NCLEX

Following a diagnosis of acute glomerulonephritis (AGN) in their 6 year-old child, the parents remark that they are unclear as to how the child caught the disease. What information about the disease should the nurse understand before responding to the parents?

It is not "caught" but is an autoimmune response to a previous beta-hemolytic strep infection rationale With AGN there is the sudden onset of headache, edema, oliguria, hematuria and proteinuria. Typically the inflammation of the glomeruli of the kidneys is due to a previous beta-hemolytic streptococcal infection, such as an untreated strep throat. It is considered to be a noninfectious autoimmune renal disease. Treatment is mainly supportive and directed towards reducing the overactive immune response with corticosteroids and immune-suppressing drugs.

A nurse enters a 2 year-old child's hospital room to administer an oral medication. When the child is asked, "Are you ready to take your medicine?" the child immediately says, "No!" What action should the nurse take next?

Leave the room and return five minutes later and give the medicine rationale Because the nurse gave the child a choice about taking the medication, the nurse must comply with the child's response in order to build or maintain trust. Toddlers do not have an accurate sense of time, so leaving the room and coming back a little later will be perceived as a new interaction to the toddler. Keep in mind that the child is a toddler and the behaviors illustrated in the stem are normal behaviors. Want a more detailed rationale? Listen to the Learning Extension's Question Dissection® podcast.

A female client diagnosed with genital herpes simplex virus 2 (HSV-2) reports having dysuria, dyspareunia, leukorrhea and lesions on the labia and perianal skin. Which intervention will provide symptomatic relief? (Select all the apply.)

Local application of ice packs Dry the genital area with a blow dryer on the cool setting Over-the-counter medications such as ibuprofen Symptomatic relief includes lukewarm (not hot) baths and applying cold packs to the genital area. Sometimes using a hair dryer set to a low or cool setting can help relieve symptoms. Over-the-counter medications such as ibuprofen and acetaminophen can help with local tenderness. A client with HSV-2 should increase their fluid intake when using acyclovir, but increasing fluids will not directly relieve symptoms. There's no evidence that echinacea can relieve the symptoms of HSV-2.

Prior to discharge home, a treatment plan is being developed for a client with severe arthritis. What is the most important part of the treatment plan?

Maintain and preserve functional status rationale To maintain quality of life and to ensure safety, the treatment plan must emphasize maintaining functional status. The client's ability to perform activities of daily living (ADLs) and instrumental activities of daily living (IADLs) should be assessed; if needed, referrals for physical and/or occupational therapy can be made. All clients should understand the purpose of any prescribed medications, as well as how and when to take them, expected side effects and possible adverse effects. Want a more detailed rationale? Listen to the Learning Extension's Question Dissection® podcast.

A nurse is caring for an adolescent after a spinal fusion for scoliosis. Which intervention is appropriate in the immediate postoperative period?

Maintain in a flat position, logrolling as needed rationale The bed should remain flat for at least the first 24 hours to prevent injury. Logrolling is the best way to turn the client who is on bed rest. As you read the answers, ask yourself which of these actions would maintain the spine in alignment and would this make sense for someone who had a spinal fusion?

An 82 year-old client is prescribed eye drops for treatment of glaucoma. What other data is needed before a nurse begins to reinforce proper administration of the eye drops?

Manual dexterity rationale Inability to self-administer eye drops is a common problem among the elderly due to decreased finger dexterity related to aging. The key here is to recognize what would be most important for the client to self-administer eye drops.

A nurse is assisting in the exam of a pregnant client in her third trimester. The ultrasound suggests that the baby is small for gestational age (SGA). An earlier ultrasound indicated normal growth. The nurse understands that this change is most likely associated with what condition?

Maternal hypertension rationale Pregnancy-induced hypertension (also known as gestational hypertension or pre-eclampsia) is a common cause of late pregnancy fetal growth restriction. Vasoconstriction reduces placental exchange of oxygen and nutrients, resulting in poor fetal growth.

A client who takes warfarin after coronary artery stent placement calls the health clinic to ask, "Can I take Alka-Seltzer for an upset stomach?" How should the nurse respond?

"Avoid Alka-Seltzer because it contains aspirin." rationale Alka-Seltzer is an over-the-counter aspirin-antacid combination. Aspirin, an antiplatelet medication, will potentiate the anticoagulant effect of warfarin and may result in increased bleeding tendencies.

The nurse at a walk-in clinic is checking a client with a history of hypertension. What is a priority question the nurse should ask?

"What over-the-counter medications do you take?" rationale Over-the-counter medications, especially those that contain cold preparations, can increase the blood pressure to the point of acute hypertension or hypertensive crisis. The other options should also be asked, but the priority question is to ask about over-the-counter (or herbal) medications.

The clinic nurse is reinforcing health promotion concepts with a group of parents. A mother asks, "How can I prevent Reye's syndrome?" Which statement should the nurse include with the response?

"Avoid the use of aspirin or aspirin products when viral infections are suspected." rationale Reye's syndrome causes swelling in the liver and brain. Even though the cause of Reye's syndrome remains unknown, there is a link between giving children with viral infections aspirin or aspirin products and developing Reye's syndrome. Evidence suggests that the risk is sufficiently grave enough to include the warning on aspirin and aspirin products. Children from birth to 19 years of age are not to take aspirin or products with aspirin in them if a viral infection is suspected.

The mother of a child diagnosed with a neural tube defect asks the nurse, "What can I do to decrease the chances of having another baby with this same defect?" The nurse should reinforce which information in the response?

"Folic acid should be taken before and after conception." rationale The American Academy of Pediatrics recommends that all childbearing women increase folic acid from dietary sources and/or supplements before and during pregnancy. There is evidence that increased amounts of folic acid to 0.4 milligrams per day at least one month before conception and continued through the first trimester prevents neural tube defects.

The nurse is collecting data from a client on admission to a community mental health center. The client discloses that "I have been thinking about ending my life." What's the best initial response by the nurse to this statement?

"Have you thought about how you would do it?" rationale This response provides an opening to discuss intent and a means of committing suicide. When a higher risk of suicide is apparent, the questioning should be directed at determining if a plan has been decided and/or what steps have been taken. Remember that you are being asked to select the "initial response," which means that all of the options will be correct. Associate the word "thought" with the words "thinking about" in the question, because this is the only option that is most directly related to what the client has disclosed. The other options can all be done at a later time. Client safety is the priority.

The nurse caring for a client diagnosed with type 1 diabetes mellitus is discussing the client's medication. What statement made by the client is incorrect and indicates a need for further reinforcement of information?

"I always make sure to shake the NPH bottle hard to mix it well." rationale The bottle should by rolled gently, not shaken. Shaking the bottle results in small air bubbles, which may result in errors when drawing up the insulin in the syringe.

A nurse is talking to the mother of a 5 month-old infant during a routine checkup. Which statement by the mother is incorrect and indicates a need for further teaching?

"I dip the pacifier in honey so my baby will take it." rationale Honey has been associated with infant botulism and should be avoided until after 12 months of age. Note that "further teaching" indicates that the answer has to be a problem or is incorrect. You will also notice that three of the options are similar in that they all address "feedings." The correct response is different from the other three.

The licensed practical nurse (LPN) is preparing a client for a myelogram scheduled at 9 am. Which statement by the client indicates a contraindication for this test and should prompt the LPN to notify the registered nurse (RN)?

"I took my regular dose of warfarin last night." rationale Relative contraindications to myelography include a history of an adverse reaction to the iodinated contrast media; an allergy to shellfish is no longer considered a contraindication. Clients who are on anticoagulant therapy such as warfarin (Coumadin) are supposed to discontinue these drugs prior to undergoing myelography for about 48 hours before and 24 hours after the myelogram. A headache after a spinal tap is often caused by lack of fluids after the procedure. Claustrophobia and an aversion to loud noises would be an issue for someone undergoing a MRI.

While caring for a hospitalized toddler, a nurse reinforces information about the expected developmental changes for this child's age group to the parents. Which statement by the mother shows that she understands the child's developmental needs?

"I understand the need of my child to use new skills." rationale Erikson describes the stage of the toddler as being the time when there is normally an increase in autonomy. The child needs to use motor skills to explore the environment. The key is to look for an "expected developmental" change for the toddler. The word "new" in one option implies a change has occurred. The other three options are more associated with safety issues.

A client, scheduled for coronary artery bypass surgery, is discussing the disease with the nurse. Which statement made by the client is incorrect and should alert the nurse that reinforcement of information is needed?

"I will need to change positions slowly to prevent my blood pressure from rising." rationale The client should change positions slowly, but that's because the medication the client will be taking may cause blood pressure to drop. Antihypertensives, vasodilators and beta blockers tend to reduce the workload of the heart and can cause orthostatic hypotension (a drop in systolic blood pressure greater than 20 mm Hg with changes in position from lying to sitting or standing.) Remember that when answering these types of questions, you will select the statement that is incorrect.

An adolescent female is newly diagnosed with bulimia. The nurse is reinforcing instructions about the therapeutic benefits of imipramine (Tofranil) to the client and her parents. Which statement demonstrates an understanding about the medication by the client?

"I will need to take the medication for at least two weeks before I can see any benefit." rationale Imipramine is a tricyclic antidepressant that is sometimes used to treat eating disorders and panic disorders. Therapeutic effects of the medication may not be noticed for at least two weeks. Therapy is usually prolonged and individual and family counseling are helpful in identifying and addressing issues such as self-esteem. It should be noted that there is a Black Box warning about the relationship between teens and young adults who take antidepressants and suicidal thinking.

The nurse is teaching a client with migraine headaches about almotriptan. Which statement by the client indicates that the teaching was effective?

"I will take the medication as soon as I notice migraine symptoms." rationale Almotriptan and other triptans are serotonin receptor agonists that work by causing vasoconstriction of intracranial arteries. The drug is most effective when taken as soon as migraine symptoms start but before the onset of acute pain. It will not prevent headaches or reduce the number of attacks. One of the most common side effects of this medication is dry mouth. After taking a dose, if the headache goes away and comes back, it is acceptable to take a second dose. The client should not take more than two doses of any triptan in 24 hours.

After talking with her partner, a client voluntarily admits herself to the substance abuse unit. The next day the client states to the nurse, "My partner told me to get treatment or we would have to get divorced. I don't believe I really need treatment, but I don't want my partner to leave me." Which response by the nurse would be of assistance to the client?

"In early recovery it's quite common to have mixed feelings. Let's discuss the benefits of sobriety for you." rationale Only the correct option focuses on the client and the client's problem (alcohol). This is the best response because it gives the client the opportunity to decrease ambivalent feelings by focusing on the benefits of sobriety. The other options are not therapeutic and do not have the client's best interests at heart. The option about being pressured to come might encourage clients to project blame for their behavior on someone else. The option of outpatient care might be a goal for this client, but it is inappropriate to suggest outpatient counseling at this time. To label the client's behavior as "unmotivated" might simply reinforce the client's ambivalence about treatment.

On admission to the ambulatory surgery unit, a nurse notices the client's fingernails are painted with dark polish. On reviewing the pre-op orders, the nurse notes that pulse oximetry has been ordered. Which statement by the nurse is appropriate?

"In order to measure your oxygen level, please remove the polish from at least two nails." rationale In order to effectively measure pulse oximetry, there can be no dark nail polish on the finger with the reading device. The client should be approached using therapeutic communication skills. The other options are not appropriate. Studies have reported that light-colored polish does not result in inaccurate readings.

A nurse is caring for a client who is four days postop after a transverse colostomy was done. The client, to be discharged in the morning, asks the nurse to empty the colostomy pouch. How should the nurse best respond to the client?

"Show me what you have learned about emptying your pouch." rationale Most adult learners obtain skills by participating in the activities. Anxiety about discharge can be causing the client to forget the mastered skill of emptying the pouch. Client should show the nurse how they empty the pouch as the nurse observes and reinforces any steps in the process.

A parent asks a nurse about the use of syrup of ipecac to induce vomiting. What is the appropriate response by the nurse?

"Syrup of ipecac is effective at removing all poisons if given immediately after ingestion." rationale "Syrup of ipecac is no longer recommended in any situation."

The client is a 15 year-old female diagnosed with anorexia nervosa. During the admission process, the nurse finds a container of assorted pills in a drawer in the client's room. The client tells the nurse, "They are antacids for stomach pains." Which of these statements made by the nurse would be the best response?

"Tell me about the week prior to you being admitted." rationale This is an open-ended, nonjudgmental statement that allows for further discussion. The topic is non-threatening and will give the nurse insight into the client's view of events leading up to admission. It is the only option that is client-centered; the other options focus on the pills. The nurse can eventually ask about the pills (and remove them from the drawer.)

The parent of a toddler who has bilateral tympanostomy (PE) tubes placed into the tympanic membranes asks the nurse if the toddler can swim in the family pool. Which response by the nurse would be the best response?

"The child can swim but must wear ear plugs while in the pool." rationale Water should not enter the ears. Children should use ear plugs when bathing or swimming and should not put the head under the water. The tubes usually fall out in 6 to 12 months on their own. Advise the parents that after tube placement, sounds may be louder for children until they get used to sounds. You'll note that two of the options are all or nothing options and you'll recall that these types of options are rarely correct. You'll also note that the correct option is the only response with the word "ear" in it, which matches the information in the question.

After working with a very demanding client, an unlicensed assistive person (UAP) tells a nurse, "I have had it with that client. I just can't do anything that pleases this person. I'm not going in there again." The nurse should respond to the UAP with which of these statements?

"The client is scared and is lashing out at you. Let's try to figure out what to do." rationale This response explains the client's behavior without belittling the UAP's feelings. The UAP is encouraged to help solve the problem with the nurse. This approach illustrates a collaborative approach to problem solving with the team member's input.

The nurse is reviewing medications with a client diagnosed with heart failure. The client asks the nurse how much longer he has to take the prescribed diuretic. Which is the best response by the nurse?

