropriate? A. assess the insertion site for presence of subcutaneous emphysema B. notify the surgeon of a large air leak C. take no action as the chest tube is functioning appropriately D. turn down the wall suction until the bubbling disappears

B Blood-tinged sputum is common and can occur from inflammation of the airway, but hemoptysis of bright red blood can indicate hemorrhage, especially if a biopsy was performed Option A: absence of the gag reflex for about 2 hours following the procedure is expected from the topical anesthetic Option C: headache is not a complication of bronchoscopy Option D: respirations of 10/min and saturation of 92% are expected after mild sedation before and/or during the procedure

The nurse in the outpatient procedure unit is caring for a client immediately post bronchoscopy. Which assessment data indicate that the nurse needs to contact the health care provider immediately? A. absence of gag reflex B. bright red blood mixed with sputum C. headache D. respirations 10/min and saturation of 92%

ADE Option B: this statement represents denial, a common maladaptive defense mechanism in which substance misuse or addiction is minimized and/or clients deny having a problem with substance use Option C: this statement represents rationalization, a common maladaptive defense mechanism in which the client makes excuses to justify substance use

The nurse in the outpatient treatment facility evaluates the plan of care for a client with alcohol use disorder. Which of the following client statements indicate positive progress toward recovery? Select all that apply A. "drinking led to my divorce and the loss of my children" B. "I am in control now; I drink only on special occasions" C. "I will have no desire to drink once I get over my divorce" D. "my focus is now on fitness training and going back to college" E. "when cravings occur, I call my alcoholics anonymous sponsor"

C Wilms tumor (nephroblastoma) is a kidney tumor that usually occurs in children <5. Most often it involves only one kidney, and the prognosis is good if the tumor has not metastasized. Wilms tumor is usually diagnosed after caregivers observe an unusual contour in the child's abdomen. Once the diagnosis is suspected or confirmed, the abdomen should not be palpated, as this can disrupt the encapsulated tumor. It is important to post the sign "DO NOT PALPATE ABDOMEN" at the bedside. It is also essential that the child be handled carefully during bathing

The nurse is admitting a 4 year old diagnosed with Wilms tumor. The child is scheduled for a right nephrectomy in the morning. Which action is a priority in the preoperative care plan? A. assessment of the child's emotional maturity level B. auscultating for adventitious breath sounds C. instructions not to palpate the abdomen D. monitoring blood pressure closely

BCD Options A & E: orthopnea, paroxysmal nocturnal dyspnea, and crackles in lung bases are clinical manifestations of left-sided heart failure. Blood is not effectively pumped into systemic circulation, resulting in the backup of blood into the pulmonary vessels that causes congestion of the pulmonary vessels and, potentially, pulmonary edema. Pulmonary hypertension and right-sided heart failure typically present with dyspnea on exertion rather than orthopnea or PND.

The nurse is admitting a client with a diagnosis of right-sided heart failure resulting from pulmonary hypertension. What clinical manifestations are most likely to be assessed? Select all that apply A. crackles in lung bases B. increased abdominal girth C. jugular venous distension D. lower extremity edema E. orthopnea

CE Prevention of West Nile focuses on avoiding mosquitos and using an insect repellent. Prevention also includes wearing long sleeves, long pants, and light colors and avoiding outdoor activities at dawn and dusk when mosquitos are most active. Option A: food and water precautions are emphasized for infectious diseases contracted through contaminated water or food, such as hepatitis A or typhoid fever Option B: limiting contact with infected pets is classic advice for avoiding ringworm, a superficial fungal skin infection Option D: washing bedding in hot water is a classic instruction to help reduce allergies/asthma or scabies

The nurse is answering questions at a hospital-sponsored health fair. What actions should the nurse encourage to help prevent contracting the West Nile virus? Select all that apply A. avoid raw, unpeeled fruits or vegetables B. limit contact with infected pets C. use insect (mosquito) repellent D. wash all bedding in hot water E. wear long-sleeved, light-colored clothes

A During the first 3-4 days of life, a weight loss of approx 5-6% of birth weight is expected due to fluid excretion. Weight loss usually ceases around 5 days of life in healthy newborns, who return to their birth weight by 7-14 days of life. A weight loss of >7% of birth weight warrants further evaluation Option B: peeling of the term newborn's skin is a sign of physical maturity and is expected around the third day of life. Cracked, peeling skin may be present at birth in post-term newborns Option C: feeding every 2-3 hours is normal for breastfed newborns; breastmilk is easily digested and more frequent feeding is noted than in formula-fed newborns Option D: after passing meconium, newborns produced transitional stools that are thin and yellowish-brown or yellowish-green. Stools of breastfed newborns progress to a seedy, yellow paste. Bottle-fed newborns have firmer, light brown stools

The nurse is assessing a 4 day old term neonate who is breastfed exclusively. Which assessment finding should the nurse report to the health care provider for further assessment regarding possible formula supplementation? A. 10% weight loss since birth B. cracked, peeling skin C. feeds every 2-3 hours D. runny, seedy, yellow stools

B Option A: stranger anxiety is part of the infant's normal social and cognitive development and usually begins around age 6 months Option C: transferring objects from one hand to the other hand is a fine motor skill that usually develops between age 6 and 9 months. Failure to develop this skill may indicate neuromuscular or developmental delays Option D: a 3 month old is usually not strong enough to roll from the back to the front. Infants should be able to turn from the abdomen to the back at around age 4 months and then from the back to the abdomen by age 6 months. Failure to roll over by age 6 months may indicate slower than normal neck, leg, back and arm muscle development and should be investigated

The nurse is assessing a 4 month old during a well child visit. Which developmental finding should the nurse expect to observe in the client? A. infant cries and clings to parent when members of the health team come near B. infant kicks legs, smiles and coos when a familiar face comes into view C. infant transfers a ball from one hand to the other hand D. infant turns from the back to the abdomen

B Option A: limited hip abduction occurs as contractures develop, particularly once the infant is age >3 months Option C: in children with one-sided DDH, the affected leg may be shorter than the opposite leg. However, this is also apparent after age 3 months Option D: if DDH is not corrected in infancy, additional manifestations develop when the child learns to walk. These signs include a notable limp, walking on the toes, and a positive trendelenburg sign (pelvis tilts down on unaffected side when standing on the affected leg). In the case of bilateral DDH, the child may also develop a waddling gait and severe lordosis

The nurse is assessing a 4 week old infant during a routine office visit. Which assessment finding is most likely to alert the nurse to the presence of right hip developmental dysplasia? A. decreased right hip adduction B. presence of extra gluteal folds on right side C. right leg longer than the left leg D. right pelvic tilt with lordosis

ADE Option B: UAP can measure, empty and document the output of a drain, but the registered nurse is responsible for assessing proper drain function and the type, amount, color and odor of drainage Option C: with a disgruntled family member, there may be a need for skilled communication to keep the situation from escalating. The visitor should be escorted off the unit by a security officer

The nurse is assigned to care for clients with assistance from unlicensed assistive personnel. Which of the following tasks are appropriate for the nurse to assign to UAP? Select all that apply A. emptying a urinary drainage bag and recording output volume B. emptying and verifying the potency of an accordion drain C. escorting a disgruntled family member off the unit D. providing perineal care around and indwelling urinary catheter E. reapplying bilateral sequential compression devices

ACE Duchenne muscular dystrophy is an X-linked recessive disorder that causes the progressive replacement of dystrophin, a protein needed for muscle stabilization, with connective tissue. The proximal lower extremities and pelvis are affected first. In response to proximal muscle weakness, the calf muscles hypertrophy initially and are later replaced by fat and connective tissue. Children with Duchenne muscular dystrophy raise themselves to a standing position using the classic Gower sign/maneuver (placing hands on the thighs to push up to stand) and walk on tiptoes. Parents may also report frequent tripping and falling Option B: joint pain that is worse in the morning is a symptom of juvenile idiopathic arthritis. Children with this type of arthritis also experience symptoms of joint swelling and stiffness, high fever, and skin rash Option D: rigid extension of the arms and legs is seen in the tonic phase of a tonic-clonic seizure. During this time, muscles become stiff, the jaw becomes clenched and pupils can be fixed and dilated

The nurse is assessing a 4 year old boy in a pediatric clinic. Which behaviors by the client would concern the nurse for possible Duchenne muscular dystrophy? Select all that apply A. frequently trips and falls at home B. has painful knees and elbows in the morning C. places hands on the thighs to push up to stand D. suddenly rigidly extends the arms and legs E. walks on tiptoes and has disproportionately large calves

B The nurse should follow up immediately if the client reports dizziness or lightheadedness, which may indicate profound hypotension. If the client is found to be hypotensive, the nurse may need to decrease or discontinue the infusion

The nurse is assessing a client 15 minutes after initiating nitroglycerin infusion for suspected acute coronary syndrome. Which clinical finding is the priority? A. the client reports a headache B. the client reports feeling dizzy and lightheaded C. the client reports feeling flushed D. the client reports feeling nervous

D Propranolol is a nonselective beta-blocker. Bronchoconstriction may occur due to the effect on the beta2 receptors. The presence of wheezing in a client taking propranolol may indicate that bronchoconstriciton or bronchospasm is occurring. Option A: a headache is a common occurrence with hypertension Option B: this is the first dose of propranolol that the client has received. It may take several days of treatment for the blood pressure to reduce to a more normal reading Option C: a reduction in heart rate is expected with a beta blocker.

The nurse is assessing a client with hypertension and essential tremor 2 hours after receiving first dose of propranolol. Which assessment is most concerning to the nurse? A. client reports a headache B. current blood pressure is 160/88 mm Hg C. heart rate has dropped from 70 to 60 D. slight wheezes auscultated during inspiration

A A client with a current, recent, or chronic infection should not take a TNF inhibitor due to the immunosuppressive action of TNF inhibitors. Option B: TNF inhibitors can activate latent tuberculosis. Therefore, a tuberculin skin test should be administered prior to beginning TNF inhibitor therapy, and clients who test positively for latent TB must also undergo treatment for TB before starting therapy. Option C: clients taking immunosuppressive TNF inhibitors should receive an annual inactivated influenza vaccine to reduce the risk of contracting the flu virus. Option D: many clients with rheumatoid arthritis use non steroidal anti-inflammatory medications in conjunction with anti rheumatic and/or targeted therapies

The nurse is assessing a client with rheumatoid arthritis who is being considered for adalimumab therapy. Which statement made by the client needs further investigation? A. "I am taking an antibiotic for a urinary tract infection" B. "I had a negative tuberculosis skin test 2 weeks ago" C. "I just received my yearly flu shot a week ago" D. "I will continue taking naproxen at night to help with pain"

A Distention of jugular neck veins should be performed with the client sitting with the head of the bed at a 30- to 45-degree angle. The nurse will observe for distention and prominent pulsation of the neck veins. The presence of JVD in the client with heart failure may indicate an exacerbation and possible fluid overload

The nurse is assessing for the presence of jugular venous distention on a newly admitted client with a history of heart failure. Which is the best position for the nurse to place the client in when observing for JVD? A. head of the bed elevated to a 45 degree angle B. head of the bed elevated to a 60 degree angle C. head of the bed elevated to a 90 degree angle D. head of the bed flat

C School age children deal with the conflict of industry versus inferiority. Attaining a sense of industry is the most significant developmental goal for children age 6-12. Parents should be encouraged to provide a hospitalized child with missed school work on a regular basis. This will help the child keep up with school demands, learn new skills, cope with stressors of hospitalization and avoid a sense of inferiority Option A: fantasy play with puppets is more appropriate for a preschool age child as imaginary play and magical thinking peak during this stage of development Option C: although school-age children enjoy spending time with friends, peer relationships are significantly more important during the adolescent period Option D: watching television is a good diversion for all hospitalized children, but it does not promote age-specific growth and development

The nurse is caring for a 10 year old diagnosed with osteomyelitis. What is the best activity the nurse can suggest to promote age-specific growth and development during hospitalization? A. fantasy play with puppets B. invite friends to come visit C. provide missed schoolwork D. watch favorite movies

A Tetralogy of Fallot = chronic hypoxemia = compensation for prolonged tissue hypoxia = erythropoietin production increases to produce additional oxygen carrying RBCs. Increased RBCs result in increased circulatory viscosity or polycythemia. Polycythemia increases the risk for blood clotting which can cause a stroke. Therefore, a hemoglobin level of 24.9 g/dL is a priority to report to the health care provider because close observation and additional interventions such as IV hydration and partial exchange transfusion are required.

The nurse is caring for a 2 week old client who has tetralogy of Fallot. Which assessment finding is a priority to report to the health care provider? A. hemoglobin level of 24.9 B. murmur noted on heart auscultation C. newborn becomes fatigued during feeding D. newborn has gained 0.6 lb since birth

C Early signs of colorectal cancer are usually nonspecific and include fatigue, weight loss, anemia and occult gastrointestinal bleeding. Clients should have regular screening colonoscopy for colon cancer starting at age 50 if their risk is average or earlier if their risk is high. Colorectal screening can also include fecal occult blood test or fecal immunochemical test annually. New onset anemia should be taken seriously at this client's age, and colon cancer must be ruled out. The etiology of anemia must be determine prior to recommending treatment

The nurse is caring for a 50 year old client in the clinic. The client's annual physical examination revealed a hemoglobin value of 10 g/dL compared to 13 g/dL a year ago. What should be the nurse's initial action? A. encourage intake of over-the-counter iron pills B. encourage intake of red meat and egg yolks C. facilitate a screening colonoscopy D. facilitate another blood test in 6 months

46 Anterior torso (18) + anterior arms (4.5 + 4.5) + anterior legs (9 + 9) + perineum (1) = 18 + 9 + 18 + 1 = 46

The nurse is caring for a adult client who has sustained partial-thickness burns to all anterior body surfaces below the neck. Using the rule of nines, calculate the percentage of total body surface area affected. Record your answer using a whole number. ______________ %

B Measuring the client's abdominal girth daily is an important nursing intervention to note any worsening intestinal gas-associated swelling. Clients are made NPO and receive nasogastric suction to decompress the stomach and intestines. Parenteral hydration and nutrition and IV antibiotics are given

The nurse is caring for a baby born at 30 weeks gestation and diagnosed with necrotizing enterocolitis. Which nursing action should be implemented? A. encourage parents to increase skin-to-skin care B. measure abdominal girth daily C. measure rectal temperature every 3-4 hours D. position client on side and check diaper for stool

ABD Option C: drinking through a straw creates suction that causes localized pressure at the back of the throat and may contribute to bleeding. The client should avoid use of straws or other pointed objects in the mouth Option E: routine suctioning can cause trauma to the surgical site and induce bleeding. Suction equipment should be available but used only for emergency airway obstruction

The nurse is caring for a chid who has had a tonsillectomy. Which of the following are appropriate nursing interventions? Select all that apply A. anticipate ear pain and give acetaminophen as needed B. educate parents to expect the child to develop bad breath postoperatively C. encourage the child to drink cold liquids through a straw D. notify the health care provider about frequent, increased swallowing E. use an oral suction device regularly to remove secretions from the back of the throat

A Breaths may become shallow as the client experiences pain with inspiration, which can result in a buildup of secretions, atelectasis, and pneumonia. The nurse should ensure adequate pain control prior to encouraging pulmonary hygiene techniques.

The nurse is caring for a client admitted with incomplete fractures of right ribs 5-7. The nurse notes shallow respirations, and the client reports deep pain on inspiration. What is the priority at this time? A. administer prescribed IV morphine B. facilitate hourly client use of incentive spirometry C. instruct client on gently splinting injury during coughing D. notify the health care provider immediately

CD Option A: dairy products do not typically lead to heartburn and are an important source of calcium during pregnancy Option B: the client can minimize gastric distention, gastric acid production, and subsequent reflux by drinking small amounts of fluid while eating and avoiding overeating. The client should be instructed to cluster fluid intake between meals instead Option E: lying down immediately after eating exacerbates reflux and may lead to more discomfort

The nurse is caring for a client at 21 weeks gestation with reports of occasional, bothersome heartburn (pyrosis). Which of the following lifestyle changes should the nurse recommend? Select all that apply A. avoid intake of dairy products B. drink large amounts of fluids with meals C. eat several small meals each day D. eliminate fried, fatty foods E. lie down on the left side after meals

ABCE Option D: performing strict hand washing and limiting sick visitors are important infection-control measures; however they do not prevent noninfectious aspiration pneumonia Option E: encourage clients to facilitate swallowing by flexing the neck (chin to chest)

The nurse is caring for a client at risk for aspiration pneumonia due to a stroke. What nursing actions help prevent this potential complication during hospitalization? Select all that apply A. add a thickening agent to the fluids B. avoid administering sedating medications before meals C. place the client in an upright position during meals D. restrict visitors who show signs of illness E. teach the client to flex the neck while swallowing

ACDEF Option B: the client receiving brachytherapy for endometrial cancer is instructed to remain on bedrest while the radiation implant is in place. If the implant dislodges from the vaginal cavity, the implant is never touched with the hands; instead, long-handled forceps are used to pick it up for placement in a lead container

The nurse is caring for a client diagnosed with endometrial cancer who is receiving brachytherapy. Which interventions should the nurse implement while caring for this client? Select all that apply A. cluster care to limit each staff member's time in the room to 30 minutes a shift B. instruct the client to be up and around in the room but not to leave the room C. keep the door to the room closed as radiation is emitting constantly from the client D. teach family members and visitors to stay at least 6 feet away from the client E. use a lead apron when providing direct client care to reduce exposure to radiation F. wear a radiation film-badge while in the client's room to monitor radiation exposure

BCD Option A: oseltamivir is an appropriate antiviral medication for this client who reports onset of influenza symptoms 36 hours ago. Option E: The influenza virus is spread via droplet transmission when infected persons cough or sneeze. Hospital personnel caring for clients with influenza should adhere to droplet precautions in addition to standard precautions

The nurse is caring for a client diagnosed with influenza who has had high fever, muscle aches, headache, and sore throat for 36 hours. The health care provider prescribes ibuprofen and oseltamivir. Which of the following actions by the nurse are appropriate? Select all that apply A. clarify the prescription for oseltamivir with the health care provider B. instruct the client to cover the mouth and nose while coughing or sneezing C. place a mask on the client when transporting the client though the halls D. plan discharge teaching about the importance of annual influenza vaccination E. use contact precautions when providing care for the client

ABCE Option A &B: meningococcal meningitis is highly infectious and requires strict droplet isolation precautions Option C: the client should be on bed rest with the head of the bed elevated 10-30 degrees to promote venous return from the brain and reduce sudden changes in intracranial pressure

