NCLEX Comprehensive Exam 1

A client with a history of heart failure is brought to the emergency department with severe dyspnea, anxiety, tachypnea, and tachycardia. Which prescribed medication should the nurse administer first? - morphine sulfate 4 mg I.V. push - diazepam 2.5 mg I.V. push - nitroglycerin infusion 5 mcg/min - furosemide 60 mg I.V. push

morphine sulfate 4 mg I.V. push Rational: Morphine works quickly to decrease anxiety, improve alveolar gas exchange, and increase cardiac output by reducing ventricular preload and afterload. Additional treatment includes removing fluids with furosemide and improving oxygen supply to the cardiac muscle with nitroglycerin.

A parent of a 9-year-old child who is scheduled to have surgery expresses concern about the potential for a postoperative infection. Which information would be most important for the nurse to tell the parent? - "All visitors should wash their hands before they leave or enter the room." - "Cover your mouth and nose when you cough or sneeze in the room." - "Do not bring fresh flowers or fruit to the room after surgery." - "Wear an isolation gown when entering the room."

"All visitors should wash their hands before they leave or enter the room." Rational:Hand washing upon entry and when leaving the client's room should be stressed to visitors to prevent the spread of disease. During the postoperative period, visitors could inadvertently bring in infectious agents to the client. Telling the family to cover their mouths and noses when coughing and sneezing does not decrease postoperative infection risks as much as hand washing would impact the client. Fresh flowers and fruit are restricted for neutropenia clients. Isolation gowns would not be necessary in a noninfected postoperative client.

The nurse instructs a group of parents about emergency treatment for accidental poisoning and injury. The nurse would need to do further teaching if a participant makes which statement? - "I should flush my child's eye with room temperature tap water for 15 to 20 minutes if a caustic material gets into it." - "I should save the emesis if my child vomits." - "I should call the poison control center if there are any symptoms." - "I shouldn't induce vomiting unless the poison control center instructs me to."

"I should call the poison control center if there are any symptoms." Rational: Many poisons require immediate attention but do not cause immediate symptoms. Therefore, parents who believe that a child has ingested or otherwise been exposed to a poisonous substance should immediately call the Poison Control Center. Eyes should be flushed for 15 to 20 minutes with saline or room temperature tap water. Emesis should be saved for analysis, especially if the type or amount of poison ingested is not clear. Vomiting caustic substances may lead to esophageal or airway damage; therefore, vomiting should only be induced if directed by the Poison Control Center.

A nurse has been teaching an adolescent how to self-administer insulin. Despite repeated instruction, the adolescent will use only the left thigh for insulin administration. What is the best question for the nurse to ask the adolescent before conducting further teaching? - "What makes you feel in control of your situation?" - "Do you need me to spend more time teaching you?" - "Is it less painful for you when you use the same site?" - "Are you afraid of scarring and bruising in other areas?"

"Is it less painful for you when you use the same site?" Rational: Repeatedly injecting the same site causes scar tissue (lipohypertrophy) to form, and little or no pain is felt with subsequent injections. It also decreases insulin absorption. Scarring is more likely to occur with same-site injection than with rotating injection sites.

The nurse is preparing to administer a vitamin K injection to a male neonate shortly after birth. What statement by the mother indicates that she understands the purpose of the injection? - "My baby does not have the normal bacteria in his intestines to produce this vitamin." - "My baby is at a high risk for a problem involving his blood's ability to clot." - "The red blood cells my baby formed during pregnancy are destroying the vitamin K." - "My baby's liver is not able to produce enough of this vitamin so soon after birth."

"My baby does not have the normal bacteria in his intestines to produce this vitamin." Rational:For vitamin K synthesis in the intestines to begin, food and normal intestinal flora are needed. However, at birth, the neonate's intestines are sterile. Therefore, vitamin K is administered via injection to prevent a vitamin K deficiency that may result in a bleeding tendency. When administered, vitamin K promotes formation in the liver of clotting factors II, VII, IX, and X. Neonates are not normally susceptible to clotting disorders, unless they are diagnosed with hemophilia or demonstrate a deficiency of or a problem with clotting factors. Hemolysis of fetal red blood cells does not destroy vitamin K. Hemolysis may be caused by Rh or ABO incompatibility, which leads to anemia and necessitates an exchange transfusion. Vitamin K synthesis occurs in the intestines, not the liver.

A female client with bipolar disorder who has been taking risperidone 2 mg orally twice a day informs the nurse that she is 8 weeks pregnant. The clients asks if she should continue the medication. What is the nurse's best response? - "You should immediately stop this medication to decrease the risk of a major birth defect." - "Your health care provider will slowly wean you off risperidone over the next several weeks." - "The benefits of you staying on this medication that has controlled your symptoms outweighs the risk the fetus." - "Risperidone is safe to take during pregnancy, but you won't be able to breastfeed your baby."

"The benefits of you staying on this medication that has controlled your symptoms outweighs the risk the fetus." Rational: Risperidone has been associated with extrapyramidal symptoms in neonates and is classified as a pregnancy category "C" drug, meaning potential benefits often warrant use of the drug in pregnant women despite potential risks to the fetus.Suddenly stopping risperidone can bring on withdraw symptoms and exacerbate the client's bipolar disorder.Most antipsychotic medications are pregnancy category "C", so attempting to switch the client from a medication that is controlling her symptoms to a safer drug may not be feasible.Available evidence shows antipsychotic medications cross breast milk in very low levels, but benefits for mother and baby of breastfeeding may once again outweigh the risks of the medication.

A client was recently enrolled in a clinical trial for lung cancer treatment. The client's naturopathic therapist contacts the nurse who is caring for the client and inquires about the client's status, treatment regimen, and possible adverse effects of the medication the client is taking. How can the nurse best respond? - "I can give you that information so that you will be better able to assist in the client's therapy." - "I will ask the client's permission before releasing any information to you." - "I will ask the client to contact the primary care provider to tell you about the study." - "There is a Certificate of Confidentiality which was issued; therefore, no information can be released."

"There is a Certificate of Confidentiality which was issued; therefore, no information can be released." Rational: The nurse can best respond by stating that a Certificate of Confidentiality was issued. This certificate protects researchers and institutions from disclosing information that identifies research subjects. The Certificate of Confidentiality helps the researcher promote client participation by guaranteeing confidentiality while the client is enrolled in the study. Providing information, asking the client's permission to release information, and asking the client to contact the naturopath does not ensure client confidentiality, which is guaranteed when a client enters a research study.

After conducting a class for female adolescents about human reproduction, which student statement indicates that the school nurse's teaching has been effective? - "Under ideal conditions, sperm can reach the ovum in 15 to 30 minutes, resulting in pregnancy." - "I won't become pregnant if I abstain from intercourse during the last 14 days of my menstrual cycle." - "Sperm from a healthy male usually remain viable in the female reproductive tract for 96 hours." - "After an ovum is fertilized by a sperm, the ovum then contains 21 pairs of chromosomes."

"Under ideal conditions, sperm can reach the ovum in 15 to 30 minutes, resulting in pregnancy." Rational: Under ideal conditions, sperm can reach the ovum in 15 to 30 minutes. This is an important point to make with adolescents who may be sexually active. Many people believe that the time interval is much longer and that they can wait until after intercourse to take steps to prevent conception. Without protection, pregnancy and sexually transmitted diseases can occur. When using the abstinence or calendar method, the couple should abstain from intercourse on the days of the menstrual cycle when the woman is most likely to conceive. Using a 28-day cycle as an example, a couple should abstain from coitus 3 to 4 days before ovulation (days 10 through 14) and 3 to 4 days after ovulation (days 15 through 18). Sperm from a healthy male can remain viable for 24 to 72 hours in the female reproductive tract. If the female client ovulates after coitus, there is a possibility that fertilization can occur. Before fertilization, the ovum and sperm each contain 23 chromosomes. After fertilization, the conceptus contains 46 chromosomes unless there is a chromosomal abnormality.

When obtaining the nursing history from the mother of an infant with suspected intussusception, which question would be most helpful? - "What do the stools look like?" - "When was the last time your child urinated?" - "Is your child eating normally?" - "Has your child had any episodes of vomiting?"

"What do the stools look like?" Rational: For the infant with intussusception, stools characteristically have the appearance of currant jelly because of the intestinal inflammation and hemorrhage resulting from intestinal obstruction. These stools occur later in the course of the disease process. Questions that focus on urination, vomiting, and food intake do not elicit information about the effects of intussusception.

At a well-child check, the parents of a 4-year-old child tell the nurse that they understand what their child says but others have difficulty. What is the nurse's best response? - "It's very normal for parents to understand what their 4-year-old is saying when others can't." - "Your child may benefit from a referral to a speech pathologist for an evaluation." - "Do you think your child sounds like the other 4-year-olds he plays with?" - "I can do a screening at this visit to help rule out any hearing problems."

"Your child may benefit from a referral to a speech pathologist for an evaluation." Rational: By age 4 a child should speak clearly enough to be understood by others. An articulation disorder occurs when a child cannot produce certain individual sounds, making speech difficult to understand. A speech pathologist can diagnose articulation disorders and provide specific treatments. A 4-year-old child increasingly interacts with people other than parents. They need to speak clearly enough to be understood or they will become frustrated in new social situations. Determining if a child can communicate as well as other children the same age is important, but the parents have already identified a problem, which needs a referral. The nurse can perform a hearing screen in the office to rule out major hearing loss, but this screening will not treat the problem.

The nurse is teaching a postpartum client about the prevention of mastitis. Which information should be included in the teaching? Select all that apply. - "Refrain from wearing a bra during the day to prevent nipple abrasions." - "Limit feedings to four times a day to give your breasts a rest between feeding." - "Breastfeed every one to two hours with position changes at each feeding." - "Use plastic-lined breast pads so that your nipples don't become wet from leakage." - "Allow your nipples to air dry after breastfeeding, and avoid using cloths for drying."

- "Breastfeed every one to two hours with position changes at each feeding." - "Allow your nipples to air dry after breastfeeding, and avoid using cloths for drying." Rational: Frequent breastfeeding is a preventive measure; by emptying the breast, it prevents engorgement and stasis. Limiting feedings to four times a day would suppress lactation and increase the chance of mastitis and abscess formation. A supportive bra is recommended because it will reduce nipple abrasion. Plastic-lined breast pads trap moisture against the nipple and encourage proliferation of bacteria. Allowing the breasts and nipples to air dry helps prevent proliferation of bacteria on the skin surface.

A client is involved in a motor vehicle collision and is transferred by ambulance to the emergency department with head trauma. Upon assessment the client is awake and able to speak. Which questions by the nurse would best assess cerebral function? Select all that apply. - "Can you tell me your home address?" - "How would you describe your eyesight?" - "Have you noticed a change in your coordination?" - "Have you noticed a change in your muscle strength?" - "What is your date of birth?"

- "Can you tell me your home address?" - "What is your date of birth?" Rational: Asking the client to tell you the address and date of birth require recall and will determine memory loss. The client will be able to provide a clear and correct answer. The other questions are based on opinion rather than fact.

A client is admitted to the hospital for frottage and refuses to talk about the problem. Which response from the nurse would be appropriate? Select all that apply. - "I need to understand why you are here." - "It is your right not to answer my questions." - "I understand this must be difficult for you." - "It is important that you answer a few questions." - "You will have to be discharged right away."

- "I need to understand why you are here." - "I understand this must be difficult for you." - "It is important that you answer a few questions." Rational: It is important to acknowledge the client's feelings in order to initiate open communication. The client may not realize that details are needed to complete the assessment and treatment plan. It is also helpful for the nurse to acknowledge the difficulties associated with the client being asked to share personal information and reassure the client of the privacy in which it will be held. Clients have rights, but data collection is necessary so that help with the problem can be offered. It is not therapeutic and is demeaning to threaten a client with the pressure of facing immediate discharge.

The home care nurse is working with an older adult client who was discharged from a rehabilitation facility after experiencing a hip fracture from a fall at home. The client lives alone and utilizes a walker to ambulate. What statements by the client lead the nurse to determine that additional home safety education is needed? Select all that apply. - "I will use a chair with a back as my stepstool." - "I will wear my slippers in the house." - "I will get up slowly after sitting." - "I will keep nightlights on when I sleep." - "I will not be able to use the walker in the bathroom."

- "I will use a chair with a back as my stepstool." - "I will wear my slippers in the house." - "I will not be able to use the walker in the bathroom." Rational: Additional education is needed when the client states a plan to wear slippers in the house, not being able to use the walker in the bathroom, and using a chair with a back as a stepstool. The client should wear shoes both in and out of the house. The client should try to avoid having items placed high where a chair or stepstool is needed to reach them. However, if this unavoidable, the client should use a stepstool that has a bar to hold on to. A chair, whether with or without a back, should never be used as a stepstool. The client should get up slowly after either sitting or lying to prevent possible dizziness upon standing. The client should use nightlights in the home so that pathways are lit if the client needs to get up at night. The client should take the walker into the bathroom to ensure safety. The client may need to have someone remove throw rugs and other obstacles from their path.

A client diagnosed with primary (essential) hypertension is taking chlorothiazide. The nurse determines teaching about this medication is effective when the client makes which statement? Select all that apply. - "I'll weigh myself at the same time each day." - "I won't drink alcoholic beverages while on this medication." - "I'll reduce salt intake in my diet." - "If I have severe dizziness, I'll reduce my dosage." - "If I have prolonged exposure to sunlight, I'll use sunscreen." - "I'll take the drug before I go to bed."

- "I'll weigh myself at the same time each day." - "I won't drink alcoholic beverages while on this medication." - "I'll reduce salt intake in my diet." - "If I have prolonged exposure to sunlight, I'll use sunscreen." Rational: Chlorothiazide causes increased urination and decreased swelling (if there is edema) and weight loss. It is important to check and record weight two to three times per week at same time of day with similar amount of clothing. Clients should not drink alcoholic beverages or take other medications without the approval of the health care provider (HCP). Reducing sodium intake in the diet helps diuretic drugs to be more effective and allows smaller doses to be taken. Smaller doses are less likely to cause adverse effects, and therefore excessive table salt as well as salty foods should be avoided. Chlorothiazide is a diuretic that is prescribed for lower blood pressure and may cause dizziness and faintness when the client stands up suddenly. This can be prevented or decreased by changing positions slowly. If dizziness is severe, the HCP must be notified. Diuretics may cause sensitivity to sunlight, hence the need to avoid prolonged exposure to sunlight, use sunscreens, and wear protective clothing. Chlorothiazide causes increased urination and must be taken early in the day to decrease nighttime trips to the bathroom. Fewer bathroom trips mean less interference with sleep and less risk of falls. The client should not change the dosage without consulting the HCP.