"The medication must be continued as long as the fluid problem needs to be controlled." rationale The most therapeutic response is the one that addresses the client's health condition and gives the client accurate information, which is that he will take the medication for as long as needed to treat his medical condition. The nurse should determine if the client understands why he is taking this and any other medications and to reinforce teaching on possible side effects or adverse effects and when to notify the health care provider.

A client diagnosed with a spontaneous pneumothorax has a chest tube inserted. What information should the nurse reinforce?

"The tube will remove excess air from your chest." rationale The purpose of the chest tube is to create negative pressure and to allow the removal of the air that has accumulated in the pleural space in a pneumothorax. In a hemothorax pleural effusion, or empyema, the purpose is to primarily remove the blood or other fluid.

A nurse is assigned to a client who recently delivered a baby and who is also diagnosed with human immunodeficiency virus (HIV). The client asks about the newborn's risk for developing HIV. Which response by the nurse reflects an understanding of perinatal-acquired HIV?

"With proper care for yourself and your baby, the risk of your baby getting HIV is low." rationale Anti-HIV medications during pregnancy, a Cesarean delivery and bottle-feeding rather than breast-feeding reduce the likelihood of mother-to-child transmission of HIV. In the United States, less than 2% of infants born to HIV-positive mothers become HIV positive.

A client experiences hallucinations that are markedly increased at night. The client is very frightened by the hallucinations. The client's partner asks to stay a few hours beyond the visiting time in the client's private room. What would be the best response by the nurse?

"Yes, staying with the client and orienting the client to the surroundings may help to decrease the anxiety." rationale Encouraging a family member or a close friend to stay with the client in a quiet surrounding can help increase orientation and minimize confusion and anxiety. Remember to use the information in the question to help you select the best response. There are two options that indicate the client's partner can stay, but only one option indicates that the partner can "stay a few hours beyond the visiting time..."

A client diagnosed with depression is scheduled for electroconvulsive therapy treatments (ECT). One hour before the first treatment is scheduled, the client becomes anxious and states, "I do not want to go through with this!" Which statement by the nurse is most appropriate?

"You have the right to change your mind. You seem anxious about the treatment. Can we talk about it rationale This response indicates acknowledgment of the client's rights and the opportunity for the client to clarify and ventilate concerns. Further exploration or assessment would need to be done prior to notification of the health care provider.

The health care provider orders blood tests for a client diagnosed with acute hepatitis B (HBV). Which serum lab test does the nurse expect to be elevated?

ALT (alanine aminotransferase) rationale ALT and AST (aspartate aminotransferase) are enzymes located in liver cells that can leak out into the bloodstream when liver cells are injured. Elevated ALT (and AST) indicate liver damage. One of the liver's jobs is to make albumin; low albumin can be a sign of liver disease. Leukopenia (a decrease in the number of WBCs) is a common finding associated with HBV. BUN and creatinine are used to evaluate kidney function.

A couple is attempting to conceive and asks the nurse when ovulation occurs. The woman reports a regular 32-day cycle. Using the beginning of the client's cycle as a starting point, how many days later would the nurse anticipate ovulation to occur?

17 to 19 days rationale Ovulation occurs 14 days prior to menses. Considering that the woman's cycle is 32 days, subtracting 14 from 32 suggests ovulation occurs around the 18th day. If you can't remember this information, you can probably eliminate two of the responses right away because they are too early in the cycle. When deciding between the remaining options, you will note that the correct option is a little more than halfway through the cycle.

A nurse is reinforcing effective stress management techniques with a client one hour before surgery. Which approach should the nurse include?

Deep breathing rationale Deep breathing is a reliable and valid method for stress reduction. It can be taught and reinforced in this short period of time preoperatively. The incorrect responses are actions that require more time and repetition for effective outcomes.

A caretaker has numerous questions about normal growth and development of a 10 month-old infant. Which characteristic should be of most concern to the nurse?

50% increase of birth weight rationale Birth weight should double by 6 months of age, triple at 1 year, and quadruple by 18 months. The other characteristics are normal for the age of this infant. A tip for answering this question is to recognize that the question being asked is about what would be abnormal for a 10 month-old.

A client of Hispanic heritage refuses emergency unit treatment until a curandero is called. What should the nurse understand about the practices of a curandero?

A curandero uses holistic healing practices rationale A curandero is a folk healer (or shaman) who uses a holistic approach that includes herbs, aromas and rituals, to treat the ills of the body, mind and spirit. Many times, the curandero works with traditional Western health care providers to restore health.

A client with late-stage lung cancer was started on chemotherapy two days ago. Which findings indicate a complication from the chemotherapy? (Select all that apply.)

A serum creatinine level of 2.4 mg/dL Weakness and muscle cramps A serum uric acid level of 22 mg/dL Tumor Lysis Syndrome (TLS) is a metabolic complication in response to chemotherapy and is a medical emergency. Massive cell destruction releases intracellular components such as potassium and phosphate that are metabolized into uric acid. High levels of uric acid crystalize in the distal tubules of the kidneys and lead to acute kidney injury (AKI), as evidenced by the elevated creatinine level.TLS usually occurs within 24-48 hours after the initiation of chemotherapy and may persist for about 5-7 days.Hallmark signs of TLS include: hyperuricemia, hyperphosphatemia, hyperkalemia and hypocalcemia. In addition, the client might experience weakness, muscle cramps, nausea and vomiting (N/V) and diarrhea.

The nurse is gathering data on the nutritional status of a 2 year-old client. What general knowledge should the nurse recall?

A serving size at this age is about two tablespoons rationale In children, a general guide to serving sizes is one tablespoon of solid food per year of age. Understanding this, the nurse can assess adequacy of intake. Notice that two of the options focus on the age group in the stem of this question, but that in the incorrect option, the word "not" is used. The question is asking about "what is" and not "what isn't."

A licensed practical nurse (LPN) from the pediatric unit is assigned to work in the orthopedic-neuro unit. Which of these clients might be assigned to the LPN?

A young adult in skeletal traction three days following a motor vehicle accident rationale The client in skeletal traction is the most stable with a predictable outcome and minimal risk of instability. The health care status of the other clients is less predictable; the range and complexity of actions required to intervene, if adverse outcomes occur, will require the expertise of the RN.

The nurse prepares to perform tracheal suctioning on a client who is a paraplegic. What is the reason for placing the client in a high-Fowler's position prior to suctioning?

Maximize expansion of the client's lungs rationale High or semi-Fowler's positions maximize lung expansion and allows for effective coughing to help facilitate the removal of lung secretions during the suctioning process.

A client is receiving heparin therapy for a deep vein thrombosis of the left leg. Which side effect should the nurse address first?

Black, tarry stools rationale Tarry stools indicate blood in the gastrointestinal (GI) tract and must be reported to the health care provider immediately. It is a priority over the other options. When reading the options, decide which findings would require your attention first - a rash, bleeding, fever or pain and then select the one that is the most potentially life-threatening.

The nurse observes low set ears, short palpebral fissures, flat nasal bridge and indistinct philtrum on a newborn infant. What would be a priority focus when the nurse talks to the parents?

Alcohol use during pregnancy rationale The identification of this cluster of facial characteristics is often linked to fetal alcohol syndrome (FAS). Facial abnormalities including small head (microcephaly); small maxilla (upper jaw); short, up-turned nose; smooth philtrum (groove in upper lip); smooth and thin upper lip; and narrow, small, and unusual-appearing eyes with prominent epicanthal folds. The palpebral fissure separates the upper and lower eyelids.

A nurse is caring for a pregnant woman diagnosed with abruptio placentae. Which nursing intervention would be most beneficial to the fetus prior to an emergency caesarean section?

Administer PRN oxygen rationale Abruptio placentae is the premature separation of the placenta from the uterus. Clients typically present with bleeding, uterine contractions and fetal distress. Administering oxygen prior to the caesarean section would increase the circulating oxygen in the mother's circulation, promoting oxygenation of the fetus that is likely in distress.

The nurse plans to administer liquid medicine to a 9 month-old infant. Which method is appropriate for the nurse to use?

Administer the medication with a needleless syringe next to the tongue rationale Using a needleless syringe to give liquid medicine to an infant is the safest method. If the nurse directs the medicine toward the side of the mouth, gagging will be reduced. Associate the words "administer liquid medicine" in the stem of the question with the words "administer" and "syringe" in the correct response.

The nurse is collecting data from a client with asthma. Following an acute asthma episode, the client had low-pitched wheezes present at the end of exhalation. One hour later, the client had high-pitched wheezes extending throughout exhalation. The nurse should determine that which action is the client's greatest need at this time?

Administer the ordered PRN bronchodilator Correct Response rationale During an acute asthmatic episode, the client's greatest need is for bronchodilation, which can be accomplished by first administering a short acting bronchodilator (SABA) such as albuterol. This may be administered as a nebulizer or as an inhaler. After the bronchodilator, it would be appropriate to administer a corticosteroid; however, corticosteroids are not ordered prn because they take time to work. They are used to control asthma, not as a rescue medication. The client does not have rhonchi or secretions that can't be expectorated, so there is no need for suctioning. Without achievement of bronchodilation first, any supplemental oxygen will not be optimally beneficial to the client.

A client reporting severe shortness of breath is diagnosed with acute heart failure. The pulse oximetry reading is 80%. The client's color changes to gray. The client then expectorates a large amount of pink frothy sputum. What should be the first intervention by the nurse?

Administer the ordered PRN oxygen rationale The client is experiencing acute pulmonary edema. All responses are correct actions by the nurse, but the most important action is to immediately deliver supplemental oxygen to the client. When all options are possibilities, ask yourself what this client needs the most or first. The correct response is oxygen.

A client is newly admitted with severe injuries from a motorcycle accident. The client's vital signs are BP 120/50, rate 110, respiratory rate of 28 and oxygen saturation 90%. Which of these actions should be done as an initial nursing intervention?

Administer the ordered oxygen therapy rationale This client demonstrates early findings of shock with hypoxia, rapid heart rate and respirations. Oxygen therapy is the most important initial intervention by the nurse. The other interventions are secondary to oxygen therapy.

A client has been receiving heparin for five days and now has an order to begin taking warfarin in the evening. Which intervention should the nurse take next?

Administer the warfarin in the evening as prescribed rationale Warfarin takes two to three days before its anticoagulant effect begins to peak at a therapeutic level. Therefore, the heparin is continued until that point. The prothrombin time (PT) or international normalized ratio (INR) is used to monitor the effectiveness of warfarin therapy and heparin will be monitored daily using the activated partial thromboplastin time (aPTT) lab test.

A nurse is assigned to a client who is prescribed warfarin therapy for a deep vein thrombosis of the leg. Today's INR lab value is 5.0 (normal INR value without anticoagulant therapy is 1). Which order from the health care provider would the nurse implement first?

Administer vitamin K and recheck lab rationale Clients should have an INR of 2.0 to 3.0 for basic blood thinning needs. When the INR is above this range, there is a high risk for bleeding. The antidote, vitamin K, should be administered first and then the nurse should observe for abnormal bleeding. The key words here are "implement first." The only action word among the answers is the word "administer," which is the correct response. The other option words "observe," "assess" and "monitor" are data collection words.

A client who is in critical condition is admitted to the hospital. Which of these available documents should be addressed to guide the care of this client?

Advance directives rationale Advance directive forms allow a written platform for clients to state their desires for medical treatment when they become ill, and/or name a person (health care surrogate or a durable power of attorney for health care decisions) whom the client wants to make decisions about health care when the client is unable to do so.

An adolescent client diagnosed with hemophilia A is hospitalized with pain in the knee joints from a bleeding episode. Which order should be questioned by a nurse?

Aspirin for pain management rationale Aspirin, an antiplatelet medication, is contraindicated in any client who is actively bleeding. Acetaminophen (Tylenol) or non-steroidal anti-inflammatory drugs (NSAIDs) are more commonly administered for pain relief.

The clinic nurse is counseling about the risks of continued cocaine use to a postpartum client who is a known drug user. In order to provide continuity of care, which nursing diagnosis should the nurse anticipate to be identified as a priority?

Altered parenting rationale The client who abuses cocaine puts her newborn and other children at risk for negligence and abuse. Continued use of drugs has the potential to impact parenting behaviors. Social service referrals are indicated. To best answer this question, you should look for the response that addresses both the mother and the newborn because the question is asking about "continuity of care."

A nurse is reinforcing information about actions to prevent hypercalcemia to a client diagnosed with metastatic bone disease. Which topic is important for the nurse to discuss with the client?

Ambulation rationale Ambulation promotes mineralization of bones and can reduce serum calcium levels. During reinforcement of client teaching, it is preferred that the interventions that are most client-focused and least invasive be emphasized first. Volume expansion, hemodialysis and diuretics can also all decrease serum calcium levels. If you are unsure of the correct response, you should note that three of the options involve medical, and not nursing, interventions. Ambulation is the only client-centered and nursing response.

A nurse is assigned to the care of a client with atrial fibrillation. Which finding related to this diagnosis is most important for the nurse to report to the registered nurse (RN)?

An episode of severe lightheadedness rationale All of the manifestations can exist in atrial fibrillation. However, the most important one for the nurse to report to the RN is near-syncope or lightheadedness. This is an indication that the client is not tolerating the arrhythmia and it requires treatment. It endangers the client and suggests a need for further assessment. If you are unsure of the answer, ask yourself which manifestation would lead to the worst possible outcome for the client - irregular pulse, anxiety, fatigue or fainting.

A client is in the 33rd week of her first pregnancy. She tells the nurse that she has everything ready for the baby and has made plans for the first weeks together with the baby at home. The client is exhibiting which emotional reaction to her pregnancy?

Anticipation of the birth rationale Directing activities toward preparation for the newborn's needs and personal adjustment are indicators of an appropriate emotional response in the third trimester. The nurse would expect ambivalence in the first trimester. Normal second trimester emotions include accepting the pregnancy and focusing on fetal development.