The nurse is caring for a client in the acute phase of meningococcal meningitis. Which nursing actions should be included in the client's plan of care? Select all that apply A. assign client to a private room B. don mask before entering room C. elevate head of bed 10-30 degrees D. keep padded tongue blade at bedside E. maintain dimmed room lighting

C The presence of an air leak is indicated by continuous bubbling of fluid at the base of the water seal chamber. If the client has a known pneumothorax, intermittent bubbling would be expected. Once the lung has re-expanded and the air leak is sealed, the bubbling will cease. The nurse is expected to assess for the presence or absence of an air leak and to determine whether it originates from the client or the chest tube system Option A: section A is the suction control chamber. Gentle, continuous bubbling indicates that suction is present Option B: section B is part of the water seal chamber, but an air leak will not be evident in this upper portion. Tidaling of fluid is expected in this portion of the chamber and indicates latency of the tube Option D: section D is the collection chamber, where drainage from the client will accumulate. The nurse will assess amount. and color of the fluid and record these as output

The nurse is caring for a client involved in a motor vehicle collision who had a chest tube inserted to evacuate a pneumothorax caused by fractured ribs. Where would the nurse observe an air leak? A. section A B. section B C. section C D. section D

B Option A: sweet potatoes and kale are low in energy and protein and difficult to eat on the go Option C: spaghetti with meatballs and fruit salad are difficult to eat on the go Option D: vegetable soups and salads are often low in protein and energy and difficult to eat on the go. Caffeinated drinks should be avoided as they may increase mania and activity

The nurse is caring for a client newly admitted with an acute manic episode of bipolar disorder. The nurse identifies which dinner selection as the most appropriate to promote client nutrition? A. baked sweet potato, kale, yeast roll, water B. cheeseburger, apple, vanilla milkshake C. spaghetti with meatballs, fruit salad, milk D. vegetable soup, salad, dinner roll, iced tea

B Alzheimer disease is a progressive neurocognitive disorder resulting in memory loss, personality changes, and inability to perform self-care. Due to the progressive course of AD, it is important to discuss advance directives while the client can make informed decisions

The nurse is caring for a client newly diagnosed with mild Alzheimer disease. Which action should the nurse prioritize a this time when teaching the client and family? A. demonstrate behavioral management techniques to caregivers B. encourage the client to make an advance directive before cognitive decline worsens C. inform the client that mentally stimulating activities can slow disease progression D. provide information about local adult daycare programs

B Option A: in acute pericarditis, the inflamed pericardium rubs against the heart, causing pain that often worsens with deep breathing or when positioned supine. Option B: when assessing clients with pericarditis, it is critical for the nurse to observe for signs of cardiac tamponade. Development of cardiac tamponade requires emergency pericardiocentesis to prevent cardiac arrest Option C: ST-segment elevation in almost all ECG leads is a characteristic of acute pericarditis that typically resolves as pericardial inflammation decreases. This is in contrast to acute myocardial infarction, in which ST-segment elevation is seen in only localized leads Option D: pericardial friction rub is an expected finding with acute pericarditis that occurs from the layers of the pericardium rubbing together to create a characteristic high-pitched, leathery, and grating sound

The nurse is caring for a client with acute pericarditis. Which clinical finding would require immediate intervention by the nurse? A. client reports chest pain that is worse with deep inspiration B. distant heart tones and jugular venous distention C. ECG showing ST-segment elevations in all leads D. pericardial fruition rub auscultated at the left sternal boarder

C After cardiac catheterization, clients must remain supine with the head of the bed at ≤30 degrees and the affected extremity straight to prevent bleeding from the catheter insertion site. The charge nurse should intervene if the nurse is assisting the client to sit on the side of the bed to use the urinal. Option A: a small amount of bleeding can be expected after the catheter is removed. It is appropriate to apply pressure above the insertion site to control bleeding. Option B: it is important to verify adequate perfusion to the affected limb by frequently palpating the pedal pulses. Bilateral pulses should be palpated for comparison Option D: chest pain after ablation may be due to cardiac muscle damage but could also be caused by cardiac ischemia. This should be reported immediately to the health care provider

The nurse is caring for a client who 30 minutes ago, underwent an ablation procedure for supreventrivcular tachycardia in the cardiac catheterization laboratory. The client has a dressing over the femoral insertion site with a small amount of oozing blood. Which action by the nurse causes the charge nurse to intervene? A. applies pressure above the femoral insertion site B. assesses bilateral pedal pulses frequently C. assists client to sit on the side of the bed to use the urinal D. reports client chest pain of 2 on a scale of 0-10 to the health care provider

A The priority intervention is to assess vital signs as the manifestations associated with third-spacing include weight gain, decreased urinary output, and signs of hypovolemia, such as tachycardia and hypotension. If third-spacing is not recognized and corrected early on, postoperative hypotension can lead to decreased renal perfusion, prerenal failure, and hypovolemic shock

The nurse is caring for a client who is 1 day postoperative extensive abdominal surgery for ovarian cancer. The client is receiving IV ringer's lactate at 100 mL/hr and continual epidural morphine for pain control. The Foley catheter urine output has decreased to <20 mL/hr over the past 2 hours. The postoperative hematocrit is 36% and the hemoglobin is 12 g/dL. Which action should the nurse carry out first? A. assess vital signs B. increase the IV rate to 125 mL/hr C. notify the health care provider D. perform a bladder scan

A The best method for checking for a pulsatile rhythm is to assess a central (apical, femoral) pulse. This rate should be compared to the electrical rate displayed on the cardiac monitor to assess for pulse deficit. Option B: blood pressure is an important assessment relating to cardiac output and organ perfusion, but it does not determine if the client's pacemaker is capturing the mechanical activity of the heart Option C: a 12 lead ECG does not assess mechanical capture of cardiac activity via the client's pacemaker Option D: peripheral pulses are not the best indicators of mechanical action of the heart. Peripheral vasculature may have anatomical changes that impair pulse quality, leading to false perception of a pulse deficit

The nurse is caring for a client who just had a permanent ventricular pacemaker inserted. The nurse observes the cardiac monitor and sees a pacing spike followed by a QRS complex for each heartbeat. How should the nurse assess for mechanical capture of the pacemaker? A. auscultate the client's apical pulse rate B. measure the client's blood pressure C. obtain a 12 lead ECG D. palpate the client's radial pulse rate

ACDE Option B: ambulation is encouraged after ESWL to facilitate passage of the stone fragments

The nurse is caring for a client who received extracorporeal shock wave lithotripsy with ureteral stent placement for treatment of a kidney stone. Which discharge instructions provided by the nurse are appropriate? Select all that apply A. "contact your health care provider if you develop a fever or chills" B. "except for using the bathroom, you should stay on bed rest for the next 48 hours" C. "increase your fluid intake to help flush out the kidney stone fragments" D. "it is common to have some blood in the urine up to 24 hours after this procedure" E. "you may develop some bruising on your back or on the side of your abdomen"

B Neurologic injury is the most common cause of morality in clients who have had cardiac arrest, particularly ventricular fibrillation or pulseless ventricular tachycardia. Inducing therapeutic hypothermia in these clients within 6 hours of arrest and maintaining it for 24 hours has been shown to decrease mortality rates and improve neurologic outcomes. It is indicated in all clients who are comatose or do not follow commands after resuscitation

The nurse is caring for a client who was just resuscitated following an out-of-hospital cardiac arrest. The client does not follow commands and remains comatose. What intervention does the nurse anticipate being added to the client's plan of care? A. assisting the health care provider in discussing a do-not-resuscitate order with the family B. obtaining equipment and cold fluids for induction of therapeutic hypothermia C. placing a small-bore nasogastric feeding tube for enteral nutrition D. planning for passive range-of-motion exercises to prevent contractures

BDE Option A: unlike levonorgestrel IUDs, copper IUDs have an immediate contraceptive effect; backup contraception is not required. Condoms are recommended for clients who are at risk for sexually transmitted infections Option C: although pregnancy risk is low when using the copper iUD, pregnancy is possible. Ovulation and menses still occur when using the copper IUD because the device does not contain hormones. A pregnancy test is necessary if a period is missed

The nurse is caring for a client who will have a copper intrauterine device (IUD) inserted. When reinforcing teaching related to the copper IUD, which of the following nurse statements are appropriate? Select all that apply A. "backup contraception is needed for 2 days until the IUD is effective" B. "heavier menses and more menstrual cramping are common in clients using a copper IUD" C. "missing a period while using a copper IUD is normal and no reason for concern" D. "you may have cramping and vaginal spotting for a short time after IUD insertion" E. "you should check for the IUD strings at least once a month after menses"

C

The nurse is caring for a client with a pulmonary contusion. Assessment reveals restlessness, chest pain on inspiration, diminished breath sounds, and oxygen saturation of 86%. Which acid-base imbalance does the nurse correctly identify? A. metabolic acidosis B. metabolic alkalosis C. respiratory acidosis D. respiratory alkalosis

BCD Options A & E: albumin holds water inside the blood vessels. In cirrhosis, the liver is unable to synthesize albumin (protein), so hypoalbuminemia would be expected. The kidneys perceive this as low perfusion and try to reabsorb both sodium and water. The large amount of water in the body results in a dilutional effect (low sodium)

The nurse is caring for a client with cirrhosis of the liver. Which blood test values would the nurse typically anticipate to be elevated when reviewing the client's morning laboratory results? Select all that apply A. albumin B. ammonia C. bilirubin D. prothrombin time E. sodium

C The client with cirrhosis is at risk of hepatic encephalopathy. Hypokalemia, high protein intake, gastrointestinal bleeding, constipation, hypovolemia, and infection can precipitate hepatic encephalopathy. Use of furosemide can cause hypokalemia, which must be corrected immediately to prevent the precipitation of hepatic encephalopathy and dangerous arrhythmias.

The nurse is caring for a client with end-stage liver failure from hepatitis C who is being seen in the clinic for worsening ascites. The client is treated in the infusion center with IV albumin, iV furosemide, and oral spironolactone. The following day the nurse checks the client's labs. Which of the following lab findings is most important for the nurse to communicate to the health care provider? A. albumin 2.5 g/dL B. INR 1.4 C. potassium 3.0 mEq/L D. sodium 131 mEq/L

CE Immune thrombocytopenia purpura (ITP) is an autoimmune condition in which antibodies bind to and cause destruction of platelets. Clients with ITP have a platelet count of <150,000/mm3 and are at increased risk of bleeding. Option C: clients with ITP should use electric razors instead of safety or straight razors. Electric razors have a more complete guard, reducing the risk of accidentally nicking the skin Option E: clients with ITP should avoid non steroidal anti-inflammatory drugs, which further impair platelet function. Acetaminophen and opiates are better options for pain management.

The nurse is caring for a client with immune thrombocytopenia purport. Which client statements indicate a need for further teaching? Select all that apply A. "I use a soft-bristle toothbrush and mild mouth rinse" B. "I enjoy walking and wear nonskid footwear for safety" C. "I use a safety razor and gentle shaving cream" D. "sometimes I get constipated, so I have been taking docusate" E. "when I have a headache, I take over-the-counter ibuprofen"

BDE Option A: each aid must be cleaned with a soft cloth. Hearing aids should not be immersed in water, as this can damage the electrical components Option C: store hearing aids in a safe, dry place when not in use. This will help prevent the hearing aids from becoming lost or damaged

The nurse is caring for a client with newly prescribed hearing aids. Which of the following actions by a client indicate proper use and care of hearing aids? Select all that apply A. keeps hearing aids clean by rinsing them with water B. lowers television volume when talking with nurse C. places hearing aids on food tray when not in use D. turns volume completely down prior to insertion of aid into the ear E. verifies that battery compartment is closed before insertion

BCDE Overflow urinary incontinence occurs due to compression of the urethra or impairment of the bladder muscle. Both types involve incomplete bladder emptying and urinary retention, which lead to overdistention and overfilling of the bladder and frequent involuntary dribbling of urine Option A: fluid restriction can lead to dehydration with concentration urine, which irritates the bladder and increases the risk for urinayr tract infection. Dehydration also contributes to constipation, which worsens incontinence by compressing the bladder

The nurse is caring for a client with overflow urinary incontinence related to diabetic neuropathy. Which of the following interventions are appropriate? Select all that apply A. decrease fluid intake to 1 glass with each meal and at bedtime B. encourage the client to bear down while attempting to void C. inspect the perineal area for evidence of skin breakdown D. measure postvoid residual volumes as prescribed E. tell the client to wait 30 seconds after voiding and then attempt to void again

BD Option A: many clients with hearing impairment will lip-read. The room lights should be on so that the speaker's lips and face are well illuminated Option C: when speaking to a client with hearing loss, speech should be directed toward the least-affected ear and should be at a normal volume. Raising the voice to speak loudly creates a higher pitch that is harder to understand Option E: the nurse should ensure that any hearing aids are functional and in place before attempting to speak to the client

The nurse is caring for a client with partial hearing loss. Which interventions would be appropriate to promote effective communication? Select all that apply A. dim lights to prevent overstimulation B. post a hearing impairment sign on the client's door C. raise voice to speak more loudly D. speak directly facing the client E. tell family to take hearing aids home so they will not be lost

C The priority action after placing a subclavian central venous catheter is to check the results of the chest x-ray to ensure that the catheter tip is placed correctly in the superior vena cava. Obtain verification before using the catheter as perforation of the visceral pleura can occur during insertion and lead to an iatrogenic pneumothorax or hemothorax

The nurse is caring for a client with surgical complications who requires continuous total parenteral nutrition. The nurse assists the health care provider with the insertion of a subclavian triple lumen central venous access device. What is the nurse's priority action before initiating the TPN infusion? A. attach a filter to the IV tubing B. check baseline fingers tick glucose levels C. check the results of the portable chest x-ray D. program the electronic infusion pump

B During IV therapy, the nurse should monitor the site to assess for potency and signs of infection. Infiltration is a complication that occurs when solution infuses into the surrounding tissues of the infusion site. Option A: peripheral IV sites should be changed no more frequently than every 72-96 hours unless complications develop Option C: it is important to flush saline locks every 8-12 hours as prescribed. However, this client is not the highest priority Option D: an IV infusing at 20 mL/hr will take 5 hours to complete when 100 mL remain in the bag

The nurse is caring for a group of clients. Which finding requires immediate action by the nurse? A. client scheduled for discharge who has had a peripheral IV in place for 84 hours B. client with a do-not-resuscitate prescription who has swelling at the IV site C. client with a saline lock who had a scheduled IV saline flush due 15 minutes ago D. client with an IV infusing at 20 mL/hr who has 100 mL fluid remaining in the bag

ABDE Option C: the presence of parents or the primary caregiver during hospitalization reduces separation anxiety and decreases the infants stress response. Therefore, caregivers should remain whenever possible throughout all the client's care

The nurse is caring for a hospitalized 6 month old client. Which of the following interventions should the nurse implement to provide developmentally appropriate care for this client? Select all that apply A. adhere to the child's home routine when possible during hospitalization B. encourage parents to bring the child's favorite toy from home C. have the parents step out of the room during procedures D. promote a quiet sleep environment with reduced stimuli E. provide a parent's shirt for the child to hold during procedures

ADE Nurses may delegate the following to the UAP: - performing routine oral care, which will not affect medical stability in a client with a tracheostomy tube - measuring and obtaining vital signs - testing blood glucose - performing personal hygiene and skin care - performing passive and/or active range-of-motion exercises - measuring output Although an elevated HOB is necessary to prevent ventilator-acquired pneumonia and improve chest expansion, teaching is not within the scope of the UAP and should only be performed by nurses.

The nurse is caring for a mechanically ventilated client with a tracheostomy tube in the intensive care unit. What client care tasks can the nurse safely delegate to the unlicensed assistive personnel? Select all that apply A. applying moisturizing solution to the oral mucosa and lips B. cleaning the area around the tracheostomy stoma with normal saline C. educating the family to maintain the head of the bed at least 30 degrees D. obtaining and documenting respiratory rate and pulse oximetry readings E. performing passive and active range-of-motion exercises

B When helping the family cope with the crisis, the nurse needs to keep the lines of communication open and offer support. The nurse should use open-ended therapeutic communication techniques that encourage the family members to verbalize what they are feeling or experiencing Option A: this is a true statement; supportive counseling is usually beneficial to new parents of children with disabilities. The nurse can refer clients to family support groups or even make the initial phone call for them. However, the nurse should first encourage the parents to express how they are feeling Option C: this is not the best response. The nurse has a role and responsibility to offer support to clients experiencing a crisis Option D: this is accusatory and non therapeutic. The nurse should avoid asking "why" questions when attempting to gain more information

The nurse is caring for a new mother whose infant has been diagnosed with Down syndrome. The client says to the nurse, "I'm so worried. My husband is so devastated that he won't even look at the baby." What is the best response by the nurse? A. "both of you will benefit from supportive counseling" B. "how are you feeling about your baby?" C. "I will have the doctor speak to your husband" D. "why do you think your husband feels this way?"

