NCLEX PN prep

The medication prescribed is hydromorphone hydrochloride 3 mg intramuscularly, every 4 hours as needed. The medication label reads hydromorphone hydrochloride 4 mg/1 mL. The nurse should prepare to administer how many mL to the client?

0.75mL

A primipara is being evaluated in the clinic during her second trimester of pregnancy. Which occurrence indicates an abnormal physical finding that necessitates further testing? 1. Quickening 2. Braxton Hicks contractions 3. Consistent increase in fundal height 4. Fetal heart rate of 180 beats per minute

4; Rationale: The fetal heart rate depends on the gestational age. It is 160 to 170 beats per minute during the first trimester, and it slows with fetal growth to approximately 120 to 160 beats per minute. Options 1, 2, and 3 are normal expected findings.

The primary health care provider's (PHCP's) prescription reads acetaminophen 240 mg orally every 6 hours as needed for relief of pain, for a 5-year-old child. The medication label reads "acetaminophen 160 mg per 5 mL." How many mL per dose should the nurse administer to the child?

7.5

The client with acute myelocytic leukemia is being treated with busulfan. Which laboratory value should the nurse specifically monitor during treatment with this medication? 1. Clotting time 2. Uric acid level 3. Potassium level 4. Blood glucose level

2; Rationale: Busulfan can cause an increase in the uric acid level because of massive cell death of malignant cells. Hyperuricemia can produce uric acid nephropathy, renal stones, and acute kidney injury. Clotting time, potassium, and glucose blood levels are not specifically related to this medication.

The nurse is reinforcing instructions to a new mother about cord care and how to monitor for the presence of an infection. The nurse should tell the mother that which is a sign of infection? 1. A darkened drying stump 2. A moist cord with discharge 3. A purple stump that shows pinkness around the base 4. A purple stump that shows some moistness at the base

2; Rationale: Signs of infection of the umbilical cord are moistness, oozing, discharge, and a reddened base. If signs of infection occur, the primary health care provider is notified. Antibiotic treatment may be necessary.

The nurse is assigned to assist with caring for a client who is at risk for eclampsia. If the client progresses from preeclampsia to eclampsia, the nurse should take which action first? 1. Administer oxygen by face mask. 2. Clear and maintain an open airway. 3. Check the blood pressure and the fetal heart tones. 4. Prepare for the administration of intravenous magnesium sulfate.

2; Rationale: The first actions are to maintain an open airway and to prevent injuries to the client. The client should be turned to the side and monitored for airway compromise. Options 1, 3, and 4 may be components of care, but they are not the first actions.

The nurse reviews the record of an infant who is seen in the clinic. The nurse notes that a diagnosis of esophageal atresia with tracheoesophageal fistula (TEF) is suspected. The nurse expects to note which most likely manifestation of this condition in the medical record? 1. Incessant crying 2. Coughing at nighttime 3. Choking with feedings 4. Severe projectile vomiting

3 Rationale: Any child who exhibits the "3 C's"—coughing and choking during feedings and unexplained cyanosis—should be suspected of having TEF. Options 1, 2, and 4 are not specifically associated with TEF.

The nurse assists with admitting a child with a diagnosis of acute stage Kawasaki disease. When obtaining the child's medical history, which manifestation is likely to be noted? 1. Cracked lips 2. A normal appearance 3. Conjunctival hyperemia 4. Desquamation of the skin

3 Rationale: During the acute stage of Kawasaki disease, the child presents with fever, conjunctival hyperemia, a red throat, swollen hands, a rash, and enlargement of the cervical lymph nodes. During the subacute stage, cracking lips and fissures, desquamation of the skin on the tips of the fingers and toes, joint pain, cardiac manifestations, and thrombocytosis occur. During the convalescent stage, the child appears normal, but signs of inflammation may be present.