A nurse is participating in a community health fair. As part of the health promotion process, when should the nurse conduct a mental status examination?

Anytime health screening is done rationale A mental status check is a critical part of baseline information and should be a part of every examination, whether general or specific. You will notice that three of the options indicate a problem with mental status; however, this is a "health promotion" question. Associate the word "health" in the correct option with the question. Additionally, this is a general question and the only general option is the correct option.

A child has just returned from surgery for application of a hip spica cast. What nursing action will be the priority?

Apply waterproof plastic tape to the cast around the genital area rationale The most important aspects of caring for the cast is to keep it clean and dry. Shortly after returning from surgery, waterproof plastic tape will be applied around the genital area to prevent soiling. The child should be turned every two hours to help facilitate drying, from side to side and front to back, with the head elevated at all times. If a crossbar is used to stabilize the legs, it should not be used to turn the child (it may break off). After the cast has completely dried and it becomes damp, it can be either exposed to air, or a hair dryer, set to warm or cool, may be used to help dry the cast.

A nurse is assisting with the care of a trauma victim who has experienced a significant blood loss. Immediately following multiple blood transfusions, what is the most accurate indicator of adequate oxygenation?

Arterial blood gases (ABGs) rationale Arterial blood gases (ABGs) are the most accurate measure of oxygenation at this time. An ABG measures PaO2, PaCO2, pH, HCO3 and oxygen saturation. Pulse oximetry would not be as accurate during and after blood replacement therapy because it is a peripheral test. When a person is in shock, the peripheral extremities are typically vasoconstricted. A CBC examines all components of blood, including hemoglobin and hematocrit.

The nurse is providing home care for a male client with a low hemoglobin. What should be the initial action by the nurse?

Ask the client if he has noticed any dark stools or blood in the stool rationale Depending on the lab, normal hemoglobin for males is 13-18 g/dL and normal hematocrit is 42% to 52%. The first thing the nurse should do is ask the client if he's noticed any bleeding or change in his stools that could indicate bleeding from the GI tract. The other actions are appropriate, but can be done after determining if there are any indications of bleeding. In answering this question, look for client-centered options (asking the client a question) and then determine which option is most related to hemoglobin - blood or breathing.

A 75 year-old client scheduled for surgery with a general anesthetic refuses to remove dentures prior to leaving the surgical unit for the operating room. Which approach by the nurse is the most appropriate intervention?

Ask the client if it would be preferred to remove the dentures in the operating room receiving area rationale Prior to surgery, clients may experience a variety of fears. This choice allows the client control over the situation and fosters the client's sense of self-esteem and self-concept. The client may simply be concerned about physical appearance during the trip through the halls of the hospital to the surgical suite.

A nurse is assisting with a well-child clinic at a day care center. A staff member interrupts the examinations to ask for assistance with an emergency. The nurse finds a crying toddler on the floor, the mouth is wide open and the gums are bleeding. Two unlabeled bottles lie open next to the child. What should be the nurse's first action?

Ask the staff about the contents of the bottles nationale The nurse needs to assess what the child ingested before determining the next action. Once the substance is identified, the poison control center and emergency response team should be called. Remember, usually the first action means "data collection." The only option that involves "data collection" is asking the staff about the contents of the bottles. Syrup of ipecac is rarely recommended any more.

A client is admitted to the psychiatric unit after complaining to friends and family that neighbors have bugged the house in order to hear personal business. The client remains aloof from other clients, paces the floor, and believes that the hospital is a house of torture. Which nursing intervention would be the most appropriate for this client?

Assist the client to develop a trust in the staff through therapeutic relationships rationale Establishing a trusting and therapeutic relationships will form an alliance between staff and the client. The client is exhibiting paranoid behaviors, which indicates an extreme mistrust of others and the environment. To help answer this question, notice that two of the options focus on helping the client. You should then decide which intervention might best help a client who is exhibiting paranoid behavior - a trusting therapeutic relationship or participating in a group activity?

A client is admitted to the mental health inpatient unit after refusing to get out of bed. The client talks to unseen people and regularly voids on the floor. A nurse could best handle the problem of voiding on the floor by which action?

Assist the client to the toilet more frequently With altered thought processes, the most appropriate nursing approach to alter a behavior is by attending to the client's physical needs. Notice that three of the options are punitive actions, which would always be inappropriate, while the correct response is supportive and positive. Furthermore, assisting the client to the bathroom or bedside commode every 30 minutes will be more effective than the other actions.

A nurse is to collect a sputum specimen for acid-fast bacillus (AFB) from a client. Which action should the nurse take first?

Assist with oral hygiene without the use of mouthwash rationale The nurse should obtain a specimen after mouth care, early in the morning, so that particles of food will be removed. Mouthwash should not be used because it may have alcohol in it and this could alter the sputum as it travels through the mouth. The other actions would follow this first action: The client should take several deep breaths then cough into the appropriate sterile container to obtain the AFB specimen of the sputum.

Which of these tasks can be safely assigned to an unlicensed assistive person (UAP)?

Assist with stoma care for a client who has a well-functioning colostomy The care of a mature stoma and the application of an ostomy appliance may be assigned to the UAP. This implementation of a routine task with an expected outcome does not require independent nursing judgment, unlike the other options.

A nurse manager informs the nursing staff at a morning report that a clinical nurse specialist will be conducting a research study on staff attitudes toward client care. All staff are invited to participate in the study if they wish. This affirms the ethical principle of which process during research?

Autonomy rationale Individuals must be free to make independent decisions about participation in research without coercion from others. The key to this question is to notice that each staff member can choose whether to participate in the research study. "Individual choice" only relates to the correct response.

The health care provider has ordered a vanillylmandelic acid test and catecholamine test for a middle-aged client. Which of the following points should the nurse discuss with the client prior to these tests? (Select all that apply.)

Avoid caffeinated beverages, bananas, chocolate, cocoa, licorice and citrus fruit Identify and minimize factors contributing to stress and anxiety A 24-hour urine collection procedure is required Avoid excessive physical exercise several days prior to the test rationale The nurse should confirm what the client has discussed with the health care provider about medications. Many times the client is instructed to stop taking antihypertensive medications prior to the test. Clients should be instructed to avoid anything that would increase urinary catecholamine levels and alter the test results before starting this 24-hour urine test, which is used to help diagnose a tumor in the adrenal glands. Catecholamines (dopamine, epinephrine, norepinephrine) increase heart rate, blood pressure, breathing rate, muscle strength and mental alertness.

The nurse is reinforcing information about chlorpromazine with a client. What information should the nurse be sure to emphasize?

Avoid direct sunlight rationale Chlorpromazine (Thorazine) is used to treat the symptoms of schizophrenia, Tourette's syndrome and mania. Since this medication increases skin sensitivity to sunlight, clients should wear protective clothing, sunglasses and sunscreen and avoid unnecessary or prolonged exposure to sunlight. Clients taking monoamine oxidase inhibitors (MAOIs) should avoid consuming foods high in tyramine. A gluten-free diet is recommended for people with celiac disease. Many medications affect urine color (phenytoin, for example, can cause red urine), but chlorpromazine does not affect urine color.

A nurse is assigned to a client with clinical depression who is receiving an MAO inhibitor. When reinforcing information about this medication, what action should the nurse emphasize?

Avoid eating chocolate and aged cheeses rationale Foods high in tryptophan, tyramine and caffeine, such as chocolate and cheese, may precipitate a hypertensive crisis. Clients should also avoid aged meats and foods, such as anchovies. The two types of cheeses these clients can eat are cream cheese and cottage cheese (which are not aged cheeses). Side effects of MAO inhibitors can include daytime sleepiness, hypotension, weight gain and paresthesia.

A mother with a Roman Catholic belief system has given birth in an ambulance on the way to the hospital. The neonate is in very critical condition with little expectation of surviving the trip to the hospital. Which of these requests should the nurse in the ambulance anticipate and be prepared for?

Baptize the neonate on the way to the hospital rationale Baptism may be requested and anyone may perform this if the infant or child is gravely ill. Mormons believe in divine healing with the laying on of hands. Buddhists may place a thread around the neck or wrist after death. After someone's death, Muslims may want to wash the body and point their deceased loved one's face toward Mecca.

The client diagnosed with glaucoma is being discharged. Prior to discharge, which observed behavior by the client would suggest a need for more reinforcement of information about this disease?

Bends over to pick up items off the floor rationale Glaucoma is a condition of high intraocular pressure (IOP) and bending at the waist to pick up items from the floor increases the IOP. The nurse should reinforce that this should be avoided. The other options don't have a direct effect on glaucoma (although clients should not drink excessive fluids at any one time because this can temporarily increase IOP). Recall that the statement "needs more reinforcement" implies that the client is doing something contradictory to the treatment plan. You simply need to decide which option might have the greatest effect on increasing pressure in the eye.

A nurse is caring for a hospitalized 12 year-old client diagnosed with hemophilia A. Which intervention should the nurse plan on implementing as a priority?

Bleeding precautions rationale The risk associated with hemophilia A is hemorrhage because the blood cannot clot properly to stop bleeding. Therefore, the client should be on bleeding precautions. The stool checks would be secondary because prevention is a priority and bleeding precautions are preventive.

The nurse needs to assess what the child ingested before determining the next action. Once the substance is identified, the poison control center and emergency response team should be called. Remember, usually the first action means "data collection." The only option that involves "data collection" is asking the staff about the contents of the bottles. Syrup of ipecac is rarely recommended any more.

Board games with rules rationale The purpose of play for the 7 year-old is cooperation. Rules are very important. Logical reasoning and social skills are developed through play. The other options are either too young or too old for 7 year-old children.

There's a new medication order that reads: "administer 1 gtt ciprofloxacin solution OD Q 4 h" What action should the nurse take?

Call the prescriber to clarify and rewrite the order rationale Abbreviations, symbols and dose designations can be misinterpreted and lead to medication errors. "OD" can mean "right eye" (oculus dexter) or "once daily"; it should never be used when communicating medical information. The abbreviation "Q" should be written out as "every." Although "gtt" is not on the official "Do Not Use List", it's best to use "drop" instead. Asking other nurses to interpret an order is a potentially dangerous "workaround." The nurse should call the health care provider who prescribed the medication and clarify the order.

The health care provider orders the antidepressant trazodone ER 150 mg at bedtime. Which common side effect of this drug should the client understand?

Causes drowsiness rationale This medication is chemically unrelated to the SSRIs, TCAs or MAO inhibitors, even though it inhibits the uptake of serotonin by nerves in the brain. The sedative effects of this antidepressant is why this medication is also successfully used to treat insomnia. People with insomnia may sleep better immediately, but it may take a week or two before maximum antidepressant effects are noticed. Other common side effects of trazodone include dry mouth, stuffy nose, constipation or change in sexual interest/ability.

A client with a nasogastric (NG) tube is experiencing nausea. What should be the first action taken by the nurse?

Check for the patency of the tube rationale A first indication that the NG tube is obstructed is often a client's complaint of nausea. NG tubes may become obstructed with mucus or sediment. The other options are also correct but are not the priority; they may be done afterward.

A nurse finds an adult client lying still on the floor while doing morning rounds. The nurse, after checking for responsiveness and calling for help, should take which action?

Check the carotid pulse rationale After determining that the client is unresponsive and calling for help, the nurse should check the carotid pulse for no more than 10 seconds. When there is no pulse, the nurse will begin administering chest compressions.

A client with spinal cord injury at the C-5 level reports having a "pounding" headache. The blood pressure is 180/120 mm Hg. A nurse should take which action first?

Check the urinary catheter tubing for kinking rationale This client is exhibiting findings of autonomic dysreflexia (or autonomic hyperreflexia), which is a medical emergency that occurs in clients with spinal cord injury above the C-6. level in response to noxious stimuli. A distended bladder or bowel is the most common cause of autonomic dysreflexia. Prompt relief of this by draining the bladder, in the case of bladder distention from kinked catheter tubing, will relieve findings. A sitting position will not resolve the problem. Nuchal rigidity (neck stiffness) is associated with meningitis or a cerebral bleed, not autonomic dysreflexia.

A client is 48 hours post-insertion of an abdominal catheter for peritoneal dialysis. During a fluid exchange the nurse knows that the appearance of which finding needs to be reported to the health care provider immediately?

Cloudy peritoneal drainage rationale Cloudy dialysate, fever and leukocytosis (high white blood cell count) are findings that indicate infection. Peritonitis (an inflammation of the peritoneum) is a serious complication of peritoneal dialysis. The other responses are expected side effects that can occur during the peritoneal dialysis procedure. Pink-tinged drainage is expected for the first few days after catheter placement.

An older adult client with a history of alcoholism is 12 hours post-op. The client calls a nurse and says "Get me out of this boat - the sharks are going to eat me." Which action should the nurse take?

Collect data about the client's respiratory rate and pulse oximetry rationale A sudden change in mental status (for example, hallucinations) in any post-op client should trigger a nursing intervention directed toward correcting an abnormal oxygenation status. However, the nurse first needs to collect data about the problem before any intervention. Pu oximetry and respiratory rate and effort would be an appropriate initial assessment. An alcohol-dependent person may have hallucinations if alcohol ingestion is suddenly stopped, but this assessment is not as important as pulse oximetry. Hallucinations are not commonly associated with an abnormal serum glucose level and this client gives no evidence for needing cardiac monitoring.

A nurse is assisting in the care of a client with a history of hoarseness and difficulty swallowing for several weeks. The client is diagnosed with laryngeal carcinoma. Which nursing intervention should have priority attention?

Compare daily weights with the admission weight rationale Clients with these findings may not get adequate nourishment. An evaluation of the nutritional state can be accomplished by assessing the weight regularly. The client will certainly need to have alternatives to family support for any help through the therapy that may be necessary. Remember Maslow's hierarchy of needs: physiologic needs supersede psychosocial needs.

The nurse is assisting with the admission of a child with a diagnosis of suspected lead poisoning. What findings should the nurse expect when collecting data about this child?