B Patent ductus arteriosus (PDA) is an acyanotic congenital defect more common in premature infants. When fetal circulation changes to pulmonary circulation outside the womb, the ductus arteriosus should close spontaneously. This closure is caused by increased oxygenation after birth. If a PDA is present, blood will shunt from the aorta back to the pulmonary arteries via the opened ductus arteriosus. Many newborns are asymptomatic except for a loud, machine-like systolic and diastolic murmur. The PDA will be treated with surgical ligation or IV indomethacin to stimulate duct closure

The nurse is caring for a newborn with patent ductus arteriosus. Which assessment finding should the nurse expect? A. harsh systolic murmur B. loud machine-like murmur C. soft diastolic murmur D. systolic ejection murmur

BDE OO The examination for skin cancer follows the ABCDE rule: 1. Asymmetry (one half unlike the other) 2. Border irregularity (edges are notched or irregular) 3. Color changes and variation (different brown or black pigmentation 4. Diameter of 6 mm or larger (about the size of a pencil eraser) 5. Evolving (appearance is changing in shape, size, color) Option A: normal variations in skin will blanch with manual pressure. Failure to blanch is typically an indication that there is blood beneath the skin, as in petechiae and/or purpura Option C: pus or purulent drainage is usually indicative of an infectious process, not cancer

The nurse is caring for an adult client at the clinic who asks the nurse to look at a "black skin lesion." What assessment findings would be a classic indication of a potential malignant skin neoplasm? Select all that apply A. blanches with manual pressure B. half of the lesion is raised and half is flat C. history of purulent drainage D. lesion is the size of a nickel E. various color shades are present

C Hirschsprung disease occurs when a child is born with some sections of the distal large intestine missing nerve cells, rendering the internal anal sphincter unable to relax. As a result, there is no peristalsis and stool is not passed. These newborns exhibit symptoms of distal intestinal obstruction. They have a distended abdomen and will not pass meconium within the expected 24-48 hours. They also have difficulty feeding and often vomit green bile. Surgical removal of the defective section of bowel is necessary and colostomy may be required A potentially fatal complication is Hirschsprung enterocolitis, an inflammation of the colon, which can lead to sepsis and death. Enterocolitis will present with fever, lethargy; explosive, foul-smelling diarrhea; and rapidly worsening abdominal distention

The nurse is caring for an infant diagnosed with Hirschsprung disease who is awaiting surgery. Which assessment finding requires the nurse's immediate action? A. abdominal distention with no change in girth for 8 hours B. did not pass meconium or stool within 48 hours after birth C. episode of foul-smelling diarrhea and fever D. excessive crying and greenish vomiting

C Option A: unless the client has improper air exchange, oxygen administration is not needed. The nasal cannula will most likely bother the child and lead to unnecessary movement during needle placement Option B: the HCP performing the lumbar puncture will feel the spine for correct needle placement and then sterilize and prepare the chosen area for needle insertion Option D: unless the client is unstable, there is no need to record vital signs every 15 minutes. The client should be awake and alert, and the procedure should be fairly short in duration

The nurse is caring for an infant with suspected meningitis and preparing to assist with a lumbar puncture. What is the appropriate nursing intervention? A administer oxygen via nasal cannula for client comfort and safety B. clean area with povidone iodine in a circular motion moving outward C. hold the child with the head and knees tucked in and the back rounded out D. monitor and record vital signs every 15 minutes throughout the procedure

ABD Option C: lines, tubes, and drains tether the client to the bed or equipment and limit mobility, increasing fall risk. In addition, indwelling urinary catheters increase risk for infection and should be used only when clinically indicated, not for the nurse's convenience Option E: raising all side rails is considered a physical restraint and is associated with more severe fall injuries from clients attempting to climb over the side rails

The nurse is caring for an older adult client who is confused and has a high risk for falls. The client is incontinent of urine and frequently attempts to get out of bed unassisted to use the restroom. Which nursing interventions are appropriate when caring for this client? Select all that apply A. ensuring bed alarm remains activated B. initiating an hourly rounding schedule C. inserting an indwelling urinary catheter D. moving client to a room close to the nurse's station E. raising all side rails of the client's bed

D Expect yellow exudate on the penis after the first day, a normal part of the healing process. Exudate should not be removed forcefully and disappears in 2-3 days. Swelling, increasing redness, odor, or abnormal discharge may indicate infection.

The nurse is evaluating a client's understanding of postcirucmcision care for a 24 hour old newborn. Circumcision was performed using the clamp method. Which statement by the client demonstrates a need for further teaching? A. "bleeding should be no larger than the size of a quarter" B. "I should cleanse the glans with warm water occasionally" C. "I should expect at least 2 wet diapers in the next 24 hours" D. "yellow exudate on the glans penis indicates infection"

BD Option A: exhalation through pursed lips is done for 4 seconds, not 2 seconds, or twice as long as inhalation. Option C: inhalation is done through the nose, not the mouth. Option E: inhalation is done for 2 seconds not 4 seconds.

The nurse is evaluating how well a client who chronic obstructive pulmonary disease understands the discharge teaching. Which statements made by the client indicate an understanding of the pursed-lip breathing technique? Select all that apply A. "I exhale for 2 seconds through pursed lips" B. "I exhale for 4 seconds through pursed lips" C. "I inhale for 2 seconds through my mouth" D. "I inhale for 2 seconds through my nose, keeping my mouth closed" E. "I inhale for 4 seconds through my nose, keeping my mouth closed"

BCEF Option A: frequent (not difficult) arousal from sleep is associated with OSA

The nurse is gathering data on a client with obstructive sleep apnea. Which findings are consistent with this client's diagnosis? Select all that apply A. difficulty arousing from sleep B. excessive daytime sleepiness C. morning headaches D. postural collapse and falling E. snoring during sleep F. witnessed episodes of apnea

B Following cataract surgery, the client will be instructed that for several days, activities that may increase intraocular pressure should be avoided to decrease the risk of damage to sutures or surgical site. These include bending, lifting more than 5 lb, sneezing, coughing, rubbing or placing pressure on the eye, or straining during a bowel movement Option A: it may take 1-2 weeks before visual acuity is improved Option C: it is common for the client to experience itching, photophobia, and mild pain for several days following surgery. Purulent drainage, increased redness, and severe pain should be reported Option D: sleeping on 2 pillows will elevate the head of the bed and decrease intraocular pressure

The nurse is making follow-up phone calls to clients who had cataract surgery with intraocular lens implantation the previous day. The nurse reviews which client report that requires priority intervention? A. blurry vision in the affected eye B. constipation C. itching in the affected eye D. sleeping on 2 pillows at night

ABE Antiplatelet therapy is initiated to prevent platelet aggregation in clients at risk for myocardial infarction, stroke, or other thrombotic events. This therapy increases bleeding risk, so clients should be assessed for bruising, tarry stools, and other signs of bleeding. Clients should be taught to self-monitor for these signs. In addition, clopidogrel may cause thrombotic thrombocytopenia purport, so platelets should be monitored periodically

The nurse is monitoring a client who has been on clopidogrel therapy. Which assessments are essential? Select all that apply A. assess for bruising B. assess for tarry stools C. monitor intake and output D. monitor liver function tests E. monitor platelets

A The Nägele rule uses a standard formula based on the last normal menstrual period to determine EDB based on a 28 day menstrual cycle: (LMP - 3 months) + 7 days

The nurse is obtaining a client's history during an initial prenatal visit. The client's last menstrual period was from March 1 to March 5. Unprotected intercourse occurred on March 15. Slight vaginal spotting was noted on March 23. The client's menstrual cycles are regular and 28 days long. Using the Nägele rule, what is the estimated date of birth? A. December 8 B. December 12 C. December 22 D. December 30

B Murmurs are produced by turbulent blood flow across diseased or malformed cardiac valves. They can be characterized as musical, blowing, swooshing, or rasping sounds heard between normal heart sounds. The aortic area is located at the second intercostal space, right sternal border Option A: an arterial bruit is a turbulent blood flow sound heard in a peripheral artery Option C: a pericardial friction rub is a high-pitched, scratchy sound during S1 or S2 at the apex of the heart. It is best heard with the client sitting and leaning forward and at the end of expiration. It occurs when inflamed surfaces of the heart rub against each other Option D: an S3 gallop is an extra heart sound that occurs closely after S2. It is a low-pitched sound heard in early diastole that is similar to the sound of a horse's gallop. The mitral area is located at the fifth intercostal space, medial to the mid-clavicular line

The nurse is performing a cardiac assessment on a client. The nurse auscultates a loud blowing sound at the second intercostal space, right sternal border. How should the nurse document this finding? A. arterial bruit B. murmur heard at the aortic area C. pericardial friction rub D. S3 gallop heard at the mitral area

BCE Option A: pain is the fifth vital sign and is subjective data. A 10 year old can describe and rate pain accurately Option D: 10 year olds will think there is something seriously wrong with them if the nurse and parent will not explain the results of the examination to them

The nurse is performing a physical examination on a 10 year old client with abdominal discomfort. Which actions would be appropriate during the examination? Select all that apply A. ask the accompanying parent to rate and describe the client's pain B. ask the client to describe the chief symptom C. conduct a head-to-toe assessment in the same manner as an adult assessment D. explain the outcome of the examination to the parent without the child present E. honor the client's request to be examined without a parent present

B Hypertensive crisis poses a high risk for end-organ damage, hemorrhagic stroke, kidney injury, heart failure, papilledema. The nurse should prioritize neurological assessment as decreased LOC may indicate onset of hemorrhagic stroke, which requires immediate surgical intervention. Options A & C: assessing heart and lung sounds allows the nurse to identify and monitor for other complications of hypertensive crisis. However, this client's vital signs do not indicate respiratory distress; therefore, neurological assessment is the priority because a change in LOC may indicate a life-threatening hemorrhagic stroke Option D: the nurse should assess for vision changes or papilledema, as these are signs of progressing hypertensive crisis; however, assessment of LOC is the priority

The nurse is performing an initial assessment on a client in hypertensive crisis. What is the nurse's priority assessment? A. heart sounds B. level of consciousness C. lung sounds D. visual fields and acuity

ABDE Option C: during pregnancy, a collection of secretions forms a "mucous plug" in the cervical canal, acting as a protective barrier. Although the client may notice expulsion of the mucous plug in the days preceding labor, it is not necessarily a sign of labor

The nurse is performing telephone triage with a client at 38 weeks gestation who thinks she may be in labor. Which questions would help the nurse determine whether the client is in labor? Select all that apply A. "do you feel like the contractions are getting stronger?" B. "does anything you do make the pain better?" C. "have you lost your mucous plug?" D. "how frequent are the contractions?" E. "where do you feel the contraction pain most?"

BCD Myopia, or nearsightedness, is reduced visual acuity when viewing objects at a distance. Myopia occurs when the eye structure causes images to focus before they arrive at the retina. Near vision is usually intact, and many clients with myopia report needing to hold objects near their face or sit near objects to see clearly

The nurse is performing visual acuity screenings on a group of students. Which of the following student comments does the nurse recognize as indicating possible myopia? Select all that apply A. "I can see my teacher better if I sit in the back of the classroom" B. "I have to hold my book close to my face so that the words are clear" C. "if I squint or close one eye, I can read the road signs when we travel" D. "my parents always tell me that I am sitting too close to the television" E. "sometimes, I have to ask my parents if I've chosen socks that match"

C Lateral curvature to the spine of this 10 year old girl may indicate scoliosis, which is one of the most commonly diagnosed spinal deformities and is characterized by lateral curvature of the spine and spinal rotation. Although scoliosis may result from congenital or pathologic conditions, it is most often determined to be idiopathic. It is commonly first noticed during periods of rapid growth, particularly during early adolescence in girls. Option A: the lateral bowing of the legs is common in toddlers as they learn to walk Option B: a rounded, nearly circular chest shape with the front-to-back diameter approximately equal to the side-to-side diameter is an expected finding in a healthy infant Option D: an S3 heart sound is considered normal when heard in children

The nurse is performing well-child examinations in a pediatric clinic. Which finding requires further evaluation? A. bilateral bowlegs (genu varum) in a 15 month old B. chest rounded with the anteroposterior diameter equal to the lateral diameter in an infant C. lateral curvature to the spine noted on examination of a 10 year old girl D. presence of an S3 heart sound in a 2 year old

A Quadriplegia occurs when the lower limbs are completely paralyzed and there is complete or partial paralysis of the upper limbs. This is usually due to injury of the cervical spinal cord. Depending on the area of injury and extent of cord edema, the airway can be adversely affected. The priority assessment for this client is the status of the airway and oxygenation. The nurse should frequently assess breath sounds, accessory muscle use, vital capacity, tidal volume, and arterial blood gas values

The nurse is planning care for a client being admitted with newly diagnosed quadriplegia (tetraplegia). Which intervention will the nurse prioritize? A. assess vital capacity and tidal volume once per shift and PRN B. perform passive range of motion exercises on affected joints every 4 hours C. provide time during each shift for the client to express feelings D. turn the client every 2 hours throughout the day and night

A Meniere disease results from excess fluid accumulation inside the inner ear. Clients have episodic attacks of vertigo, tinnitus, hearing loss, and aural fullness. Option B: an emesis basin should be provided at the bedside, but fall precautions are the priority. Option C: a quiet environment can help minimize vertigo. However, it is a lower priority than the fall precautions Option D: most clients with Meniere disease require parenteral fluids given the nausea and vomiting. However, these are not the highest priority

The nurse is planning care for a client experiencing an acute attack of Meniere disease. Which action is a high priority to include in the plan of care? A. initiate fall precautions B. keep the emesis basin at bedside C. provide a quiet environment D. start intravenous fluids

ABCE Sjögren's syndrome is a chronic autoimmune disorder in which moisture-producing exocrine glands of the body are attacked by white blood cells. The most commonly affected glands are the salivary and lacrimal glands, leading to dry eyes and dry mouth. Dryness in these areas can lead to corneal ulcerations, dental caries, and oral thrush.

The nurse is planning teaching for a client newly diagnosed with Sjögren's syndrome. Which measures will the nurse include in the teaching plan? Select all that apply A. chewing sugar-free gum or using artificial saliva B. scheduling regular dental examinations C. showering with lukewarm water and avoiding harsh soaps D. using over-the-counter decongestants to alleviate nasal symptoms E. using over-the-counter lubricants to ease vaginal dryness

BC Option A: glass shards may be present in the medication after an ampule is opened. To prevent the accidental administration of glass shards, the nurse must use a filter needle, rather than an injection needle, when withdrawing medication Option D: unlike when withdrawing medication from a vial, air should not be injected into a glass ampule; this causes the contents to spill from the container Option E: ensure that the filter needle does not touch the glass edges, which are not sterile, as this can introduce bacteria

The nurse is preparing an injection of IM haloperidol from a glass ampule. Which of the following actions by the nurse are appropriate? Select all that apply A. attaches an 18-gauge injection needle to a syringe for withdrawal of medication B. breaks the ampule neck away from the nurse's body to prevent injury from the glass C. disposes of the empty glass impulse in a sharps container D. injects air into the glass ampule prior to withdrawing the medication E. rests and steadies the needle on the ampule's outer rim to withdraw the medication

BCE

The nurse is preparing discharge instructions for a client with a history of alcohol abuse on the third day after an emergency appendectomy. The nurse suspects delirium tremens based on which assessment data? Select all that apply A. bradypnea B. diaphoresis C. hallucinations D. lethargy E. tachycardia

D IV furosemide may cause ototoxicity, particularly when high doses are administered in clients with compromised renal function. The rate of administration should not exceed 4 mg/min in doses > 120 mg. To determine the correct rate of administration for the dose above, use the following formula: (160 mg)/(4mg/min) = 40 min Option A: bradycardia is an adverse effect of beta blockers, calcium channel blockers, and digoxin. It is not an adverse effect of furosemide Option B: hypokalemia is common with furosemide administration due to the potassium-wasting effects of this loop diuretic. However, slower infusion is unlikely to prevent this adverse effect Option C: although nephrotoxicity can occur with IV furosemide administration, it is dependent on the dose, not the rate of administration

The nurse is preparing to administer 160 mg of furosemide IV piggyback to a client with chronic kidney disease and fluid overload. The nurse plans to give the dose slowly over 40 minutes to prevent which adverse effect? A. bradycardia B. hypokalemia C. nephrotoxicity D. ototoxicity

C Sodium polystyrene sulfonate retention enema is a medicated enema administered to clients with high serum potassium levels. The resin in Kayexalate replaces sodium ions for potassium ions in the large intestine and promotes evacuation of potassium-rich waste from the body, thereby lowering the serum potassium level. Kayexalate can also be given orally and is much more effective Option A: a barium enema uses contrast medium administered rectally to visualize the colon using fluoroscopic x-ray Option B: a fleet enema relieves constipation by infusing a hypertonic solution into the bowel, pulling fluid into the colon and causing distention and then defecation Option D: a neomycin enema is a medicated enema that reduces the number of bacteria in the intestine in preparation for colon surgery

The nurse is preparing to administer a sodium polystyrene sulfonate retention enema. Which explanation by the nurse best describes the purpose of this type of enema? A. "a contrast medium is administered rectally to visualize the colon via X-ray" B. "bedridden clients receive this enema to stimulate defecation and relieve constipation" C. "this enema assists the large intestines in removing excess potassium from the body" D. "this enema is administered before bowel surgery to decrease bacteria in the colon"

BC Option A: non-dihydropyridine calcium channel blockers can decrease HR and should be held in clients with bradycardia Option D & E: all beta blockers, including eye drops that can be absorbed systemically, can decrease the HR and should be held until the prescriptions can be clarified by the HCP

The nurse is preparing to administer medications to a client admitted with atrial fibrillation. The nurse notes the vital signs shown. Which medications due at this time are safe to administer? Select all that apply A. diltiazem extended-release PO B. heparin subcutaneous injection C. lisinopril PO D. metoprolol PO E. timolol ophthalmic

A Typically, antihypertensives are held before dialysis to prevent hypotension. Other commonly held medications include water-soluble vitamins (B & C), antibiotics, and digoxin

The nurse is preparing to administer morning medications to a client with type 2 diabetes mellitus and end-stage renal disease who is scheduled for dialysis today. Which medication should the nurse hold for clarification prior to administration? A. atenolol B. calcium acetate C. insulin lispro D. vitamin E

C Vancomycin is a very potent antibiotic that can cause nephrotoxicity and ototoxicity. Measuring for serum concentrations is a way to monitor for risk of nephrotoxicity as well as for therapeutic response. Trough serum vancomycin concentrations are the most accurate and practical method for monitoring efficacy. A trough should be obtained just prior to administration of the next dose

The nurse is preparing to administer the fourth dose of vancomycin IVPB to a client with infective endocarditis. Which intervention does the nurse anticipate? A. administering PRN antiemetic prior to the infusion B. administering via an infusion pump over at least 30 minutes C. drawing a trough level just prior to administration of the vancomycin D. starting a new IV line before administration

C A 10 mL syringe is generally preferred for flushing the lumen of a CVC. A smaller syringe creates more pressure, which increases the risk for damage to the CVC

The nurse is preparing to flush a client's central venous catheter. Which size syringe is best for the nurse to choose? A. 1 mL B. 3 mL C. 10 mL D. 30 mL

D Cranial nerve IX (glossopharyngeal) is involved in the gag reflex, ability to swallow, phonation, and taste.