The nurse is planning care for a client with GAD (generalized anxiety disorder). Which statements by the nurse are made in the working phase of the nurse-client relationship? Select all that apply. - "Let's talk about how you would like to deal with your anxiety." - "I plan to meet with you every day after breakfast for 15 minutes." - "I know this will be difficult for you but you can do this by yourself." - "Tell me how you have dealt with anxiety in the past." - "I can see you are learning some of these new relaxation techniques."

- "Let's talk about how you would like to deal with your anxiety." - "Tell me how you have dealt with anxiety in the past." - "I can see you are learning some of these new relaxation techniques." Rational: The therapeutic nurse-client relationship consists of three phases: orientation, working, and termination. During the working phase, the nurse and client evaluate and refine the goals established during the orientation phase. In addition, major therapeutic work takes place and insight is integrated into a plan of action. This is seen where the nurse is asking the client about how they have dealt with anxiety in the past, how they plan to in the future, and the improvement that has been recognized through education. The orientation phase involves assessing the client, formulating a contract, exploring feelings, and establishing expectations about the relationship. Here this is seen when the nurse plans appointments with the client. During the termination phase, the nurse prepares the client for separation and explores their feelings about the end of the relationship. This is seen above where the nurse assures the client that "this can be done by them."

A client is being discharged with a home oxygen delivery device. Which comments indicate that the client understands safety regarding home oxygen? Select all that apply. - "No one can smoke within 10 feet (3 meters) of the oxygen." - "I can carry my oxygen in a bag for easy portability." - "I need to keep my oxygen away from electrical sources." - "I should keep my oxygen away from direct heat." - "I'll keep my oxygen out of the sun in all circumstances."

- "No one can smoke within 10 feet (3 meters) of the oxygen." - "I need to keep my oxygen away from electrical sources." - "I should keep my oxygen away from direct heat." Rational" The client demonstrates understanding about the safe use of oxygen therapy at home when the client states that no one should smoke within 10 feet of oxygen and that the client should keep the oxygen away from electrical sources and direct heat and sunlight. It isn't safe to place oxygen in a bag; the tank should have adequate airflow around the concentrator. It's best not to place the oxygen tank in direct sunlight, but it isn't necessary to keep it out of the sun at all times

The client phones the outpatient surgery center following skin biopsy on the left shoulder. The client states that the site continues to drain pinkish drainage and is uncomfortable. Which triage questions are appropriate to evaluate the client's concern? Select all that apply. - "Did you have any other skin biopsies that day?" - "On which day did you have the biopsy completed?" - "Can you describe the drainage that you see." - "When is your follow-up appointment?" - "What is your pain level on a 0-10 pain scale?" - "How are you cleaning the area?"

- "On which day did you have the biopsy completed?" - "Can you describe the drainage that you see." - "What is your pain level on a 0-10 pain scale?" - "How are you cleaning the area?" Rational: When triaging a client's concern following a surgical biopsy, it is most important for the nurse to obtain information about the site and postoperative care. Knowing the date of the surgery allows for the nurse to determine the amount and type of drainage that is normal for that stage of healing. Understanding the characteristics of the drainage helps the nurse assess if the drainage is from a healing process or from a potential infection. Assessing the pain level provides information of the inflammatory and infectious process. The nurse compares the client's pain rating with the rating scale typically noted for this procedure. Lastly, the nurse assesses how the wound is being cleaned. The nurse wants to assess understanding regarding the cleaning process. The nurse remains focused on the skin biopsy site of concern. Other biopsy sites may have been at different sizes and depths leading to a different healing time frame. Knowing the follow-up appointment does not focus on the client's concern.

In the emergency department, a client reveals to the nurse a lethal plan for dying by suicide and agrees to a voluntary admission to the psychiatric unit. Which information would the nurse discuss with the client to answer the question "How long do I have to stay here?" Select all that apply. - "You may leave the hospital at any time unless you're suicidal or homicidal or unable to meet your basic needs." - "Let's talk after the health care team has assessed you." - "Once you've signed the papers, you are required to follow the treatment plan." - "Because you have stated that you want to hurt yourself, you must be safe before being discharged." - "You need legal representation to help you make an informed decision." - "All clients need a court hearing before leaving the hospital."

- "You may leave the hospital at any time unless you're suicidal or homicidal or unable to meet your basic needs." - "Let's talk after the health care team has assessed you." - "Because you have stated that you want to hurt yourself, you must be safe before being discharged." Rational: A person who is admitted to a psychiatric hospital may voluntarily sign out of the hospital unless the health care team determines that the person is harmful to self or others. The health care team evaluates the client's condition before discharge. If there is reason to believe that the client may be harmful to self or others, a hearing can be held to determine if the admission status should be changed from voluntary to involuntary. Not all discharges require a hearing. The client still has rights after committing himself or herself to a psychiatric unit. The client does not need a lawyer to leave the hospital. A court hearing is held only if the client may pose a threat to self or others and requires further treatment.

A student nurse performed a urinary catheterization with a intra-partum client with the instructor present. The student nurse is asking if there is any legal recourse if there are complications from the procedure. What is the best response by the instructor? Select all that apply. - An attorney can summon all caregivers including students if there is legal concern. - The staff nurse was not present during the procedure and is not liable for the procedure. - The client consented to the urinary catheterization so the student is not liable for complications. - The student will be liable for any deviation from the procedure and failure to document. - The documentation is supported by the institutional policy and procedure.

- An attorney can summon all caregivers including students if there is legal concern. - The student will be liable for any deviation from the procedure and failure to document. - The documentation is supported by the institutional policy and procedure. Rational: An attorney can summon all caregivers including students if there is legal concern. The legal responsibilities are included the client's agreement to the urinary catheterization. The student and instructor have liability insurance and the student followed the institutional policy and procedure with the catheterization and the documentation. The staff nurse needs to be aware of the procedure because the staff nurse shares the assignment.

A client who had undergone an abdominal hysterectomy is in the recovery room. The surgeon has prescribed a 250-mL bolus of normal saline over 1 hour to replace blood loss. The IV solution infusing in the client was 1,000 mL normal saline with 40 mEq of potassium chloride at 100 mL/h. What should the nurse do? Select all that apply. - Increase the IV infusion rate to 250 mL/h for 1 hour. - Add 250 mL of normal saline to the current infusion bag, and continue at 100 mL/h. - Connect a 250-mL bag of normal saline to the Y-connection, and calculate to infuse over 1 hour. - Contact the health care provider regarding continuation of the primary - IV infusion during the bolus infusion. - Administer the normal saline bolus via an IV infusion pump.

- Connect a 250-mL bag of normal saline to the Y-connection, and calculate to infuse over 1 hour. - Contact the health care provider regarding continuation of the primary IV infusion during the bolus infusion. - Administer the normal saline bolus via an IV infusion pump. Rational: The additional fluids should run through a separate line using a Y connector. The nurse must contact the surgeon to clarify if the client should receive the additional 100 mL/h of IV fluids containing potassium chloride during the bolus infusion. Rapid infusion of potassium chloride can cause hyperkalemia with adverse cardiac outcomes such as arrhythmias. Bolus infusions of IV fluids should be run via an infusion pump to avoid excess fluid administration. Increasing the current IV infusion rate or adding additional fluids to the existing infusion is not safe because the current infusion contains potassium.

A client, diagnosed with Alzheimer's disease, is a new resident in a long-term care facility. The client has difficulty finding their room and is seen wandering into the room of others. When discussing the situation at a multidisciplinary conference, which client centered actions would the nurse suggest? Select all that apply. - Provide a map of the unit as a guide with the room highlighted. - Ensure that the client has prescribed hearing aids and glasses on throughout the day. - Place a box with familiar personal items outside the client's door for visual recognition. - Assign the client to a room close to the nursing station for closer monitoring. - Provide verbal cueing as to where the client's room is located. - Place the client with a roommate having similar cognitive deficits.

- Ensure that the client has prescribed hearing aids and glasses on throughout the day. - Place a box with familiar personal items outside the client's door for visual recognition. - Assign the client to a room close to the nursing station for closer monitoring. - Provide verbal cueing as to where the client's room is located. Rational: Alzheimer's disease is a chronic, organic mental disorder that involves a progressive, irreversible loss of memory. Disorientation, especially when brought to an unfamiliar environment, is a common occurrence. Safety of the individual is a priority. Client-centered actions would focus on interventions to promote the identification of the client room and reduce the instances of wandering. Visual recognition via memory boxes, ensuring the client has glasses and hearing aids to facilitate orientation, and verbal cueing are helpful in assisting the client. Placing the client in a location where the nursing staff can interact with the new resident is also helpful. Providing a map for the client to analyze would be difficult for the client with Alzheimer's disease. A roommate, who also has cognitive deficits, would not be identified as a strategy to prevent wandering.

A client has Raynaud's phenomenon. What information should the nurse include in a teaching plan about managing an attack? Select all that apply. - Go to a warm room. - Move the fingers and toes. - Place hands under hot, running water. - Massage the fingers and toes. - Place hands under the armpits.

- Go to a warm room. - Move the fingers and toes. - Massage the fingers and toes. - Place hands under the armpits. Rational: When the client with Raynaud's disease is having a vasospastic attack the nurse can teach the client to go to a warmer room, move the fingers and toes to improve circulation, massage the extremities to promote circulation and put the hands under the armpits to take advantage of body heat. The client should not put the hands or fingers under hot water as there is a risk of burns. If necessary, the client can warm the hands and fingers under slightly warm water.

A nurse is caring for a middle-aged client who has undergone hemicolectomy for colon cancer. The client has two children. Which concepts about family would the nurse apply when providing care for this client? Select all that apply. - Illness in one family member can affect all family members. - Families become stronger when one member is ill. - A family member may have more than one role at a time in the family. - Children respond more positively when they know what is going on. - The effects of an illness on a family depend on the stage of the family's life cycle. - Changes in sleeping and eating patterns may be signs of stress in a family.

- Illness in one family member can affect all family members. - A family member may have more than one role at a time in the family. - The effects of an illness on a family depend on the stage of the family's life cycle. - Changes in sleeping and eating patterns may be signs of stress in a family. Rational: Illness in one family member can affect all family members, even children. Families do not necessarily become stronger when one family member is ill. Illnesses can create stressful family environments, which may put a lot of pressure on family members. When one family member cannot fulfill a role because of illness, the roles of the other family members are affected. While age-appropriate information is provided to the child, children are still impacted by the change in living situation and stress in the environment. And being informed may not always be the best thing for children. Families move through certain predictable life cycles (such as birth of a baby, a growing family, adult children leaving home, and grandparenting). The impact of illness on the family depends on the stage of the life cycle as family members take on different roles and the family structure changes. Illness produces stress in families; changes in eating and sleeping patterns are signs of stress.

A postoperative client has an abdominal incision. While getting out of bed, the client reports feeling a "pulling" sensation in the abdominal wound. The nurse assesses the client's wound and finds that it has separated and that the abdominal organs are protruding. Which nursing interventions are most appropriate at this time? Select all that apply. - Notify the client's primary physician. - Cover the wound with saline-soaked sterile gauze. - Give the client a dose of antibiotics. - Order an abdominal binder from the supply department. - Push the organs back into the abdomen. - Cover the wound with sterile gauze.

- Notify the client's primary physician. - Cover the wound with saline-soaked sterile gauze. Rational: Dehiscence (separation of the surgical incision) and evisceration (protruding of the abdominal organs) are considered medical emergencies. Therefore, the client's physician should be notified immediately and the nurse should prepare the client for surgery. While the nurse is waiting for the physician to arrive, the wound and the abdominal organs should be covered with saline-soaked sterile gauze. Saline is an isotonic solution that prevents damage to the client's tissue, and sterile gauze is used to prevent wound infection. Even though wound infection is the most common cause of dehiscence, administering antibiotics without a physician's order is not permissible and can result in the loss of a nursing license. An abdominal binder may be appropriate but only after the client returns from the operating room and with a physician's order. Pushing the organs back into the abdomen is inappropriate and could result in rupture, hemorrhage, or strangulation of the bowel. The nurse should also monitor the client's vital signs.

A nurse is caring for a client on life support in the cardiac care unit. The client's family, which is strongly religious, is unable to unanimously decide to remove life support. What should the nurse do? Select all that apply. - Notify the hospital's ethics committee of the ethical dilemma. - Ask the family to leave the unit to pray for a unified decision. - Request pastoral services to assist the family in this decision. - Supply the family with information and pamphlets on funeral services. - Initiate family discussions around what the client would have wanted.

- Notify the hospital's ethics committee of the ethical dilemma. - Request pastoral services to assist the family in this decision. - Initiate family discussions around what the client would have wanted. Rational: Ethics committees are a valuable resource for reviewing difficult cases and helping ensure a careful and unbiased decision when advocating for the client. Since the family is religious, it is appropriate to request pastoral services or ask them if they would like their spiritual advisor called. Therapeutic communication with the family about their loved one's wishes is appropriate and often helpful. It is not therapeutic to ask a family to leave their loved one to pray or to pressure the family for a unified decision. It is inappropriate to provide pamphlets on funeral services to a family struggling with end-of-life decisions.

Which of the following actions would the nurse perform if the nurse suspects the complication of thrombophlebitis in the leg in a postpartum woman? Select all that apply. - Prepare the client for venous Doppler ultrasound. - Assess vital signs. - Prepare for administration of Tissue Plasminogen Activator (TPA). - Place client on bed rest. - Administer estrogens for lactation suppression.

- Prepare the client for venous Doppler ultrasound. - Assess vital signs. - Place client on bed rest. Rational: Tenderness, elevated temperature of limb, consistent pain, and edema are indicators of thrombophlebitis. Changes in limb color of either blueness or redness can also occur with thrombophlebitis. With symptoms of thrombophlebitis, the client should be placed on bed rest, and the nurse should assess vital signs frequently. The client will need a diagnostic ultrasound of the vein for confirmation. The client will require anticoagulation, not TPA therapy. TPA in a postpartum woman would cause uncontrollable hemorrhage. Although the nurse wants to prevent dehydration, suppression of lactation would not be indicated. Giving the estrogens needed to stop breast milk production would also further increase the client's risk of clotting.