Complaints of numbness and tingling in feet rationale A child who has unusual neurologic findings, neuropathy, footdrop or anemia that cannot be attributed to other causes may be suffering from lead poisoning. This most often occurs when a child ingests or inhales paint chips from lead-based paint or dust from remodeling in older buildings. Chronic lead poisoning results in developmental delays and/or hyperactivity. To help answer this question, you can narrow the choices down to the two answers that are similar but dissimilar. In this case, this would be the two options that are neurological (sleep and numbness/tingling in the feet). Then select the response that would potentially have the worst outcome for this child

A nurse is planning to review nutrition information with a pregnant woman. What should be the first action the nurse takes?

Conduct a diet history to determine her normal eating routines rationale Collection of more data is always the first step in the reinforcement of teaching for any client.

The partner of a client with Alzheimer's disease expresses concern about the burden of caregiving. Which action by a nurse should be a priority?

Connect the caregiver with a support group rationale The nurse can assist and encourage caregivers to locate and join a support group. Family members, and especially the primary caregiver, should be able to share feelings with others who understand their particular situation and get the support they need while caring for a loved one with a terminal disease. The nurse should also provide information about respite services. Health education is available through local and national Alzheimer's chapters.

The nurse is performing postmortem care on a deceased client who was diagnosed with methicillin resistant staphylococcus aureus (MRSA). Which type of transmission-based precaution is appropriate for the nurse to use?

Contact rationale The resistant bacteria of MRSA remain alive for up to three days after death. Therefore, contact precautions must still be used. Also, the deceased body needs to be labeled so that the funeral home staff can protect themselves as well. Gown and gloves are required, and a mask and goggles should be used if any splashing is anticipated.

Ref # 527 The licensed practical nurse (LPN) is assisting with the discharge of a client following inpatient treatment for pulmonary tuberculosis. What information would be important for the LPN to reinforce?

Continue medication use as prescribed rationale Clients should understand that they must continue any therapy as prescribed. Early cessation of treatment may lead to the development of medication resistant bacteria. The other options are incorrect statements. There is no need to avoid children, pregnant women or immunocompromised individuals and medication should be taken on an empty stomach.

A young child is receiving treatment for lead poisoning. Which of the following is the most serious effect of long-term exposure to lead?

Damage to the central nervous system rationale Lead toxicity can affect every organ system but it is especially dangerous for the brain. Lead can even alter the structure of the blood vessels in the brain and can lead to bleeding and brain swelling. In children, lead exposure is associated with lower IQ scores, learning disabilities, hyperactive behavior, and impaired hearing; higher levels of exposure can cause seizures and death. Neurological effects may persist into adulthood, despite treatment. Anemia (and fatigue), damage to the kidneys and abdominal pain (also called lead colic) are potentially reversible with treatment.

The nurse is documenting care in the client's chart. Which of these entries is correctly written?

Dark green drainage of 100 mL from nasogastric tube in the last 4 hours rationale Entries in clients' records need to be complete, accurate and factual. Records used by third-party payers for reimbursement require accuracy, reliability and validity. Remember that correct charting is specific and detailed. The incorrect responses are too general, using the words "severe abdominal pain" without the location of the injection or specific site of the pain; "seems anxious" without specific behaviors; and "adequate" without specific numbers. This leaves only one option as the only specific and detailed answer (and the one that is measurable).

The nurse checks on a comatose client who is scheduled to receive a gastric tube feeding. Which observation requires an immediate action by the nurse?

Decreased breath sounds in right lung, middle lobe rationale The most common problem associated with enteral feedings is atelectasis from aspiration. Position the client with the head of the bed elevated about 30 degrees during feedings and for at least two hours afterward. Monitor for signs of aspiration, that is, decreased breath sounds, crackles and rales. Check for tube placement and gastric residual prior to each feeding or every four to eight hours if it's a continuous feeding. Remember "respiratory" problems carry more immediacy than GI and urinary ones.

A nurse is caring for a client who has been diagnosed with cardiac tamponade. Which finding should the nurse consider as the greatest concern?

Decreased level of consciousness rationale In cardiac tamponade, intrapericardial pressures rise to a point at which venous blood cannot flow into the heart. This leads to a decrease in cardiac output. The most important indicator of this is a decrease in the level of consciousness. This is a high-priority concern for the nurse. Weakened, irregular pulses, a drop in the urine output and a decrease in blood pressure. This is an emergency condition in which fluid around the heart must be drained to save the person's life.

A 76 year-old adult resident of a nursing home has a tympanic temperature of 100.6 F (38 C). This is a sudden change in an otherwise healthy client. Which data should the nurse focus on first?

Degree of alertness and orientation rational Assessing for changes in level of consciousness and mental status is the most important data to collect in helping the health care provider determine the severity of the infection. A temperature this high in an older adult is likely to indicate a severe infection, as the fever response in this population is less pronounced than in younger adults. Be careful not to automatically rule out options because you are are thinking you should rely on the "ABCs" for data collection. Changes in mental status take priority over breath sounds for initial data collection, especially in older adults.

The nurse is reinforcing information about the management of asthma with a group of parents. Which action by the parents best indicates that the teaching was effective?

Demonstrate how to use a peak flow meter. rationale A peak expiratory flow meter (PEFM) is used in the management of asthma and provides an objective way to monitor asthma symptoms and allow for the early recognition of an acute exacerbation. Therefore, it is important for the client and client's caregiver(s) to know how to correctly use a PEFM. A return demonstration would be a good way for the nurse to evaluate whether teaching was effective or if reinforcement is needed. The other actions are too subjective and won't be as helpful in recognizing a worsening of the child's asthma.

The nurse is collecting data about a 16 year-old's use of coping mechanisms. The teen had multiple serious injuries after a motor vehicle accident. Which characteristics are most likely to be displayed by this teen?

Denial, projection, regression rationale Helplessness and hopelessness may contribute to regressive, dependent behavior. Denying or minimizing the seriousness of the injuries is used to avoid facing the worst situation or consequence of the accident.

The nurse is caring for a client with a colostomy who is two days post-op. The client begins to cry saying, "I'll never be attractive again with this ugly red thing." The first response by the nurse should include which approach?

Determine the client's understanding of the colostomy rationale One of the greatest fears of clients who have a colostomy is that sexual intimacy is no longer possible. However, the specific concern of the client needs to be examined before specific suggestions for dealing with the sexual concerns are given. Remember, when a client has a problem, further data collection (the first step of the nursing process) is most often the best action.

The nurse collects data on a client with type 1 diabetes mellitus. Which finding requires an immediate nursing action?

Diaphoresis and shakiness rationale Diaphoresis, shakiness, nervousness and irritability are signs of hypoglycemia and warrant immediate attention. Hypoglycemia can rapidly reduce the level of consciousness and progress to a hypoglycemic coma. Clients diagnosed with type 1 diabetes have a lack of insulin production and require blood glucose testing and administration of insulin multiple times per day to control blood glucose levels. You should recall that short-term problems in type 1 diabetes are hyperglycemia and hypoglycemia, and the only option that focuses on this content is the correct response. Intense thirst and hunger are associated with hyperglycemia, but it is less dangerous in the short term than hypoglycemia. The nonspecific way in which this question asks about diabetes mellitus type 1 suggests that the more general answer is most likely correct.

A nurse is reinforcing home care to the parents of a child with rheumatic fever. The nurse should make it a priority to emphasize which topic?

Difficulty breathing or swelling in the legs and feet should be reported. rationale Rheumatic fever can cause damage to the heart valves resulting in signs of heart failure such as fatigue with activity, shortness of breath and fluid retention. These findings should be reported to the provider, as they may represent heart failure requiring medical treatment.

The nurse becomes aware of feelings of reluctance to interact with a manipulative client. What approach would be the most appropriate action the nurse should take?

Discuss the feeling of reluctance with an objective peer or supervisor rationale The nurse who experiences stress in a therapeutic relationship can gain objectivity through dialogue with colleagues following directly observed supervision. Nurses must attempt to discover attitudes and feelings that may enhance or adversely influence nurse-client relationships.

The nurse is assisting with the discharge of a client following a total hip arthroplasty. Which information should be emphasized during the discussion of home care with this client?

Do not cross your legs at any time rationale To avoid dislocating the hip prosthesis, hip flexion should not exceed 60 degrees. To help narrow the options down, look at the the two that are the most similar but dissimilar. This would lead to options about the legs and not doing something. Then ask yourself which position would be contraindicated - climbing or crossing legs? (Still not sure? Cross your legs now and feel how the hip joint is a little stressed.)

The nurse is caring for a client, who is the mother of a close friend. The friend asks the nurse for an update about her mother's condition on a social networking website. How should the nurse respond?

Do not respond to the friend on the social networking website rationale A nurse cannot disclose information about a client except to those who are directly involved in the care of the client. Also, clients must be informed about how their personal health information will be used and given the opportunity to object to or restrict the use or release of information. Nurses cannot use social networking websites, like Facebook, to disclose patient information, even with the use of privacy settings or when no names are used. Each health care organization has strict policies prohibiting the disclosure of protected health information.

The nurse makes home visits for a client who has completed an inpatient substance abuse disorder program. Which behavior is most revealing about the client's commitment to continued sobriety?

Evidence of drug and/or alcohol use rationale Feeling full of self pity or crises may trigger a relapse. Missed appointments are a form of dishonesty, which is also a red flag for a relapse. But continued drug or alcohol use is the most revealing because it demonstrates a lack of commitment to the treatment program. However, since substance use disorder is a chronic disease, the nurse will understand that relapse can occur. Lapsing back to drug or alcohol use indicates that treatment needs to be reinstated or adjusted, or another treatment should be tried.

A nurse is caring for a client who has received an extracorporeal shock-wave lithotripsy (ESWL) procedure. What information is the priority focus for the nurse to reinforce?

Drink at least 3000 mL of fluid each day for one month rationale Drinking approximately 3000 mL of fluid each day will aid passage of fragments and help prevent formation of new renal calculi. This is the priority. The first essential action is to understand that all options are conceivably correct. Next, you need to look at the clues. One clue is the word "lithotripsy" with "lith," which means stone. Ask yourself what organs have stones. The kidney is associated with calcium or purine intake and the gall bladder is associated with fat intake. Then reread the options to note that calcium and water are in two options. So it must be a kidney stone problem where the stones are shocked outside of the body ("extra" = outside and corporal = body). Then think through the sequence of what happens - first, the parts of the stone need to be passed, then extra walking would help the situation, and then consider the actions that would help prevent further stones.

The client is diagnosed with superficial thrombophlebitis of the left leg. Which nursing intervention should be given the highest priority?

Elevate the affected leg Unlike deep vein thrombosis, superficial venous thrombosis involves a sudden inflammatory reaction (redness, pain, swelling), but it rarely involves an embolism. Treatment involves elevating the leg because dangling the extremity will increase the swelling and the pain. Other treatment options include warm compresses and analgesics (aspirin or another NSAID); sometimes a low-molecular weight heparin is also prescribed. Clients do not need to be on bed rest but they should wear elastic support stockings (or multiple elastic bandages) when out of bed.

A client has been on antibiotics for 72 hours to treat cystitis. Which findings reported by the client require priority attention by the nurse?

Elevated temperature rationale Elevated temperature after 72 hours on an antibiotic indicates that the antibiotic has not been effective in eradicating the offending organism. The health care provider should be informed immediately so that an appropriate medication can be prescribed and complications, such as pyelonephritis, are prevented. The smelly urine and burning are expected with cystitis and during initial treatment. Gastrointestinal findings may be related to the antibiotics as a side effect and should also be reported. However, they are a lower priority and may resolve if the antibiotic is changed.

A licensed practical nurse (LPN) is caring for a client diagnosed with multiple myeloma who is undergoing radiation therapy. Which side effect should be reported to the registered nurse (RN) immediately?

Elevated temperature rationale Elevated temperature is the first finding of infection. Radiation suppresses the body's production of white blood cells, which increases the risk for infection. Remember that because multiple myeloma is generalized in the body, the radiation therapy would be as well. Therefore, you can eliminate all the options dealing with specific locations and select the more generalized symptom (temperature elevation).

A nurse is caring for a client with a subclavian vascular access device for hemodialysis. Which finding necessitates immediate action by the nurse?

Elevated temperature rationale It is a priority to report an elevated temperature because clients with a central line, such as the hemodialysis catheter, are prone to infection and the first finding of infection is an elevated temperature. Further data collection is needed to identify the source of the infection. Other findings should be reported to the care provider as well, but do not require immediate action.

A nurse is caring for a client with schizophrenia who has been treated with quetiapine for one month. Today the client is increasingly agitated and reports having muscle stiffness. Which of these additional findings should be reported to the health care provider?

Elevated temperature and sweating rationale Neuroleptic malignant syndrome (NMS) is a rare disorder that can occur as a side effect of antipsychotic medications. It is characterized by muscular rigidity, tachycardia, hyperthermia, sweating, altered consciousness, autonomic dysfunction, and increased creatine phosphokinase (CPK). This is a life-threatening complication that can occur anytime during therapy with antipsychotic medications.

The nurse is obtaining data related to the client's psychosocial needs. Which action should the nurse include?

Elicit the client's description of experiences, thoughts and behaviors rationale The nurse's understanding of the client is more comprehensive if obtained by listening to the client's self-revelation. To help answer this question, you will notice that the correct response states that the nurse will "elicit" a client's response and this can be related to "obtain data" in the question. Remember, the first step in the nursing process is to collect data.

A 6 year-old child is admitted to the emergency department. The x-rays show a femur fracture near the epiphysis. What information does the nurse understand about long bone fractures in children?

Epiphyseal fractures often interrupt a child's normal growth pattern rationale The epiphyseal plate in children is where active bone growth occurs. Damage to this area may cause growth arrest in either longitudinal growth of the limb or in progressive deformity if the plate is involved. An epiphyseal fracture is serious because it has potential to interrupt and alter growth of the bone.