The nurse is providing discharge education for a postoperative client who had a partial laryngectomy for laryngeal cancer. The client is concerned because the health care provider said there was damage to the ninth cranial nerve. Which statement made by the nurse is most appropriate? A. "I will ask the health care provider to explain the consequences of your procedure" B. "this is a common complication that will require you to have a hearing test every year" C. "this is a common complication; your health care provider will order a consult for the speech pathologist" D. "this is the reason you are using a special swallowing technique when you eat and drink"

A Option A: daily application of water-based lotion is necessary to minimize scar formation and alleviate itching. Infection is not likely as the rehabilitation phase begins after the wounds are fully healed

The nurse is providing discharge teaching for a client who suffered full-thickness burns. Which statement by the client demonstrates a need for further instruction on the rehabilitation phase of a burn injury? A. "I should avoid using lotion to prevent infection" B. "I should perform range-of-motion exercises daily" C. "I will avoid direct sun exposure for at least 3 months" D. "I will wear pressure garments to minimize scars"

BCE Warfarin (Coumadin) is a vitamin K antagonist used to prevent blood clots in clients with atrial fibrillation, artificial heart valves, or a history of thrombosis. Excessive intake of vitamin K-rich foods (broccoli, spinach, liver) can decrease the anticoagulant effects of warfarin therapy. Clients should be consistent with intake of foods high in vitamin K after initiation of warfarin because dosing is individualized to the client and dietary changes may require dose adjustment

The nurse is providing discharge teaching to a client with a new prescription for warfarin. The nurse should instruct the client to avoid excess or inconsistent intake of which foods? Select all that apply A. bananas B. broccoli C. liver D. oranges E. spinach

ABD Leafy green vegetables are the best dietary sources of folic acid. However, other appropriate food choices include cooked beans, rice, fortified cereals, and peanut butter, which provide at least 40 mcg folic acid per serving

The nurse is providing nutrition counseling during a preconception visit to a client who does not eat green vegetables. In addition to a daily prenatal vitamin, which foods can the client add to the daily diet to decrease the risk of neural tube defects? Select all that apply A. black beans and rice B. fortified breakfast cereal and milk C. medium baked sweet potato D. peanut butter on whole wheat toast E. raw carrots with cheese dip

ACD Option B: this client's death was expected. It is not necessary to contact the medical examiner for an autopsy Option E: leave dentures in place, or replace if removed, to maintain the shape of the face; it is difficult to place dentures once rigor mortis sets in. A towel folded under the chin may be needed to keep the jaw closed

The nurse is providing postmortem care for a client who has died after a long hospitalization. The client had a do-not-resuscitate prescription in place at the time of death. Which of the following interventions should the nurse include during postmortem care in preparation for transfer to the funeral home? Select all that apply A. allow family member to assist with care B. call the medical examiner for an autopsy C. gently close the client's eyes D. place a pad under the perineum E. remove the client's dentures

B Although removal of hemorrhoids is a minor procedure, the pain associated with it is due to spasms of the anal sphincter and is severe. Option A: encourage a high-fiber diet and adequate fluid intake. Administer a stool softener such as docusate as prescribed. An oil-retention enema may be used if constipation persists for 2-3 days. Option C: postoperatively, the health care provider may pack the rectum and apply a T-binder to hold the packing in place. The dressing is usually removed 1-2 days postoperatively unless excess soaking is noted before. Option D: warm sitz baths are used beginning 1-2 days postoperatively, 2-3 times daily for 7-10 days to provide pain relief, decrease swelling, and cleanse the rectal area

The nurse is providing postoperative care to a client returning from a hemorrhoidectomy. Which action is the priority for the nurse to perform? A. administer docusate and teach the client to avoid straining during defecation B. give pain medications and instructions related to pain control C. remove the rectal dressing and check the client for bleeding D. teach the client how to self-administer a sitz bath 2-3 times daily

A Marfan syndrome is an autosomal dominant disorder affecting the connective tissues of the body. Abnormalities are mainly seen in the cardiovascular, musculoskeletal, and ocular systems. Clients with Marfan syndrome are very tall and thin, with disproportionately long arms, legs and fingers. Cardiovascular manifestations of Marfan syndrome include abnormalities of the aorta and cardiac valves, including aneurysms, tears, and leaky heart valves that may require replacement or repair. Therefore, competitive or contact sports are discouraged due to the risk of cardiac injury and sudden death

The nurse is providing teaching to the parents of a child with Marfan syndrome. Which topic is the priority for the nurse to address? A. avoiding participation in contact sports B. informing the dentist of the child's condition C. monitoring for development of scoliosis D. scheduling annual eye examinations

AD Calcium and vitamin D are nutrients in cow's milk that are essential for proper bone development in children and adolescents. To obtain the recommended 500 mg of daily calcium, the parents should serve foods such as beans, dark green vegetables, and calcium-fortified cereals and juices. Vitamin D, which enhances the absorption of calcium, is synthesized in the skin by exposure to direct sunlight. alternate dietary sources include fish oils, egg yolks, and vitamin D-fortified foods

The nurse is reinforcing discharge teaching for the parents of a 1 year old with a newly diagnosed cow's milk allergy. Which nutrients normally provided by milk should be obtained from other sources? Select all that apply A. calcium B. fiber C. iron D. vitamin D E. vitamin K

AD Option A: protected sex is important even with HIV-positive partners as HIV has multiple strains and coinfection results in HIV superinfection, which may hasten progression to AIDS Option B: sharing personal hygiene devices that may have been exposed to blood increases HIV transmission risk and should be avoided Option C: immunosuppressed clients should be educated to avoid raw or undercooked foods to avoid food borne illness Option D: clients with HIV should use latex or synthetic condoms and/or dental dams during sexual activity involving mucous membrane exposure to semen or vaginal secretions. Natural barriers do not prevent transmission of STIs due to the presence of small pores Option E: to prevent transmission of HIV, hep b virus, and other blood borne diseases, IV drug users should be taught to avoid reusing or sharing needles or syringes

The nurse is reinforcing education about home and lifestyle alterations to a client recently diagnosed with HIV. Which of the following statements by the client indicates a need for further education? Select all that apply A. "I dont have to use protection if my sexual partner is also HIV positive" B. "I have to make sure my family knows not to borrow my razors" C. "I need to avoid eating raw or undercooked meats and eggs" D. "I started to use lambskin condoms during sex, as I have a latex allergy" E. "I won't reuse or share any needles or syringes that I use to inject heroin"

BCDE Option A: pregnancy is a hypercoaguable state that augments the risk of thrombus formation. The nurse should encourage pregnant clients who embark on long travel to walk every 1-2 hours to decrease the risk of thrombus formation Option B: carry an updated copy of the prenatal record in case emergency medical care is necessary during travel Option C: increase fluid intake to prevent dehydration and reduce the risk of thrombus formation or preterm contractions Option D: secure the lap belt under the gravid abdomen and across the hips and, if available, place shoulder belts lateral to the uterus and between the breasts to prevent complications from abdominal trauma Option E: wear compression stockings and unrestrictive clothing to improve venous return and decrease the risk of thrombus formation

The nurse is reinforcing instructions to a client at 34 weeks gestation who is preparing to travel by airplane. Which of the following instructions are appropriate? Select all that apply A. avoid getting up during the flight unless you need the restroom B carry a copy of your most up-to-date prenatal record C. increase fluid intake before and during the flight D. secure the lap belt below the abdomen and across your hips when seated E. wear compression hose and loose-fitting clothing

D Option A: engage in sexual intercourse or masturbation to reduce discomfort related to retained prostatic fluid. Clients should use a barrier prophylactic method when engaging in sexual activity with a partner to prevent transmission of the causative organism. Option B: hydrate with clear liquids. Avoid coffee, tea, and other caffeinated beverages due to diuretic and stimulant properties, which may worsen symptoms Option C: complete the full course of antibiotics regardless of symptom improvement to ensure infection resolution Option D: take stool softeners as prescribed to reduce straining during defecation; tension of the pubic muscles presses against the prostate, causing pain

The nurse is reinforcing instructions to a client being discharged from the clinic with a diagnosis of acute prostatitis. Which statement by the client indicates an understanding of the instructions? A. "having sex will make the infection worse" B. "I enjoy iced tea, so I will drink more to stay hydrated" C. "I should take ciprofloxacin until I feel better" D. "I should take docusate to prevent straining"

ACD Home management for PAD includes: - Lower the extremities below the heart when sitting and lying down - improves arterial blood flow - engage in moderate exercise - promotes collateral circulation and distal tissue perfusion - perform daily skin care, including application of lotion - prevents skin breakdown from dry skin - maintain mild warmth - improves blood flow and circulation - stop smoking - prevents vessel spasm and constriction - avoid tight clothing and stress - prevents vasoconstriction - take prescribed medications - increases blood flow and prevents blood clot development

The nurse is reviewing discharge instructions on home management for a client with peripheral arterial disease. Which statements indicate a correct understanding of the instructions? Select all that apply A. "I will apply moisturizing lotion on my legs every day" B. "I will elevate my legs at night when I am sleeping" C. "I will keep my legs below heart level when sitting" D. "I will start walking outside with my neighbor" E. "I will use a heating pad to promote circulation"

A In the event of an accidental decannulation or another urgent need to change a tracheostomy tube, the most important action is the quickly replace the tube as it is the client's only means to ventilate. Clients should always carry two spare tracheostomy tubes, one the same size and one a size smaller. If the tube is not easily replaced or is meeting resistance, the smaller tube should be used

The nurse is reviewing discharge instructions with the parents of a child who just had a tracheostomy. Which statement made by the parents indicates teaching has been effective? A. "I will always travel with two tracheostomy tubes, one of the same size and one a size smaller" B. "I will immediately change the tracheostomy tube if my child has difficulty breathing" C. "I will provide deep suctioning frequently to prevent any airway obstruction" D. "I will remove the humidifier if my child starts developing more secretions"

ABDE Option C: signs of retinal detachment include floaters, sudden flashes of light, and loss of vision. If signs of detachment occur, the surgeon should be notified immediately.

The nurse is reviewing discharge teaching for a client who had surgical repair of a retinal detachment. Which of the following instructions are appropriate for the nurse to include in the teaching? Select all that apply A. avoid rubbing or scratching the affected eye B. avoid straining when having a bowel movement C. except occasional flashes of light during recovery D. report any sudden pain to the health care provider E. rest the eyes of refraining from reading and writing

ABCE Option D: immunocompromised clients should not receive live attenuated vaccines. In addition, the vaccine is not indicated for a client who has already developed immunity after recovering from VZV infection

The nurse is reviewing discharge teaching with the parent of a child with acute myelogenous leukemia who was admitted with varicella-zoster virus. The client has multiple lesions that have not crusted. Which of the following instructions should the nurse include? Select all that apply A. "apply diphenhydramine cream sparingly to lesions after bathing your child" B. "keep giving your child the acyclovir at home as prescribed to fight the virus" C. "you can give your child acetaminophen for pain and fever" D. "your child should receive the varicella vaccine in 30 days" E. "your child will no longer be infectious after all the lesions have crusted over"

D An INR of 5.0 or higher places the client at risk for bleeding and requires a dosage adjustment of the warfarin or the administration of vitamin K as an antidote Option A: warfarin should not be administered with an INR of 5. The nurse should hold the dose until further instructions have been received by the HCP Option B: fresh, frozen plasma is considered when major bleeding is occurring related to warfarin overdose, but this is typically after the vitamin K has been administered Option C: protamine is the reversal agent for heparin overdoses

The nurse is reviewing laboratory data of a client who is receiving warfarin therapy for atrial fibrillation. Today's INR is 5.0. What action should the nurse take? A. administer the next scheduled dose of warfarin B. anticipate infusing fresh, frozen plasma C. call the pharmacy to see if protamine is available d. request a prescription from the health care provider for vitamin K

ABDE Option A: having multiple sexual partners (>1 lifetime partner) increases the chance of HPV exposure Option B: smoking tobacco is believed to promote cell mutation and increase the likelihood of HPV infection Option C: condoms help prevent HPV transmission between partners, and not taking oral contraceptives is associated with a decreased risk for cervical cancer Option D: being infected with other STIs increases the likelihood of HPV infection Option E: the most important risk factor for cervical cancer is persistent human papillomavirus (HPV) infection - a common, transient, and often asymptomatic sexually transmitted infection that can be identified in almost all clients with cervical cancer

The nurse is reviewing medical histories with several clients during a community health screening event. Which of the following client statements indicate a risk factor for cervical cancer? Select all that apply A. "I have had four sexual partners during my lifetime" B. "I have smoked cigarettes for many years" C. "I never used birth control pills because my partners wore condoms" D. "I received treatment for chlamydia when I was younger" E. "I tested positive for human papillomavirus a few years ago"

B Dicyclomine is an anticholinergic/antispasmodic drug prescribed to manage symptoms of intestinal hyper motility in clients with irritable bowel syndrome. Dicyclomine is contraindicated in clients with paralytic ileum as it decreases intestinal motility and would exacerbate the condition. The nurse should question this prescription and contact the health care provider Option A: tumor lysis syndrome occurs due to rapid lysis of cells and the resulting release of intracellular potassium and phosphorus into serum. Phosphorus binds to calcium, leading to hypocalcemia. The breakdown of cellular nucleic acids causes severe hyperuricemia. IV hydration and hypouricemic medications are prescribed to promote purine excretion and prevent acute kidney injury Option C: although opioids can cause constipation, symptoms can be managed with pharmacologic and nonpharmacologic interventions. Percutaneous nephrolithotripsy breaks and removes kidney stones, and can lead to severe pain. Therefore, pain medication is appropriate Option D: levofloxacin, a fluoroquinolone antibiotic prescribed to treat urinary tract infections, has no known cross-sensitivity to penicillin. However, cross-sensitivity with other fluoroquinolones can occur

The nurse is reviewing prescriptions for the assigned clients. Which prescription should the nurse question? A. allopurinol for a client who developed tumor lysis syndrome from chemotherapy with acute leukemia B. dicyclomine for a client with a history of irritable bowel syndrome who develops a postoperative paralytic ileus C. IV morphine for a client after percutaneous nephrolithotripsy who resorts the last bowel movement was 2 days ago D. levofloxacin for a client with a urinary tract infection who has a history of anaphylaxis to penicillin drugs

C Lavender aromatherapy is a safe, low-risk intervention to implement in conjunction with anxiolytic medications Options A & D: the herbal supplements kava and valerian root - both used for anxiety, insomnia, and depression - may increase central nervous system depression when used with benzodiazepines. Kava should not be combined with benzodiazepines because this increases the risk of hepatotoxicity Option B: melatonin is a hormone supplement used at bedtime to promote sleep and may increase drowsiness and CNS depression when taken with clonazepam. Combining melatonin with benzodiazepine medications can exaggerate side effects of the benzodiazepine

The nurse is reviewing teaching about newly prescribed clonazepam with a client who is receiving palliative care for cancer. Which client statement shows a correct understanding of the nurse's teaching? A. "I am glad that I can continue to take my kava supplement each morning" B. "if I can't sleep, I will take some melatonin with my evening dose of clonazepam" C. "if I feel restless, I can put some drops of lavender essential oil in a diffuser to calm myself" D. "when my anxiety is getting really intense, I will drink some valerian tea to help me relax"

D Desmopressin is a medication often used to treat central diabetes insipidus, a disease characterized by reduced antidiuretic hormone levels that may result in dehydration and hypernatremia. Desmopressin mimics the effects of naturally occurring ADH, which increases renal water resorption and concentrates urine. However, this effect also increases the risk for water intoxication from decreased urine output. Clients receiving desmopressin must have their fluid and electrolyte status closely monitored for symptoms of water intoxication/hyponatremia. The nurse should immediately notify the health care provider of client reports of water intoxication symptoms, as severe hyponatremia may progress to seizure, neurologic damage, or death

The nurse is speaking to a client who takes desmopressin nasal spray for diabetes insipidus. Which statement by the client is most important for the nurse to report to the health care provider? A. "I am tired of restricting my fluid but know I need to" B. "I feel like I am beginning to get sick with a bad cold" C. "I have been getting a lot of nasal pain with this spray" D. "I have recently started to experience frequent headaches"

D Option A: although orange juice is a source of vitamin C, it contains a large amount of sugar and lacks fiber. Toddlers should have no more than 4-6 oz of 100% fruit juice per day Option B: sweetened cereals, especially those marketed towards children, can be high in sugar and low in nutrients Option C: raw carrot sticks are hard and pose a choking risk. Parents should serve carrots and other hard vegetables grated or cooked

The nurse is teaching a class on nutrition and feeding practices for young children. What should the nurse recommend as the best snack for a toddler? A. 1/2 cup orange juice B. dry, sweetened cereal C. raw carrot sticks D. slices of cheese

ACDE Option B: cold water will cause vasoconstriction and worsen the condition Option C: implementing stress management strategies can prevent vasospasms

The nurse is teaching a client diagnosed with Raynaud phenomenon about ways to prevent recurrent episodes. Which instructions should the nurse include? Select all that apply A. avoid excessive caffeine B. immerse hands in cold water C. practice yoga or tai chi D. refrain from using tobacco products E. wear gloves when handling cold objects

C Option A: it is best to avoid naps during the day, especially later in the day. Any naps taken should be short (20-30 min) Option B: the client should keep the bedroom slightly cool, quiet, and dark for comfort Option D: as much as possible, the client should develop a consistent sleep-wake pattern to obtain 7-8 hours of sleep nightly

The nurse is teaching a client with insomnia about techniques to improve sleep habits. Which statement by the client requires further teaching? A. "I will avoid naps later in the day" B. "I will keep the bedroom temperature cool" C. "I will read in bed before trying to go to sleep" D. "I will try to go to bed and wake up at the same time each day"

C Option A: five to ten minutes per breast may be insufficient to feed and may lead to inadequate breast emptying and insufficient nutritional intake Option B: awkward manipulation of the head while breastfeeding makes it difficult for the newborn to latch and feed comfortably. The mother should support the newborn's head and keep it in alignment with the body in all breastfeeding positions Option D: if the newborn grasps the nipple only, breastfeeding will be painful due to pinching

The nurse is teaching a postpartum client about breastfeeding. Which statement by the client indicates a correct understanding of teaching? A. "I will feed my baby for 5-10 minutes on each breast" B. "I will hold my baby on their back with the head turned toward my breast" C. "If I need to reposition my baby's latch, I will use my finger to break the suction first" D. "the baby's mouth should grasp only the nipple without the areola"

A Clients should avoid sexual activity when lesions are present as the virus spreads through contact with the lesion; barrier contraception is not sufficient during an outbreak

The nurse is teaching self-care management to a client experiencing an outbreak of genital herpes. Which statement by the client indicates a need for further teaching? A. "I will be sure to use condoms during intercourse as long as I have lesions" B. "I will not touch the lesions to prevent spreading the virus to other parts of my body" C. "I will use a hair dryer on a cool setting to dry the lesions after taking a shower" D. "I will use warm running water and mild soap without perfumes to wash the area"

A A cone-tip applicator is used to instill the irrigation solution into the stoma. An enema should never be used to irrigate a colostomy. A cone-tip applicator is specifically made to avoid damage to the sensitive colostomy opening