The nurse is monitoring a client who is receiving oxytocin to induce labor. Which assessment findings should cause the nurse to immediately discontinue the oxytocin infusion? Select all that apply. 21. Fatigue 2. Drowsiness 3. Uterine hyperstimulation 4. Late decelerations of the fetal heart rate 5. Early decelerations of the fetal heart rate

3, 4; Rationale: High-dose protocols have been associated with more uterine hyperstimulation and more cesarean births related to fetal stress. Late decelerations, a nonreassuring fetal heart rate pattern, is an ominous sign indicating fetal distress. Oxytocin infusion must be stopped when any signs of uterine hyperstimulation are present. Drowsiness and fatigue may be caused by the labor experience

Which client is most likely at risk to become a victim of elder abuse? 1. A 75-year-old man with moderate hypertension 2. A 68-year-old man with newly diagnosed cataracts 3. A 90-year-old woman with advanced Alzheimer's disease 4. A 70-year-old woman with early diagnosed Lyme disease

3; Rationale: Elder abuse is widespread and occurs among all subgroups of the population. It includes physical and psychological abuse, the misuse of property, and the violation of rights. The person at highest risk of abuse is an elder with dementia that occurs with Alzheimer's disease

After birth the nurse prevents hypothermia as a result of evaporation by performing which action? 1. Warming the crib pad 2. Closing the doors of the room 3. Drying the baby with a warm blanket 4. Turning on the overhead radiant warmer

3; Rationale: Evaporation occurs when moisture from the newborn's wet body surface dissipates heat along with moisture. By keeping the newborn dry (and by drying the wet newborn at birth), evaporation is prevented. Conduction occurs when the newborn is on a cold surface, such as a cold pad or mattress. Convection occurs as air moves across the newborn's skin from an open door and heat is transferred to the air. Radiation occurs when heat from the newborn radiates to a colder surface.

The nurse is monitoring a client with mild gestational hypertension (GH). Which data indicate that GH is a concern? 1. Urinary output has increased. 2. There is no evidence of proteinuria. 3. The client complains of a headache and blurred vision. 4. The blood pressure reading has returned to the prenatal baseline.

3; Rationale: Options 1, 2, and 4 are all signs that gestational hypertension is not present. Option 3 is a symptom of the worsening of the gestational hypertension and is a concern that needs to be reported.

209. The nurse is collecting data from a client who is pregnant with triplets. The client also has a 3-year-old child who was born at 39 weeks' gestation. The nurse should document which gravida and para status on this client? 1. Gravida I, para I 2. Gravida II, para I 3. Gravida II, para II 4. Gravida III, para II

2; Rationale: Gravida is a term that refers to a woman who is or who has been pregnant, regardless of the duration of the pregnancy. Parity is a term that means the number of births after 20 weeks' gestation; it does not reflect the number of fetuses or infants. Options 1, 3, and 4 are incorrect on the basis of these definitions.

The nursing instructor asks a nursing student about phenylketonuria (PKU). Which statement made by th e student indicates a need for further teaching? 1. "PKU is an autosomal-recessive disorder." 2. "PKU primarily affects the gastrointestinal system." 3. "Treatment of PKU includes the dietary restriction of phenylalanine." 4. "All 50 states require routine screening of all newborns for PKU."

2; Rationale: PKU is a genetic disorder that results in CNS damage from toxic levels of phenylalanine in the blood, not the gastrointestinal system. PKU is an autosomal-recessive disorder and treatment includes the dietary restriction of phenylalanine intake. All 50 states require screening newborns for PKU.

The nurse is reviewing the record of a child with increased intracranial pressure and notes that the child has exhibited signs of decerebrate posturing. During data collection about the child, the nurse expects to note which characteristic of this type of posturing? 1. Flaccid paralysis of all extremities 2. Adduction of the arms at the shoulders 3. Rigid extension and pronation of the arms and legs 4. Abnormal flexion of the upper extremities and extension and adduction of the lower extremities

3 Rationale: Decerebrate (extension) posturing is characterized by the rigid extension and pronation of the arms and legs. Option 1 is incorrect. Options 2 and 4 describe decorticate (flexion) posturing.

The nurse, employed in a long-term care facility, is planning the clinical assignments for the day. The nurse knows not to assign which staff member to the client with a diagnosis of herpes zoster? 1. A staff member who has never had roseola 2. A staff member who has never had mumps 3. An unlicensed assistive personnel who has never had chickenpox 4. An unlicensed assistive personnel who has never had German measles

3 Rationale: Herpes zoster is caused by a reactivation of the varicella zoster virus, which is the causative virus of chickenpox. Individuals who have not been exposed to the varicella zoster virus are susceptible to chickenpox. Options 1, 2, and 4 are not associated with the herpes zoster virus.

The nurse is preparing to administer an intermittent tube feeding to a client. The nurse aspirates 90 mL of residual from the tube. What should the nurse do? Select all that apply 1. Hold the feeding. 2. Document the amount of residual. 3. Place it into a container for laboratory analysis. 4. Reinstill the residual and administer the feeding. 5. Deduct the amount of the residual from the new feeding before administering.