A nurse walks into a client's room and finds the client lying still and silent on the floor. The nurse should first take what action?

Establish that the client is unresponsive rationale The first step in basic life support (BLS) is to establish unresponsiveness. Calling for help and checking for a pulse are actions that should follow establishing unresponsiveness. Getting a history of the fall should follow after the clinical situation has been resolved and stabilized. You will note that the correct response is the only data collection answer. The other options are actions or interventions.

The mother of a preschooler asks the nurse: "Should I be concerned about the tendency of my child to stutter?" What focus should be the most useful when responding to this parent?

Expected consequence of the child's age rationale During the preschool period, children are using their rapidly growing vocabulary faster than they can produce words. This failure to master sensorimotor integrations results in stuttering. This dysfluency in speech pattern is a normal characteristic of language development at this age period. Therefore, knowing the child's age is most important in determining if any true dysfunction might be occurring.

The nurse is caring for a 4 year-old child. Which behavior should be of the greatest concern to the nurse when caring for a preschool age child?

Expresses shame rationale Erikson describes the stage of the preschool child as being the time when there is normally an increase in initiative. The child should have resolved the sense of shame and doubt as a toddler. The key words in this question are "preschool aged child" and "most concern to the nurse," which implies you should look for an answer that would be abnormal for a child this age.

The nurse is reinforcing information about clozapine. What information about side effects should the nurse emphasize?

Extreme salivation rationale Clozapine (Clozaril) is prescribed for the management of severely ill schizophrenics who fail to respond to standard drug treatment for schizophrenia. There is a significant risk of agranulocytosis and seizure. Many clients who take clozapine experience extreme salivation and other autonomic nervous system findings.

A client says, "It's raining outside and it's raining in my heart. Did you know that St. Patrick drove the snakes out of Ireland? I've never been to Ireland." How will the nurse identify this speech pattern in the progress notes?

Flight of ideas rationale Flight of ideas is characterized by over-productivity of talk and verbally skipping from one idea to another. It is classic with clients diagnosed with bipolar disorder and occurs in the manic state of this disease. Flight of ideas can also occur in schizophrenia and intoxication with toxic psychoactive substances. Perseveration is persistent repetition of words or ideas, such as "I think I will put on my hat, my hat, my hat, my hat, my hat..."). Neologisms is the making of new, nonsensical words.

The nurse needs to administer medications through a jejunostomy tube (J-tube). Which approach is correct?

Flush the tube with water between each medication and after the last medication rationale The best response is to flush the tube with water between each medication and after the last medication. All medications cannot be crushed - be sure to check first before crushing a medication or ask pharmacy for a liquid formula. Medications should never be added to the formula. Medications should be administered one at a time - never mixed together.

A nurse is reinforcing information to a child and parents about the medication phenytoin prescribed for seizure control. Which more common side effect should the nurse include in the discussion?

Gingival hyperplasia rationale You will note that this question is asking for a specific side effect of phenytoin (Dilantin). Dizziness and drowsiness are common side effects of many different drugs, so these options can be eliminated right away. A butterfly-shaped rash on the face (lupus erythematosus) is a severe adverse effect associated with phenytoin and should be immediately reported to the health care provider. Swollen or any overgrowth of tender gums often occurs with the use of phenytoin. The effects can be minimized with good oral hygiene, such as brushing after each meal and flossing once a day, as well as regular visits to the dentist.

A child is treated for acute otitis media with amoxicillin suspension, 200 milligrams per dose. The child weighs 30 lb (15 kg) and the daily dose range is 20-40 mg/kg/day every eight hours. The nurse should take which action?

Give the medication as ordered rationale Amoxicillin is commonly prescribed to treat acute otitis media. To answer this question, you first need take to calculate the prescribed dosage and then ask if this is a correct order or not (either "give the medication" or "hold the medication" and "call the practitioner"). The dose range is 20-40 mg/kg/day divided every eight hours. 15 kg x 40 mg = 600 mg, divided by 3 = 200 mg per dose. The prescribed dose is correct and should be given as ordered.

The nurse is providing care for an infant who has had a pyloromyotomy. Which of these approaches for the first postop feeding is most appropriate?

Glucose and electrolyte solution rationale A pyloromyotomy is a surgical procedure to correct pyloric stenosis. Postoperatively, the infant is NPO for about 3 to 12 hours. The initial feedings are clear liquids provided in small quantities to provide calories and electrolytes. Later, if tolerating the clear liquids, the infant can be given watered-down formula or breast milk and eventually switched over to regular breast milk or formula.

A toddler is diagnosed with iron-deficiency anemia. Which dinner menu would be best for providing the most iron for this toddler?

Ground beef patty, lima beans, wheat roll, raisins, milk rationale Iron rich foods include red meat, fish, egg yolks, green leafy vegetables, green beans, liver, watermelon, legumes, whole grains and dried fruits such as raisins. The dinner option highest in iron and appropriate for a toddler includes the ground beef patty, lima beans, wheat roll, raisins and milk.

A nurse is working in a variety of health care settings. Which of these actions is a priority in the prevention of infections in various settings such as acute care agencies, clinics or home settings?

Hand washing rationale Hand washing remains the most effective way to avoid the spread of infection. This would be a priority to reinforce to clients and families. Nurses need to wash their hands before and after client care, touching objects in a client's room, after removing gloves, or whenever hands are soiled. Alcohol-based hand sanitizer may be used between washing the hands.

The nurse is reinforcing information about the use of sublingual nitroglycerin. What information about side effects should the nurse emphasize?

Headache rationale The most common side effect is headache, which is related to the generalized vasodilatation.

The nurse is caring for a client in a long leg synthetic cast. The most important reason for the nurse to elevate the casted leg is for what purpose?

Improve venous return rationale Elevation of the leg both improves venous return and minimizes swelling. Secondary benefits of the elevation are the other options.

A polydrug user has been in recovery for eight months. Recently, the client has begun to skip breakfast, has not been eating regular dinners, and has been seen frequenting bars to "see old buddies." What should these client behaviors indicate to the nurse?

Headed for relapse rationale It takes 9 to 15 months to adjust to a lifestyle free of chemical use. Thus, it is important for clients to acknowledge that relapse is a possibility and then to identify early warning signs and actions to take to prevent a relapse. When answering this question, determine if the client's behavior of seeing old buddies in bars indicates recovery or a potential for relapse. Although socialization with others is important in recovery, this could be better accomplished by attending a 12-step program meeting, and not by going to a bar.

A postpartum mother is unwilling to allow a partner to participate in the newborn's care, although the partner is interested in doing so. She states, "I am afraid the baby will be confused about who the mother is. Baby raising is only for mothers." The nurse's best initial intervention is which action

Help the mother to express her feelings and concerns about the issue rationale Nonjudgmental support for expressed feelings may lead to resolution of competitive feelings in a family with a new member. Cultural influences or prior life experiences may also be revealed during further data collection. The incorrect responses are actions that should be done later, after the initial discussion.

A client with a brain tumor is scheduled for a CT scan with contrast. Which of the options listed below would be a concern for the nurse when preparing the client for this test? (Select all that apply.)

History of asthma Positive pregnancy test BUN is 40 mg/dL (14.28 mmol/L) People at higher risk for a reaction include those with past reactions to contrast media, asthma, and a history of heart, kidney and thyroid diseases. Individuals taking beta blockers or metformin are also at higher risk. Clients with poor renal function will not be able to clear the contrast agent from the kidneys (normal BUN is 7 - 20 mg/dL [2.5 - 7.1 mmol/L]). Pregnancy is typically a contraindication to a CT.

A health care provider's written order reads, "Aspirate nasogastric (NG) feeding tube every four hours and check pH of aspirate." The pH of the aspirate is 10. Which action should a nurse take?

Hold the tube feeding and notify the provider rationale A pH of less than 4 or 5 indicates that the tube is appropriately placed in the stomach, a highly acidic environment. A high (or more alkaline) pH indicates small intestine placement, which is incorrect for this client because the tube is supposed to be in the stomach. In humans, the stomach is a highly acidic environment - maintained at pH 1.5 to 2 by the secretion of hydrochloric acid (HCl) — with peptidase digestive enzymes (primarily pepsin).

The nurse is interviewing the parents of a child diagnosed with asthma. About which of the following issues should the nurse gather more data?

Household pets rationale Animal dander is a very common allergen affecting children with asthma. Other triggers may include pollens, peanuts, carpeting, mold, mildew, second-hand cigarette smoke and household dust.

A client telephones the clinic to ask about a home pregnancy test she used that morning. A nurse understands that the presence of which hormone strongly suggests that any woman is pregnant?

Human chorionic gonadotropin (HCG rationale Human chorionic gonadotropin (HCG) is the biologic marker on which pregnancy tests are based. Reliability is about 98%, but the test does not positively confirm pregnancy. This same hormone is the stimulus for morning sickness.

The client is admitted with a pressure ulcer that's two inches in diameter with no tunneling. It is a shallow open ulcer with loss of dermis and a red/pink wound bed. The nurse observes some serous drainage. What intervention does the nurse anticipate will be ordered to treat this wound?

Hydrogel dressing rationale This ulcer is a partial thickness wound. These types of wounds heal by tissue regeneration, which is why the nurse would expect a gel dressing to be ordered. This dressing will keep the wound moist, provide protection from infection and promote healing; also, the cool sensation provided by the gel offers pain relief. Pink/red wound edges are considered normal in the inflammatory stage of healing; the wound does not require debridement. There is nothing to indicate that there's an infection, which is why the alginate with silver is not needed; also, alginate dressings are better for wounds with moderate-to-heavy drainage and are good for filling cavities or tracts. An alternating pressure pad overlay would not treat the wound.

A client diagnosed with chronic glaucoma is providing information to the nurse about this disease. Which statement made by the client would the nurse associate with this disease?

I have to turn my head to see objects in the room." rationale Chronic glaucoma, a condition of abnormal intraocular pressure, typically causes disturbances in the client's peripheral vision. Because of this, clients need to turn their head more than usual to see peripheral objects. In acute glaucoma, the vision may be blurred suddenly if the intraocular pressure increases. Being bothered by bright lights and specks floating in the eyes are associated with normal changes of aging and not just glaucoma. Continuous blurred vision is more commonly associated with cataracts.

The client needs assistance to insert bilateral in-the-ear hearing aids. What action should the nurse take before inserting the hearing aids?

Identify the hearing aid that goes in the right ear and left ear rationale Since hearing aids are customized for each ear, the nurse should make sure the correct hearing aid is inserted in the correct ear (a red dot indicates the right ear.) The volume should be turned down when inserting the devices and adjusted after they are in the ear. Hearing aids should only be cleaned with a soft cloth; water or alcohol can damage the device. The battery door should never be used as a handle.

A 68 year-old client is prescribed an anticholinergic metered dose inhaler (MDI) for chronic obstructive pulmonary disease (COPD). Why would the nurse suggest a spacer for this client?

Improve the aerosol delivery from the MDI rationale Spacers improve the medication delivery in clients who are unable to coordinate the MDI. They are commonly used by children and older adults, both of whom may have difficulty with coordination. Because using the spacer may make it easier to use the medication, compliance may be increased, which may prevent exacerbation of the disease.

The nurse is checking on a client diagnosed with chronic obstructive lung disease (COPD) who reports the onset of sudden sharp pain on the right side of the chest. The client is now cyanotic with a tracheal deviation. What should the nurse expect when auscultating the lungs?

Inaudible lung sounds on one side of the chest rationale Crackles in the bases, wheezes in the upper airways and rhonchi throughout the lungs are not indicative of a pneumothorax. Inaudible lung sounds on one side indicates a pneumothorax (or hemothorax), which is the likely diagnosis in a client who suddenly develops respiratory distress and tracheal deviation, which occurs with tension pneumothorax, and is a medical emergency. You will notice that three of the options indicate sounds that are found in auscultation. The correct option indicates no sound; select the "odd" option.

The client is diagnosed with Addison's disease. What should the nurse understand about the diet of a person with this diagnosis?

Increase sodium and drink at least 1.5 liters of water each day rationale In Addison's disease, the adrenal glands do not make enough of the hormone cortisol (and sometimes aldosterone). This results in sodium wasting and potassium retention. The findings are typically dehydration, hypotension, hyponatremia, hyperkalemia and acidosis. Mineralocorticoids are usually the preferred treatment. Also, fluids and dietary sodium intake should be increased; potassium intake should be restricted. Don't confuse this with Cushing's disease in which sodium intake is restricted. Eating just enough calories to maintain a healthy weight is too generic a statement for Addison's disease.

The licensed practical nurse (LPN) is caring for a preschooler two hours after tonsillectomy and adenoidectomy. Which observation must be reported immediately to the registered nurse (RN)?

Increased restlessness rationale Restlessness, along with increased respiratory and heart rates are often early signs of hemorrhage. Recall that a change in consciousness indicates initial hypoxia in this situation from a decreased cardiac output and volume of blood. Dark brown emesis is expected within a few hours after surgery from the old blood that may have been swallowed.

In the post-anesthesia care unit (PACU) a nurse provides care to a teenage client after an emergency appendectomy. Which finding is an indication that the client may be in an early stage of shock?

Increasing pulse rate rationale An early finding in shock is an increasing pulse rate. The blood pressure does not decrease in shock until later, as the compensatory mechanisms begin to fail.

A nurse assigned to a 9 year-old child with a fractured femur is told that a medication error occurred. The child received twice the ordered dose of morphine an hour ago. Which nursing diagnosis on the plan of care is a priority at this time?

Ineffective breathing patterns related to central nervous system depression rationale Respiratory depression is a life-threatening risk in narcotic overdoses.

The nurse is explaining to a practical nursing student techniques used to protect clients. The nurse asks the student to provide an example of when surgical asepsis would be used. Which of the following responses demonstrates an understanding of surgical asepsis by the student?

Insertion of an indwelling urinary catheter rationale All invasive procedures or entry into a bodily orifice or vessel require sterile technique, which is a part of surgical asepsis. The other options are actions related to medical asepsis, which require clean technique.