The team leader is caring for clients with gastrointestinal disorders on the medical-surgical unit. Which reporting tasks are appropriate to delegate to the unlicensed assistive personnel (UAP)? Select all that apply. - Report if a blood pressure is below 100/60 mmHg or pulse rate is above 110 beats per minute - Report if any client complains of pain - Report if a client is seen leaving the unit - Report condition of the perianal area to application of barrier cream - Report the quality/quantity, and color of nasogastric tube drainage

- Report if a blood pressure is below 100/60 mmHg or pulse rate is above 110 beats per minute - Report if any client complains of pain - Report if a client is seen leaving the unit Rational: The UAP can report on changes in vital signs; usually, the UAP are given parameters for notification. The UAP can report the client's pain, but cannot assess the pain. The UAP should keep other staff aware of when the client leaves the floor for anything. Evaluating drainage and judging the client's response to treatment are part of the licensed nurses' scope of practice and require additional education.

The charge nurse is preparing for the day shift on the labor and birth unit. Which would be included in the responsibilities for this position? Select all that apply. - Review the current status of each labor patient with the primary nurse. - Admit the new labor patient sent from the triage area. - Complete the work of the nurse who had to leave 30 minutes early. - Follow up with the primary nurse after a birth. - Complete report of unit with the oncoming charge nurse.

- Review the current status of each labor patient with the primary nurse. - Follow up with the primary nurse after a birth. - Complete report of unit with the oncoming charge nurse. Rational: In most settings, the charge nurse coordinates and directs the activities of the unit. Prior to the change of shift, the nurse will review and update the status of each of the laboring clients on the unit to include any difficulties or unusual situations that may be occurring with each of them, including following up with a primary nurse after a birth. A change-of-shift report with the oncoming charge nurse is among the last activities completed before ending the shift. Activities such as admitting a client in labor and completing the nursing responsibilities of the nurse who had to leave 30 minutes early can be delegated to staff members. In an emergency, the charge nurse could assume responsibility for client care.

The nurse is preparing a teaching tool to prevent back injuries for participants in a community health fair. Which information should the nurse include? Select all that apply. - Walk daily. - Engage in stretching. - Avoid the horizontal position during exercise. - Avoid wearing high heeled shoes. - Keep body weight within normal limits.

- Walk daily. - Engage in stretching. - Avoid wearing high heeled shoes. - Keep body weight within normal limits. Rational: Information that should be included when teaching on ways to prevent back injuries include walking daily with gradually increasing the distance and pace of walking, stretching to enhance flexibility, avoiding high heels because of the stress on the lower back, and keeping body weight within normal limits to prevent stress and strain on the lower back and joints of the hips and legs. The horizontal position during exercise does not place undo stress on the spine or encourage a back injury.

A nurse is completing an admission fall assessment with an adult client. What are important nursing considerations to determine a high risk for falls? Select all that apply. - advanced age - anticoagulant medication - urinary urgency - benzodiazepine medication - systolic blood pressure > 180mmHg

- advanced age - urinary urgency - benzodiazepine medication Rational: Fall risk factors include advanced age due to changes in balance, urinary elimination symptoms such as urgency and the need to get to the bathroom more frequently. The use of benzodiazepines can cause the client to feel dizzy and lose balance. The use of anticoagulants is a consideration after a fall. Clients with low blood pressure are considered at risk for falls related to potential dizziness.

A client has been prescribed sertraline. Which adverse effects are most important for the nurse to communicate to this client? Select all that apply. - agitation - agranulocytosis - sleep disturbance - intermittent tachycardia - dry mouth - seizures

- agitation - sleep disturbance - dry mouth Rational: Common adverse effects of sertraline include agitation, sleep disturbance, and dry mouth. Agranulocytosis, intermittent tachycardia, and seizures are adverse effects of clozapine.

The nurse reviews laboratory work for a client who is admitted to the acute psychiatric unit for an eating disorder (see figure). Which finding does the nurse report to the health care provider? Select all that apply. - albumin level (2.8 g/dL) - sodium level (145 mEq/L) - hemoglobin level (10.8 g/dL) - potassium level (2.7 mEq/L) - hematocrit level (37%)

- albumin level - hemoglobin level - potassium level Rational: The normal albumin level is 3.5 to 5 g/dl (35-50g/L); the normal hemoglobin level is 12 to 16 g/dl (120-160g/L); and the normal potassium is 3.5 to 5 mEq/L (3.5-5 mmol/L). These levels are all low. The client is likely not eating a sufficient amount of protein; therefore, the albumin and hemoglobin are low. The potassium level would be low if the client was purging. The sodium level is normally 136 to 145 mEq/L (136-145 mmol/L), so this is in the normal range; however, it can be high in a client with an eating disorder. The normal hematocrit level is 37% to 47% (0.37-0.47) in an adult.

A nurse practicing in a nurse-managed clinic suspects that a client's chronic sinusitis and upper respiratory tract infections may result from allergies. Which laboratory test would the nurse most likely order? Select all that apply. - complete blood count - rheumatoid factor - metabolic panel - immunoglobulin assay (IgE) - liver function studies

- complete blood count - immunoglobulin assay (IgE) Rational: The nurse would order a complete blood count, which may indicate elevated white blood cells and eosinophils, as well as an immunoglobulin assay to look specifically for IgE elevations. Rheumatoid factor would be ordered for rheumatic disorders and Sjogren's syndrome; metabolic panel and liver function studies would not provide information about allergies.

A child has an unrepaired heart defect resulting in a right-to-left shunt. As this child grows older, which assessment findings would the nurse anticipate? Select all that apply. - cyanosis of lips and nail beds - auscultation of crackles in lung fields - clubbed fingers - tachypnea - bradycardia

- cyanosis of lips and nail beds - clubbed fingers - tachypnea Rational: Children who have a heart defect that results in blood shunting from the right side of the heart to the left are cyanotic, and often have pulse oximeter readings in the 70 to 90% range. Clubbing is expected when long-term cyanosis is present. Children become tachypneic in an attempt to improve oxygenation. Tachycardia is the heart's attempt to increase cardiac output. Crackles are usually heard in children with defects that have increased pulmonary blood flow.

The community health nurse is working with a client who has limited mobility. Which interventions would the nurse implement for primary prevention of skin breakdown? Select all that apply. - care of a Stage II ulcer on the client's right heel - encouragement of the client to walk around the home three times a day - education of the client on turning frequently in the bed if lying down - assistance with the client scheduling a visit to the healthcare provider - instruction on the application of lotion for dry skin on extremities

- encouragement of the client to walk around the home three times a day - education of the client on turning frequently in the bed if lying down - instruction on the application of lotion for dry skin on extremities Rational: The client needing primary prevention of skin breakdown would not have any skin breakdown at present but would need interventions to help with this prevention. Encouraging the client with mobility, including turning in the bed and ambulating in the house, will help prevent pressure of skin, which can lead to skin breakdown. Having dry skin is also a risk factor for skin breakdown, so helping educate the client on the application of lotion will help with this. While the client may need assistance with scheduling a visit to the healthcare provider, this is not a direct intervention to prevent skin breakdown. If the client already has skin breakdown, this would involve tertiary prevention so that deterioration to a higher stage does not occur with the pressure ulcer.

What manifestations are important for the nurse to assess in a 43-year-old client who has developed thrombocytopenia after undergoing colon cancer treatment? Select all that apply. - diarrhea - hematuria - ecchymosis - melena - epistaxis

- hematuria - ecchymosis - melena - epistaxis Rational: Thrombocytopenia is an abnormal decrease in the number of blood platelets, which can result in bleeding. Hematuria, ecchymosis, melena, and epistaxis are all signs of bleeding. The client may have constipation but usually not diarrhea.

A nurse is completing a health assessment with an adult client in a health care provider's office. What assessment findings will the nurse report to the health care provider as indications of fluid volume deficit? Select all that apply. - increased heart rate - decreased blood glucose level - dry mucous membranes - hyperactive bowel sounds - muscle hyperreflexia

- increased heart rate - dry mucous membranes - muscle hyperreflexia Rational:The nurse will identify increased heart rate, dry mucous membranes, and hyperactive muscle responses as indications of fluid volume deficit. Hypoglycemia and hyperactive bowel sounds are not common findings of fluid volume deficit.

A client's stools are light gray in color. What additional information should the nurse obtain from the client? Select all that apply. - intolerance to fatty foods - fever - jaundice - respiratory distress - pain at McBurney's point - bleeding ulcer

- intolerance to fatty foods - fever - jaundice Rational :Bile is created in the liver, stored in the gallbladder, and released into the duodenum, giving stool its brown color. A bile duct obstruction can cause pale-colored stools. Other symptoms associated with cholelithiasis are right upper quadrant tenderness, fever from inflammation or infection, jaundice from elevated serum bilirubin levels, and nausea or right upper quadrant pain after a fatty meal. Pain at McBurney's point lies between the umbilicus and right iliac crest and is associated with appendicitis. A bleeding ulcer produces black, tarry stools. Respiratory distress is not a symptom of cholelithiasis.

A nurse is performing an assessment on a client with depression. Which finding should the nurse anticipate? Select all that apply. - negative and pessimistic feelings - tangentially of ideas and speech - moods vary between depression, anger, and elation - psycho-motor retardation and agitation - difficulty concentrating and making decisions

- negative and pessimistic feelings - psycho-motor retardation and agitation - difficulty concentrating and making decisions Rational: Major depression is a mood disorder that affects one's physical, psychological and social needs or well-being. Thus, symptoms from this disorder affect all those areas. According to the DSM-V, 5 of the 9 criteria need to be present in a 2 week period for a person to be diagnosed with the illness. Of the symptoms above, the common signs of depression are the following: difficulty concentrating and making decisions, psycho-motor retardation and agitation, and negative and pessimistic feelings. Variable moods and tangentially of ideas and speech are seen in bipolar mania.

The nurse is documenting care of a client who is restrained in bed with bilateral wrist restraints. Following assessment of the restraints, what should the nurse's documentation include? Select all that apply. - nutrition and hydration needs - capillary refill - continued need for restraints - need for medication - skin integrity

- nutrition and hydration needs - capillary refill - continued need for restraints - skin integrity Rational: A restraint is a method of involuntary physical restriction of a client's freedom of movement, physical activity, or normal access to his/her body. The nurse must monitor and provide care to optimize the physical and psychological well-being of the client including, but not limited to, respiratory and circulatory status, skin integrity, and vital signs. With each assessment, the nurse needs to ascertain that restraints are still required for client safety. The least restrictive intervention based on an individualized assessment of the client's medical or behavioral status or condition is needed.

The health care provider has prescribed 5 mg warfarin orally for a hospitalized client. In planning care for this client, the nurse should verify that which services have been contacted? Check all that apply. - pharmacy - dietary - laboratory - discharge planning - risk management

- pharmacy - dietary - laboratory Rational: To assure client safety when using anticoagulants, the nurse should coordinate care at this time with the pharmacist, dietitian, and laboratory. The pharmacist will collaborate in teaching the client about using the drug; dietary services will plan a diet that limits foods that have high amounts of vitamin K (spinach, cabbage, blueberries) that will interfere with anticoagulation; and the laboratory will draw daily INR levels to assure accurate dosing. Although the nurse coordinates discharge planning at the time of admission to the hospital, at this point it is too soon for discharge planning services to be involved because it is not known if the client will continue to take the warfarin when discharged. There is no indication that there has been an actual or potential error, and risk management is not needed at this time.

A nurse who works on an obstetrical inpatient unit has been assigned to the client safety committee. What client safety goals are most applicable to this setting? Select all that apply. - providing effective and timely "hand-off reports" between labor and birth staff and mother-baby staff - ensuring that preprocedural verifications are completed by health care providers (HCP) for any invasive procedure - involving clients in education to cord infections - identifying safety risks specific to the unit, such as infant abduction - car seat instruction allowing infants to ride facing backward in the front seat

- providing effective and timely "hand-off reports" between labor and birth staff and mother-baby staff - ensuring that preprocedural verifications are completed by health care providers (HCP) for any invasive procedure - involving clients in education to cord infections - identifying safety risks specific to the unit, such as infant abduction Rational: Specific safety concerns on an obstetrical unit include a very specific "hand-off report" after birth and recovery has been completed and the couplet is transitioned to mother-baby care. In any invasive procedure including tubal ligations and circumcisions, preprocedural verification is a standard procedure. Client education concerning the potential for infection in obstetrics is essential for any incision areas. Infant abduction is an ever-present concern for those working in a mother-baby unit. Car seat instructions for new parents involve the infant being in the back seat of a car facing backward-not in the front seat. Education for the family includes this important area.

A 21-year-old female client takes clonazepam. What should the nurse ask this client about? Select all that apply. - seizure activity - pregnancy status - alcohol use - cigarette smoking - intake of caffeine and sugary drinks

- seizure activity - pregnancy status - alcohol use Rational: The nurse should assess the number and type of seizures the client has experienced since starting clonazepam monotherapy for seizure control. The nurse should also determine if the client might be pregnant because clonazepam crosses the placental barrier. The nurse should also ask about the client's use of alcohol because alcohol potentiates the action of clonazepam. Although the nurse may want to check on the client's diet or use of cigarettes for health maintenance and promotion, such information is not specifically related to clonazepam therapy.

A client has received an ordered dose of chlordiazepoxide to control the symptoms of alcohol withdrawal. Which symptoms would indicate that this client should receive an additional dose of the prescribed medication? Select all that apply. - tachycardia - mood swings - elevated blood pressure and temperature - piloerection - tremors - increasing anxiety

- tachycardia - elevated blood pressure and temperature - tremors - increasing anxiety Rational: Benzodiazepines are usually administered based on elevations in heart rate, blood pressure, and temperature as well as on the presence of tremors and increasing anxiety. Mood swings are expected during the withdrawal period, and are not an indication for further medication administration. Piloerection is not a symptom of alcohol withdrawal.

The nurse is irrigating a draining wound prior to packing with gauze. Which nursing actions are appropriate? Select all that apply. - washing the hands immediately after removing the sterile gloves - removing the dressing with nonsterile gloves - donning sterile gloves for the irrigation - wearing a face shield during the irrigation - obtaining a respirator mask - using clean technique for the procedure

- washing the hands immediately after removing the sterile gloves - removing the dressing with nonsterile gloves -donning sterile gloves for the irrigation -wearing a face shield during the irrigation Rational: Due to the fact that the client's wound needs to be irrigated and packed, certain precautions are initiated—namely wearing a gown, glove, and face shield. The procedure begins with removing the dressing with nonsterile gloves. Next the nurse dons sterile gloves and, with packages open and ready, initiates the irrigation and wound packing. The nurse does not need a respirator mask for the procedure. Sterile technique is used for the procedure.

The nurse is assigned to care for a client with early stage Alzheimer's disease. Which nursing interventions should be included in the client's care plan? Select all that apply. -Make frequent changes in the client's routine. -Engage the client in complex discussions to help improve memory. -Furnish the client's environment with familiar possessions. -Assist the client with activities of daily living (ADLs) as necessary. -Assign tasks in simple steps.