2, 4, Rationale: Unless otherwise instructed or if the residual contents appear abnormal, an amount of less than 100 mL is reinstilled; then a normal amount of prescribed tube feeding is administered. The amount of residual should be documented. It is important to return the contents to the stomach to prevent electrolyte imbalances. The feeding is not held, and the residual is not sent to the laboratory. The tube feeding should continue at the prescribed rate.

When the nurse is collecting data from the older adult, which findings should be considered normal physiological changes? Select all that apply. 1. Increased heart rate 2. Decline in visual acuity 3. Decreased respiratory rate 4. Decline in long-term memory 5. Increased susceptibility to urinary tract infections 6. Increased incidence of awakening after sleep onset

2, 5, 6 Rationale: Anatomical changes to the eye affect the individual's visual ability, which leads to potential problems with activities of daily living. Light adaptation and visual fields are reduced. Respiratory rates are usually unchanged. The heart rate decreases, and the heart valves thicken. Age-related changes that affect the urinary tract increase an older client's susceptibility to urinary tract infections. Short-term memory may decline with age, but long-term memory is usually maintained. Changes in sleep patterns are consistent, age-related changes. Older persons experience an increased incidence of awakening after sleep onset

The nurse is reviewing the health care record of a client with a lesion that has been diagnosed as basal cell carcinoma. The nurse should expect which characteristics of this type of lesion to be documented in the client's record? Select all that apply. 1. Lesion has a waxy border 2. An irregularly shaped lesion 3. Papule, with a red, central crater 4. A small papule with a dry, rough scale 5. A firm nodular lesion topped with a crust

1, 2 Rationale: Basal cell carcinoma appears as a pearly papule with a central crater and a rolled, waxy border. A melanoma is an irregularly shaped pigmented papule or plaque with a red, white, or blue color. Squamous cell carcinoma is a firm nodular lesion that is topped with a crust or a central area of ulceration. Actinic keratosis, which is a premalignant lesion, appears as a small macule or papule with a dry, rough, adherent yellow or brown scale

The medication is an intramuscular dose of 400,000 units of penicillin G benzathine. The medication label reads penicillin G benzathine 300,000 units/mL. The nurse prepares how much medication to administer the correct dose?

1.3mL

The medication prescribed is methylprednisolone acetate 60 mg intramuscularly. The medication label states methylprednisolone acetate 40 mg/1 mL. How many milliliters will the nurse prepare to administer to the client?

1.5mL

Salicylic acid is prescribed for a client with a diagnosis of psoriasis. The nurse monitors the client, knowing that which finding indicates the presence of systemic toxicity from this medication? 1. Tinnitus 2. Diarrhea 3. Constipation 4. Decreased respirations

1; Rationale: Salicylic acid is absorbed readily through the skin and systemic toxicity (salicylism) can result. Symptoms include tinnitus, dizziness, hyperpnea, and psychological disturbances. Constipation and diarrhea are not associated with salicylism.

A 4-year-old child is hospitalized with a suspected diagnosis of Wilms' tumor. The nurse reviews the plan of care and should question which intervention that is written in the plan? 1. Palpate the abdomen for a mass. 2. Check the urine for the presence of hematuria. 3. Monitor the blood pressure for the presence of hypertension. 4. Monitor the temperature for the presence of a kidney infection

1; Rationale: Wilms' tumor is an intraabdominal and kidney tumor. If Wilms' tumor is suspected, the mass should not be palpated. Excessive manipulation can cause seeding of the tumor and thus cause the spread of the cancerous cells. Hematuria, hypertension, and fever are signs and symptoms that are associated with Wilms' tumor.

9. The nurse is caring for a client following a craniotomy in which a large tumor was removed from the left side. In which position can the nurse safely place the client? 1.head of the bed elevated 30 degrees 2. A flat position 3.Trendelenburg's position

1;Rationale: Clients who have undergone craniotomy should have the head of the bed elevated 30 degrees to promote venous drainage from the head. The client is positioned to avoid extreme hip or neck flexion and the head is maintained in a midline, neutral position. If a large tumor has been removed, the client should be placed on the nonoperative side to prevent displacement of the cranial contents. A flat position or Trendelenburg's position would increase intracranial pressure. A reverse Trendelenburg's position would not be helpful and may be uncomfortable for the client.