The nurse is teaching the home health client how to perform colostomy irrigation. Which client action reveals that further teaching is required? A. attached an enema set to the irrigation bag, lubricates it, gently inserts it into the stoma, and holts it in place B. fills irrigation container with 500-1000 mL of lukewarm tap water and flushed the irrigation tubing C. hangs the irrigation container on a hook at the level of the shoulder approximately 22 inches above the stoma D. slowly opens the roller clamp, allowing the irrigation solution to flow, but clamps the tubing when cramping occurs

ADE Options B, C & F: these infants should not be rocked or agitated by active play for at least 30 minutes after feeding and should be kept calm and upright. Placing them on the stomach creates abdominal pressure, which can aggravate the reflux. Infants should not be placed in a car seat after feedings as this can increase intra-abdominal pressure and cause reflux

The nurse is teaching the mother of a newborn about gastoesophageal reflux. What does the nurse suggest to help prevent reflux? Select all that apply A. burp during and after feeds B. engage baby in active play after the feeding C. feed baby in side-lying position D. hold baby upright 20-30 minutes after each feeding E. offer smaller but more frequent feeds F. place baby on tummy after feeding

B Splenic sequestration crisis occurs when a large number of "sickled" cells get trapped in the spleen, causing splenomegaly. This is a life threatening emergency as it can lead to severe hypovolemic shock. The classic assessment finding is a rapidly enlarging spleen

The nurse is triaging a 7 year old with sickle cell crisis. The client is short of breath and vomiting and has severe generalized body and joint pains. Which assessment finding requires the most immediate intervention? A. blood work showing anemia B. enlarged spleen on palpation C. right arm weakness D. swelling of hands and feet

B Options A & C: clients who are expectant due to the severity of their injuries are the lowest priority for treatment. However, the nurse should provide palliative care, if possible, while addressing the needs of others Option D: clients with non urgent needs should receive treatment after emergent and urgent clients

The nurse is triaging victims at the site of a mass casualty incident. Which victim should be seen first? A. client with a head injury and fixed, dilated pupils B. client with an open right femur fracture and palpable pedal pulses C. client with full-thickness burns covering 85% total body surface area D. client with shallow lacerations over legs and arms

ABD Option C: when the child is visibly upset, it is important to provide a calming presence and implement strategies to reduce the child's anxiety. Leaving the child alone at such times can further increase stress Option E: providing pictures of the child's family is actually beneficial, as it remains the child of something familiar and safe

The nurse on a pediatric unit is caring for a preschooler who exhibits separation anxiety when the parents go to work. Which interventions should the nurse implement? Select all that apply A. encourage the parents to leave the child's favorite stuffed animal B. establish a daily schedule similar to the child's home routine C. give the child time to calm down alone when visibly upset D. provide frequent opportunities for play and activity E. remove visual reminders of the parents from the room

A Option B: UC is an inflammatory bowel disease; fever and lower-quadrant abdominal cramping are expected findings. After assessing the client, the nurse will administer an analgesic and an antipyretic as prescribed Option C: the client is on telemetry; in most facilities, if dysrhythmias occur, the monitor technician/nurse will notify the primary care nurse immediately. The goal INR is 2.0 to 3.0 for atrial fibrillation. An INR of 3.2 is expected when adjusting the warfarin dose Option D: the nurse should perform a baseline assessment before dialysis is initiated. The nurse should then prepare the client by making sure the client eats breakfast, administering prescribed morning medications that are not dialyzed out, and holding those that are dialyzed out. Elevated creatinine level is an expected finding. (normal 0.6-1.3 mg/dL)

The nurse on the medical unit finishes receiving the change of shift hand-off report at 7:30 AM. Which assigned client should the nurse see first? A. client with a gastrointestinal bleed, who is receiving a unit of packed red blood cells B. client with an ulcerative colitis flare-up has temperature of 101 F and abdominal cramping C. client with atrial fibrillation, on telemetry, prescribed warfarin, with an International Normalized Ratio (INR) of 3.2 D. client with chronic kidney disease scheduled for bedside hemodialysis at 8:00 AM, with a serum creatinine of 8.4 mg/dL

B Displacement, one of many ego defense mechanisms, occurs when a person shifts uncomfortable feelings or impulses about one situation or person to a substitute situation or person deemed acceptable to receive these uncomfortable feelings or impulses. Compensation involves experiencing a perceived deficit in one area and making up for it by overachieving in another. Projection involves feeling uncomfortable with an impulse or feeling and easing the anxiety by assigning it to another person. An example is a husband with thoughts of infidelity who then accuses his wife of being unfaithful. Reaction formation involves transforming an unacceptable feeling or impulse into its opposite. An example is a client with cancer who fears dying by behaves in an overly optimistic and fearless manner about his treatment and prognosis.

The nurse on the mental health unit recognizes the use of which defense mechanism when a client leaves a stressful family meeting and immediately begins to verbally abuse a roommate? A. compensation B. displacement C. projection D. reaction formation

ABDE Option C: persons with PTSD are typically restless and hyper vigilant and have trouble falling or staying asleep

The nurse performs an initial assessment on a client with suspected post-traumatic stress disorder. Which assessments would support this diagnosis? Select all that apply A. difficulty concentrating B. feeling detached from others C. feeling lethargic and apathetic D. flashbacks of the traumatic event E. persistent angry, fearful mood

D An increase in BP of ≥30 mm Hg systolic or ≥15 mm Hg diastolic over pre/early pregnancy measurements, even in the absence of hypertension, is a deviation from normal physiologic BP responses in pregnancy and requires further assessment for other signs/symptoms Option A: early in the first trimester, minimal weight gain is expected for clients with a normal BMI Option B: occasional headaches relieved by acetaminophen may be normal for some pregnant clients. Severe, frequent, or worsening headaches require further assessment Option C: hyperemic gums are common in pregnancy and may be susceptible to mild bleeding during brushing. Gentle cleaning with a soft toothbrush may help prevent bleeding

The nurse performs initial assessments of four clients in a prenatal clinic. Which client findings are abnormal and require further assessment? A. client at 9 weeks gestation with a normal BMI and a weight gain of 2 lb from pre-pregnancy weight B. client at 15 weeks gestation with headaches relieved by acetaminophen C. client at 19 weeks gestation with bleeding gums after brushing and flossing teeth D. client at 20 weeks gestation with an increase in diastolic blood pressure of 15 mm Hg since last visit

C Hemophilia is a bleeding disorder caused by a deficiency in coagulation proteins. Clients with classic hemophilia, or hemophilia A, lack factor VIII. Clients with hemophilia B lack factor IX. When injured, clients with hemophilia should be monitored closely for external as well as internal bleeding. The most frequent sites of bleeding are the joints, especially the knee. Hemarthrosis can occur with minimal or no trauma, with episodes beginning during toddlerhood when the child is active and ambulatory. Over time, chronic swelling and deformity can occur

The nurse planning teaching for the parents of a child newly diagnosed with hemophilia will include information about which long-term complication? A. heart valve injury B. intellectual disability C. joint destruction D. recurrent pneumonia

C If the client consumes alcohol while taking disulfiram, unpleasant side effects (headache, intense nausea/vomiting, flushed skin, sweating, dyspnea, confusion, tachycardia, hypotension) can occur.

The nurse provides teaching for a client newly prescribed disulfiram for alcohol abstinence Which information is the priority for the nurse to include? A. disulfiram is not a cure for alcoholism B. importance of continuing to see a therapist C. list of everyday items containing hidden alcohol D. medical alert bracelet should identify disulfiram therapy

ADE Option B: an erythematous, maculopapular, morbilliform rash is characteristic of measles, but it is not typically pruritic. Calamine lotion is effective for soothing pruritic rashes Option C: a tracheostomy tray is not required for this client with measles because respiratory paralysis or emergency intubation is not expected

The nurse plans care for a child admitted with measles. Which of the following interventions will the nurse include in the plan of care? Select all that apply A. advise measles vaccination for susceptible family members B. apply calamine lotion to reduce itching C. place a tracheostomy tray at the bedside D. place the client in a negative-pressure isolation room E. use a N95 respirator mask during client contact

CE Levothyroxine is used to replace thyroid hormone in clients with hypothyroidism and for those who have had their thyroid removed. These clients must understand that this medication must be taken for the rest of their lives. A client's dose is adjusted based on serum TSH levels to prevent too much or too little hormone. Clients must be taught to report signs of excess thyroid hormone such as heart palpitations/tachycardia, weight loss, and insomnia

The nurse plans teaching for a client who was newly prescribed levothyroxine sodium after thyroid removal. Which instructions will the nurse include in the teaching plan? Select all that apply A. drowsiness is a common side effect; taking the dose at bedtime will make this less noticeable B. notify the health care provider if you become pregnant as the medication is harmful to the fetus C. notify the health care provider if you feel a fluttering or rapid heartbeat D. take the medication with a meal to prevent stomach upset E. you will need to take this medication for the rest of your life

A Children are often fearful of injections, exhibiting unpredictable and/or uncooperative behavior. The nurse should explain the procedure to the child using simple, age-appropriate language to reduce anxiety. According to Piaget's cognitive developmental stages, school-age children develop concrete thought and may fear a loss of control. To improve the child's sense of control, the nurse should offer a specific, task-based coping technique

The nurse prepares a 7 year old client for an influenza injection. The nurse explains that the client will receive "medicine under the skin," and the client is visibly anxious. Which nursing intervention is appropriate? A. ask the child to count to 10 during injection B. ask the parent to hold the child's arms tightly C. explain to the child that the injection will not hurt D. keep the injection needle out of the child's view

ABCDE Postmenopausal women should consume plenty of calcium-rich foods (dairy products; green, leafy vegetables), engage in weight-bearing exercise, monitor cholesterol levels, consider dietary counseling to maintain healthy weight, eat a diet rich in fruits and vegetables, and seek support for any emotional symptoms

The nurse prepares a community education program about health promotion strategies for postmenopausal women. Which of the following teaching points are appropriate to include? Select all that apply A. consider seeing a dietitian for help with healthy weight maintenance B. consult with a health care provider for cholesterol monitoring C. engage in a daily weight-bearing exercise program D. prioritize consumption of green, leafy vegetables and dairy products E. seek support to cope with any emotional symptoms

ACE Beta blockers and angiotensin-converting enzyme inhibitors are antihypertensive medications. The nurse should assess blood pressure prior to administration. Beta blockers lower heart rate by blocking the action of beta receptors that increased heart rate and contractility. The nurse should assess blood pressure and heart rate prior to administration. ACE inhibitors increase serum potassium by decreasing urinary potassium excretion. The nurse should assess blood pressure and serum potassium levels prior to administration

The nurse prepares to administer 9:00 AM medications to a client. Which data should the nurse evaluate prior to administration? Select all that apply A. blood pressure B. blood sugar C. heart rate D. international normalized ratio E. potassium level

AB Vancomycin is a glycopeptide antibiotic that is excreted by the kidneys. It is used to treat serious infections with gram-positive microorganisms and diarrhea associated with C-diff. BUN and creatinine levels are monitored regularly in clients receiving the drug due to increased risk of nephrotoxicity, especially in those with impaired renal function, receiving aminoglycosides, and who are > 60 years old. Option C: an elevated BGL is expected in a client with an infection due to physiological stress and gluconeogenesis; this does not need to be reported to the HCP Option D: a hemoglobin level of 15 g/dL is normal and does not need to be reported to the HCP Option F: a white blood cell count of 14,000/mm3 is elevated and expected in a client with a serious infection; this does not need to be reported to the HCP

The nurse prepares to administer IV vancomycin to an 80 year old client with a methicillin-resistant staphylococcus aureus infection. The nurse should notify the health care provider about which serum laboratory results before administering the drug? Select all that apply A. blood urea nitrogen is 60 mg/dL B. creatinine is 2.1 mg/dL C. glucose is 140 mg/dL D. hemoglobin is 15 mg/dL E. magnesium is 1.5 mEq/L F. white blood cell count is 14,000/mm3

ABCE Option D: enemas are administered at room temperature or warmed, as cold enema solutions cause intestinal spasms and painful cramping. Enemas may be warmed by placing the container of solution in a basin of hot water

The nurse prepares to administer a cleansing enema to a client with constipation. Which interventions are appropriate? Select all that apply A. assist the client into left lateral position with right knee flexed B. encourage the client to retain the enema for as long as possible C. insert tubing into the rectum with the tip directed toward the umbilicus D. keep the enema solution refrigerated until ready to administer E. slow administration rate if the client reports abdominal cramping

C The recommended rates for an intermittent IV infusion of potassium chloride are no greater than 10 mEq over 1 hour when infused through a peripheral line and no greater than 40 mEq/hr when infused through a central line. If the nurse were to administer the medication as prescribed, the rate would exceed the recommended rate of 10 mEq/hr. A too rapid infusion can lead to pain and irritation of the vein and post infusion phlebitis

The nurse prepares to administer an IV infusion of potassium chloride through a peripheral vein to a client with hypokalemia. The health care provider's prescription states: IV potassium chloride 10 mEq (10 mmol)/100 mL 5% dextrose in water now, infuse over 30 minutes. What is the nurse's priority action? A. assess the potency of the peripheral IV site B. check the most current serum potassium level C. contact the health care provider to verify the prescription D. set the electronic IV pump to 100 mL/hr

B Clozapine is highly effective at controlling schizophrenia; however, it has many severe, life-threatening adverse effects, including agranulocytosis, cardiac disease, and seizures. Agranulocytosis increases the risk for infection. Clients require serial monitoring of white blood cell counts and frequent assessment for signs of infection, which should be reported immediately to the health care provider. Option A: weight gain is a common side effect. Clients should be educated about weight management. Option C: hypersalivation and drooling are common side effects. When excessive, they can occasionally pose risk for aspiration, especially while the client is sleeping. This is important but not an immediate priority. Option D: many clients experience significant sedation when the medication is started. Most will develop tolerance to this and eventually improve

The nurse prepares to administer clozapine to a client with schizophrenia. Which client statement would require priority investigation before administering the medication? A. "I have gained a few pounds since I started this medication" B. "I have had a sore throat for 3 days and feel feverish today" C. "I have noticed increased salivation and drooling" D. "I often feel sleepy when I take this medication"

C Postpartum hemorrhage may be primary (<24 hours since birth) or secondary/delayed (>24 hours but <6 weeks postpartum). Secondary PPH usually results from uterine sub involution, retained placental fragments/membranes, or uterine infection. Option A: postpartum fatigue is common due to the adjustments needed to provide newborn care or may be related to postpartum anemia. Follow up is necessary, but it is not the most concerning statement Option B: bright red bleeding with defecation is associated with hemorrhoids, a common finding in pregnancy. Hemorrhoids usually begin to shrink following birth Option D: physiologic fluid retention in pregnancy may cause medial nerve compression, an expected discomfort of pregnancy marked by a tingling or burning sensation of the hands

The nurse provides a follow-up phone call to a client who gave birth at a birthing center 5 days ago. Which statement by the client should the nurse be most concerned about? A. "I am really tired all of the time since giving birth" B. "I saw some bright red blood in my bowel movement yesterday" C. "my bleeding is like a really heavy period with some blood clots" D. "my hands feel tingly when I hold the baby for a long time"

B A cervical cerclage is placed to prevent preterm delivery, usually in clients with histories of second trimester loss or premature birth. A heavy suture is placed transvaginally or transabdominally to keep the internal cervical os closed. Placement occurs at 12-14 weeks gestation for clients with a history of cervical insufficiency or up to 23 weeks gestation if signs of cervical insufficiency Discharge instructions include activity restriction and recognition of signs of preterm labor (low back aches, contractions, pelvic pressure) and rupture of membranes

The nurse provides discharge instructions to a client at 14 weeks gestation who has received a prophylactic cervical cerclage. Which client statement indicates an understanding of teaching? A. "I need to be on bed rest for the duration of my pregnancy" B. "I will notify my health care provider if I start having low back aches" C. "pelvic pressure is to be expected after cerclage placement" D. "the cerclage will be removed once my baby is at 28 weeks"

BCD Option A: clients do not need to avoid traveling in a car or airplane. However, during extended travel (>4 hours), clients must use preventative measures Option E: clients should avoid crossing the legs at the knees or ankles because this compresses the veins and limits venous return

The nurse provides discharge instructions to a client who was hospitalized for deep venous thrombosis that is now resolved. Which of the following instructions should the nurse include to prevent the reoccurrence of DVT? Select all that apply A. "do not take car rides longer than 4 hours for at least 3-4 weeks" B. "drink plenty of fluids every day and limit caffeine and alcohol intake" C. "elevate legs on a footstool when sitting and dorsiflex the feet often" D. "resume your walking program as soon as possible after getting home" E. "sit in a cross-legged position for 5-10 minutes to improve circulation"

CDE Option A: malnutrition is not commonly associated with hemophilia; a regular diet is indicated. Clients with cystic fibrosis are at risk for malnutrition and need a high-calorie diet Option B: dehydration is not commonly associated with hemophilia. Avoiding dehydration is important for those with sickle cell anemia

The nurse provides discharge teaching for the parents of a child newly diagnosed with hemophilia A. Which statements by the parents indicate that teaching has been effective? Select all that apply A. " a high-calorie, high-protein diet is best for our child" B. "it is extremely important that we do not allow our child to become dehydrated" C. "our child should wear a medical alert bracelet at all times" D. "we should avoid giving our child over-the-counter medicine containing aspirin" E. "we should encourage a noncontact sport such as swimming"

ABCD Von willebrand disease is a genetic bleeding disorder caused by a deficiency of von willebrand factor, which plays an important role in coagulation. Intranasal desmopressin or topical therapies may be prescribed to stop minor bleeding, whereas major bleeding may require replacement of vWF. Clients should wear medical identification bracelets in case of emergency. Option E: clients should avoid medications that can exacerbate bleeding, including aspirin and NSAIDs. Clients should instead use the mnemonic RICE (rest, ice, compression, elevation) to help with pain and inflammation

The nurse provides home care education to a client newly diagnosed with von Willebrand disease. Which of the following client statements demonstrate correct understanding of the education? Select all that apply A. "I can use a humidifier to help prevent nosebleeds" B. "I need to avoid contact sports such as soccer or hockey" C. "I should use a soft-bristled toothbrush and floss carefully" D. "I will call my health care provider if I soak a menstrual pad every hour" E. "I will take naproxen to decrease inflammation if I am injured"

C Methotrexate is classified as a folate antimetabolite, antineoplastic, immunosuppressant drug used to treat various malignancies and as a nonbiologic disease-modifying anti rheumatic drug (DMARD) used to treat rheumatoid arthritis and psoriasis. Methotrexate can cause bone marrow suppression resulting in anemia, leukopenia, and thrombocytopenia. Leukopenia and its immunosuppressant effects can increase susceptibility to infection. Clients should be educated about obtaining routine killed (inactivated) vaccines and avoiding crows and persons with known infections. Live vaccines are contraindicated in clients receiving immunosuppressants, such as methotrexate