-Furnish the client's environment with familiar possessions. -Assist the client with activities of daily living (ADLs) as necessary. -Assign tasks in simple steps. Rational: A client with Alzheimer's disease experiences progressive deterioration in cognitive functioning. Familiar possessions may help to orient the client. The client should be encouraged to perform ADLs as much as possible but may need assistance with certain activities. Using a step-by-step approach helps the client complete tasks independently. A client with Alzheimer's disease functions best with consistent routines. Complex discussions do not improve the memory of a client with Alzheimer's disease.

A nurse is teaching a client about withdrawal from the excessive use of caffeine. What will the nurse include in the teaching? Select all that apply. - One of the first symptoms of withdrawal will be a headache. - Drink fluids to help with the withdrawal. - The only problem will be drowsiness. - Nausea and muscle pain may occur with withdrawal. - Try to stop the caffeine all at once to lessen the withdrawal symptoms.

-One of the first symptoms of withdrawal will be a headache. -Drink fluids to help with the withdrawal. -Nausea and muscle pain may occur with withdrawal. Rational: The symptoms of caffeine withdrawal are headache, fatigue, drowsiness, irritability, and depression. Nausea and muscle pain can also occur. Drinking fluids during the withdrawal can prevent dehydration. Stopping the caffeine abruptly will not lessen symptoms.

transferred to hospice care. Which information regarding hospice care would the nurse include in the teaching plan? Select all that apply. - The focus of care is on controlling symptoms and relieving pain. - A multidisciplinary team provides care. - Services are provided on third party insurance reimbursement. - Hospice care is provided only in hospice centers. - Bereavement care is provided to the family. - Care is provided in the home, independent of healthcare providers.

-The focus of care is on controlling symptoms and relieving pain. -A multidisciplinary team provides care. -Bereavement care is provided to the family. Rational: Hospice care focuses on controlling symptoms and relieving pain at the end of life. A multidisciplinary team—consisting of nurses, healthcare providers, chaplains, aides, and volunteers—provides the care. After the client's death, hospice provides bereavement care to the grieving family. Hospice services are provided based on need, not on the ability to pay or insurance reimbursement. Hospice care may be provided in a variety of settings, such as freestanding hospice centers, the home, a hospital, or a long-term care facility. Care is provided under the direction of a healthcare provider, who is a key member of the hospice team.

A nursing assistant is caring for a client with Clostridium difficile diarrhea and asks the charge nurse, "How can I keep from catching this from the client?" Which interventions does the charge nurse remind the nursing assistant to employ? Select all that apply. - Place the client on protective isolation. - Wash hands before and after care of this client. - Provide disposable utensils and dishes for the client. - Use contact isolation procedures when caring for the client. - Minimize time spent with the client to avoid infection.

-Wash hands before and after care of this client. -Use contact isolation procedures when caring for the client. Rational: C. difficile can be transmitted from person to person by hands or waste containers, such as a bedpan. A nurse who is in direct contact with the client should practice contact isolation, which includes wearing gloves and a gown. Protective isolation is used to protect a client who is immunocompromised, which is not evident in this case. There is no need for disposable utensils and dishes as this is not part of contact isolation procedures. Clients should not be isolated because of this infection. Just the opposite, spending the usual amount of time with the client or more if possible will improve the client's spirits.

A nurse is analyzing a client's laboratory values in the morning on a medical-surgical unit. Which laboratory value is critical to report the health care provider? Select all that apply. - bicarbonate 22 mEq/L (22 mmol/L) - magnesium 1.2 mEq/L (1.2 mmol/L) - phosphate 3.5 mEq/L (3.5 mmol/L) - chloride 100 mEq/L (100 mmol/L) - sodium 158 mEq/L (158 mmol/L)

-magnesium 1.2 mEq/L (1.2 mmol/L) -sodium 158 mEq/L (158 mmol/L) Rational: The nurse needs to report the decreased magnesium level 1.2 mEq/L (1.2 mmol/L) and the increased sodium level 158 mEq/L (158 mmol/L). Potassium, sodium, calcium, and magnesium is needed for neuromuscular activity. Magnesium influences use of potassium, calcium, and protein, and when there is a magnesium deficit, there is frequently a potassium and calcium deficit. Normal bicarbonate levels are 20-30 mEq/L (20-30 mmol/L), normal phosphate levels are 3.0-4.5 mEq/L (3.0 - 4.5 mmol/L, and normal chloride is 95-105 mEq/L (95-105 mmol/L).

A health care provider prescribes vitamin B12 for a client with pernicious anemia. Which sites are appropriate for the nurse to administer vitamin B12 to an adult? Select all that apply. - median cutaneous - greater femur trochanter - acromion muscle - ventrogluteal - upper back - dorsogluteal

-ventrogluteal -dorsogluteal Rational: A client with pernicious anemia has lost the ability to absorb vitamin B12 either because of the lack of an acidic gastric environment or the lack of the intrinsic factor. Vitamin B12 must be administered by a deep intramuscular route. The ventrogluteal and dorsogluteal locations are the most acceptable sites for a deep intramuscular injection. The other sites are not acceptable.

A physician orders meperidine 30 mg I.M. as preoperative medication for a school-age child who weighs 66 lb (30 kg). The meperidine is supplied as 50 mg/mL. How much meperidine should the nurse administer? - 0.3 mL - 0.5 mL - 0.6 mL - 0.8 mL

0.6 mL

Diet and exercise have failed to control a client's blood glucose level. The physician orders metformin. After oral administration, the onset of action is: - 15 to 30 minutes. - 30 to 60 minutes. - 1 to 3 hours. - 3 to 4 hours.

1 to 3 hours. Rational: Metformin begins to act in 1 to 3 hours.

A client with a deep vein thrombosis has heparin sodium infusing at 1,500 units/hour. The concentration of heparin is 25,000 units/500 mL. If the infusion remains at the same rate for a full 12 hour shift, how many milliliters of fluid will infuse? Record your answer using a whole number

360 25,000 u/500 ml = 50 units/ml. 1 ml/50 units x 1500 units/hour = 30 ml/hour x 12 hours = 360 ml

A client is admitted with a diagnosis of diabetic ketoacidosis. An insulin drip is initiated with 50 units of insulin in 100 ml of normal saline solution. The I.V. is being infused via an infusion pump, and the pump is currently set at 10 ml/hr. How many units of insulin each hour is this client receiving? Record your answer using whole number.

5 To determine the number of insulin units the client is receiving per hour, the nurse must first calculate the number of units in each milliliter of fluid: (50 units)/(100 mL)= 0.5 units/mL 0.5 units x 10 mL/hour=5 units/hour

A nurse is teaching a postpartum client who has decided to breast-feed her neonate. She has questions regarding her nutritional intake and wants to know how many extra calories she should eat. What number of additional calories should the nurse instruct the client to eat per day? Record your answer using a whole number.

500 Rational: The recommended energy intake for a lactating client is 500 calories more than her nonpregnant intake.

At 5 minutes of age, a neonate is pink with acrocyanosis; has flexed knees, clenched fists, a whimpering cry, and a heart rate of 128 beats/minute; and withdraws the foot when slapped on the sole. What 5-minute Apgar score would the nurse record for this neonate?

8 Rational: The Apgar score provides an assessment of a neonate's health immediately after birth and at 5 minutes of age. Criteria assessed include heart rate, respiratory effort, muscle tone, reflex irritability, and color, each receiving a score from 0 (poor) to 2 (normal). This neonate has a heart rate above 100 beats/minute (score of 2); a weak cry (score of 1); good flexion (score of 2); a good response to a slap on the sole (score of 2); and pink color with acrocyanosis (score of 1). Thus, the total Apgar score is 8.

A nurse is caring for four clients on the orthopedic unit. Which client should the nurse see first? - A client scheduled for a total hip replacement in 1 hour - A client who is scheduled to ambulate for the first time after knee surgery - A client due for a subcutaneous anticoagulant now - A client whose family member is requesting to speak with the nurse

A client scheduled for a total hip replacement in 1 hour Rational: The client who is scheduled for surgery must be assessed first to ensure all preoperative prescriptions are in place and that the client is stable enough for the procedure. Once ensuring the preoperative client is ready, the nurse can speak with the family member before administering the anticoagulant, as this medication is a routinely scheduled drug that is not required to be given STAT. Once the medication is administered, the nurse can then assist the client in ambulating.

A nurse is supervising a new graduate registered nurse who is caring for a client hospitalized with active tuberculosis (TB). Which action by the new graduate requires the nurse to intervene? - A surgical face mask is applied before entering the client's room. - Hand washing is performed before entering the client's room. - A box of tissues is brought to the client from the supply room. - A sputum culture is collected, labeled, and taken to lab as ordered.

A surgical face mask is applied before entering the client's room. Rational: A high-efficiency particulate-absorbing (HEPA) mask, rather than a standard surgical mask, should be used when entering the client's room because the HEPA mask can filter out 100% of small airborne particles. All of the other interventions are correct and appropriate for the nurse to perform.

A family brings a client into the emergency room with reports of chest pain and a blood pressure of 115/65 mm Hg, heart rate of 88 beats/min, respiratory rate of 20 breaths/min and oxygen saturation of 98% on room air. The health care provider writes out several prescriptions. Which prescribed action should the nurse carry out first? - Administer 2.5 mg morphine intravenously PRN. - Administer 2 to 3 liters of oxygen by nasal cannula. - Administer 0.4 mg nitroglycerin spray sublingually PRN. - Perform a 12-lead electrocardiogram.

Administer 0.4 mg nitroglycerin spray sublingually PRN. Rational: Of the interventions listed, the priority is the administration of nitroglycerin (nitro) to create vasodilation for the reduction of chest pain. The administration of nitro can also serve as a diagnostic as if it is noncardiac pain, the nitro should not relieve the pain. Nitro works primarily through systemic venous vasodilation, which reduces preload and decreases oxygen demand of the myocardial cells to reduce angina. Although the client's blood pressure is a little low for someone experiencing chest pain, it is within a safe level (systolic greater than 90). An electrocardiogram (ECG) is a priority to help identify ST elevation myocardial infarction (MI) but the nurse would still administer the nitro immediately and then obtain the ECG. The client's oxygen saturation is above 90% on room air, and current guidelines only recommend oxygen during MI in hypoxic clients. Morphine should not be given until after 3 doses of nitro have been tried and the pain persists. Although the acronym "MONA" is often used (representing morphine-oxygen-nitroglycerine-aspirin), this may lead to misconceptions about the priority order of interventions. A more accurate acronym for these interventions would be NOAM (pronounced "know-em").

The nurse is preparing a teaching plan for a client about crutch walking using a two-point gait pattern. What information should the nurse include? - Advance a crutch on one side, and then advance the opposite foot; repeat on the opposite side. - Advance a crutch on one side, and simultaneously advance and bear weight on the opposite foot; repeat on the opposite side. - Advance both crutches together, and then follow by lifting both lower extremities to the level of the crutches. - Advance both crutches together, and then follow by lifting both lower extremities past the level of the crutches.

Advance a crutch on one side, and simultaneously advance and bear weight on the opposite foot; repeat on the opposite side. Rational: A two-point gait involves partial weight bearing on each foot, with each crutch advancing simultaneously with the opposing leg. Advancing a crutch on one side and then advancing the opposite foot, and repeating on the opposite side, illustrates the four-point gait. When the client advances both crutches together and follows by lifting both lower extremities to the same level as the crutches, the gait is called a "swing to" gait. When the client advances both crutches together and follows by lifting both lower extremities past the level of the crutches, the gait is called a "swing through" gait. The "swing through" gait is often used by paraplegic clients because it allows them to place weight on their legs while the crutches are moved one stride ahead.

Two nurses disagree on what is the most important information for the client with a stress related illness to have during a discharge teaching session. How should the nurse assigned to provide the discharge teaching proceed? - Share all the information that both nurses thought was important. - Review the policies related to required discharge teaching. - Be aware of different interpretations and personal biases held by nurses. - Ask the client what is most important for them as they prepare for discharge.

Ask the client what is most important for them as they prepare for discharge. Rational: The discharge teaching session will be most effective if the nurse uses a client-centered approach to better assess what the client needs and, therefore, what information to share. Sharing all the information does not respect the knowledge that the client already has. Reviewing the policies is one area to help identify important areas for teaching, but in order to ensure that client needs are met further assessment is required. Awareness of personal biases should not be used to determine what is important for the client.

The young sister of a young adult client with leukemia asks, "Can you check my blood? When my sister got pneumonia, so did I. And I think I have this, too." Which of the following by the nurse would be inappropriate? - Ask the client's health care provider to take a sample of the sister's blood. - Explain to the sister that leukemia is not a communicable disease. - Discuss the sister's concern with her parents. - Tell the sister's parents about a group for siblings of clients with terminal illness.

Ask the client's health care provider to take a sample of the sister's blood. Rational: Taking a blood sample is an unnecessary, invasive procedure that would not directly address the sister's fear. Leukemia is not considered a communicable disease. Providing an explanation and alerting the parents to the sibling's concern and the resources available to assist siblings to deal with the terminal illness are all appropriate interventions.

A client has not had a bowel movement for 2 days and is feeling uncomfortable. The physician writes an order that states, "laxative of choice." How should the nurse proceed with this order? - Ask what type of laxative the client would like to have. - Ask the physician to prescribe a specific laxative. - Give mineral oil because it does not require a physician's order. - Ask if the client would prefer to have an enema administered.

Ask the physician to prescribe a specific laxative. Rational: The physician's order leaves the nurse in the position of prescribing a medication. To be a complete order, the physician must write the drug, dose, frequency, route, and purpose or reason for the drug. The other options are incorrect because they put the nurse in the position of prescribing a medication and not following established professional standards for the administration of medication.

A client with acute asthma is experiencing inspiratory and expiratory wheezing, and decreased forced expiratory volume. What is the nurse's priority intervention? - Beta-adrenergic blockers - Bronchodilators - Inhaled steroids - Oral steroids

Bronchodilators Rational: Bronchodilators are the first line of treatment for asthma because bronchoconstriction is the cause of reduced airflow. Beta-adrenergic blockers aren't used to treat asthma, and can cause bronchoconstriction. Inhaled or oral steroids may be given to reduce inflammation but aren't used for emergency relief.