The nurse reviews a client's electrolyte results and notes a potassium level of 5.5 mEq/L (5.5 mmol/L). The nurse understands that a potassium value at this level would be noted with which condition? 1. Diarrhea 2. Traumatic burn 3. Cushing's syndrome 4. Overuse of laxatives

2 Rationale: A serum potassium level that exceeds 5.0 mEq/L (5.0 mmol/L) is indicative of hyperkalemia. Clients who experience the cellular shifting of potassium, as in the early stages of massive cell destruction (i.e., with trauma, burns, sepsis, or metabolic or respiratory acidosis), are at risk for hyperkalemia. The client with Cushing's syndrome or diarrhea and the client who has been overusing laxatives are at risk for hypokalemia.

The nurse is reviewing the record of a child with a diagnosis of pyloric stenosis. Which data should the nurse expect to note as having been documented in the child's record? 1. Watery diarrhea 2. Projectile vomiting 3. Increased urine output 4. Vomiting large amounts of bile

2 Rationale: Signs and symptoms of pyloric stenosis include projectile, nonbilious vomiting; irritability; hunger and crying; constipation; and signs of dehydration, including a decrease in urine output.

The nursing instructor asks a nursing student about sudden infant death syndrome (SIDS). Which statement by the student indicates further teaching is needed? 1. "Some of the interventions that are used to prevent SIDS include having infants sleep in the supine position." 2. "The incidence of SIDS has been found to be higher in breastfed infants and infants that use a pacifier." 3. "Infants exposed to cigarette smoking during pregnancy and after birth are considered at risk for SIDS." 4. "SIDS refers to sudden infant death syndrome that can occur in healthy infants under 1 year of age, and no exact cause is known."

2 Rationale: The incidence of SIDS has been found to be lower in breastfed infants and infants who sleep with a pacifier. Options 1, 3 and 4 are correct.

The nurse is assisting with the insertion of a nasogastric tube into a client. The nurse should place the client in which position for insertion? 1. Right side 2. Low Fowler's position 3. High Fowler's position 4. Supine, with the head flat

3; Rationale: Before insertion of a nasogastric tube the nurse places the client in a sitting or high Fowler's position to reduce the risk of pulmonary aspiration if the client should vomit. A pillow may be placed behind the head and shoulders to promote the client's ability to swallow during procedure. Options 1, 2, and 4 do not facilitate the insertion of the tube or prevent aspiration.

During a prenatal visit, the nurse checks the fetal heart rate of a client in the third trimester of pregnancy. The nurse determines that the FHR is normal if which heart rate is noted? 1. 80 beats per minute 2. 100 beats per minute 3. 150 beats per minute 4. 180 beats per minute

3; Rationale: Fetal heart rate depends on gestational age. It is normally 160 to 170 beats per minute during the first trimester, but it slows with fetal growth to 110 to 160 beats per minute near or at term.

Which intervention should be implemented for the older client with presbycusis who has a hearing loss? 1. Speak louder 2. Speak more slowly 3. Use low-pitched tones 4. Use high-pitched tones

3; Rationale: Presbycusis refers to the age-related, irreversible, degenerative changes of the inner ear that lead to decreased hearing acuity. As a result of these changes, the older client has a decreased response to high-frequency sounds. Low-pitched tones of voice are more easily heard and interpreted by the older client. Speaking loudly, softly, or slowly is not helpful.

The nurse has provided instructions to the mother of an infant with viral pneumonia. Which statement by the mother would indicate the need for further teaching? 1. "I understand I will need to have my baby on antibiotics for this pneumonia." 2. "I will need to give a cough suppressant before meals if his cough gets too bad." 3. "I will be careful and allow my baby to sleep, so he can conserve energy and fight this infection." 4. "I understand that my baby has viral pneumonia and I need to monitor his temperature because of the risk for febrile seizures."

1 Rationale: The child with viral pneumonia will not be prescribed antibiotics, it is bacterial pneumonia that requires antibiotics for treatment. It is important to monitor the infant for fever spikes because of the risk for febrile seizures. Use of a cough suppressant may be prescribed before rest times and meals if the cough is disturbing and unproductive. Promoting bed rest to conserve energy, encouraging fluid intake and the administration of antipyretics for fever, and bronchodilators are typical interventions for pneumonia

The nurse is monitoring a client who has been newly diagnosed with diabetes mellitus for signs of complications. Which statement made by the client would indicate hyperglycemia and thus warrant primary health care provider (PHCP) notification? 1. "I am urinating a lot." 2. "My pulse is really slow." 3. "I am sweating for no reason." 4. "My blood pressure is really high."