A client is admitted with a tentative diagnosis of heart failure. When collecting data about the client, which finding would be the priority for the nurse to observe for and document?

Inspiratory crackles rationale All of the responses can be manifestations of heart failure. The most important observation listed is inspiratory crackles, a finding that reflects fluid buildup in the lungs.

At 7:30 am, a client diagnosed with type 1 diabetes has a blood glucose reading of 306 mg/dL (17 mmol/L). The client reports being very hungry and thirsty. After the nurse reports the lab result and the client's comments, what type of insulin should the nurse anticipate to administer?

Insulin lispro (Humalog) rationale Insulin lispro (Humalog) is a rapid-acting insulin that will help to quickly reduce the client's serum glucose level. Be sure the client's breakfast tray is delivered within 5 to 10 minutes after using any rapid-acting insulin. NPH insulin is an intermediate-acting insulin. Insulin glargine (Lantus) and insulin detemir (Levemir) are long-acting or "basal" insulins; they are usually administered once a day, at bedtime.

The client is trembling and appears fearful as he enters a locked behavioral health unit for the first time. Which initial action by the nurse would be best for the client?

Introduce self to the client and accompany the client to his room rationale Anxiety is triggered by change that threatens an individual's sense of security. The nurse should remain calm, minimize stimuli and move the client to a safer and quieter setting. This client is not ready to interact with others or listen to unit rules. It would not be the correct response to assign care to another staff person.

The client's is newly diagnosed with atrial fibrillation. Which finding would the nurse expect when caring for this client?

Irregularly irregular pulse ranging from 100 to 140 BPM rationale Atrial fibrillation is is defined by irregularly irregular ventricular pulse and apical-radial mismatch; the heart rate is typically between 110 and 140 BPM. A premature ventricular contraction (PVC) pattern is a normal beat, an extra beat (the PVC), a slight pause, and then a stronger-than-normal beat. Bradycardia is a slow heart rate. Ventricular fibrillation causes unconsciousness and, if untreated, a person will have a brief seizure and then become unresponsive with no detectable pulse.

The nurse is collecting data on a newly admitted infant with a malfunctioning ventriculoperitoneal (VP) shunt. Which manifestation would the infant be most likely to exhibit?

Irritability rationale Findings of increased intracranial pressure in infants include bulging fontanel, high-pitched cry, and irritability with crying when held or cuddled. Vital sign changes include a pulse that is variable, (ie., rapid, slow and bounding or feeble). Respirations are more often slow, deep, and irregular. Lethargy would be a finding at the very late stages of increased intracranial pressure.

The nurse is discussing information about liquid iron supplements with the parents of toddler who is receiving this medication. Which information should the nurse be sure to reinforce?

Mix the medicine with orange juice and have the child drink it through a straw rationale Iron is best absorbed with ascorbic acid (vitamin C). Also because liquid iron preparations will stain the teeth, the child should use of a straw. Iron is best absorbed on an empty stomach, but if the medicine upsets the child's stomach it may be taken with a small snack. Dairy products, spinach, whole grain cereal and bread products will prevent adequate absorption of the iron; the child should not eat or drink these one hour before or two hours after taking the medication.

The 54 year old client is scheduled for a coronary angiography. The client's medical history includes angina, type 2 diabetes mellitus and mild renal insufficiency. Which of the following orders does the nurse anticipate?

Monitor serum creatinine levels pre- and post-procedure rationale Coronary angiography requires the use of a contrast dye. Persons with diabetes and/or impaired kidney function are at high risk for developing contrast media-induced nephrotoxicity (CIN). Adequate hydration helps maintain renal blood flow and reduces the time the contrast media is in contact with the renal tubules and, therefore, will help prevent CIN. Serum creatinine levels are used to monitor for the development of CIN. Nephrotoxic drugs, such as ibuprofen, should not be used for procedures requiring contrast media. The oral hypoglycemic drug metformin increases the risk of lactic acidosis if CIN were to occur; it should be held the day of the procedure until kidney function returns to baseline (as determined by serum creatinine).

A client is admitted for treatment of a frontal lobe brain tumor and undergoes a craniotomy for tumor removal. The client is comatose afterwards. Which postoperative nursing intervention would have the highest priority?

Monitor the level of consciousness rationale Positioning, keeping the head elevated (to prevent increased intracranial pressure) and monitoring the pupils are all necessary post-craniotomy interventions. However, monitoring the level of consciousness and any movements is the highest priority, as it provides important information about the client's brain function following surgery. Certain movements and body positions called posturing can indicate worsening of brain function.

A neonate is having difficulty maintaining a temperature above 98 F (36.6 C) and is placed in an infant warming system (IWS). Which of the following actions will ensure the safety of the neonate?

Monitor the neonate's temperature continuously rationale When using a warming device, the neonate's temperature should be continuously monitored using a probe that's securely attached to the skin. Monitoring the neonate's temperature is the priority safety concern because skin burns, permanent brain damage or even death can result due to improper use or monitoring of equipment. No clothing or swaddling is needed in the IWS; usually babies are dressed only in a diaper (although bubble wrap blankets or plastic wrap blankets can be used to minimize heat loss in high risk newborns.) For healthy term newborns, nurses should warm their hands and stethoscopes prior to contact with the baby.

A client is admitted to the hospital with a diagnosis of heart failure. At home, the client was taking furosemide (Lasix) only. Which finding should the nurse anticipate on the initial admission history?

Muscle weakness rationale A client taking the loop diuretic furosemide will most likely need a potassium supplement to prevent hypokalemia. This client did not take supplemental potassium. Findings of hypokalemia include weakness and muscle cramps in the legs or abdomen. To help answer this question, think about the purpose of furosemide. If you recall that it is a diuretic (or "water pill") and that will help eliminate water and sodium, chloride, and potassium. If the client is not getting enough potassium in the diet (or not taking a supplement) the nurse might expect muscle weakness.

The nurse is caring for a client diagnosed with acute renal calculi. Which health care provider order would be a priority to implement?

Narcotic client controlled analgesia rationale Administering narcotic analgesics provides prompt relief of the severe pain caused by kidney stones. Note first that this is a priority question where all four options are conceivably correct and the goal is to select the best of these options. Recall that pain is the fifth vital sign and takes priority over the other presented problems.

The client is undergoing radiation therapy for Hodgkin's disease. The nurse should recognize that which finding is most likely associated with the radiation treatment?

Nausea rationale Because the client with Hodgkin's disease is usually healthy when therapy begins, the nausea is especially troubling. Hodgkin's disease is cancer of the lymphatic system. The content of this question is "radiation therapy," not Hodgkin's disease. All options, except one, are associated with this disease and not the radiation therapy.

A client is receiving erythromycin 500 mg IV every six hours to treat pneumonia. Which of these findings is the most common side effect of the medication?

Nausea rationale Erythromycin is a macrolide anti-infective. Nausea is a common side effect of erythromycin, regardless of the route of administration. You should note that the other options listed are not "common" side effects of most medications.

Several days after a total hip replacement, an 80 year-old client is ambulating in the hallway with a walker. The client is to be discharged later in the day. Which finding documented in the morning nurse's notes requires priority attention by the registered nurse (RN) before the client is discharged?

New onset of agitation and confusion rationale Agitation along with confusion may alert the nurse to an alteration in cerebral tissue perfusion, side effects of medications or a new infection such as a urinary tract infection. In older adults, confusion is often the first sign of an infection. This may suggest an embolus to the lung from the lower extremity. Pulmonary embolism, often from a fat embolism, is a more common complication after hip replacement. The other responses are expected postoperative findings.

A client being treated for hypertension returns to the clinic for a follow up visit. The client states to a nurse, "I know these water pills are important, but I just can't take them anymore. I drive a truck for a living and can't stop every 20 minutes to go to the bathroom." During a team meeting, which nursing diagnosis should the nurse suggest?

Noncompliance related to medication side effects rationale The client kept the appointment and stated a knowledge that the pills were important. The client is unable to comply with the regimen due to the side effects of the diuretics being in conflict with the occupation, not a lack of knowledge about the disease process or medication's importance.

The nurse is caring for a child who has just returned from a tonsillectomy and adenoidectomy surgery. Which intervention by the nurse is most important?

Observe swallowing patterns and ability rationale The nurse should observe for increased swallowing frequency or inability to swallow, which usually indicates bleeding with a risk of hemorrhage or excessive swelling at the surgical site. Remember, the first action usually involves data collection before an intervention. The correct option is the only data collection response.

The nurse is collecting data about the occurrence of constipation in a 75 year-old client. Which approach should be a priority for the nurse?

Obtain an activity, elimination and dietary preferences history rationale Initially, the nurse should obtain information about the frequency of the constipation as well as details about recent changes in bowel habits, physical and emotional health, medications, activity pattern, and food/fluid history. This information may suggest causes as well as guide an appropriate and safe treatment plan.

The nurse is reinforcing information to a client about taking ibuprofen. Which common side effect of nonsteroidal anti-inflammatory medications (NSAIDs) should the nurse make the client aware of?

Occult bleeding Nonsteroidal anti-inflammatory medications, such as ibuprofen (Motrin, Advil), may cause serious side effects when taken for long periods of time. Common side effects include bleeding in the gastrointestinal tract, abdominal aching or cramping, and diarrhea.

The client is newly diagnosed with hypertension. How should the nurse measure the initial blood pressure on this client?

On both arms rationale Blood pressure should be taken in both arms due to the fact that one subclavian artery may be stenosed, which may cause a false high in the affected arm. It's also possible that the health care provider would like the blood pressure to be measured when lying down and sitting or standing (not standing and then sitting, as indicated in an incorrect response.)

A child with a congenital heart defect visits the clinic several weeks before a planned surgery. Which issue should the nurse give the most attention to when collecting data?

Oxygenation rationale All of the options are important when treating a child with congenital heart defects. However, persistent hypoxemia can result in acidosis, which can further decrease pulmonary blood flow. Remember the ABCs: Airway, Breathing, Circulation

The nurse is caring for a newly admitted 6 month-old infant diagnosed with nonorganic failure-to-thrive (NOFTT). What findings would the nurse expect to observe during the initial assessment?

Pale skin, thin arms and legs, and uninterested in surroundings rationale Diagnosis of NOFTT is weight consistently below the 3rd to 5th percentile for age and gender, progressive decrease in weight to below the 3rd to 5th percentile, or a decrease in the percentile rank of two major growth parameters in a short period of time. The nurse would expect to see a child who avoids eye contact, has pale skin, thin arms and legs, and is easily fatigued. NOFTT is due to psychosocial problems such as neglect, lack of knowledge about proper feeding or of the infant's needs. Many times the child engages in self-stimulatory behaviors (head banging or rocking) and is wary of close contact with people.

A newborn presents with a pronounced cephalohematoma after being born in a posterior position. The licensed practical nurse (LPN) anticipates that the plan for care will address which nursing diagnosis?

Parental anxiety related to knowledge deficit rationale This hematoma is caused by pressure and/or trauma during labor; it is often caused by forceps used in the delivery. This painless condition is usually benign and resolves on its own in four to six weeks. The swelling does not cross the suture lines. Parental anxiety must be addressed by listening to their fears and reinforcing the information provided by the health care team.

A nurse is caring for a post-surgical client at risk for the development of deep vein thrombosis (DVT). Which action is preventative and should be reinforced by the nurse?

Perform range of motion exercises and walk rationale Mobility reduces the risk of DVT in the post-surgical client and in any adults at risk. Clients should perform ROM exercises of the legs while in bed, and they should get out of bed to stand, sit in a chair or walk in the hallway several times a day. It is contraindicated to place pillows under the knees because pillows will press against the veins and cause an increase in venous stasis. Antiplatelet agents are not the drug of choice for DVT prevention. Leg massage should be avoided as it can dislodge a thrombus causing pulmonary embolism, which is a very serious complication of DVT.

The nurse is caring for a client with chronic renal failure. Which of the following orders written by the health care provider would the nurse question?

Potassium chloride (Micro-K) 20 mEq daily with breakfast rationale Hyperkalemia is the most common and life-threatening metabolic complication of renal failure. Consequently, additional potassium would be contraindicated. Recombinant human erythropoietin is prescribed to treat anemia. Diuretics such as furosemide are used to treat edema caused by chronic kidney failure. Kayexalate is a potassium-binding resin used to prevent or treat hyperkalemia.

The nurse is to administer a new medication to a client. Which of the following actions best demonstrates an awareness of safe and proficient nursing practice?

Prior to administration of the medication, the nurse should ask: "What is your name? What allergies do you have?" and then check the client's name band and allergy band. rationale A dual check is always done for a client's name. This would involve verbal and visual checks. Because this is a new medication an allergy check is appropriate. The other options have parts that might be correct actions. However, to be the correct answer all of the parts of an option need to be correct.

The nurse is caring for a client who has received alteplase (Activase) to treat an acute cerebral vascular accident (CVA). Which nursing intervention should receive priority consideration?

Protect invasive lines or tubes rationale Alteplase is a potent thrombolytic enzyme. Because bleeding is the most common side effect, it is essential to protect invasive lines from accidental dislodgement and monitor for any bleeding.

The nurse is assigned to care for a client who has seizures. Which nursing action is a priority for a client during a seizure?

Protect the client from injury rationale The priority during a seizure is to protect the client. Next, it is a priority to observe, and then record what movements are seen during a seizure. The diagnosis and subsequent treatment often rests on the seizure description. Suctioning may be done after seizure activity, as well as loosening clothing. Remember that safety always takes "priority" when it is an option, and the question is about a priority action.

The nurse is collecting information about a newly admitted client. Which finding contraindicates the use of haloperidol and warrants withholding the medication?

Rash, anemia and severe depression rationale Rash and blood dyscrasias are adverse effects of antipsychotic medications. A history of severe depression is a contraindication with the use of neuroleptics, also called antipsychotics.