A nurse is reviewing the health care provider's (HCP's) admitting prescriptions for a post-menopausal woman scheduled for a dilatation and curettage. The nurse is unable to decipher the handwriting but thinks the medication prescription reads either metoprolol or topiramate. What should the nurse do next? -Ask the client if she has hypertension. -Ask the client if she has migraines. -Call the HCP to clarify the prescription. -Ask the pharmacist to interpret the prescription.

Call the HCP to clarify the prescription. Rational: The nurse must clarify this prescription with the admitting HCP to ensure medication accuracy and client safety. In health care settings without computerized medical records or computer prescribing, misinterpretation of handwriting remains a leading cause of medication errors. It is not safe practice to question the client regarding a diagnosis and assume the medication is correctly prescribed. The pharmacist will need clarification of the prescription as well. It is not the role of the pharmacist to interpret the prescription.

The nurse is instructing the spouse of a client who had an incision and drainage procedure for an abscess how to care for the wound at home. What information should the nurse give the spouse about cleaning the wound? - Clean the incision and drainage sites simultaneously. - Clean from the incision site to the drainage site. - Clean from the drainage site to the incision site. - Clean both sites independently.

Clean both sites independently. Rational: The sites should be treated as separate sites to avoid cross contamination. This adheres to the principle of cleaning from the least contaminated area to the most contaminated area. Each site is considered a separate area for wound care.

To reduce the risk of dumping syndrome, what should the nurse teach the client to do? - Sit upright for 30 minutes after meals. - Drink liquids with meals, avoiding caffeine. - Avoid milk and other dairy products. - Decrease the carbohydrate content of meals.

Decrease the carbohydrate content of meals. Rational: Carbohydrates are restricted, but protein, including meat and dairy products, is recommended because it is digested more slowly. Lying down for 30 minutes after a meal is encouraged to slow movement of the food bolus. Fluids are restricted to reduce the bulk of food. There is no need to avoid caffeine.

A female client with bulimia nervosa reports that her major problem is eating too much food in a short period of time and then vomiting. Which short-term goal is the most important? - Help the client understand every person has a satiety level. - Encourage the client to verbalize fears and concerns about food. - Determine the amount of food the client will eat without purging. - Obtain a therapy appointment to look at the emotional causes of bulimia nervosa.

Determine the amount of food the client will eat without purging. Rational: This client must meet her nutritional needs to prevent further complications. She must identify the amount of food she can eat without purging as her first short-term goal. Binge eaters cannot recognize their satiety level or their feelings of fullness. Obtaining knowledge, or verbalizing her fears and feelings about food are not priority goals for this client. After meeting immediate physiologic needs, therapy is an important of treatment for this disorder.

A client is receiving chemotherapy and tells the nurse about also taking herbal therapy. What should the nurse do next? - Determine what substances the client is using, and make sure that the health care provider (HCP) is aware of all therapies the client is using. - Guide the client in the decision-making process to select either Western or alternative medicine. - Encourage the client to seek alternative modalities that do not require the ingestion of substances. - Recommend that the client stop using the alternative medicines immediately.

Determine what substances the client is using, and make sure that the health care provider (HCP) is aware of all therapies the client is using. Rational: The role of the nurse is to assess what substances or medications the client is using and to document and inform other members of the health care team. It is very important to encourage the client to keep the HCP informed of all therapeutic agents, medications, and supplements she is using, to avoid adverse interactions. It is not appropriate for the nurse to suggest that the client choose either Western or alternative therapies or to discourage the client's use of alternative therapies. The nurse should remain objective about the client's treatment choices and respect her autonomy.

A client seeks medical attention for a ganglion. Which statement about this musculoskeletal mass is true? - A ganglion is the most common benign soft-tissue mass in the foot. - A ganglion is a precursor to a primary bone tumor. - Surgical excision is the treatment of choice for a ganglion. - Dorsiflexion exacerbates signs and symptoms of a ganglion.

Dorsiflexion exacerbates signs and symptoms of a ganglion. Rational: Dorsiflexion exacerbates signs and symptoms of a ganglion. A ganglion is the most common benign soft-tissue mass in the hand, not foot. It isn't a known precursor to a primary bone tumor. To treat a ganglion, the physician aspirates the ganglion, then injects a corticosteroid into the joint; the physician may also order nonsteroidal anti-inflammatory agents. Surgical excision is necessary only if signs and symptoms persist and the client's range of motion is impaired.

A nurse is part of a group of nurses working at a local clinic that serves a culturally diverse population. The nurses are working to improve their cultural competence in delivering care to the various cultures. To achieve success in this endeavor, which action would the nurses need to do first? - Examine how each of the nurses' own cultures have shaped their beliefs and practices. - Look for resources to help increase their understanding of the cultural populations being served by the clinic. - Gain familiarity with the diverse cultural beliefs, practices, and lifestyles of the different ethnic groups seen at the clinic. - Develop skill with practice in performing the necessary components of a cultural assessment.

Examine how each of the nurses' own cultures have shaped their beliefs and practices. Rational: Before the nurses can gain cultural knowledge and skills necessary to develop cultural competence, the nurses must first gain cultural awareness. This involves becoming aware of, appreciating, and becoming sensitive to the values, beliefs, customs, and behaviors that have shaped each nurse's individual culture and examining each's own sociocultural heritage to gain personal insight. Once cultural awareness is attained, the nurses can then develop cultural knowledge by looking for resources and develop cultural skills by gaining familiarity with the diverse cultural groups and learning how to perform a cultural assessment.

A nurse is performing a neurological assessment during a client's routine physical examination. To assess for a Babinski reflex, indicate the point where the nurse places the tongue blade to begin stroking the foot.

Heel

A client with chronic obstructive pulmonary disease (COPD) is experiencing dyspnea and has a low PaO2 level. The nurse plans to administer oxygen as ordered. Which statement is true concerning oxygen administration to a client with COPD? - High oxygen concentrations will cause coughing and dyspnea. - High oxygen concentrations may inhibit the hypoxic stimulus to breathe. - Increased oxygen use will cause the client to become dependent on the oxygen. - Administration of oxygen is contraindicated in clients who are using bronchodilators

High oxygen concentrations may inhibit the hypoxic stimulus to breathe. Rational: Clients who have a long history of COPD may retain carbon dioxide (CO2). Gradually the body adjusts to the higher CO2 concentration, and the high levels of CO2 no longer stimulate the respiratory center. The major respiratory stimulant then becomes hypoxemia. Administration of high concentrations of oxygen eliminates this respiratory stimulus and leads to hypoventilation. Oxygen can be drying if it is not humidified, but it does not cause coughing and dyspnea. Increased oxygen use will not create an oxygen dependency; clients should receive oxygen as needed. Oxygen is not contraindicated with the use of bronchodilators.

At the health clinic, a sexually active 15-year-old girl tells a nurse she is worried that her parents may find out about her sexual activity. "They would never approve," she says. Which nursing diagnoses should the nurse formulate? - Delayed growth and development related to parent expectations - Impaired social interaction related to parent expectations - Ineffective sexuality patterns related to parent expectations - Fear related to parent expectations

Ineffective sexuality patterns related to parent expectations Rational: This girl is expressing concerns about the conflict between her parents' expectations and her own desires. Sexual activity is a normal experimental pattern for many adolescents, but she verbalizes that she is worried and anxious regarding parental expectations against this behavior. Sexual activity does not suggest a delay in growth and development, the expression of fear, or problems with social interactions.

A child with meningococcal meningitis is being admitted to the pediatric unit. In preparation for the child's arrival, what should the nurse do first? - Institute droplet precautions. - Obtain the child's vital signs. - Ask the parent about medication allergies. - Inquire about the health of siblings at home.

Institute droplet precautions. Rational: The child with meningococcal meningitis requires droplet precautions for at least the first 24 hours after effective therapy is initiated to reduce the risk of transmission to others on the unit. After the child has been placed on droplet precautions, other actions, such as taking the child's vital signs, asking about medication allergies, and inquiring about the health of siblings at home, can be performed.

The nurse is providing dietary teaching for a client with diabetes. Which statement about the diet would be accurate? - It is based on nutritional requirements that are the same for all clients. - It is planned around a wide variety of commonly available foods. - It is rigidly controlled to avoid similar diabetic emergencies. - It does not include processed foods because they have too many variables.

It is planned around a wide variety of commonly available foods. Rational: Each client should be given an individually devised diet selecting commonly used foods from the Diabetic Association exchange diet. Family members should be included in the diet teaching. Nutritional requirements are not the same for all clients. Flexibility is needed based on activity, not rigid control. Seasoning and processed food should be managed.

The nurse has answered the telephone at the nurses' station, and the individual on the line states that there is bomb in the healthcare facility. What is the nurse's best response? - Keep the individual on the line in order to gather more information about the details of the threat. - Hang up the telephone immediately, and instruct a colleague to call 911 promptly. - Inform the authorities, and begin evacuating clients and closing doors. - Hang up the telephone, and use the overhead paging system to call all staff to the nurses' station.

Keep the individual on the line in order to gather more information about the details of the threat. Rational: If a bomb threat is received, the nurse should keep the caller on the line and talking as long as possible in order to gather information about the location of the bomb and a description of the bomb and the caller. The threat must be reported promptly, but the nurse should not hang up in order to do this.

A client with chronic pain reports to the manager that the nurses have not been responding to requests for pain medication. What is the manager's priority action? - Perform a pain assessment and pain history on the client. - Check the medication record and the nurses' notes for the last couple of days. - Meet with the nurses responsible for this client. - Have the clinical nurse educator review an in-service on pain management.

Meet with the nurses responsible for this client. Rational: A manager must assess the performance of staff in relation to this client. After information is gathered from the nurses, information can also be obtained from the records and the client. The clinical educator can be of assistance if there is a knowledge deficit regarding pain management.

A nurse is reviewing the causes of gastroesophageal reflux disease (GERD) with a client. What area of the GI tract causes the reduced pressure associated with GERD?

Normally, there is enough pressure around the lower esophageal sphincter (LES) to close it. Reflux occurs when LES pressure is deficient or when pressure in the stomach exceeds LES pressure. https://www.physio-pedia.com/Gastroesophageal_Reflux_Disease

An older adult client with advanced cancer and a serum creatinine level of 2.5 mg/dL (220 µmol/L) has been receiving regular morphine, controlled release for pain control. The client has increasing pain and agitation despite regular doses of the analgesic. What action should the nurse take? - Notify the healthcare provider and recommend changing the opioid prescription to fentanyl. - Notify the healthcare provider and recommend increasing the morphine, controlled release. - Withhold all opioids and notify healthcare provider for naloxone prescription. - Notify healthcare provider for immediate release PRN prescription for morphine sulfate.

Notify the healthcare provider and recommend changing the opioid prescription to fentanyl. Rational: Older adult clients and clients with impaired glomerular filtration rate (elevated creatinine level) are at increased risk for developing opioid-induced neurotoxicity. This condition develops due to an accumulation of active metabolites of opioids such as codeine and morphine. Neurotoxicity can be reduced by administering opioids with little to no active metabolites such as fentanyl. A client with advanced cancer should not have opioids withheld and fully reversed with naloxone, because these would cause too much pain. The cause of the client's symptoms may be the morphine so neither increasing the dose of the controlled-release formula nor asking for immediate-release morphine sulfate is appropriate.

A client undergoes total gastrectomy. Several hours after surgery, the nurse notes that the client's nasogastric (NG) tube has stopped draining. How should the nurse respond? - Notify the physician. - Reposition the tube. - Irrigate the tube. - Increase the suction level.

Notify the physician. Rational: The nurse should notify the physician because an NG tube that fails to drain during the postoperative period may be clogged, which could increase pressure on the suture site because fluid isn't draining adequately. Repositioning or irrigating an NG tube in a client who has undergone gastric surgery can disrupt the anastomosis. Increasing the level of suction may cause trauma to GI mucosa or the suture line.

Nurses were identified by the Centers for Disease Control and Prevention (CDC) as the people most likely to care for clients infected after the intentional release of the smallpox virus. Based on CDC guidelines, which group should volunteer to receive the smallpox vaccine? - Nurses age 50 and older who work in the emergency departments of community hospitals. - Nurses who served in the military and are now working in public health settings. - Nurses born after 1971 who are employed as triage nurses in large medical center emergency departments. - Nurses vaccinated against smallpox as children who are now working in a pediatric unit.

Nurses age 50 and older who work in the emergency departments of community hospitals. Rational: The CDC recommends the smallpox vaccine for nurses who received the vaccine as children (which includes those older than age 50) who work in the emergency department; emergency department nurses are most likely to care for those infected with the smallpox virus. Nurses born after 1971 weren't previously vaccinated against smallpox so the vaccine isn't currently recommended for those nurses. Military history doesn't dictate whether or not the vaccine is recommended. Nurses who work in the pediatric unit aren't at high risk for smallpox exposure; therefore, the vaccine isn't recommended for this group.

During the manic phase of bipolar disorder, a client's lithium carbonate level measures 0.15 mEq/L. The client dresses flamboyantly, acts provocatively, and has seriously impaired judgment. What is the nurse's priority when planning this client's care? - Administer lithium carbonate I.M. - Observe the client's behavior closely in the milieu. - Begin aversion therapy to extinguish undesirable behaviors. - Initiate suicide precautions because the client's judgment is impaired.

Observe the client's behavior closely in the milieu. Rational: Because a client with manic symptoms has impaired judgment, the nurse should observe closely to prevent the client from acting on dangerous impulses. Although lithium carbonate is used to control mania, it's available only in oral form. Aversion therapy is inappropriate because the client can't control the behavior. Suicide precautions are inappropriate because the client hasn't displayed suicidal intentions.

During her first prenatal visit, a pregnant client admits to the nurse that she uses cocaine at least once per day. What is the nurse's priority implementation? - Obtain urine and serum drug screens. - Refer the client for drug counseling. - Report the client to child protective services. - Explain why the pregnancy is at risk.

Obtain urine and serum drug screens. Rational: Even though this client disclosed the use of cocaine, it does not mean there may not be other illicit drugs involved. It is important for all healthcare personnel to know what drugs are involved so the risks can be identified and any necessary interventions performed. In an adult, cocaine will be present in the urine for 24-48 hours. The nurse should be proactive, supportive, and caring for the client. The key to success is being nonjudgmental. Assure the client that all information is confidential. The nurse should provide counseling about the effects of cocaine on the pregnancy and the fetus. The client should be referred to outreach programs or therapy. The mother is not reported to child protective services; this would be done after delivery if the baby tests positive for drugs.

Soon after a pregnant client arrives at the birthing center, the nurse observes a brown-tinged mucous discharge. What should the nurse do next? - Check fetal descent by performing Leopold's maneuvers. - Perform a vaginal examination to determine cervical dilation. - Check for rupture of the membranes with a sterile speculum. - Notify the primary care provider of possible abruption of the placenta.