1 Rationale: The classic symptoms of hyperglycemia include polydipsia, polyuria, and polyphagia. Options 2, 3, and 4 are not signs of hyperglycemia.

The nurse provides homecare instructions to the parent of a child with attention deficit hyperactivity disorder regarding behavioral therapy interventions. Which statement by the parent indicates a need for further teaching? 1. "I hear that the side effects of the medication that my child will be on can cause overeating." 2. "I know that consistent medication and regular follow-up visits are a part of the plan for my child." 3. "I know I need to maintain a consistent home environment because my child is easily distracted." 4. "I understand that I will need to learn some behavioral modification techniques to help my child's impulsivity."

1 Rationale: The treatment plan for children with attention deficit hyperactivity disorder includes stimulant medications that may have the adverse effect of appetite suppression and weight loss, not overeating. Treatment for these children includes behavioral therapy, maintaining a consistent environment, and appropriate classroom placement. Regular medication administration and regular follow-up visits are also important instructions for the parents.

The nurse is reinforcing teaching for a client regarding how to mix regular insulin and NPH insulin in the same syringe. Which action performed by the client indicates the need for further teaching? 1. Withdraws the NPH insulin first 2. Withdraws the regular insulin first 3. Injects air into NPH insulin vial first 4. Injects an amount of air equal to the desired dose of insulin into the vial

1 Rationale: When preparing a mixture of regular insulin with another insulin preparation, the regular insulin is drawn into the syringe first. This sequence will avoid contaminating the vial of regular insulin with insulin of another type. Options 2, 3, and 4 identify the correct actions for preparing NPH and regular insulin.

The nurse is preparing for the admission of an infant with a diagnosis of bronchiolitis caused by the respiratory syncytial virus (RSV). Which interventions should be included in the plan of care? Select all that apply. 1. Place the infant in a private room. 2. Place the infant in a room near the nurses' station. 3. Ensure that the infant's head is in a flexed position. 4. Wear a mask at all times when in contact with the infant. 5. Place the child in a tent that delivers warm, humidified air. 6. Position the infant side-lying, with the head lower than the chest.

1, 2 Rationale: The infant with RSV should be isolated in a private room or in a room with another child with RSV. The infant should be placed in a room near the nurses' station for close observation. The infant should be positioned with the head and chest at a 30- to 40-degree angle and the neck slightly extended to maintain an open airway and to decrease pressure on the diaphragm. Cool, humidified oxygen is delivered to relieve dyspnea, hypoxemia, and insensible water loss from tachypnea. Contact precautions (wearing gloves and a gown) reduce the nosocomial transmission of RSV.

The nurse is caring for a postoperative client who has a Jackson-Pratt drain inserted into the surgical wound. Which actions should the nurse take in the care of the drain? Select all that apply. 1. Check the drain for patency. 2. Check that the drain is decompressed. 3. Observe for bright red, bloody drainage. 4. Maintain aseptic technique when emptying. 5. Empty the drain when it is half full and every 8 to 12 hours. 6. Secure the drain by curling or folding it and taping it firmly to the body.

1, 2, 3, 4, 5; Rationale: A drain is a tube that is placed to drain out fluid and blood near the surgical site and could lead to infection. The tube is connected to a bulb, which is compressed to create a vacuum and pull out the fluid. The nurse should check for patency and that fluid is being pulled out. The bulb should be, and look, decompressed in order to create the vacuum. The drainage usually is dark red as a result of blood content, but may be pale yellow with serous fluid. Aseptic technique must be used when emptying the drainage container to avoid contamination of the wound. The bulb of the drain should be emptied when it is half full and at least every 8 to 12 hours. The amount of drainage is documented in the client medical record under intake and output. Curling or folding the drain prevents the flow of the drainage.

The nurse is preparing a list of self-care instructions for a postpartum client who has been diagnosed with mastitis. Which instructions should be included on the list? Select all that apply. 1. Rest during the acute phase. 2. Wear a supportive, nonunderwire bra. 3. Maintain a fluid intake of at least 3000 mL. 4. Continue to breastfeed if the breasts are not too sore. 5. Take prescribed antibiotics until the soreness subsides. 6. Avoid decompression of the breasts by breastfeeding or breast pumping.