The nurse provides teaching about methotrexate to a client with rheumatoid arthritis. It is most important to address which topic regarding this drug? A. need for an eye examination B. need for sunblock C. risk for infection D. risk for kidney injury

A Hemophilia is a bleeding disorder caused by a deficiency in coagulation proteins. Treatment consists of replacing the missing clotting factor and teaching the client about injury prevention. Clients with hemophilia who are injured should be monitored closely for bleeding. Signs of an intracranial bleed include lethargy, headache, irritability and vomiting. An intracranial bleed is lethal if unchecked, so administration of factor VIII to a client with hemophilia A is the first order of action, followed by a CT scan

The nurse receives 4 prescriptions for a child diagnosed with hemophilia A who was brought to the emergency department following an injury on the school playground. The child has vomited once and has a headache. Which prescription should the nurse carry out first? A. administer IV factor VIII B. administer IV ondansetron C. blood draw for hemoglobin D. CT scan of the head

D Head tilt and chin lift is a maneuver used to open the airway. The tongue may fall back and occlude the airway due to muscular flaccidity after general anesthesia. Manifestations associated with airway obstruction include snoring, use of accessory muscles, decreased oxygen saturations and cyanosis

The nurse receives an obese client in the post-anesthesia care unit who underwent a procedure under general anesthesia. The nurse notes an oxygen saturation of 88%. Which is the most appropriate initial intervention? A. assess pupillary response B. auscultate lung sounds C. inform anesthesia professional D. perform head tilt and chin lift

C Epiglottitis, a sudden-onset medical emergency due to Haemophiulus influenzae, causes severe inflammatory obstruction above and around the epligottits. The affected child will typically progress from having no symptoms to having a completely occluded airway within hours. Option A: oxygen saturation ≥90% is the treatment goal for bronchiolitis caused by respiratory syncytial virus Option B: this temperature is an expected finding in the setting of otitis media and does not carry the urgency of airway impairment Option D: a barking-type cough is seen in viral coup syndromes. The resonant hoarse cough is secondary to narrowed airways. Croup is typically mild but can become life-threatening if the airway swells excessively. This child would need to be assessed next

The nurse receives change of shift report on 4 clients. Which client should the nurse assess first? A. 6 month old with respiratory syncytial virus and pulse oximetry of 90% B. 1 year old with otitis media and a temperature of 102.5 F rectally C. 2 year old with suspected epiglottitis D. 3 year old who has a barking-type cough

A The client's non palpable pedal pulse that is present only with doppler distal to the graft can indicate compromised blood flow or graft occlusion and should be reported to the health care provider immediately. Option B: chronic venous insufficiency is the inability of the leg veins to efficiently pump blood back to the heart. It can lead to venous stasis, increased hydrostatic pressure, and venous leg ulcers. Edema and thick skin with brown pigmentation are expected manifestations, so this is not the priority assessment Option C: gangrene of the foot is a complication of peripheral arterial disease associated with decreased blood flow to the extremity. Coolness of the skin and shiny, hairless legs, feet and toes are expected manifestations of PAD, so the nurse would not assess this client first Option D: intermittent claudication is leg pain caused by decreased blood flow to the muscles that reoccurs during activity such as walking and dissipates with rest. It is an expected manifestation of PAD of the lower extremities, so the nurse would not assess this client first

The nurse receives hand-off report on assigned clients. Which client should the nurse assess first? A. client 1 day post femoral-popliteal bypass surgery who now has a non palpable pedal pulse present only with doppler B. client with chronic venous insufficiency who has edema and brown discoloration of the lower extremities C. client with peripheral arterial disease and gangrene of the foot who has a cool-to-the-touch, hairless extremity D. client with peripheral arterial disease who reports severe cramping pain in the calf with activity such as walking

B Asthma exacerbations may require repeat nebulization every 20 minutes, or continuous nebulization for 1 hour, to relieve severe bronchoconstriction until the administered corticosteroids take effect and start to reduce the inflammation

The nurse receives handoff of care report on four clients. Which client should the nurse assess first? A. client 1 day post-thoracotomy wedge resection who has subcutaneous emphysema at the chest tube insertion site B. client with asthma who reports shortness of breath following an albuterol nebulizer treatment 15 minutes ago C. client with COPD exacerbation who is receiving bi-level positive airway pressure (BIPAP) therapy and has a pulse oximetry reading of 90% D. client with leg cellulitis following a spider bite who needs the IV restarted to initiate prescribed antibiotics

A Convenience or replacement for nursing care when the client is elderly, confused, incontinent or voids frequently is inappropraite

The nurse reviews a prescription to insert an indwelling urinary catheter in a hospitalized client. Which rationale for indwelling urinary catheter insertion is most appropriate? A. the client has acute urinary retention B. the client is confused and incontinent C. the client is elderly and at risk for falls D. the client is receiving intravenous diuretics

C Options A & B: addressing a client's postoperative pain and nausea and further assessing a client with hyperglycemia and diabetes are important but are lower priorities than initiating care for SIRS Option D: a client with persistent diarrhea should have both total intake and output and recent electrolyte levels assessed, but signs of SIRS should be addressed first

The nurse receives handoff of care report on four clients. Which client should the nurse assess first? A. client who had an appendectomy today and reports severe nausea and 8 out of 10 pain B. client with a diabetic foot ulcer who has current blood glucose level of 301 mg/dL C. client with a fever of unknown origin whose arterial blood gas reveals PaCO2 30 mm Hg D. client with persistent diarrhea who has continuous lactated ringer solution IV infusing at 125 mL/hr

C If pericardial effusions accumulate rapidly or are very large, they may compress the heart, altering the mechanics of the cardiac cycle. Cardiac tamponade decreases atrioventricular filling and impairs the heart's ability to contract and eject blood; it is life threatening without prompt recognition and treatment

The nurse receives handoff of care report on four clients. Which client should the nurse see first? A. client with atrial fibrillation who reports feeling palpitations and has an irregular pulse of 122/min B. client with liver cirrhosis who reports bleeding from an IV insertion site and has a platelet count of 48,000 mm3 C. client with pericarditis whose blood pressure has decreased from 122/70 mm Hg to 96/68 mm Hg over the past hour D. client with pneumonia whose white blood cell count has increased from 14,000 mm3 8 hours ago to 30,000 mm3

C Pregnant clients, especially those with placental abruption and intrauterine fetal demise, are at risk for disseminated intravascular coagulation (DIC). Thromboplastin from the retained dead fetus activates the clotting cascade, followed by consumption of clotting factors and platelets that leads quickly to life-threatening external and internal bleeding

The nurse receives report for a client at 36 weeks gestation who is being transferred to the unit for labor induction from a rural health care facility with an intrauterine fetal demise of unknown duration. Which intervention is most important when receiving care of the client? A. apply tocodynamometer and evaluate current contraction pattern B. ask the client about the family's desire for speaking with a chaplain C. draw coagulation tests, fibrinogen, and complete blood count with platelets D. initiate oxytocin prescription to begin induction of labor

C The nurse should first assess the client showing symptoms of a deep vein thrombosis. DVT is a postoperative complication related to venous stasis and subsequent thrombosis.

The nurse receives report on 4 assigned clients. Which client should the nurse assess first? A. client 1 hour post laparoscopic cholecystectomy for gallstones who reports right shoulder pain B. client 4 hours post tracheostomy who has a small amount of pink drainage on the tracheostomy dressing C. client 48 hours post abdominal hysterectomy who is ambulatory and reports aching in the right leg D. client 3 days post open gastric bypass who reports fever and foul-smelling discharge at the surgical site

A Amyotrophic lateral sclerosis (ALS) is characterized by the progressive loss of motor neurons in the brainstem and spinal cord. The client with ALS and worsening ability to speak may also have dysphagia and respiratory distress; this client should be seen first.

The nurse receives report on 4 clients. Which client should be seen first? A. client with amyotrophic lateral sclerosis experiencing increased dysarthria B. client with chronic obstructive pulmonary disease reporting increasing leg edema C. client with strep throat and a fever of 102 F on antibiotics for 12 hours D. client with urolithiasis reporting wavelike flank pain and nausea

C A new-onset finding is more concerning that chronic or expected findings. There is a risk of spinal cord compression from a metastatic tumor in the epidural space. The classic symptoms are localized, persistent back pain; motor weakness; and sensory changes. There can also be autonomic dysfunction, reflected by bowel or bladder dysfunction

The nurse receives report on the assigned team of clients on the oncology unit. All are receiving chemotherapy. Which client should the nurse check on first? A. alopecia nad oral mucositis noted on assessment B. morning hemoglobin result is 8 g/dL C. new onset back pain and weakness in legs D. persistent vomiting and potassium results is 3.4 mEq/L

B The nurse should assess first the newly admitted client with gastroenteritis as prolonged vomiting increases the risk for dehydration, acid-base and electrolyte disturbances and potential cardiac dysrhythmias. The client is exhibiting manifestations of hypokalemia, including muscle cramps and muscle weakness. Hypokalemia can lead to dangerous cardiac arrhythmias

The nurse receives the hand-off shift report on assigned clients. Which information is most concerning and prompts the nurse to assess that client first? A. client 1 day post colon resection who is receiving continual epidural morphine and reports severe itching B. client admitted 2 hours ago with gastroenteritis who has been vomiting for 36 hours and has muscle cramps and weakness C. client who has received IV bumetanide for 3 days for heart failure and experiences dizziness when standing up D. client with acute post streptococcal glomerulonephritis who is receiving antibiotics and has gross hematuria

ABCD Option E: providing a night light in the sleeping area can prevent falls, aid in orientation, and decrease illusions

The nurse reinforces education about safety modifications in the home for the spouse of a client diagnosed with Alzheimer disease. What instructions should the nurse include? Select all that apply A. arrange furniture to allow for free movement B. keep frequently used items within easy reach C. lock doors leading to stairwells and outside areas D. place an identifying symbol on the bathroom door E. provide a dark room free of shadows for sleeping

D Cane length should equal the distance from the client's greater trochanter to the floor as incorrect cane length can cause back injury Option A: hold the cane on the stronger side to provide maximum support and body alignment, keeping the elbow slightly flexed Option B: for maximum stability, move the weaker leg forward to the level of the cane, so that body weight is divided between the cane and the stronger leg Option C: place the cane 6-10 inches in front of and to the side of the foot to keep the body weight on both legs to provide balance

The nurse reinforces the physical therapist's teaching regarding the use of a cane when caring for a client with osteoarthritis of the left knee. Which client statement indicates the need for further teaching? A. "I will hold the cane in my right hand" B. "I will move my left leg forward after moving the cane" C. "I will place the cane several inches in front of and to the side of my right foot" D. "my cane should equal the distance from my waist to the floor"

ABE Option A: amitriptyline is a tricyclic antidepressant used to treat depression and neuropathic pain; its anticholinergic properties may cause dry mouth, constipation, blurred vision and dysrhythmias Option B: chlorpheniramine is a sedating histamine H1 antagonist used to treat allergy symptoms. Increased central nervous system effects may occur due to its reduced clearance in the elderly Option E: lorazepam is a benzodiazepine with a long half-life. Side effects include drowsiness, dizziness, ataxia and confusion

The nurse reviews an elderly client's medication administration record and identifies which prescriptions as having the potential for injury in the elderly? Select all that apply A. amitriptyline B. chlorpheniramine C. docusate D. donepezil E. lorazepam

BDE Option A: COPD may lead to polycythemia (increased red blood cells), in which the body attempts to compensate for chronic hypoxia by increased proliferation of erythrocytes. This occurs when erythropoietin is released from the kidneys in response to hypoxemia and least to erythropoiesis. This ultimately has the opposite effect of anemia, making supplementation with iron not necessary and possibly even harmful Option C: clients with COPD have increased work of breathing and are often winded by simple activities. Clients should eat frequent, small, high-calorie meals to conserve energy and meat nutritional requirements

The nurse reviews discharge instructions with a client who has advanced chronic obstructive pulmonary disease. Which client statement indicates appropriate understanding? Select all that apply A. "I need to take iron supplements to prevent anemia" B. "I should report an increase in sputum" C. "I will eat a low-calorie diet" D. "I will get a pneumococcal vaccine" E. "I will use albuterol if I am short of breath"

C This client who was prescribed spironolactone, a potassium-sparing diuretic that counteracts the potassium loss caused by other diuretics, has high serum potassium. The continuation of this medication puts the client at risk for life-threatening hyperkalemia-induced cardiac dysrhythmias. This finding is of highest priority for the nurse to follow-up with the health care provider

The nurse reviews the assigned clients' laboratory results and medication administration records. Which finding is the highest priority for the nurse to follow-up with the health care provider? A. gram-negative infection and positive blood cultures in a client prescribed tobramycin B. serum b-type natriuretic peptide 650 pg/mL in a client prescribed furosemide C. serum potassium 5.7 mEq/L in client prescribed spironolactone D. serum sodium 132 mEq/L in a client prescribed IV normal saline solution at 175 mL/hr

AD Bumetanide is a potent loop diuretic used to treat edema associated with heart failure and liver and renal disease. The diuretic inhibits reabsorption of sodium and water from the tubules and promotes renal excretion of water and potassium. The nurse should question he bumetanide prescription as the client with heart failure has hypokalemia and is already at increased risk for life-threatening cardiac dysrhythmias associated with this electrolyte imbalance Isoniazid is a first-line anti tubercular drug used to treat latent or active tuberculosis. The nurse should question this prescription as increased liver function tests can indicate development of drug-induced hepatitis

The nurse reviews the serum laboratory results and medication administration records for assigned clients. Which prescriptions should the nurse question and validate with the health care provider before administering? Select all that apply A. bumetanide in the client with heart failure who has hypokalemia B. calcium acetate in the client with chronic kidney disease who has hyperphosphatemia C. carvedilol in the client with heart failure who has an elevated B-type natriuretic peptide level D. isoniazid in the client with latent tuberculosis who has elevated liver enzymes E. metronidazole in the client with clostridium difficile infection who has leukocytosis

A Increased creatinine (normal 0.6-1.3 mg/dL), increased blood urea nitrogen (normal 6-20 mg/dL), and an abnormal urinalysis can indicate the presence of lupus nephritis, a potentially serious complication of SLE. Option B: an elevated ESR (normal <30 mm/hr), can indicate the presence of an active inflammatory process and would be expected in a client with an inflammatory disease such as SLE, especially during a disease flare. Option C: a positive antinuclear antibody (ANA) titer (>1:40) indicates the presence of ANAs, which the body produces against its own DNA and nuclear material. This would be expected in a client diagnosed with SLE Option D: anemia, mild leukopenia (white blood cell count <4,000/mm3) and thrombocytopenia (platelet count <150,000/mm3) are often present in SLE. The nurse would report these to the health care provider, but they are not of greatest concern

The nurse reviews the serum laboratory results of a client who was seen in the clinic 2 days ago for worsening joint pain from a flare up of systemic lupus erythematous. Which result is of greatest concern and prompts the nurse to notify the health care provider? A. creatinine of 1.8 mg/dL B. elevated erythrocyte sedimentation rate C. positive antinuclear antibody titer D. white blood cell count of 3,600/mm3

D NPH is an intermediate-acting insulin with a duration of 12-18 hours; it is generally prescribed 2 times daily (morning and evening). Regular insulin and other rapid-acting insulins (lispro, aspart, glullisine) are typically used with a sliding scale for tighter control of blood glucose throughout the day. These are generally taken before meals and at bedtime

The nurse teaches a client about the use of regular and neutral protamine Hagedorn (NPH) insulin. Which statement by the client indicates that further teaching is needed? A. "I will always check my blood glucose prior to using the sliding scale" B. "I will eat breakfast 30 minutes after taking my morning NPH and regular insulin" C. "I will use a new insulin syringe each time I give myself an injection" D. "I will use the sliding scale to determine my NPH dose 4 times a day"

C This client is exhibiting signs and symptoms of neuroleptic malignant syndrome, a rare but potentially life-threatening reaction. NMS is most often seen with the "typical" antipsychotics. However, even the newer "atypical" antipsychotic drugs can cause the syndrome. The most important intervention is to immediately discontinue the antipsychotic medication and notify the HCP for further assessment

The nurse working on the inpatient psychiatric unit is preparing to administer 9:00 AM medications to a client. The medication administration record is shown. On assessment, the client is tremulous, exhibits muscle rigidity, and has a temperature of 101.1 F. Which action should the nurse take? A. give all medications, including acetaminophen, and reassess in 30 minutes B. hold the haloperidol, give acetaminophen, and reassess in 30 minutes C. hold the haloperidol and notify the health care provider immediately D. hold the hydrochlorothiazide and notify the HCP immediately

ADE Option B: desquamation (peeling skin) is a normal finding is some newborns, especially those born at late- or post-term gestation. Moisturizers can be applied if desired, but desquamation resolves on its own over several days Option C: average newborn head circumference is approximately 13-14 in. A smaller or larger head circumference may indicate an abnormal condition

The nursery nurse is performing assessments of several newborns. Which of the following findings are abnormal and need to be reported to the health care provider? Select all that apply A. chest wall retractions B. desquamation of the feet C. head circumference of 13.5 in D. jaundiced appearance E. no voiding in 24 hours

ABC Option D: positioning a child with epistaxis in a horizontal position or with the head tilted backward promotes drainage of blood into the throat, which increases the risk of swallowing or aspirating blood. Clients with epistaxis should sit upright and tilt the head forward Option E: epistaxis is typically managed at home. However, the caregiver should seek emergency care if the client's breathing is impaired, or the bleeding is excessive or uncontrollable with home measures or resulted from a traumatic injury

The parent of a 5 year old child calls the clinic to report the recurrence of a nosebleed for which the child was seen a week ago. Which of the following instructions should the nurse reinforce? Select all that apply A. apply a cold cloth to the bridge of the nose B. apply pressure by pinching the nostrils together C. attempt to keep the child calm and quiet D. have the child lie down and turn to the left side E. take the child to the emergency department

D The recommendation for re-warming is immersion of the affected area in warm water for about 30 minutes or until the area turns pink in cases of frostbite. The face and ears can be re-warmed with the application of warm facecloths

The parent of a 6 year old calls the nurse and reports that the child was playing outside in the snow and the child's feet now appear red and swollen. What is the best response by the nurse? A. "bring the child to the health care providers office immediately" B. "give your child something warm to drink" C. "massage the child's feet gently until they warm up" D. "place the child's feet in warm water immediately"

A The CDC recommends that the first dose of MMR vaccine be given to children between age 12-15 months to ensure optimal vaccine response. However, the vaccine is safe for children age <12 months; it could provide some protection or modify the clinical course of the disease if administered within 72 hours of a child's initial measles exposure. A child who receives the MMR vaccine prior to the first birthday will need to be revaccinated at age 12-15 months and again between age 4-6 years

The parent of an 11 month old child calls the pediatric outpatient clinic and tells the nurse that the child was exposed to measles 2 days ago during a family trip to a theme park. What is the best response by the nurse? A. bring the baby into the clinic for measles, mumps, rubella vaccine B. check the baby's temperature twice a day C. do not allow the child to have contact with other children D. does your child have a fever or rash?