Perform a vaginal examination to determine cervical dilation. Rational: The nurse is observing normal bloody show which occurs when the cervix begins to dilate. The mucous can be brown, pink, or red-tinged. Thus, the nurse would perform a vaginal examination to determine cervical dilation. For any bloody show or vaginal bleeding in large amounts, the nurse should not perform a vaginal examination because a large amount of bleeding may indicate abruptio placentae or placenta previa. Leopold's maneuvers help to determine fetal positioning not fetal descent. Rupture of the fetal membranes results in the escape of amniotic fluid not bloody show. Abruptio placenta is usually accompanied by boardlike abdominal pain and bleeding, which is frequently concealed.

A suicidal client is placed in the seclusion room and given lorazepam because she tried to harm herself by banging her head against the wall. After 10 minutes, the client starts to bang her head against the wall in the seclusion room. What action should the nurse take next? - Call hospital security for assistance. - Place the client in restraints. - Call the health care provider (HCP) for additional medication prescriptions. - Instruct a staff member to sit in the room with the client.

Place the client in restraints. Rational: The nurse and staff should place the client in restraints to protect her from further self-harm. The client's behavior is out of control and necessitates external controls for her safety. The health care team is trained to deal with this type of behavior, so there is no reason to call hospital security at this time. Calling the HCP for additional medication prescriptions is not appropriate because the lorazepam given by the nurse may take effect if the client remains still. The nurse is responsible for judging whether additional medication is needed later. Instructing a staff member to sit in the room with the client is unsafe for the client and the staff member.

A 15-year-old client is 4 cm dilated and 100% effaced and is in active labor with her first baby. The nurse contacts the physician to communicate the findings of fetal heart rate decelerations, thick meconium in the amniotic fluid, and low fetal scalp pH results. What is the most appropriate nursing action at this time? - Encourage the client to get into the right lateral position. - Increase the oxygen to 7 L/min. - Prepare the client for an assisted or cesarean birth. - Contact the social worker to inform him/her of imminent birth.

Prepare the client for an assisted or cesarean birth. Rational: Fetal heart decelerations, thick meconium, and low fetal scalp pH indicate severe fetal distress. Because the client is a primigravida and in early labor at 4 cm cervical dilatation, it is unlikely that the baby will tolerate further labor and a vaginal birth. It is prudent for the nurse to begin preparing the client for an assisted or operative birth. While changing maternal position and increasing oxygen availability may enhance placental perfusion and fetal oxygenation, these interventions do not meet the immediate fetal needs. There are no implications that a social worker needs to be involved in the care provided at this particular stage.

A physician orders a tricyclic antidepressant for a client who has suffered an acute myocardial infarction (MI) within the previous 6 months. Which action should the nurse take? - Administer the medication as ordered. - Discontinue the medication. - Question the physician about the order. - Advise the client to discuss the MI with the physician.

Question the physician about the order. Rational: Cardiovascular toxicity is a problem with tricyclic antidepressants, and the nurse should question the use of these drugs in a client with cardiac disease. Administering the medication would be an act of negligence. A nurse can't discontinue a medication without a physician's order. It's the nurse's responsibility, not the client's, to discuss questions of care with the physician.

Assessment of a primigravid client in active labor reveals cervical dilation at 9 cm with complete effacement and the fetus at +1 station. What is the most appropriate action for the nurse to take when the health care provider (HCP) prescribes morphine 2 mg IM for the client? - Administer the medication in the left ventrogluteal muscle. - Be certain that naloxone is at the client's bedside. - Ask the HCP to validate the dosage of the drug. - Refuse to administer the medication to the client.

Refuse to administer the medication to the client. Rational: The nurse should refuse to administer the medication to the client because of the risk of respiratory depression in the neonate. Morphine, given IM, peaks in 30 to 60 minutes and lasts 4 hours. Based on the assessment findings, the client most likely will be delivering within that time frame, increasing the risk of respiratory depression in the neonate, a serious consequence. Therefore, the nurse should not administer the drug. Naloxone should be readily available whenever opioids that can result in respiratory depression are used. Asking the HCP to validate the dosage is not necessary.

The nurse is assisting a client to develop independence during a stay at a rehabilitation hospital. Which should the nurse prioritize first in caring for this client? - Demonstrate ways independence can be regained for activities. - Reinforce success in tasks accomplished. - Establish long-term goals for the client. - Point out errors in performance.

Reinforce success in tasks accomplished. Rational: To aid motivation, the nurse should focus on the positive aspects of the client's progress. Independence is a higher priority than demonstration. Long-term goals, although important, are not an immediate priority.

A client has just returned from having a central venous catheter placed and is prescribed I.V. solution to run at 100 ml/hr. What is the appropriate action by the nurse? -Administer the I.V. solution as prescribed. -Assess for blood return prior to administering the solution. -Review the x-ray results to ensure correct catheter placement. -Contact the healthcare provider to verify the prescription.

Review the x-ray results to ensure correct catheter placement. Rational: The nurse should review the x-ray to ensure the tip of the catheter is in the proper place prior to beginning the infusion of the solution. While it is important for the nurse to check for blood return prior to administering the medication, the nurse should first check that the tip of the catheter is in the proper place. There is no need to verify the prescription with the healthcare provider at this time.

Which nursing diagnosis is a priority for a client with a traumatically amputated lower extremity? - Impaired skin integrity related to effects of the injury - Anticipatory grieving related to the loss of a limb - Disturbed body image related to changes in the structure of a body part - Risk for injury related to amputation

Risk for injury related to amputation Rational: The priority diagnosis for this client is Risk for injury related to amputation. Patient safety takes priority. Amputation typically causes an unsteady gait until the client receives physical therapy and learns to ambulate safely. Impaired skin integrity, Anticipatory grieving, and Disturbed body image are also appropriate for a client presenting with a traumatic amputation of an extremity, but Risk for injury is the priority nursing diagnosis.

A nurse discovers that a hospitalized client with stage 4 esophageal cancer and major depression has a gun in the home. What is the best nursing intervention to help the client remain safe after discharge? - Give the client the number of a 24-hour crisis phone line for use, if needed. - Tell the health care provider (HCP) the client is too high risk for discharge at this time. - Have the client promise to use the gun only for home protection. - Talk with the health care provider (HCP) about requiring gun removal as a condition of discharge.

Talk with the health care provider (HCP) about requiring gun removal as a condition of discharge. Rational: The only action that keeps the client safe is removal of the gun. If the HCP is considering discharge, the client is medically stable and will not be able to remain in the medical hospital any longer. The client's lack of current suicidal ideation means he cannot be hospitalized for psychiatric reasons. While helpful, the crisis phone line number and the client's promise do not ensure safety.

A nurse is feeling the apical impulse of a 28-month-old child. Identify the area where the nurse would assess the apical impulse.

The heart's apex for a toddler is located at the fourth intercostal space immediately to the left of the midclavicular line. It is one or two intercostal spaces above what's considered normal for the adult because the heart's position in a child of this age is more horizontal and larger in diameter than that of an adult.

Pancrelipase, an enzyme replacement, has been prescribed for a client with chronic pancreatitis. Which points should the nurse include in the client's teaching plan about the drug? - The enzyme mixture should be taken after each meal. - The client should be careful not to inhale the powder when mixing it with food. - The enzyme mixture should be stored in the refrigerator to keep it fresh. - If taking the capsule, the client should chew it thoroughly.

The client should be careful not to inhale the powder when mixing it with food. Rational: When mixing the enzyme (lipase, protease, amylase) powder into food, the client should be careful not to inhale it as the powder may trigger an asthma attack.The enzymes are taken before or with each meal, not after.The drug does not need to be stored in the refrigerator.The client should not chew the capsules.

What information should the nurse include when developing the teaching plan for the parents of a child with juvenile idiopathic arthritis who is being treated with naproxen? - Anti-inflammatory effect will occur in approximately 8 weeks. - Within 24 hours, the child will have anti-inflammatory relief. - The nurse should be called before giving the child any over-the-counter medications. - If a dose is forgotten or missed, that dose is not made up.

The nurse should be called before giving the child any over-the-counter medications. Rational: The first group of drugs typically prescribed is the nonsteroidal anti-inflammatory drugs, which include naproxen. Once therapy is started, it takes hours or days for relief from pain to occur. However, it takes 3 to 4 weeks for the anti-inflammatory effects to occur, including reduction in swelling and less pain with movement. Naproxen is included in only a few over-the-counter medications, but aspirin is in several. The family should check with the nurse before giving any over-the-counter medications. Toxicity or GI bleeding may occur when nonsteroidal anti-inflammatory drugs are combined. The missed dose will need to be made up to maintain the serum level and to maintain therapeutic effectiveness of the drug.

A health care provider (HCP) is calling the pediatric unit and asking the nurse to go into the medical record for test results of a fellow pediatrician. How should the nurse respond to this request? - Verify that the caller is the HCP of record or has a need to know. - Access the medical record, and give the HCP the test results. - Decline to give the HCP the information requested. - Determine whether the nurse can access the medical record.

Verify that the caller is the HCP of record or has a need to know. Rational: The nurse should determine if the HCP is the HCP of record and should have access to the information in the medical record. The medical record is not for public access. The nurse would not give client information to any HCP or refuse to give information without first determining the HCP of record and/or a legitimate need to know. As an employee, the nurse should have access to medical records, but it is not acceptable to enter a medical record without justification.

The nurse plans care for four mothers and their newborns. After reviewing the clients' medical records, the nurse should make rounds on which client first? - an 18-year-old G2 P2 with an uncomplicated spontaneous vaginal birth 12 hours ago who has abdominal cramps - a 35-year-old G4 P4 with an uncomplicated vaginal birth 4 hours ago; the nurse's notes indicated she soaked two peripads over the last 2 hours; fundus is firm - a 16-year-old G1 P1 with a caesarean birth 4 hours ago, diagnosed with preeclampsia and receiving magnesium sulfate at 2 g/h; reflexes are 2+, and the nurse's notes indicate she has a headache; vital signs are T 99.4 F (37.4 C), P 88, R 20, BP 128/86 mm Hg - an 18-year-old G2 P2 who had a caesarian birth 2 days ago and now has severe breast pain; vital signs are T 99.8 F (37.7 C), P 96, R 22

a 35-year-old G4 P4 with an uncomplicated vaginal birth 4 hours ago; the nurse's notes indicated she soaked two peripads over the last 2 hours; fundus is firm Rational: The criteria for hemorrhage is saturating one pad per hour. The 35-year-old who delivered 4 hours ago had saturated a peripad per hour. Even though her fundus is firm, she may have experienced a cervical laceration, which would be the source of the bleeding. She needs to be evaluated first, based on the bleeding. The 18-year-old who has abdominal cramps is within normal limits for a G2 P2 and is experiencing afterbirth pains normally seen in a multiparous client; she will need pain medication. The 16-year-old status post cesarean birth on magnesium sulfate is stable with adequate urinary output and normal reflexes. Her vital signs are within normal limits for a postpartum client. The headache is the one area of concern for this client. The 18-year-old who is 2 days postpartum with breast pain may be experiencing her milk coming in, although it does not indicate whether she is breast- or bottle-feeding; either situation may find a mother with milk developing within her system. The vital signs for this client are slightly elevated, but this may be from the milk coming in and would require nursing evaluation but is not emergent.

While auscultating the heart sounds of a client with heart failure, the nurse hears an extra heart sound immediately after the second heart sound (S2). The nurse should document this as - a first heart sound (S1). - a third heart sound (S3). - a fourth heart sound (S4). - a murmur.

a third heart sound (S3). Rational: An S3 is heard following an S2, which commonly occurs in clients experiencing heart failure and results from increased filling pressures. An S1 is a normal heart sound made by the closing of the mitral and tricuspid valves. An S4 is heard before an S1 and is caused by resistance to ventricular filling. A murmur is heard when there is turbulent blood flow across the valves.

Which intervention is an example of primary prevention? - administering digoxin to a client with heart failure - administering a measles, mumps, and rubella immunization to an infant - obtaining a Papanicolaou (Pap) test to screen for cervical cancer - using occupational therapy to help a client cope with arthritis

administering a measles, mumps, and rubella immunization to an infant Rational: Immunizing an infant is an example of primary prevention, which aims to prevent health problems. Administering digoxin to treat heart failure and obtaining a Pap test for screening are examples of secondary prevention, which promotes early detection and treatment of disease. Using occupational therapy to help a client cope with arthritis is an example of tertiary prevention, which aims to help a client deal with the residual consequences of a problem or to prevent the problem from recurring.

Which statement indicates that the client with chronic obstructive pulmonary disease (COPD) who has been discharged to home understands the care plan? The client: - will avoid direct contact with family and friends. - can state actions to reduce pain. - will use oxygen via a nasal cannula at 5 L/min. - agrees to call the health care provider (HCP) if dyspnea on exertion increases.

agrees to call the health care provider (HCP) if dyspnea on exertion increases. Rational: Increasing dyspnea on exertion indicates that the client may be experiencing complications of COPD. Therefore, the client should notify the HCP. It is not necessary to avoid being around others. Pain is not a common symptom of COPD. Clients with COPD use low-flow oxygen supplementation (1 to 2 L/min) to avoid suppressing the respiratory drive, which, for these clients, is stimulated by hypoxia.

The nurse should use which type of precautions for a client being admitted to the hospital with suspected tuberculosis? - standard precautions - contact precautions - droplet precautions - airborne precautions

airborne precautions Rational: Airborne precautions prevent transmission of infectious agents that remain infectious over long distances when suspended in the air (e.g., Mycobacterium tuberculosis, measles, varicella virus [chickenpox], and possibly SARS-CoV). The preferred placement is in an isolation single-client room that is equipped with special air handling and ventilation. A negative pressure room, or an area that exhausts room air directly outside or through HEPA filters, should be used if recirculation is unavoidable. While standard precautions such as hand hygiene and wearing gloves and a gown is important, they are not sufficient to prevent transmission of tuberculosis. Contact precautions are used with clients with known or suspected infections who present an increased risk for contact transmission. Droplet precautions are intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions. Because these pathogens do not remain infectious over long distances in a health care facility, special air handling and ventilation are not required to prevent droplet transmission

Three days after mitral valve replacement surgery, the client tells the nurse there is a "clicking" noise coming from the chest incision. The nurse's response should reflect the understanding that the client may be experiencing? - anxiety related to altered body image - depression related to altered health status - altered tissue perfusion - lack of knowledge regarding the postoperative course

anxiety related to altered body image Rational: Verbalized concerns from this client may stem from anxiety over the changes in the body after open heart surgery. Although the client may experience depression related to altered health status or may have a lack of knowledge regarding the postoperative course, the client is pointing out the changes in the body image. The client is not concerned about altered tissue perfusion.