The health care provider orders an osmotic diuretic for a client diagnosed with a traumatic brain injury (TBI). Why is this medication ordered?

Reduce intracranial pressure rationale Osmotic diuretics, such as mannitol, are used to reduce intracranial or intraocular pressure. Osmotic diuretics reduce the amount of water normally reabsorbed by the renal tubules and loop of Henle, so urinary output is increased. Osmotic diuretics can cause excessive loss of water and electrolytes, which can lead to serious electrolyte imbalances. In addition to water intoxication and dehydration, adverse reactions of osmotic diuretics include pulmonary edema and circulatory overload. Anticonvulsants prevent seizures.

The 86 year-old client will be participating in a transitional care program after discharge from the hospital. What is the primary purpose of a transitional care program?

Reduce readmissions to the hospital rationale Older adults who complete a transitional care program after being discharged from the hospital are much less likely to be readmitted to the hospital. The Affordable Care Act mandates that each facility have a "quality assurance and performance improvement program", designed to help reduce unnecessary hospital readmissions.

A newborn who is delivered at home and without a birth attendant is admitted to the hospital for observation. The initial temperature is 95 F (35 C) axillary. The nurse should recognize that cold stress may lead to what complication?

Reduced partial pressure of oxygen in arterial blood (PaO2) rationale Hypothermia and cold stress cause a variety of physiologic stresses including increased oxygen consumption, metabolic acidosis, hypoglycemia, tachypnea and decreased cardiac output. The baby delivered in such circumstances needs careful monitoring. In this situation, the newborn must be warmed immediately to increase its temperature to at least 97 F (36 C). Normal core body temperature for newborns is 97.7 F to 99.3 F (36.5 C to 37.3 C).

The licensed practical nurse (LPN) is caring for a client in isolation. Which task should the LPN assign to an unlicensed assistive person (UAP)?

Reinforce isolation precautions to any visitors rationale The key word in the correct response is "reinforce" - the UAP may reinforce information that has already been taught by the nurse. Nursing assessment, evaluation, judgement or teaching cannot be assigned to a UAP.

The nurse is assisting clients with trigeminal neuralgia (tic douloureux) and their nutrition needs. During home care of these clients, which approach should be taken by the nurse?

Reinforce the need for small meals containing high-calorie and soft-textured foods rationale If a client is losing weight because of poor appetite due to the facial pain, the nurse can reinforce the need for foods that are high in calories and nutrients. The goal is to provide more nourishment with less chewing. Reinforce that frequent, small meals be eaten instead of three large meals. To minimize jaw movements when eating, the nurse could suggest pureed or liquid forms of nutrition. To help answer this question, you can ask yourself: Which function of the body would be associated with food and nerves? You might think: "eating and chewing." You could then ask: Is this condition painful? If yes, you will notice that only one option focuses on soft food (that would require less chewing).

A child's parents are concerned because their school-aged child is a picky eater. What initial approach should the nurse encourage the parents to take with the child?

Reinforce two main consequences of an unbalanced diet with the child rationale It is important for the parents to reinforce to their child the appropriate diet and the problems that might arise if the diet is not adequate. The other options are appropriate and might be done at a later time. Remember the "initial" approach needs to include the child.

A nurse is caring for an adolescent who is prescribed albuterol inhaled for asthma. The adolescent asks, "Why do I have to take this medication?" What is the best response by the nurse?

Relax the smooth muscles in the airways rationale The most accurate and simplest response is that albuterol relaxes the smooth muscles in the airways. Albuterol (a beta-adrenergic agonist) is a bronchodilator and is the medication of choice in treating asthma because it allows the smooth muscle in the airways to relax. This relaxation results in airways that dilate, which increases air flow to the lungs.

A nurse is caring for elderly residents who live in a long-term care setting. Which activity would most effectively meet the growth and developmental needs for the elderly?

Reminiscence groups rationale According to Erikson's theory, older adults need to find and accept the meaningfulness of their lives, or they may become depressed, angry and fear death. Reminiscing contributes to successful adaptation by maintaining self-esteem, reaffirming identity, and working through loss. Erikson identifies this developmental challenge of the elderly as "ego integrity versus despair."

The nurse is assessing the client during a home health visit and the client states: "I had physical therapy yesterday. I thought it was supposed to help but my back hurts so much after each visit." The nurse's responsibilities include which of the following actions? (Select all that apply.)

Report the client's findings to the nursing supervisor for further assessment Report the client's findings to the physical therapist Gather more information about the location, duration and intensity of the pain The needs of the client can be best addressed by further assessment of the client (collecting more information about the findings of pain) and then communicating the client's needs to the interdisciplinary team members. Before any medication is given or any appointments are made, more information about the pain is needed.

When caring for a client receiving an intravenous (IV) infusion via an electronic pump, which of these actions should the nurse safely ask an unlicensed assistive person (UAP) to perform?

Report the reading on the pump for milliliters remaining rationale When directing the UAP, communicate clearly and specifically what the task is. When and what should be reported to the nurse is critical. Only actions or routine tasks should be assigned to UAPs. Reporting the read out on the pump does not require independent nursing judgment.

A client receiving acute peritoneal dialysis is undergoing a dialysate exchange. Which finding would alert the nurse to the possible development of an acute complication?

Respiratory rate of 30 with crackles in the lungs rationale The development of an increased respiratory rate with crackles in the lungs indicates fluid overload, which can be an acute complication of peritoneal dialysis. In one incorrect response the vital signs are within normal parameters. Sleeping throughout the fluid exchange is a normal expectation and indicates that the client is comfortable. Clear fluid on the dressing around the catheter indicates leakage of the dialysate fluid and can be controlled by instilling less fluid with each exchange.

The nurse is consulting with a nutritionist regarding an appropriate diet for a client recently diagnosed with renal disease. Select the most appropriate diet for the client with renal disease.

Restricted protein, low sodium, low phosphorus rationale Dietary modification is important with renal disease. Protein intake should be limited to decrease nitrogenous waste production (typically, 1 gram of protein per kilogram of body weight per day is recommended). The client should also follow a sodium, potassium and phosphorous-restricted diet.

A hospitalized client who has been receiving enteral nutrition has had four loose or watery stools in the past 24 hours. What action should a nurse take first?

Review the medications the client has received Antibiotics or substances containing sorbitol (often contained in liquid drug preparations) may contribute to frequent, loose stools. Further information is needed. After this step, the charge nurse should be notified of the problem. When asked about what should be done "first," think data collection; only the response that states to review the medications is about data collection.

A client is admitted with a diagnosis of end-stage cirrhosis. When helping to plan care, a nurse should identify which nursing diagnosis as most important?

Risk for injury rationale The client with end-stage cirrhosis is at great risk for injury or hemorrhage due to impaired coagulation and fragile esophageal varices. This is a higher priority than the other options. As you read the answer options, you will realize that three options address client issues that are not mentioned in the question. The odd option is the correct one.

The nurse is reinforcing teaching with a client about compromised host precautions. The client is receiving filgrastim (Neupogen) for neutropenia. Which lunch selection suggests the client has learned about the necessary dietary changes?

Roast beef, mashed potatoes, sauteed green beans rationale Low white blood counts and susceptibility to infection are expected when the client's immune system is compromised. Consequently, these clients need to minimize the risk of food-related infections. General recommendations include eating foods that are either cooked or canned. The client should avoid raw fruits and vegetables, undercooked meat and eggs, soft "moldy" cheeses, lunch meat and salads from the deli counter. They should consume only pasteurized dairy products and fruit juices and avoid cold-brewed teas and drinks. Want a more detailed rationale? Listen to the Learning Extension's Question Dissection® podcast.

A nurse is caring for a client who is receiving methyldopa. Which assessment finding would indicate to the nurse that the client may be having an adverse reaction to the medication?

Sedation rationale Methyldopa (Aldomet) is used to treat hypertension. The nurse should assess the client for alterations in mental status, such as sedation. Other common side effects are dizziness, dry mouth, headache and weakness. These changes should be reported to the health care provider.

A nurse is caring for a 2 year-old child. What should be understood as a major stressor for this child during hospitalization?

Separation anxiety Correct! rationale Note that a toddler will experience all of these listed stresses. However, separation from parents or the caretaker is the major stressor.

A Latina client, diagnosed with ovarian cancer, refuses both radiation and chemotherapy because they are "hot." Which action would be the best for the nurse to take at this time?

Set aside time to talk to the client about the meaning of "hot" rationale In Hispanic folk medicine, it is believed that disease is caused by an imbalance between hot and cold principles. Health is maintained by avoiding exposure to extreme temperatures and by consuming appropriate foods and beverages. Examples of "hot" diseases or states include pregnancy, hypertension, diabetes and indigestion. "Cold" diseases include pneumonia. Care and treatment regimens can be negotiated with clients within this framework. The correct response is the best answer because it is client-centered and also provides for further data collection about the problem. The incorrect responses can be done later.

Which observation made by the nurse suggests that a client is in a manic episode?

Shares grandiose ideas rationale Grandiosity is characteristic of a manic episode, as well as pressured speech, minimal sleep and continuous movement or activities.

All medications have side effects. Which medication has the highest risk of causing depression?

Simvastatin (Zocor) for high cholesterol rationale Some medications can cause depression in some clients; the elderly are at a higher risk for developing depression. The following drugs are reported to cause depression: zovirax (used to treat viral infections), barbiturates, benzodiazepines (used to treat anxiety or insomnia, such as lorazepam, diazepam, alprazolam ), beta blockers (used to treat various heart problems, including metoprolol, carvedilol), accutane (used to treat severe acne), and statins (used to lower cholesterol, such as atorvastatin, simvastatin). The effects of these drugs may or may not abate when the medication is discontinued.

A client calls the office nurse and reports a sudden deep throbbing pain in one leg. What initial suggestion should the nurse give the client?

Sit in a recliner chair with the legs elevated rationale The complaint suggests deep vein thrombosis. The client must be maintained on bed rest or stay inactive until the health care provider has been notified. Because "deep throbbing pain" in a leg is usually related to vascular problems, you can eliminate the two options with activity because this is contraindicated by leg pain. When comparing the remaining options, eliminate the option that would decrease circulation. The only option left is rest of the extremity with elevation.

A health care provider orders digoxin 0.125 mg and furosemide 40 mg by mouth every day. The nurse would recommend the client should eat which of these foods on a daily basis?

Slice of watermelon rationale A slice of watermelon is the highest in potassium and will replace any potassium lost by the diuretic. A tomato has high potassium but not as much as a slice of watermelon. The other foods do not have high levels of potassium.

The nurse is collecting data on an acutely ill school-aged client who has asthma. Which of these findings would require the nurse's immediate attention?

Slow, irregular respirations A slow and irregular respiratory rate is a sign of fatigue in an acutely ill child with respiratory problems such as asthma. Fatigue can rapidly lead to respiratory arrest. The other options are of a concern but the respiratory status is the priority concern. Remember ABCs.

The nurse is caring for a client diagnosed with a confirmed myocardial infarction (MI). Which finding requires the immediate notification of the registered nurse (RN)?

Spells of lightheadedness rationale Cardiac arrhythmias may cause a transient drop in cardiac output and decreased blood flow to the brain. Episodes of lightheadedness may be due to runs of ventricular tachycardia, periods of bradycardia, or superventricular tachycardia and should be reported immediately. You will notice that two of the options are not life-threatening (loss of appetite and tiredness with fatigue), so you can eliminate these. Shortness of breath is a vague finding that could be attributed to several different factors, but transient lightheadedness can indicate many serious conditions and should be reported immediately to the RN.

A health care provider has written an order for the nurse to change a dressing and clean an incision on a post-surgical client. Which process should the nurse use to clean the surgical incision?

Start at the incision and clean in an outward direction from the incision rationale In order to prevent the introduction of microorganisms into the surgical incision during cleaning, follow the principle to clean from the area of least contaminated to most contaminated. Recall tip: "clean to dirty."

The nurse is providing care to older adult clients in an assisted living facility. What approach is best to use with medication dosing to older adults?

Start with lower doses and increase slowly rationale Due to physiological changes in older adults, as well as conditions such as dehydration, hyperthermia, immobility, low albumin and liver disease, the rate for the metabolism of medications may decrease. As a result, medications can accumulate to toxic levels sooner and cause serious adverse reactions. Remember this adage about medication dosing for older adults: "start low and go slow."

During a home visit, the nurse observes the mother of a school-aged child in a long leg synthetic cast using a cloth-covered wooden spoon handle to relieve itching inside the cast. Which response by the nurse is most appropriate?

Suggest placing an ice pack (protected by plastic) over the area that is itching rationale Because itching is a common and frustrating problem for a person with a cast, it would not be therapeutic to simply remind the mother and child that itching is normal. But using anything to scratch the skin inside the cast is not recommended because this can injure the skin, increasing the risk for infection. Clients may use a hair dryer to help relieve itching, but the temperature must be set to cool or cold. Of the given choices, applying ice (protected by a plastic bag) is the most appropriate. Cool temperatures constrict blood vessels, minimizing itching (just like heat vasodilates and intensifies itching.) Sometimes over-the-counter antihistamines may help relieve itching.

The nurse is working on the mother/baby unit and learns a newborn was diagnosed with hypospadias. What intervention would the nurse expect for this infant?

Surgery will be performed in stages rationale Hypospadias is a condition in which the urethral opening is located on the ventral side (or undersurface) of the penis or below the penis head. It is corrected in stages as soon as the infant can tolerate surgery. Notice that two options focus on the wrong content. The content of this question is "hypospadias," not "circumcision." You will also notice that two options focus on a surgical repair and can be associated with the content of this question. Then ask yourself if it makes sense to delay the surgery by years or to perform the surgery in stages.

A client frequently compliments a nurse and then invites the nurse to go to a movie and dinner. The nurse should take which approach when responding to the client?

Talk about the boundaries of the nurse-client relationship rationale The nurse-client relationship is one with professional boundaries. Consistent adherence to the limits of the professional relationship builds trust. A discussion with the client about boundaries is essential in such situations.