A Children age 3-6 are in Piaget's preoperaitonal stage of cognitive development. At age 5, children are not able to fully understand cause and effect and will therefore ascribe inappropriate causes to phenomena (eg, scraped knee was caused by earlier misbehavior) Five-year-olds are developmentally capable of understanding adoption on a basic level; however, it may be difficult for them to understand the concept of having another family. The child might notice that friends are not adopted. Preschool-age children Amy also believe they are responsible for being adopted and may develop separation issues and fear abandonment

The parents of a 5 year old ask the school nurse for advice on how to tell their child about being adopted. Which developmentally appropriate thought about adoption by the child does the nurse counsel the parents to anticipate? A. feels responsible for being placed for adoption B. imagines what life would be like with a different family C. is unable to conceptualize differences between adoptive and biological parents D. worries about what peers will say or think

A A 3 month old can be soothed by any comforting voice Option B: a 3 month old is not developmentally capable of fearing abandonment Option C: a 3 month old might sense a parent's anxiety but is cognitively unable to process it Option D: a 3 month old cannot tell time and would not understand the concept of returning later in the day

The parents of a hospitalized 3 month old have to leave the infant while they work. One parent fears that the baby will cry as soon as they walk out. The nurse teaches both parents about separation anxiety. Which statement by the parent indicates that the teaching has been effective? A. "at this age, my baby will not cry because we are leaving" B. "I know my baby will feel abandoned when we leave" C. "my baby is too young to sense my anxiety about leaving" D. "my baby understands that we will return later in the day"

D Postpartum depression is a perinatal mood disorder that affects women following childbirth. Symptoms may include crying, irritability, difficulty sleeping, anxiety, and feelings of guilt. Symptoms typically arise within 4 weeks of delivery and can affect the mother's ability to care for herself and the newborn. The nurse should ask specific questions about depression or hopelessness to assess for PPD. It is also important to ask about thoughts of self-harm or harm to the newborn

The pediatric nurse is performing an assessment on a 4 week old client in the clinic. During the assessment, the newborn's mother starts to cry and states, "I am the worst mother in the world." What should the nurse ask next? A. "do you have a support system to help process your feelings?" B. "do you have any questions about how to care for your newborn?" C. "have you experienced difficulty falling asleep or getting rest?" D. "have you felt depressed or hopeless over the last 2 weeks?"

BCDE Option A: the suppository must be inserted past both the external and internal sphincters for proper placement. If not inserted far enough, it may be expelled before achieving a therapeutic effect

The pediatric nurse is preparing to administer an acetaminophen suppository to an 11 month old with pyrexia. Which actions are appropriate? Select all that apply A. advance past the external sphincter only B. guide suppository along the rectal wall C. hold buttocks together firmly after insertion D. position client supine with knees and feet raised E. use gloved fifth finger for insertion

C Women who give birth by cesarean section are at particularly increased risk for deep vein thrombosis. Additional risk factors for DVT include obesity, smoking, and genetic predisposition. If unrecognized, DVT may progress to pulmonary embolism, often characterized by anxiety/restlessness pleuritic chest pain/tightness, shortness of breath, tachycardia, hypoxemia, and hemoptysis. The nurse's priority is rapidly identifying symptoms, assessing respiratory status, administering supplemental oxygen and notifying the health care provider

The postpartum nurse is assessing a client who gave birth by cesarean section 5 hours ago and is requesting pain medication. The client appears restless, has a heart rate of 110/min, and admits to recent onset of anxiety. What priority action should the nurse take? A. assess for lower extremity warmth and redness B. instruct the client in relaxation breathing techniques C. obtain oxygen saturation reading by pulse oximeter D. offer the client prescribed PRN pain medication

B The nurse should use a sterile glove during vaginal examination in the presence of ruptured membranes to prevent infection. Use of non sterile gloves and instruments during vaginal examinations increases the risk of infection in the laboring client or fetus

The precasting nurse is supervising a new obstetric nurse performing a labor admission assessment on a client with suspected spontaneous rupture of membranes. Which action by the new nurse would cause the precasting nurse to intervene? A. documenting a positive nitrazine test result when the test strip turns blue B. donning non sterile gloves and using soluble gel for vaginal examination C. palpating the client's abdomen before applying external fetal monitors D. providing the client with a variety of clear liquids to drink

D Option A: formula should never be sweetened. Honey should not be offered to children age <12 months because their immature gut systems are susceptible to Clostridium botulinum infection Option B: common allergenic foods may be introduced along with other foods starting at age 4-6 months. Previous guidelines recommended delaying introduction of these foods until age 12 months. However, recent evidence suggests that delaying introduction of these foods may actually increase the risk for food allergy Option C: infants should be transitioned to whole milk, not low fat milk, at age 12 months. Due to rapid growth, a child's brain requires the nutrition from the fat found in whole milk

The public health nurse conducts a teaching program for parents of infants. Which statement by a participant indicates that teaching has been successful? A. "after age 6 months, it is safe to use honey to sweeten my infant's formula" B. "I should wait until my infant is 1 year old to introduce egg products" C. "I will switch my 1 year old to low fat milk instead of commercial formula" D. "my infant should be able to pick up small finger foods by age 10 months"

D Observing the child feeding or when hungry will provide the nurse the opportunity to identify potential factors contributing to insufficient intake. The nurse can observe the type of food being offered, the quantity of food consumed, how the child is held or positioned while being fed, the amount of time for feeding, the parents response to the child's cues, the tone of the feeding and the interaction between the child and the parent

The public health nurse has received a referral to make a follow-up home visit to a 1 year old recently diagnosed with failure to thrive (FTT). Which intervention is the priority nursing action for this child? A. assess overall parenting skills B. compete a 24 hour dietary intake C. measure the child's height, weight and head circumference D. observe the child feeding

C Option A: the public health nurse follows the client throughout the treatment period until all sputum smears and cultures are normal, but not in the DOT program Option B: the public health nurse gives the client bus tokens or cab fare vouchers to attend scheduled clinic visits as incentives, but not in the DOT program Option D: the public health nurse screens all of the client's close contacts for possible infection and prophylactic treatment, but not in the DOT program

The public health nurse provides care for a client on a directly observed therapy (DOT) program to treat tuberculosis (TB). Which option best describes the care the nurse provides on this program? A. follows the client until 3 sputum cultures are normal B. gives the client bus tokens or cab fare vouchers to attend scheduled clinic visits C. provides and watches the client swallow every prescribed medication D. screens all of the client's close contacts

BC Option A: a paracentesis requires the client to be upright (semi- to high fowler) so that fluid accumulates in the lower abdomen where the trocar will be inserted to drain it Option B: after a liver biopsy, clients are at risk for internal bleeding due to the vascular nature of the liver. Place clients in the right side-lying position for ≥3 hours afterward to promote direct internal pressure of the liver against itself, which minimizes bleeding Option C: after cardiac catheterization via femoral entry, place clients flat or in low fowler position with the affected extremity straight for about 4-6 hours to avoid pressure at the insertion site and prevent hemorrhage or hematoma Option D: sims position (left side-lying with the right hip and knee flexed) is best for enema administration Option E: before lumbar puncture, clients are placed in the side-lying fetal position or hunched seated seated position to separate the vertebrae. Afterwards, clients remain supine in bed for 4-12 hours to minimize the risk of post-puncture headache from loss of cerebrospinal fluid

The registered nurse (RN) and licensed practical nurse (LPN) are caring for several clients. The RN delegates positioning to the LPN. While evaluating the delegated task, the RN realizes that which client positions require intervention? Select all that apply A. high fowler position in preparation for a paracentesis B. left side-lying position after percutaneous liver biopsy C. semi-fowler after cardiac catheterization via femoral entry D. sims during soap-suds enema administration E. supine position after a lumbar puncture

B An immediate intervention to help settle an out of control child is deep breathing. Taking slow, deep breaths relaxes the body, slows the heart rate, and distracts the child from inappropriate behaviors. Asking the child to blow up a balloon provides an easy mode of distraction and engages the child in a deep breathing exercise. After the child is calm, the nurse and the child can further discuss the disruptive behavior.

The school nurse is called to the classroom to assist with a 7 year old with attention deficit hyperactivity disorder who is throwing books and hitting the other children. What is the best initial action for the nurse to take? A. administer a PRN Dose of methylphenidate B. ask the child to blow up a balloon C. give the child a "time out" in a quiet place D. reinforce the consequences of disruptive behaviors

CD Option A: the RN is responsible for calling the x-ray or other departments to communicate pertinent information about the client, including the need to maintain airborne isolation precautions before and while transporting the client for diagnostic tests Option B: the RN is responsible for explaining to the client that wearing a mask during transport to another department prevents transmission of airborne microorganisms from the client to others. This is client teaching and must be done by the RN. The UAP can implement the task of applying the mask before transport Option E: the RN is responsible for talking with the family about the reasons the client is on airborne isolation precautions and teaching them about preventing the spread of the disease by wearing protective equipment upon entering the client's room

The registered nurse (RN) is caring for a client with tuberculosis who is on airborne isolation precautions. The RN can delegate which tasks to the experienced unlicensed assistive personnel (UAP)? Select all that apply A. alert the x-ray department about maintaining airborne isolation precautions B. explain to the client why the client must wear a mask during transport to another department C. post signs for airborne isolation precautions on the client's door and stock necessary equipment D. remind visitors to wear a respirator mask and keep the door closed while in the client's room E. talk with the family about the reasons for airborne isolation precautions in the client

A Option A: the client should be supine or in semi-fowler's position (max of 20-30 degrees). Elevating the head of the bed more than 30 degrees would promote sliding

The registered nurse (RN) on an orthopedic unit is orienting a new graduate nurse (GN) assigned to a client with a fractured hip and in Buck's traction. The RN intervenes when the GN performs which action? A. elevates the head of the bed 45 degrees B. holds the weight while the client is repositioned up in bed C. loosens the velcro straps when the client reports that the boot is too tight D. provides the client with a fracture pan for elimination needs

B The LPN should be assigned to clients who are medically stable and have expected outcomes; these criteria apply to the client who had a total hip replacement 2 days ago. LPNs should not be assigned to clients who require complex care and clinical judgment and have potential negative outcomes.

The registered nurse (RN) prepared to give out client care assignments. Which client is appropriate for the RN to assign to the licensed practical nurse (LPN)? A. client admitted 3 hours ago with suspected acute pancreatitis B. client who had a total hip replacement 2 days ago C. client who had a total thyroidectomy 2 hours ago D. client with alcohol withdrawal syndrome

D The client with abdominal pain has abnormal vital signs, which is a sign of a systemic condition. Adult criteria apply to adolescent clients in terms of physiological signs/symptoms. A pulse of 120/min signal dehydration and this client's respirations are above normal. This is the most serious acuity

The registered nurse is performing triage at a pediatric emergency department. Which client should be seen first? A. child with a history of cystic fibrosis has new yellow sputum and cough today B. crying infant with fiery redness and moist papules in the diaper region C. grade-school client with swollen ecchymotic ankle after playing basketball D. adolescent client with abdominal pain, heart rate 120/min, and respirations 26/min

B A reward system is one of the behavioral strategies used in the treatment of functional incontinence (due to constipation). The reward is given to encourage the child's involvement in the treatment to restore normal bowel function. Rewards are given for the child's effort and participation, not for having bowel movements while sitting on the toilet

The registered nurse is teaching the parent of a 6 year old about behavioral strategies for treating fecal incontinence due to functional constipation. Which statement by the parent indicates a need for further teaching? A. "I will give my child a picture book to look at during toilet time" B. "I will give my child a reward for each bowel movement while sitting on the toilet" C. "I will keep a log of my child's bowel movements, laxative use, and episodes of soiling" D. "I will schedule regular toilet sitting time for my child"

BCE Option A: a child with celiac disease cannot consume barley or French bread as both contain gluten Option D: peanut butter and jelly on rice cakes are permitted but not the oatmeal cookie

The school nurse creates a cafeteria menu for a newly enrolled child with celiac disease. Which lunches would be appropriate for this child? Select all that apply A. beef barley soup with mixed vegetables and French bread B. grilled chicken, baked potato, and strawberry yogurt C. Mexican corn tacos with ground beef and cheese D. peanut butter and jelly on rice cakes with an oatmeal cookie E. rice noodles with chicken and broccoli

D Hypoglycemia treatment in a conscious client is administration of 15 g of a quick-acting carbohydrate. After treatment, the nurse should recheck BG every 15 minutes, repeating treatment if it remains low Option A: the nurse should hold the client's scheduled insulin until the client's BG is normal and symptoms resolve Option B: an emergency glucagon IM injection is indicated if the client is somnolent, unconscious, seizing or unable to swallow Option C: after the client's BG improves, the client should eat a meal. However, if the next meal is more than an hour away, the nurse should give the client a serving of carbohydrate plus protein or fat to maintain glucose levels

The school nurse evaluates a 9 year old who is sweating, trembling and pale. The client has type 1 diabetes managed with insulin glargine and NPH. What is the most appropriate action by the nurse? A. administer scheduled dose of NPH insulin B. give emergency glucagon IM injection C. give peanut butter and crackers D. provide 4 oz of a regular soft drink

ACDE Dental caries (cavities) form when bacteria digest carbohydrates in the mouth, producing acids that break down tooth enamel and cause mineral loss. Oral hygiene and dietary intake are significant factors contributing to the development of caries. Option B: fruit drinks/juices contain high amounts of simple sugars; substituting these for other sugary beverages does not prevent dental cavities. Whole fruits are better choices

The school nurse is teaching a class of 10 year old children about prevention of dental caries. Which recommendations would be part of the nurse's teaching plan? Select all that apply A. chew sugar-free gum B. drink fruit drinks/juices instead of sugary, carbonated beverages C. include milk, yogurt, and cheese in dietary intake D. minimize consumption of sweet, sticky foods E. rinse mouth with water after meals when brushing is not possible

A The influenza virus has an incubation period of 1-4 days, with peak transmission starting at about 1 day before symptoms appear and lasting up to 5-7 days after the illness stage begins. Option B: influenza is transmitted by inhaling droplets that an infected individual exhales into the air when sneezing, coughing, or speaking. If contact with others is unavoidable, wearing a mask can offer some protection against virus transmission Option C: individuals with the influenza virus can transmit the virus during the incubation period and illness stage of the infection. It is not appropriate to assume that the spouse can no longer transmit the infeciton Option D: although vaccination provides immunity against influenza in about 2 weeks after inoculation, it does not offer complete protection against all virus strains. Therefore, close contact with others should be avoided during the illness stage, especially those with an impaired immune system

The spouse of an immunocompromised client is diagnosed with influenza virus infection. The spouse asks the office nurse how long contact with the client should be avoided to prevent the infection from spreading. What is the nurse's most appropriate response? A. "avoid close contact for about a week" B. "its impossible to avoid contact with the client. Just wash your hands often" C. "you are sick already, and so you are not contagious anymore" D. "you dont have to worry as long as the client has received the influenza vaccination"

B Endotracheal suctioning improves ventilation in mechanically ventilated clients by removing mucus and secretions from the ET tube. Suctioning is performed based on clinical findings such as adventitious breath sounds, elevated peak airway pressure, coughing, or signs of acute respiratory distress. Frequent suctioning increases the risk of tracheal and bronchial trauma, bleeding and hypoxia. Suctioning should be performed only when needed to reduce the risk for injury

The student nurse and the registered nurse are caring for a mechanically ventilated client with an acute lung injury. Which statement by the student nurse indicates a need for further education? A. "I will auscultate the neck to assess for endotracheal cuff leaks" B. "I will perform endotracheal suctioning routinely after oral care" C. "I will provide oral care and oral suctioning every 2 hours" D. "I will reposition the client from side-to-side at least every 2 hours"

C The radial artery site at the wrist is preferred for collecting an arterial blood gas sample because it is near the surface, is easy to palpate and stabilize, and has good collateral supply from the ulnar artery. The latency of the ulnar artery can be confirmed with a positive modified Allen's test

The student nurse observes the respiratory therapist preparing to draw an arterial blood gas from the radial artery. The RT performs the Allen's test and the student asks why this test performed before the blood sample is drawn. Which statement made by the RT is most accurate? A. "the Allen's test is done to determine if capillary refill is adequate" B. "the Allen's test is done to determine if the radial pulse is palpable" C. "the Allen's test is done to determine the potency of the ulnar artery" D. "the Allen's test is done to determine the presence of a neurologic deficit"

B The majority of cases of epiglottis are caused by Haemophlius influenza type B, which is covered under the standard vaccinations given during the 2 and 4 month visits. Epiglottis is rarely seen in vaccinated children

The triage nurse is assessing an unvaccinated 4-month-old infant for fever, irritability and open-mouthed drooling. After the infant is successfully treated for epiglottis, the parents wonder how this could have been avoided. Which response by the nurse would be most appropriate? A. "its impossible to know for suer what could have caused this episode" B. "most cases of epiglottis are preventable by standard immunizations" C. "we are still waiting for the formal report from the microbiology laboratory" D. "there is nothing you could have done; the important thing is that your child is safe now"

A Clients undergoing lower-extremity amputation may experience surgical site pain or phantom limb pain. However, should pain radiating down the arm is an unexpected finding following an extremity amputation and may indicate myocardial ischemia.