In preparation for total knee surgery, a 200-lb (90.7 kg) client with osteoarthritis must lose weight. Which exercise should the nurse recommend as best if the client has no contraindications? - weight lifting - walking - aquatic exercise - tai chi exercise

aquatic exercise Rational: When combined with a weight loss program, aquatic exercise would be best because it cushions the joints and allows the client to burn off calories. Aquatic exercise promotes circulation, muscle toning, and lung expansion, which promote healthy preoperative conditioning. Weight lifting and walking are too stressful to the joints, possibly exacerbating the client's osteoarthritis. Although tai chi exercise is designed for stretching and coordination, it would not be the best exercise for this client to help with weight loss.

A client is Rh(D)-negative and D-negative and hasn't formed Rh antibodies. When should the client receive RHO(D) immune globulin (RhoGAM) to prevent isoimmunization? - at about 28 weeks' gestation only - within 72 hours after birth only - at about 28 weeks' gestation and again within 72 hours after birth - at about 32 weeks' gestation and again within 24 hours after birth

at about 28 weeks' gestation and again within 72 hours after birth Rational: A client who is Rh(D)-negative and D-negative and who hasn't already formed Rh antibodies should receive RHO(D) immune globulin at about 28 weeks' gestation and again within 72 hours after birth. Giving RHO(D) immune globulin only at 28 weeks' gestation wouldn't prevent isoimmunization from occurring after placental separation, when fetal blood enters the maternal circulation. Giving RHO(D) immune globulin only within 72 hours after delivery wouldn't prevent isoimmunization caused by passage of fetal blood into the maternal circulation during gestation. Giving RHO(D) immune globulin at 32 weeks' gestation would be too late to prevent isoimmunization during pregnancy because Rh antibodies already have formed by then. Giving Rohm(D) immune globulin within 24 hours after birth would be too soon because maternal sensitization occurs in approximately 72 hours.

Which drug delivery system most effectively reduces the likelihood of medication errors? - floor stock - unit-dose - individual prescription - automated

automated Rational: An automated drug delivery system most effectively reduces the likelihood of medication errors by automatically dispensing the drug. Medication errors can still occur with this method but are less likely than with floor stock, unit-dose, and individual prescription methods.

A nurse is preparing a teaching plan for a male client newly prescribed atenolol. Which information is important for the nurse to teach this client? - causes and treatments for erectile dysfunction - control of excessive flatus - management of incontinence - prevention of constipation

causes and treatments for erectile dysfunction Rational: Erectile dysfunction is a potential adverse effect of beta blockers. The other symptoms are not side effects of this drug.

A client with hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome is admitted to the labor and delivery unit. The client's condition rapidly deteriorates and despite efforts by the staff, the client dies. After the client's death, the nursing staff displays many emotions. With whom should the nurse-manager consult to help the staff cope with this unexpected death? - human resource director, so she can arrange vacation time for the staff - physician, so he can provide education about HELLP syndrome - social worker, so she can contact the family about funeral arrangements and pass along the information to the nursing staff - chaplain, because his educational background includes strategies for handling grief

chaplain, because his educational background includes strategies for handling grief Rational: The chaplain should be consulted because his educational background provides strategies for helping others handle grief. Providing the staff with vacation time isn't feasible from a staffing standpoint and doesn't help staff cope with their grief. The staff needs grief counseling, not education about HELLP syndrome. Asking the social worker to contact the family about the funeral arrangements isn't appropriate.

A hospital is changing the format for documentation in an attempt to decrease the time the nurses are spending on charting. The new type of charting will require that nurses document the significant findings as a narrative note in a shorthand method using well-defined standards of practice. Which best defines this type of charting? - charting by exception - focus charting - problem, Intervention, Evaluation (PIE) charting - variance charting

charting by exception Rational: Charting by exception is a shorthand documentation method that makes use of well-defined standards of practice; only significant findings or "exceptions" to these standards are documented in the narrative notes. Charting by exception decreases charting time. Focus charting does not use a problem list of nursing or medical diagnoses but incorporates many aspects of the client and client care into a focus column. The focus may be a client strength, problem, or need. Problem, Intervention, Evaluation (PIE) charting incorporates the plan of care into the progress note, and problems are identified by an assigned number. Variance charting is used when clients fail to meet an expected outcome or a planned intervention is not implemented in the case management model.

A client who's at high risk for suicide needs close supervision. To best ensure the client's safety, the nurse should: - check the client frequently at irregular intervals. - assure the client that the nurse will hold in confidence anything the client says. - repeatedly discuss the client's previous suicide attempts. - disregard decreased communication by the client because decreased communication is typical of suicidal clients.

check the client frequently at irregular intervals. Rational: Checking the client frequently but at irregular intervals prevents the client from anticipating when observation will take place and altering behavior in a misleading way at these times. Assuring the client that information will be held in confidence may encourage the client to try to manipulate the nurse or seek attention by claiming a secret suicide plan. Repeatedly discussing previous suicide attempts may reinforce the client's suicidal ideas. Decreased communication is a sign of withdrawal that may indicate the client has decided to commit suicide; the nurse shouldn't disregard it.

A nurse is caring for several clients on an oncology unit. Which client should the nurse see first? - client who is on complete bed rest - client with a white blood cell count of 2000 µL - client receiving brachytherapy for prostate cancer - client who is 2 days postoperative following a hemicolectomy

client with a white blood cell count of 2000 µL Rational: A white blood cell count of 2000 µL puts the client at risk for infection. The nurse would want to see this client first in order to reduce the transmission of bacteria and other organisms from working with other clients. The client on bed rest can wait and the other clients are stable.

The nurse teaches the three cardinal signs of choking and total airway blockage to the parents of a toddler who was treated for a foreign body obstruction. When asked to repeat the signs, the parents identify "turn blue" and "cannot speak." What third sign would the parents identify if teaching was successful? - vomits - gasps - gags - collapses

collapses Rational: The three cardinal signs indicating that a child is truly choking and requires immediate life-saving interventions include inability to speak, blue color (cyanosis), and collapse. Vomiting does not occur while a child is unable to breathe. Once the object is dislodged, however, vomiting may occur. Gasping, a sudden intake of air, indicates that the child is still able to inhale. When a child is choking, air is not being exchanged, so gagging will not occur.

A client has a soft wrist-safety device. Which assessment finding should the nurse investigate further? -a palpable radial pulse -a palpable ulnar pulse -cool, pale fingers -pink nail beds

cool, pale fingers Rational:A wrist-safety device on the wrist may impair circulation and restrict blood supply to body tissues. Therefore, the nurse should assess the client for signs of impaired circulation such as cool, pale fingers. A palpable radial or ulnar pulse and pink nail beds are normal findings.

When assessing a client with asthma, which findings would most likely indicate the presence of a respiratory infection? - cough productive of yellow sputum - bilateral expiratory wheezing - chest tightness - respiratory rate of 30 breaths/min

cough productive of yellow sputum Rational: A cough productive of yellow sputum is the most likely indicator of a respiratory infection. The other signs and symptoms—wheezing, chest tightness, and increased respiratory rate—are all findings associated with an asthma attack and do not necessarily mean an infection is present.

A client is undergoing a diagnostic workup for suspected testicular cancer. When obtaining the client's history, the nurse checks for known risk factors for this type of cancer. Testicular cancer has been linked to - testosterone therapy during childhood. - sexually transmitted disease. - early onset of puberty. - cryptorchidism.

cryptorchidism Rational: Cryptorchidism (failure of one or both testes to descend into the scrotum) appears to play a role in testicular cancer, even when corrected surgically. Other significant history findings for testicular cancer include mumps orchitis, inguinal hernia during childhood, and maternal use of diethylstilbestrol or other estrogen-progestin combinations during pregnancy. Testosterone therapy during childhood, sexually transmitted disease, and early onset of puberty aren't risk factors for testicular cancer.

A school-age client with leukemia is receiving cyclophosphamide. The nurse should assess the client for which adverse effect of cyclophosphamide? - photosensitivity. - ataxia. - cystitis. - cardiac arrhythmias.

cystitis. Rational: Cystitis is a potential adverse effect of cyclophosphamide. The client should be monitored for pain on urination. Photosensitivity, ataxia, and cardiac arrhythmias are not adverse effects associated with cyclophosphamide

A client is recovering from coronary artery bypass graft (CABG) surgery. The nurse knows that for several weeks after this procedure, the client is at risk for certain conditions. During discharge preparation, the nurse should advise the client and their family to expect which common symptom that typically resolves spontaneously? - depression - ankle edema - memory lapses - dizziness

depression Rational: For the first few weeks after CABG surgery, clients commonly experience depression, fatigue, incisional chest discomfort, dyspnea, and anorexia. Depression typically resolves without medical intervention. However, the nurse should advise family members that symptoms of depression don't always resolve on their own. They should make sure they recognize worsening symptoms of depression and know when to seek care. Ankle edema seldom follows CABG surgery and may indicate right-sided heart failure. Because this condition is a sign of cardiac dysfunction, the client should report ankle edema at once. Memory lapses reflect neurologic rather than cardiac dysfunction. Dizziness may result from decreased cardiac output, an abnormal condition following CABG surgery. This symptom warrants immediate physician notification.

The nurse is caring for an 8-year-old child who arrived at the emergency department with chemical burns to both legs. What is the priority intervention for this child? - diluting the chemicals - applying sterile dressings - applying topical antibiotics - debriding and grafting the burns

diluting the chemicals Rational: Diluting the chemical is the priority. It will help remove the chemical and stop the burning process. The remaining treatments are initiated after dilution.

A client enters the crisis unit complaining of increased stress from studies as a medical student. The client reports increasing anxiety for the past month. The physician orders alprazolam, 0.25 mg by mouth three times per day, along with professional counseling. Before administering alprazolam, the nurse reviews the client's medication history. Which drug can produce additive effects when taken concomitantly with alprazolam? - levodopa - famotidine - diphenhydramine - norgestrel

diphenhydramine Rational: Using benzodiazepines with other central nervous system depressants such as diphenhydramine produces additive effects. Alprazolam doesn't cause clinically significant drug interactions with levodopa, famotidine, or hormonal contraceptives such as norgestrel.

A school-age client is admitted to the hospital with the diagnosis of acute rheumatic fever. Which laboratory blood finding confirms that the child has had a streptococcal infection? - high leukocyte count - low hemoglobin count - elevated antibody concentration - low erythrocyte sedimentation rate

elevated antibody concentration Rational: Exactly why rheumatic fever follows a streptococcal infection is not known, but it is theorized that an antigen-antibody response occurs to an M protein present in certain strains of streptococci. The antibodies developed by the body attack certain tissues such as in the heart and joints. Antistreptolysin O titer findings show elevated or rising antibody levels. This blood finding is the most reliable evidence of a streptococcal infection.

The physician suspects tracheoesophageal fistula in a 1-day-old neonate. Which nursing intervention is most appropriate for this child? - avoiding suctioning unless cyanosis occurs - elevating the neonate's head and giving nothing by mouth - elevating the neonate's head for 1 hour after feedings - giving the neonate only glucose water for the first 24 hours

elevating the neonate's head and giving nothing by mouth Rational: Because of the risk of aspiration, a neonate with a known or suspected tracheoesophageal fistula should be kept with the head elevated at all times and should receive nothing by mouth (NPO). The nurse should suction the neonate regularly to maintain a patent airway and prevent pooling of secretions. Elevating the neonate's head after feedings or giving glucose water are inappropriate because the neonate must remain on NPO status.

When a client is placed in balanced skeletal traction, the nurse should: - ensure that the traction weights hang freely from the bed at all times. - increase the traction weight gradually as the client's tolerance increases. - apply and remove the traction weights at regular intervals throughout the day. - remove the weights briefly as necessary to reposition the client in bed.

ensure that the traction weights hang freely from the bed at all times. Rational: In balanced skeletal traction, the appropriate pressures and counter pressures are applied to the fracture site, with the traction weights hanging freely at all times.The amount of traction weight used is determined by radiography and the alignment of the fracture.These weights are in place continuously and should never be lifted, reduced, or eliminated.

Before surgery to remove an ectopic pregnancy and the fallopian tube, which sign or symptom would alert the nurse to the possibility of tubal rupture? - amount of vaginal bleeding and discharge - falling hematocrit and hemoglobin levels - slow, bounding pulse rate of 80 bpm - marked abdominal edema

falling hematocrit and hemoglobin levels Rational: Diaphoresis, or profuse sweating, indicates shock, which occurs if the tube ruptures. Other common symptoms of tubal rupture include severe knife-like lower quadrant abdominal pain, referred shoulder pain, and falling blood pressure. The amount of vaginal bleeding that is evident is a poor estimate of actual blood loss. Slight vaginal bleeding, commonly described as spotting, is common. A rapid, thready pulse, a symptom of shock, is more common with tubal rupture than a slow, bounding pulse. Abdominal edema is a late sign of a tubal rupture in ectopic pregnancy.

What area of the chest would the nurse monitor for suprasternal retractions in an infant diagnosed with bronchiolitis?

https://www.google.com/search?q=suprasternal+retractions+in+an+infant&tbm=isch&ved=2ahUKEwi1y8Lmv6zzAhVvATQIHSMFCW4Q2-cCegQIABAA&oq=suprasternal+retractions+in+an+infant&gs_lcp=CgNpbWcQA1C3Q1i8amDXa2gBcAB4AIABPIgBqAGSAQEzmAEAoAEBqgELZ3dzLXdpei1pbWfAAQE&sclient=img&ei=8rdYYbWKIe-C0PEPo4qk8AY&bih=707&biw=897&rlz=1C5CHFA_enUS957US957 Rational: Suprasternal retractions, or retractions above the sternal area, can be noted in a child who is experiencing severe respiratory distress, secondary to airway obstruction found with bronchiolitis. The nurse should take measures to prevent worsening distress and possible respiratory failure.