When taking the client's blood pressure (BP), the nurse cannot hear the sounds through the stethoscope. Which action should the nurse take first?

Wait two minutes and retake the BP in the same arm rationale It is best to wait two minutes between readings of a BP in the same arm to allow the vessels to recover from being squeezed. The electronic cuff would also require a two-minute wait and it may not provide a reading for a very low pressure. The nurse should have palpated the brachial artery first, before applying the cuff.

While a nurse is bathing a 2 month-old infant, the mother states, "I am concerned because a flat pink birthmark on my baby's forehead and eyelid has not gone away." What information should the nurse reinforce with the parent?

Telangiectatic nevi are normal and will disappear as the baby grows rationale Telangiectatic nevi, salmon patch or "stork bite" birthmarks are a normal variation and the facial nevi will generally disappear by ages one to two years. Mongolian spots are flat birthmarks can be deep brown, slate gray, or blue-black in color. They do sometimes look similar to bruises. The edges are often, but not always, indistinct. They are most common on the lower back and buttocks, but are often found on the legs, back, sides and shoulders. They vary from the size of a pinhead to six inches or more across. They are more common in dark-skinned infants, e.g., Native Americans, Asians, Hispanics and African descent.

A client is taking prednisone and aspirin as part of the treatment plan for rheumatoid arthritis. Which intervention would be an appropriate action by a nurse?

Test the stools for occult blood rationale Both prednisone and aspirin increase the risk for bleeding from the mucus membranes. Therefore, monitoring for bleeding from the gastrointestinal tract would be appropriate.

An 18 month-old toddler is on peritoneal dialysis in preparation for a renal transplant in the near future. When a nurse obtains the child's health history, the mother indicates that the child has not had the first measles, mumps, rubella (MMR) immunization. The priority nursing action should be based on which understanding?

The MMR vaccine should be given now, prior to the renal transplant rationale MMR is a live virus vaccine and should be given at this time. Post-transplant, immunosuppressive drugs will be given and the administration of the live vaccine at that time would be contraindicated because of the compromised immune system. You will note that two of the responses address the timing of administering the vaccine; however, both the correct response and the question contain the term "MMR."

The nurse is preparing to administer 2 different vaccines to a toddler, using a separate limb for each vaccine. If the nurse uses a limb on the right side of the body for the first vaccine, which injection site would be appropriate for the second vaccine?

The anterolateral thigh muscle is the correct injection site for the toddler. It is easily accessible and provides a position where the parent or caregiver can make eye contact and provide comfort to the toddler. When more than one vaccine is scheduled during the same office visit, it's recommended to use separate limbs. If there's a reaction to one vaccine, the health care provider will know which site was used for each injection.

Privacy and confidentiality of client information is legally protected. In which of these situations should the nurse make an exception to this practice?

The client threatens harm to self and/or others rationale An exception to the privacy and confidentiality of all client information is when the client threatens to endanger self, staff, or the public.

A nurse is assisting in the assessment of a client's home in preparation for discharge. Which focus should be given priority consideration?

The family's understanding of the client's needs rationale The client's needs are important for the family to understand because this will enhance compliance and ongoing care. The other three options are not the best because they address specific needs associated with conditions. The question is a general one, with no conditions, such as mobility difficulties or expensive therapy, mentioned. In this case, the most general option is the best answer.

A practical nurse (PN) is collecting data on a healthy child at a two-year checkup. Which finding should the nurse report immediately to the registered nurse (RN)?

The height and weight percentiles vary widely On the growth curve, height and weight should be close in percentiles at this age. The wide difference may indicate a problem. You will notice that three of the options focus on only one issue (either only height or weight). The correct option focuses on a comparison between two growth parameters (both height and weight).

A newborn weighed 7 pounds 2 ounces at birth. The nurse weighs the newborn at home two days later and finds the weight to be 6 pounds 7 ounces. When the parents question this weight loss, what information should the nurse understand when responding to the parents?

The loss is within normal limits for this time period rationale A newborn is expected to lose 5% to 10% of the birth weight in the first week of life because of changes in elimination and feeding. A weight loss of 5% in the first week of life is considered normal for the formula-fed infant. A loss of 7% is average in the first week for the breastfed infant; 10% is the absolute maximum. If the newborn loses 7% in the first 72 hours, breastfeeding should be observed and, if needed, the mother should be referred to a lactation nurse consultant.

A nurse is reinforcing information about breast-feeding to an apprehensive primipara who has been having difficulty with breast-feeding. What observation at the time of discharge suggests that the initial breast-feeding reinforcement of information was effective?

The mother appears calmer and talks to the baby while breast-feeding rationale Early evaluation of successful breast-feeding can be measured by the client's voiced confidence and satisfaction with the infant. Singing to the newborn would not necessarily indicate calmness and confidence in the mother. For some, singing may be an action to decrease stress and anxiety. Correct!

A client who has just joined a health maintenance organization (HMO) asks for information about the payment obligations with this plan. What is the most accurate description of health care costs charged to a client with a HMO?

There is a predetermined fee for all services rationale A HMO plan is a plan that provides for all services based on a predetermined fee. During the specified period of enrollment, health care services are often provided with no additional charges.

The premature infant is recently diagnosed with respiratory distress syndrome. What is the infant's greatest need at this time?

Time to develop surfactant in the lungs rationale Respiratory distress syndrome is primarily a disease related to inadequate lung development and is most common when infants are born prematurely, before fetal surfactant production has started. Surfactant coats the alveolar lining, reducing alveolar surface tension which prevents the alveoli from collapsing. The infant needs time to develop so that surfactant production can begin. Surfactant replacement therapy can also be used to prevent or treat this problem. Protective isolation is standard practice when caring for premature infants who have underdeveloped immune systems. Nutrition with high protein is important as well. However, neither is as important as the infant's need for time to produce surfactant. Holding and cuddling is more of a psychosocial need that should be secondary to the physiological needs.

A client with a history of heart disease takes daily prophylactic aspirin. Which finding could indicate aspirin toxicity?

Tinnitus rationale Tinnitus, or ringing in the ears, is a potential side effect of aspirin therapy. If a client is experiencing tinnitus, the medication should be withheld and the health care provider notified. In order to help prevent side effects, the client should understand the correct dosage (usually a prophylactic dose is a 81 mg tablet taken once a day).

A nurse is caring for a group of older adult clients who are on complete bed rest. What is the appropriate action by the nurse to prevent skin breakdown?

Turn every one to two hours rationale Frequent turning, at least every one to two hours, helps prevents skin breakdown. Sheep skin or other products can decrease friction and pressure, but turning is still a priority. Although proper nutrition and hydration are important, they are not specific enough to address the current issue. Also, the nurse would want to manage any incontinence, but the question does not indicate that any of the clients are incontinent.

The nurse is reinforcing information about using oxygen at home with a client who has chronic obstructive pulmonary disease (COPD) and who smokes a pack of cigarettes per day. Which of the following topics should the nurse also reinforce to the client and the family?

Turn off the oxygen and move to another room or outside to smoke rationale Because oxygen is highly combustible, a risk of fire exists if anyone smokes near the oxygen equipment. Oxygen may remain on during meals based on the client's needs. Oxygen flow should be as low as possible to maintain a saturation of 88-91%. It may need to be increased with activity and when the client's oxygen saturation is low. The client should be taught to breathe normally through the mouth and nose. The key to answering this question is to focus on the use of oxygen and safety.

A nurse is checking an infant diagnosed with developmental hip dysplasia. Which finding should the nurse anticipate with this client?

Unequal leg length rationale A shortening of the affected leg is a finding with developmental hip dysplasia, along with an asymmetry of the gluteal folds. The option about diminished femoral pulses can be eliminated because the problem is with the hip, and not blood vessels. Also, in hip dysplasia, the problem is not adduction, but abduction.

A nurse is to perform part of the physical assessment on a toddler. Which approach would be the best to use with someone in this age group?

Use minimal physical contact initially rationale The nurse should approach a toddler slowly and initially use minimal physical contact so as to gain the toddler's cooperation. The nurse should also be flexible in the sequence of the exam for this age group of children and give only brief, simple explanations just prior to the action.

A client is admitted to the emergency department during an acute asthma attack. Which finding would be most important to monitor and report to the registered nurse (RN)?

Use of accessory respiratory muscles rationale In asthma, inflammation of the airways cause the muscles surrounding the airways to become tight and the lining of the air passages swells. Either wheezing or a cough may be the main symptom. Use of accessory muscles of breathing would be most important as an indicator of severe respiratory distress. Note that all of the findings are associated with an acute asthma attack, but accessory muscle use is a priority because it means that air is having difficulty getting into the smaller airways inside the lungs.

The nurse receives a telephone call from a health care provider who wants to give a telephone order. Which of the following actions should the nurse take? (Select all that apply.)

Verify understanding by reading the order back to the provider before hanging up Correct! Record the order word-for-word and sign the order rationale Reading the order back allows the provider to correct any misunderstanding and is a Joint Commission read-back requirement. The order should be immediately written and signed by the nurse. The order should clearly state "telephone order" as abbreviations can be misunderstood (P.O. could be interpreted as "by mouth"). Having a second person listen in on the conversation is not required unless the nurse cannot understand the health care provider. The order may be implemented right away, but it must be countersigned within the time limits set by the facility.

A client has had a total gastrectomy for stomach cancer. Which vitamin deficiency should a nurse anticipate and discuss with the client while reinforcing prior teaching?

Vitamin B12 rationale Clients who have had all or part of their stomachs removed lose intrinsic factor, which is responsible for the absorption of vitamin B12 into the body. This results in B12 deficiency and anemia. A monthly injection (IM or SC) of this vitamin will be needed for the remainder of the client's life. Deficiencies of vitamins C, K and A are not associated with gastrectomy or bariatric surgery. This is a specific question and requires a specific answer; only the correct option designates a specific "B" vitamin, whereas the other options are general.

A client is admitted for lithium toxicity. Which finding should the nurse report immediately?

Vomiting with diarrhea rationale Vomiting and diarrhea can lead to dehydration, which alters the tolerance to lithium and can produce a toxic state from elevated blood levels of lithium.

A nurse is reinforcing discharge instructions with a client diagnosed with asthma. The client is allergic to house dust mites, which makes the asthma worse. Which instruction would be the most helpful suggestion to help control the asthma?

Wash the bed linens in hot water weekly rationale For asthma clients who are allergic to house dust mites, washing the bed linens frequently is an important method of preventing asthma symptoms due to the environment. It is helpful to use mattress and pillow covers that are allergen-impermeable. All bed linens (sheets and blankets) should be washed in hot water weekly at temperatures above 130 F (54 C) to kill the dust mites. The key here is to narrow the options down to the two answers that are the most similar but dissimilar. In this case, it would be the two that both refer to washing bed linens. Then ask yourself which one is more likely to kill mites - cold, warm, or hot water?

The nurse is providing instructions for a client diagnosed with chronic heart failure. The client should be reminded to contact the health care provider if which problem occurs?

Weight gain of three pounds or more in a 48-hour period rationale It is critical for clients with cardiac problems to report and be treated for these findings before they require hospitalization: rapid weight gain (from retention of excessive fluid), decreased urinary output over 24 hours, worsening nocturnal orthopnea (difficulty breathing when lying flat), pitting ankle edema especially in the morning, increased fatigue and other findings of chronic heart failure. Early identification and treatment can potentially avoid hospitalization. If decreased appetite is persistent, it should be reported. You will note that two options are similar but dissimilar and related to weight gain. Because this is a more general question, the more general answer is the better option here.

The school nurse checks the heads of children after summer break. Which of these findings confirms the presence of pediculosis capitis?

Whitish oval specks sticking to the hair shafts rationale Diagnosis of pediculosis capitis is made by observation of the white eggs (nits) firmly attached to the hair shafts. Treatment includes shampoo application, such as lindane for children over 2 years of age, and meticulous combing and removal of all nits. Lice infestations are spread most commonly by close person-to-person contact. Dogs, cats and other pets do not play a role in the transmission of human lice. Lice move by crawling; they cannot hop or fly.

A nurse is assigned to a client with Parkinson's disease who is experiencing hallucinations. Which of these medications may have been a contributing factor?

carbidopa-levodopa (Sinemet) rationale It is unclear why, but some clients with Parkinson's disease eventually develop what is known as Parkinson's disease dementia. Common symptoms include hallucinations; delusions; changes in memory, concentration and thinking; trouble interpreting visual information; and irritability. Classic antiparkinson medications, such as carbidopa-levodopa and dopamine agonists, can inadvertently cause serious emotional and behavioral changes.

A postpartum mother is unwilling to allow a partner to participate in the newborn's care, although the partner is interested in doing so. She states, "I am afraid the baby will be confused about who the mother is. Baby raising is only for mothers." The nurse's best initial intervention is which action?

lp the mother to express her feelings and concerns about the issue rationale Nonjudgmental support for expressed feelings may lead to resolution of competitive feelings in a family with a new member. Cultural influences or prior life experiences may also be revealed during further data collection. The incorrect responses are actions that should be done later, after the initial discussion.

A nurse is following the plan of care for a 75 year-old client with community-acquired pneumonia who is normally healthy and active. Which action should be most effective for the removal of pulmonary secretions?

ncrease oral fluid intake rationale Secretion removal is enhanced with adequate hydration, because it thins and liquefies secretions. In an older adult, the amount of fluid intake should be individualized based on the client's size, coexisting conditions and other factors because of the risk of fluid overload and normal fluid intake. Chest physiotherapy is beneficial but is not as important as hydration, and may not be needed in this client who is usually healthy and active. It would also be more effective after the secretions have thinned. You'll notice that two of the options (cough suppressants and bed rest) would not help remove pulmonary secretions; in fact, they may do the opposite. Inactivity would be beneficial only if hypoxia occurs with activity, and cough suppressants should be avoided, as they can prevent clearance of secretions by suppressing the cough.