The unit secretary notifies the nurse that 4 clients called the nurses' station reporting pain. Which client should the nurse assess first? A. client who had a foot amputation today reporting left shoulder pain radiating down the arm B. client who has acute pancreatitis reporting severe, continuous, penetrating abdominal pain C. client who has multiple myeloma reporting deep pelvic pain after walking down the hall D. client who has sickle cell disease reporting severe pain in the arms and upper back

C To measure pressures accurately using continual arterial and/or pulmonary artery pressure monitoring, the zeroing stopcock of the transducer system must be placed at the phlebostatic axis. This anatomical location, with the client in the supine position, is at the 4th ICS, at the midway point of the AP diameter of the chest wall. If the transducer is placed too low, the reading will be falsely high; if it is placed too high, the reading will be falsely low. This concept is similar to the positioning of the arm in relation to the level of the heart when measuring blood pressure indirectly using a sphygmomanometer or noninvasive blood pressure monitoring device. The upper arm should be at the level of the phlebostatic axis

To obtain accurate continuous blood pressure readings via a radial arterial catheter, the nurse places the air-filled interface of the stopcock at the phlebostatic axis. Where is it located? A. angle of Louis at 2nd intercostal space to left of sternal border B. aortic area at 2nd ICS to right of sternal border C. level of atria at 4th ICD, 1/2 anterior-posterior diameter D. 5th ICS at mid clavicular line

ABC Option D: excessive hair may be clipped but never shaved as shaving may cause micro abrasions and potential portals of entry for microorganisms Option E: peripheral IV catheters should not be removed or replaced more frequently than every 72-96 hours unless signs of complications occur

What nursing care related to peripherally inserted IV catheters can reduce the incidence of catheter-related infections? Select all that apply A. after insertion, secure the catheter with a sterile, semipermeable dressing B. clean ports with an alcohol swab prior to accessing the catheter system C. prior to insertion, apply chlorhexidine, using friction, to the venipuncture site D. prior to insertion, shave excess hair over the selected venipuncture site E. replace or remove the venous catheter every 48 hours

A Preschoolers enjoy associative play, in which they engage in similar activities or play with the same or similar items, but the play is unorganized without specific goals or rules. They often borrow items from each other without directing each other's play. Preschoolers also enjoy play involving motor activities and imaginative, pretend play Option B: cooperative play is common in school-age children. These children play with one another with a specific goal, often within a rigid set of rules. Cooperative play is likely too advanced for preschool-age children, as it involves more organizational skills Option C: parallel play is more common in toddlers. During parallel play, these children play next to each other and are happy to be in the presence of peers, but they do not play directly with one another Option D: solitary play is common in infants. Children at this stage are focused on their own activity and will play alone in the presence of others

What play behavior would the nurse be met likely to observe in a group of 4 year old children? A. children playing and borrowing blocks from each other without directing others B. children playing and working together to build a castle out of blocks C. children playing next to each other with blocks, but not interacting D. children playing with blocks by themselves in separate areas of the room

BCD Option A: there is no known relationship between caregivers working outside the home and FTT. Caregivers who are fully employed may be more able to provide adequate food choices Option E: there is no indication that unmarried parents pose a higher risk for an infant to develop FTT. More important protective factors include having a stable environment and living with 2 parents

What socioeconomic indicators would the nurse identify as risk factors for a 2 month old infant to develop failure to thrive? Select all that apply A. both caregivers work outside the home B. infant lives only with mother, who is currently unemployed C. infant's primary caregiver has cognitive disabilities D. parents are socially and emotionally isolated E. parents live together but are not married

CDE Congenital heart defects that cause blood to shunt from the higher pressure left side of the heart to the lower pressure right side increase pulmonary blood flow. Left-to-right shunting results in pulmonary congestion, causing increased work of breathing and decreased lung compliance. Compensatory mechanisms result from sympathetic stimulation.

When monitoring an infant with a left-to-right-sided heart shunt, which findings would the nurse expect during the physical assessment? Select all that apply A. clubbing of fingertips B. cyanosis when crying C. diaphoresis during feedings D. heart murmur E. poor weight gain

ACDE Practicing outside of the scope of the license is reportable even if the practice meets quality standards. Documenting an intervention that was not performed is considered falsification of records regarding client care and is a reportable action. Stealing narcotics is a criminal offense and is reportable in all states. Abandonment is reportable in all states.

Which actions by a registered nurse are reportable to the state board of nursing? select all that apply A. administering hydromorphone without a prescription B. being habitually tardy to work C. documenting an intervention that was not performed D. stealing narcotics E. walking off duty in the middle of a shift

BCDE Option A: avoiding discussion of adoption details until after the birth inhibits the nurse's ability to plan care that respects the birth mother's wishes for interaction with the newborn and/or involvement of the adoptive parents in the birth process. Acknowledging the adoption plan early in the plan of care encourages the client to express emotions and be involved in decision-making

Which actions should the labor and delivery nurse perform when caring for a client who has decided to relinquish her newborn to an adoptive parent? Select all that apply A. avoid discussing the adoption details until after the birth B. encourage the birth mother to hold the newborn C. notify other staff who may interact with the client of the adoption plan D. offer the birth mother a chance to say goodbye to the newborn E. use phrases that illustrate adoption as a decision of love, not abandonment

CE Option A: autonomy is the right to make decisions for oneself. Although having an advance directive is an example of autonomy, requiring one violates the principle. The client has a right to refuse even if the nurse believes it is the client's best interest Option B: when a diagnosis is withheld, even if due to the nurse's or family's good intentions, it violates the principle of autonomy. Beneficance means to do good Option C: fidelity is exhibiting loyalty and fulfilling commitments made to oneself and others. It includes meeting the expected responsibilities of professional nursing practice and provides the basis of accountability Option D: the principle of justice refers to treating all clients fairly. Veracity is telling the truth as a fundamental part of building a trusting relationship Option E: nonmaleficence means to do no harm and relates to protecting clients from danger when they are unable to do so themselves due to a mental/physical condition and from a nurse who is impaired

Which are correct understandings of applying nursing ethical principles? Select all that apply A. autonomy is requiring the client to have an advance directive B. beneficence is withholding prognosis from a client due to family wishes C. fidelity is administering medication as prescribed to the client D. justice is telling the client the truth that the biopsy is positive E. nonmaleficence is refusing to give report to a nurse who is impaired

ABC Option D: retracted tympanic membranes occur when there is negative pressure in the middle ear, which can occur with a blocked Eustachian tube or as a complication of chronic infections. In acute otitis media, pus/fluid inside the ear produces bulging and red membranes Option E: severe pain experienced with direct pressure on the tragus or with pulling on the pinna is a manifestation of otitis externa, an infection of the outer ear. The pain associated with AOM is not affected by manipulation of the outer ear

Which assessment findings should the nurse anticipate in a child with suspected acute otitis media? Select all that apply A. frequent pulling on the affected ear B refusal to eat C. restlessness and irritability D. retracted tympanic membranes E. severe pain with pressure on the tragus

ACD Option B: at 28 weeks gestation, a newborn's feet have very smooth soles with only faint red marks or possibly a single anterior transverse crease. Creases over the entire sole and/or peeling skin would be expected in a full or post term newborn Option E: the testes of a male infant born at 28 weeks gestation would not ye have descended into the scrotal sac and may be palpable in the upper inguinal canal

Which assessment findings would the nurse most likely expect to find in a male infant born at 28 weeks gestation? Select all that apply A. abundant lanugo on shoulders and back B. deep creases and peeling skin on soles of feet C. flat areolae without palpable breast buds D. smooth, pink skin with visible veins E. testes completely descended into the scrotum

AD Option B: this change in vital signs from preprocedure to post procedure most likely reflects decreased anxiety. This client's vital signs are within normal range. Lumbar puncture does not produce bleeding serious enough to make a client hypotensive. If this client was bleeding, it would compress the spinal cord, causing paralysis in the lower extremities Option C: this client has a pulse of 62/min, which indicates a therapeutic effect of metoprolol. The nurse should monitor for bradycardia, which is a common and expected finding following administration of a beta-adrenergic blocker. Bradycardia would require nursing intervention only if the client became symptomatic Option E: a neonate's resting pulse is 110-160/min. Crying or vigorous kicking can cause a temporary rise. Vital signs are concerning if they rise when a client is at rest

Which client condition is concerning and requires further nursing assessment and intervention? Select all that apply A. before liver biopsy, pulse is 80/min and blood pressure is 120/80 mm Hg; 1 hour afterward, pulse is 112/min and BP is 90/60 mm Hg B. before lumbar puncture, pulse is 100/min and BP is 140/86 mm Hg; 1 hour afterward, pulse is 80/min and BP is 126/82 mm Hg C. client with coronary artery disease on metoprolol; pulse is 62/min D. elderly client with black stools; pulse is 112/min E. neonate crying inconsolably at feeding time; pulse is 160/min

A Dicyclomine hydrochloride is an anticholinergic medication. Anticholinergics are used to relax smooth muscle and dry secretions. Anticholinergic side effects include pupillary dilation, dry mouth, urinary retention, and constipation. The urge to urinate is normally present at 300 mL; pain is usually felt around 500 mL. This client has urinary retention and should not have the bladder smooth muscle further relaxed

Which client finding would be a contraindication for the nurse to administer dicyclomine hydrochloride for irritable bowel syndrome? A. bladder scan showing 500 mL urine B. hemoglobin of 11 g/dL C. history of cataracts D. reporting frequent diarrhea today

ABDF Option C: anorexia nervosa manifests as cold intolerance Option E: anorexia nervosa manifests as lengthy and vigorous exercise

Which clinical manifestations would the nurse identify with severe anorexia nervosa? Select all that apply A. amenorrhea B. fluid and electrolyte imbalances C. heat intolerance D. presence of lanugo E. refusal to exercise F. weight loss of 25% below normal weight

ABD Option C: children with streptococcal pharyngitis may return to school or daycare after they have completed 24 hours of antibiotics and are afebrile Option E: throat lozenges can be given to older children but are a choking hazard in younger children. Acetaminophen and ibuprofen should be given for pain

Which discharge teaching instructions should the nurse provide to the parents of a 2 year old with group A streptococcal pharyngitis? Select all that apply A. complete all the antibiotic even if your child is feeling better B. cool liquids and soft diet are recommended C. keep your child home from daycare for at least a week D. replace your child's toothbrush 24 hours after starting antibiotics E. throat lozenges may soothe your child's sore throat

C The key aspects related to radiation exposure are time and distance. The grater the distance, the less dosage received. Acute radiation syndrome has the following phases: prodromal, latent, manifest and recovery or death. Initially, all victims will appear well; however, the damage is mainly internal, leads to cell destruction and manifests later on Victims farthest away from the radiation source are the most salvageable. In this scenario, the principle of disaster nursing is to do the most good for the most people with the available resources

Which guiding principle is suitable for dealing with a disaster scenario involving radiation contamination? A. assess for copious secretions to determine exposure B. assist the victims farthest from the source first C. assist the victims with the most severe symptoms first D. monitor for diplopia to determine extent of exposure

BDE Endovascular abdominal aortic aneurysm repair is a minimally invasive procedure that involves the placement of a sutureless aortic graft inside the aortic aneurysm via the femoral artery. Option A: no abdominal incision is required in endovascular repair Option C: chest tubes are not require in endovascular repair

Which interventions should the nurse include when caring for a client who has had endovascular repair of an abdominal aortic aneurysm? Select all the apply A. assess abdominal incision every 4 hours B. check for bleeding at groin puncture sites C. measure chest tube drainage D. monitor fluid intake and urine output E. palpate and monitor peripheral pulses

A During pregnancy, it is important for the client to consume a balanced diet with appropriate nutrients, vitamins and minerals. Foods containing folic acid, protein, whole grains, iron and omega-3 fatty acids are especially important. Due to the risk for bacterial contamination, pregnant clients should avoid consuming unpasteurized milk products, unwashed fruits and vegetables, deli meat and hot dogs, and raw fish/meat. They should also avoid intake of fish high in mercury.

Which meal should the nurse recommend for a pregnant client at 13 weeks gestation? A. baked chicken, turnip greens, peanut butter cookie, and grape juice B. baked swordfish, fries, baked apples, and fat-free milk C. chilled ham and cheese sandwich, broccoli, orange slices, and water D. fried liver and onions, pasteurized cheese squares, fresh fruit cup, and water

ACE Option A: cephalexin is a cephalosporin, which is chemically similar to penicillin. If a client has had a severe allergic reaction to penicillin, there is a 1-4% chance of an allergic reaction to a cephalosporin Option B: H1 receptor antagonists decrease the inflammatory response by blocking histamine receipts. Histamine is released from mast cells during a type I (immediate) hypersensitivity reaction Option C: clients with nasal polyps often have sensitivity to non steroidal anti-inflammatory drugs (NSAIDs), including aspirin. In addition, NSAIDs can exacerbate asthma symptoms. Therefore, acetaminophen may be a better choice for these clients Option D: angiotensin-converting (ACE) inhibitors are the drugs of choice in diabetic clients with hypertension or proteinuria. This would be an appropriate administration Option E: the selective beta blockers are generally given for heart failure and hypertension control due to their beta1-blocking effect. The nonselective beta blockers, in addition, have a beta2-blocking effect that results in bronchial smooth muscle constriction. Therefore, nonselective beta blockers are generally contraindicate in clients with asthma

Which medication prescriptions should the nurse question? Select all that apply A. cephalexin for a client with severe allergy to penicillin B. fexofenadine for a client with hives C. ibuprofen for a client with asthma and nasal polyps D. lisinopril for a client with diabetes mellitus E. propranolol for a client with asthma

ABDE Option C: diets high in fat should be avoided as liver bile production, which is needed for fat digestion, may be impaired. Encourage protein and carbohydrate intake to assist with liver healing

Which nursing interventions would the nurse implement when caring for a client newly diagnosed with acute, viral Hepatitis B? Select all that apply A. offer small, frequent meals to prevent nausea B. promote rest periods between periods of activity C. provide a diet high in fat and low in carbohydrates D. teach the client not to share razors or toothbrushes with others E. teach the client to abstain from drinking alcohol

ABE Option C: the client is easily distractible and would not be able to focus on planning an activity. Option D: the client who is experiencing an acute manic episode needs reduced environmental stimuli. Eating with other clients in the dining room would be too stimulating and could exacerbate psychomotor activity. Option F: the client with acute mania is not ready to participate in group activities.

Which of the following actions would the nurse include in planning care for a client hospitalized for bipolar disorder, acute manic episode? Select all that apply A. assign the client to a private room B. choose clothing for the client C. have the client be in charge of planning an outing for the unit D. have the client join other clients in the dining room for meals E. have the client participate in physical exercise with a staff member F. include the client in group therapy sessions

CDE Option A: making staff lunch assignments is part of the management of the unit; therefore, the RN cannot delegate this task. The RN must ensure that there is adequate staff coverage to meet client needs during the assigned lunch times Option B: UAPs can give bed baths to stable, appropriate clients. The client with a new ostomy requires assessment and teaching about cleaning and caring for the ostomy; therefore, an RN must perform this task

Which of these tasks are appropriate for the registered nurse to delegate to unlicensed assistive personnel? Select all that apply A. assign lunch times to the other UAP on the unit B. assist a client with a new ostomy with bathing and changing pouches C. collect vital signs on a client 4 hours after laparoscopic appendectomy D. pickup an intravenous antibiotic from the pharmacy E. record intake and output for a client with metabolic alkalosis

A Infants do not start rolling until age 4 months and normally roll front to back at 5 months. This explanation for the injury does not fit the growth capacity of the child. Because lethargy is present, head injury must be ruled out.

Which pediatric presentation in the emergency department should the nurse follow up for possible abuse and mandatory reporting? A. a 2 month old who rolled off the changing table and is now lethargic B. a 3 month old with flat bluish discoloration on the buttock that the mother says has been present since birth C. a 3 year old with forehead bruises that the mother says come from running into a table D. a 4 year old who pulled boiling water off the stove and has splattered burns on the arms

A When an acute asthma exacerbation occurs, the child has rapid, labored respirations using accessory muscles. The child often appears tired due to the ongoing effort. In he case of severe obstruction, wheezing/breath sounds are not heard due to lack of airflow. This "silent chest" is an ominous sign and an emergency priority. In this situation, the onset of wheezing will be an improvement as it shows that air is now moving in the lungs

Which pediatric respiratory presentation in the emergency department is a priority for nursing care? A. client with an acute asthma exacerbation but no wheezing B. client with bronchiolitis with low-grade fever and wheezing C. client with runny nose with seal-like barking cough D. cystic fibrosis client with fever and yellow sputum

ABD Option C: an arm without IV infusion is preferred. If it is necessary to use the arm with the IV infusion, the specimen should be collected from a vein several centimeters below (distal to) the point of IV infusion, with the tourniquet placed in between Option E: the finger specimen should be obtained from the third or fourth finger on the side of the fingertip, midway between the edge and midpoint. The puncture should be made perpendicular to the fingerprint ridges. Puncture parallel to the ridges.

Which procedures are appropriate for the nurse to use when obtaining an adult client's blood for a laboratory test? Select all that apply A. avoid the arm on the affected side after a mastectomy B. do not make further attempts to draw blood if unsuccessful on first 2 attempts C. if necessary to use an arm with IV infusing, draw proximal to infusion point D. insert the needle bevel up at a 15 degree angle to the skin E. obtain a finger capillary specimen from the middle of the finger pad

D Therapeutic communication allows the nurse to develop a healthy interpersonal relationship with the client. A "why" question is often avoided as it is viewed negatively by clients and can make them feel defensive about their choices or emotions

Which statement made by the nurse during a therapy session demonstrates a need for further instruction regarding effective therapeutic communication techniques? A. "I dont understand what you mean. Can you give me an example?" B. "it is doubtful the president is out to get you" C. "tell me more about the day your child died" D. "why did you get so angry when she ignored you?"

ABDE Option C: although UAP may report observations of abnormal physical signs to the nurse, it is the RN's responsibility to assess the client's ongoing condition. Monitoring of RN findings can be delegated to a licensed practical nurse but not to a UAP

Which tasks can the registered nurse appropriately delegate to unlicensed assistive personnel? Select all that apply A. assist the registered nurse with ambulating a client 1-day post chest tube placement B. measure wound drainage from a bulb drain and document it on the output flow sheet C. monitor for redness and swelling at the IV insertion site and report back to the nurse D. return an unused unit of packed red blood cells to the blood bank E. take family members to the waiting room after the client goes into surgery

ADE Option B: the UAP changes the linens from the top to the bottom of the bed with assistance; clients are instructed to lift themselves using the overhead trapeze. This approach maintains immobilization of the injured extremity. Logrolling the client will require multiple staff members, including one person to stabilize weights. Option C: the RN is responsible for peripheral circulation, neuromuscular, and skin assessments

While caring for a client in skeletal traction, which tasks can the registered nurse delegate to experienced unlicensed assistive personnel to help prevent immobility hazards? Select all that apply A. assist with active and passive range of motion exercises B. change bed linens while logrolling the client from side to side C. check the color and temperature of the affected extremity D. remind the client to use the incentive spirometer E. reapply pneumatic compression device after bathing the client