The nurse is caring for a client who has a type I second-degree atrioventricular (AV) block. Which ECG rhythm would the nurse expect to see?

https://www.google.com/search?q=type+I+second-degree+atrioventricular+(AV)+block+ecg&tbm=isch&ved=2ahUKEwjXjaG2zazzAhUlAzQIHfPZDIwQ2-cCegQIABAA&oq=type+I+second-degree+atrioventricular+(AV)+block+ecg&gs_lcp=CgNpbWcQA1CkH1igI2DsJGgAcAB4AIABTIgB8AGSAQE0mAEAoAEBqgELZ3dzLXdpei1pbWfAAQE&sclient=img&ei=O8ZYYZeEGqWG0PEP87Oz4Ag&bih=707&biw=897&rlz=1C5CHFA_enUS957US957 Rational: Type I second-degree AV block is characterized by a progressively longer PR interval until a QRS complex is dropped (option D). Option A shows a type II second-degree AV block, which has a PR interval that may be prolonged but stays constant until a QRS complex is dropped. Option B shows a third-degree AV block, which has a constant PR interval and a constant interval between the QRS complexes, but there is no apparent relationship between the P waves and the QRS complexes. Option C shows a first-degree AV block, which has a consistent prolonged PR interval. No QRS complexes are dropped.

The nurse is providing the results of a community assessment to the nurse's colleagues. Which determinants of health does the nurse know is most influential on the outcomes of the postpartum families living within this community? - income and social status - education and literacy - social support networks - culture

income and social status Rational: There is strong and growing evidence that higher social and economic status is associated with better health. In fact, these two factors seem to be the most important determinants of health. The other determinants are important but not the most influential on the outcomes of health and, ultimately, postpartum health.

Short-term steroid therapy is used in clients with leukemia to - increase appetite. - alter body image. - increase platelet production. - decrease susceptibility to infection.

increase appetite. Rational: Short-term steroid therapy produces no acute toxicities, and results in increased appetite and a sense of well-being. Physical changes caused by steroid use can prompt alterations in body image that can be extremely distressing to children. Prednisone (steroid therapy) has no effect on platelet production, but may increase susceptibility to infection.

During the morning assessment, a nurse notes that a client is awake, alert, and has severe dyspnea; respirations are 34 breaths/minute and labored. Oxygen saturation is 79% on 3 L of oxygen. The nurse notes that the client's chart includes a living will. When considering best practice, the nurse should - follow the living will order and stop all treatments. - increase the oxygen flow rate to 4 L, but avoid initiating other interventions. - call the client's family and ask what they think is best. - initiate potentially life-prolonging treatment unless the client refuses.

initiate potentially life-prolonging treatment unless the client refuses. Rational: A living will doesn't go into effect unless the client is unable to make his own decisions. The nurse should give all appropriate care while also maintaining the client's right to refuse treatment. Increasing the oxygen flow rate might be an appropriate response, but it isn't the best and only action at this time. The family isn't responsible for determining care at this time.

A physician orders spironolactone, 50 mg by mouth four times daily, for a client with fluid retention caused by cirrhosis. Which finding indicates that the drug is producing a therapeutic effect? - serum potassium level of 3.5 mEq/L - loss of 2.2 lb (1 kg) in 24 hours - serum sodium level of 135 mEq/L - blood pH of 7.25

loss of 2.2 lb (1 kg) in 24 hours Rational: Daily weight measurement is the most accurate indicator of fluid status; a loss of 2.2 lb (1 kg) indicates loss of 1 L of fluid. Because spironolactone is a diuretic, weight loss is the best indicator of its effectiveness. This client's serum potassium and sodium levels are normal. A blood pH of 7.25 indicates acidosis, an adverse reaction to spironolactone.

A client in the emergency department reports that they have been vomiting excessively for the past 2 days. The client's arterial blood gas analysis shows a pH of 7.50, partial pressure of arterial carbon dioxide (PaCO2) of 43 mm Hg, partial pressure of arterial oxygen (PaO2) of 75 mm Hg, and bicarbonate (HCO3-) of 42 mEq/L. Based on these findings, the nurse documents that the client is experiencing which type of acid-base imbalance? - respiratory alkalosis - metabolic alkalosis - respiratory acidosis - metabolic acidosis

metabolic alkalosis Rational: A pH over 7.45 with a HCO3- level over 26 mEq/L indicates metabolic alkalosis. Metabolic alkalosis is always secondary to an underlying cause and is marked by decreased amounts of acid or increased amounts of base HCO3-. The client isn't experiencing respiratory alkalosis because the PaCO2 is normal. The client isn't experiencing respiratory or metabolic acidosis because the pH is greater than 7.35.

A charge nurse is completing day-shift client care assignments on the genitourinary floor. A new graduate is starting the first day on the unit. An agency nurse and an experienced nurse are also present. The charge nurse should assign the new graduate nurse to the care of which client? - client who had an ileal conduit 3 days ago - middle-aged stable client with bladder cancer awaiting surgery - middle-aged client who had a kidney transplant 3 days ago - elderly client just admitted for an acute stroke

middle-aged stable client with bladder cancer awaiting surgery Rational: The charge nurse should assign the new nurse to the middle-aged client newly diagnosed with bladder cancer awaiting surgery, as this client has a condition common to the genitourinary floor and is of low acuity and stable. The charge nurse should assign the agency nurse to the client who had an ileal conduit. That condition has lesser acuity. The charge nurse should assign the experienced nurse to the most acute clients: the middle-age kidney-transplant recipient.

Carboprost was injected into the uterus of a client to treat uterine atony during a cesarean birth. In preparing to care for this client postpartum, the nurse should assess the client for which common adverse effect of the medication? - vertigo and confusion - nausea and diarrhea - restlessness and increased vaginal bleeding - headache and hypertension

nausea and diarrhea Rational: Carboprost is an oxytocic prostaglandin that causes uterine contraction in women who are bleeding heavily. Nausea, vomiting, diarrhea, and fever are common adverse effects of prostaglandin administration. Vertigo and confusion are not associated with this drug. Carboprost may not control all cases of hemorrhage, but it does not cause bleeding. Restlessness typically is a sign of shock, not a reaction to carboprost. If too large a dose is given, the client may experience headache and hypertension because carboprost contracts smooth muscles.

During a physical examination, a nurse asks a client to hold their breath briefly, and then uses a stethoscope to auscultate over the carotid arteries. Which finding is normal when auscultating over these arteries? - no sounds over either carotid artery - faint swishing sounds over both carotid arteries - throbbing pulsations bilaterally - louder sounds over the right carotid artery than over the left carotid artery

no sounds over either carotid artery Rational: Absence of sounds over either carotid artery indicates unobstructed blood flow. Auscultation of any sounds (bruits) is abnormal and the nurse should report this finding to the physician.

A client who's actively hallucinating is brought to the hospital by friends. They tell the nurse that the client used either lysergic acid diethylamide (LSD) or angel dust (phencyclidine [PCP]) at a concert. Which common assessment finding indicates that the client may have ingested PCP? - dilated pupils - nystagmus - paranoia - altered mood

nystagmus Rational: Phencyclidine is an anesthetic with severe psychological effects. It blocks the reuptake of dopamine and directly affects the midbrain and thalamus. Nystagmus is a common physical finding of PCP use. Dilated pupils are evidence of LSD ingestion. Paranoia and altered mood occur with PCP and LSD ingestion.

A client with chronic bowel inflammation reports abdominal cramping and diarrhea for the past 4 days. The nurse would anticipate which test based on the client's concerns? - culture and sensitivity - occult blood and organisms - ova and parasites - fat and undigested food

occult blood and organisms Rational: Occult blood in the stool could indicate active bleeding; the stool should also be examined for microorganisms to detect early infections that could easily become systemic by spreading through the damaged mucosa. Culture and sensitivity is reflective for urine and potential infection. Parasite testing is not correct because this client has a chronic bowel problem. Fat and undigested food has no relation to the current problem.

Tourette syndrome is characterized by the presence of multiple motor and vocal tics. A vocal tic that involves repeating one's own sounds or words is known as: - echolalia. - palilalia. - apraxia. - aphonia.

palilalia. Rational: Palilalia is defined as the repetition of sounds and words. Echolalia is the act of repeating the words of others. Apraxia is the inability to carry out motor activities, and aphonia is the inability to speak.

A client with a UTI exhibits these vital signs; blood pressure of 90/60 mm Hg, respiratory rate of 24 breaths per minute, and heart rate 100 beats per minute. Which nursing action would be most appropriate for this client? - placing the client in modified Trendelenburg position - assisting the client to the lithotomy position - increasing the head of bed to semi-Fowler's position - assisting the client to lateral position

placing the client in modified Trendelenburg position Rational: This client has a low blood pressure and the best position would be the modified Trendelenburg to increase blood flow to the brain. Lithotomy position would be indicated for a vaginal exam, semi-Fowler's would be indicated for dyspnea, and the lateral position would be indicated for vomiting to prevent aspiration.

A nurse is giving instructions to client with a new colostomy. The client states, "I'm so tired today; I just can't think." The nurse should: - reschedule the appointment at a time when the client is rested. - give the client a written instruction sheet instead of verbal teaching. - ask the client to concentrate because the instructions are important. - give the teaching session to the spouse instead of the client.

reschedule the appointment at a time when the client is rested. Rational: The client's readiness to learn is compromised by fatigue and lack of concentration. The teaching session should be rescheduled to a better time for improved learning readiness.Written instructions or involving the spouse can supplement verbal instructions but cannot replace teaching the client directly.

Which food would be appropriate for a 12-month-old child with celiac disease? - oatmeal - pancakes - rice cereal - waffles

rice cereal Rational: The child with celiac disease should not eat foods containing wheat, oats, rye, or barley. Pancakes and waffles are made from flour that typically is derived from wheat and therefore should be avoided. Foods containing rice, such as rice cereal, or corn are appropriate. Pancakes and waffles are made from flour that typically is derived from wheat and therefore should be avoided.

A client is being treated for left lower lobe pneumonia. In what position should the nurse position the toddler to maximize oxygenation? - prone - left lateral - supine - right lateral

right lateral Rational: The client should be positioned on the right side because gravity contributes to increased blood flow to the right lung, thereby allowing for better gas exchange. Positioning the client prone, supine, or in the left lateral position doesn't allow for better gas exchange in this client.

A nurse is caring for a client who has left homonymous hemianopsia following a recent cerebral vascular accident (CVA). Which nursing diagnosis should take the highest priority? - risk for injury - impaired physical mobility - activity intolerance - impaired verbal communication

risk for injury Rational: Left homonymous hemianopsia causes loss of vision in half of the right visual field so clients cannot see past the midline without turning the head to that side, leaving the client at risk for injury. The client who has had a stroke may have impaired physical mobility, activity intolerance, and impaired verbal communication but these are not the priority according to Maslow's hierarchy of needs.

The nurse assigns an unlicensed assistive personnel (UAP) to provide care for a client with peptic ulcer disease. Concerned about possible ulcer perforation, the nurse should instruct the UAP to report to the nurse immediately if the client has: - an elevated pulse. - confusion. - severe abdominal pain. - constipation.

severe abdominal pain. Rational: A sign of ulcer perforation is the onset of sudden, severe abdominal pain. The nurse should instruct all unlicensed assistive personnel to report this symptom immediately because a perforated ulcer is a medical emergency.An elevated pulse and confusion may occur for various reasons; the assistant should report all vital signs, but the severe pain must be brought to the nurse's attention immediately.Constipation will not require immediate intervention.

A parent brings in a school-age child to the clinic for treatment. The child is small in stature, but body parts are in proportion. Which pharmacological treatments does the nurse anticipate instructing the parent about? - synthetic adrenocorticotropic hormone - somatrem - desmopressin - vasopressin

somatrem Rational: Somatrem is used to treat linear growth failure stemming from hormonal deficiency. A child who is short in stature characterizes pituitary dwarfism but body parts are in proportion. Synthetic ACTH is used to treat adrenal insufficiency and a variety of other conditions. Desmopressin acetate and vasopressin are used to treat diabetes insipidus.

A client in the second stage of labor has had no anesthesia or analgesia. The nurse should assist the client into which position so the client can begin pushing? - squatting with the body curved in a C shape - side-lying while keeping the head elevated - in the knee-chest position while keeping the head down - squatting with the back arched

squatting with the body curved in a C shape Rational: Anatomically, the squatting position enlarges the pelvic outlet and uses the force of gravity during pushing. The mother should curve her body into a C shape for the greatest effectiveness.

The nurse has responsibility for several clients. Based on the information provided, which of these clients would be a priority for the nurse to evaluate when assuming responsibility for their care at the beginning of the evening shift? - the 70-year-old client who had a total laryngectomy the previous day - the 40-year-old client with diabetes who had a fasting blood sugar of 110 mg/dL (6.1 mmol/L) - an elderly client who has Alzheimer's disease and periods of confusion - a 20-year-old with a spontaneous pneumothorax who had a chest tube inserted earlier in the day whose vital signs are stable

the 70-year-old client who had a total laryngectomy the previous day Rational: Based on the information provided, the client who is on day 1 after a total laryngectomy would be the priority client for the nurse to evaluate. This client is at risk for swelling or pressure on the trachea and should be monitored closely. Clients with acute conditions that can affect their respiratory status are a high priority for nursing care.The client with diabetes has a normal fasting blood sugar and will not require immediate intervention.The client with Alzheimer's disease is not in immediate danger and, therefore, does not require immediate evaluation.There is no evidence that the client with pneumothorax is in immediate need of evaluation.

When the client tells the nurse that they believes that God's reality is personal and that God is the creator of all beings, the nurse determines the client is expressing - faith. - agnosticism. - atheism. - theism.

theism. Rational: Theism is the belief that God's reality is personal, without a body, perfect in all things, and creator and sustainer of the universe.

Following an incisional approach to an abdominal hysterectomy, the nurse should assess the client for: - thrombophlebitis. - ascites. - peripheral edema. - hypostatic pneumonia.

thrombophlebitis. Rational: Clients who have had major pelvic surgery are especially at risk for developing thrombophlebitis postoperatively. Extensive manipulation of the pelvic organs and removal of lymph glands can lead to edema, stasis, and circulatory congestion.Ascites, peripheral edema, and hypostatic pneumonia are not complications that would be specifically anticipated after pelvic surgery.

A client at risk for lung cancer asks about the reason for having a computed tomography (CT) scan as part of the initial exam. What is the nurse's best response? "A CT scan is: - far superior to magnetic resonance imaging for evaluating lymph node metastasis." - noninvasive and readily available." - useful for distinguishing small differences in tissue density and detecting nodal involvement." - used to distinguish a malignant from a nonmalignant adenopathy."

useful for distinguishing small differences in tissue density and detecting nodal involvement." Rational: CT scanning is the standard noninvasive method used in a workup for lung cancer because it can distinguish small differences in tissue density and can detect nodal involvement. CT is comparable to magnetic resonance imaging in evaluating lymph node metastasis. CT is noninvasive and usually available, but these are not the main reasons for its use. CT can distinguish malignancy in some situations only.