1, 2, 3, 4; Rationale: Mastitis is an infection of the lactating breast. Client instructions include resting during the acute phase, wearing a supportive nonunderwire bra, maintaining a fluid intake of at least 3000 mL per day, and taking analgesics to relieve discomfort. Antibiotics may be prescribed and are taken until the complete prescribed course is finished. They are not stopped when the soreness subsides. Additional supportive measures include the use of moist heat or ice packs. Continued decompression of the breast is important to prevent the formation of an abscess.

The nurse is assisting with planning care for a client with an internal radiation implant. Which should be included in the plan of care? Select all that apply. 1. Wearing gloves when emptying the client's bedpan 2. Keeping all linens in the room until the implant is removed 3. Wearing a film (dosimeter) badge when in the client's room 4. Wearing a lead apron when providing direct care to the client 5. Placing the client in a semiprivate room at the end of the hallway

1, 2, 3, 4; Rationale: The nurse should follow standard precautions when caring for any client and wear gloves when emptying a bedpan. Linens are kept in the room as a safety precaution in case there is contamination or part of the implant is lost. The film badge dosimeter allows the nurse to visualize the estimated amount of radiation exposure during the shift. The nurse wears a lead apron to protect oneself and block the radiation waves emitted when close to the client. A private room with a private bath is essential if a client has an internal radiation implant. This is necessary to prevent the accidental exposure of other clients to radiation.

The mother of a child with Marfan syndrome asks the nurse what can be done to help her child. Which are the best responses by the nurse? Select all that apply. 1. "You may need to consider surgery in the future." 2. "You will need to make regular pediatric appointments for your child." 3. "You will need to keep your child indoors and avoid sports." 4. "You will need to make regular eye examination appointments for your child." 5. "You will need to have your child take cardiac medication(s) to decrease stress on the aorta." 6. "You will need to let the dentist know that antibiotics should be given before any procedure."

1, 2, 4, 5, 6 Rationale: Parents of the child with Marfan syndrome should be instructed to monitor for vision problems and get regular eye examinations, avoid participation in contact sports, but it is not necessary to stay indoors. Monitor the curvature of the spine as the child grows, anticipate that antibiotics should be taken before any dental procedure to prevent endocarditis, cardiac medications to decrease stress on the aorta, and surgical replacement of the aortic root and valve may be necessary. Making regular pediatric appointments is important for monitoring the child.

A child is admitted to the hospital with a probable diagnosis of nephrotic syndrome. Which findings should the nurse expect to observe? Select all that apply. 1. Ascites 2. Anorexia 3. Weight loss 4. Proteinuria 5. Decreased serum lipids 6. Periorbital and facial edema

1, 2, 4, 6 Rationale: Nephrotic syndrome is a kidney disorder that is characterized by massive proteinuria, hypoalbuminemia, periorbital and facial edema, ascites, elevated serum lipids, and anorexia. The urine volume is decreased and the urine is dark and frothy in appearance. The child with this condition gains weight.

A client is being prepared for a thoracentesis. The nurse reinforces instructions with the client given by the registered nurse. Which points should be included in the instructions? Select all that apply. 1. The client leans over a bedside table. 2. The client should sit on the edge of the bed. 3. The procedure involves obtaining a biopsy. 4. A time-out is performed before the procedure. 5. The procedure is performed during a bronchoscopy. 6. A local anesthetic is administered before the procedure.

1, 2, 4, 6; Rationale: A thoracentesis is a procedure in which fluid is removed from the pleural space. The procedure involves insertion of a needle percutaneously and then removal of the fluid by connecting the needle to a vacuum bottle. Before the thoracentesis, the nurse needs to check for allergies because a local anesthetic is administered. A time-out is performed in which the client identification, coagulation studies, and area of the pleural effusion is verified. A chest x-ray is performed after the procedure. A potential complication is a pneumothorax. The client sits on the bedside and leans over a bedside table, which exposes the area between the ribs. A lung biopsy is often done during a bronchoscopy.

The nurse is assisting with conducting a health-promotion program to community members regarding testicular cancer. The nurse determines that further teaching is needed if a community member states that which is a sign/symptom of testicular cancer? Select all that apply 1. Alopecia 2. Back pain 3. Painless testicular swelling 4. A heavy sensation in the scrotum 5. Elevation in prostate specific antigen (PSA) levels

1, 5; Rationale: Alopecia is not a sign/symptom of testicular cancer. However, it may occur as a result of radiation or chemotherapy. Elevated PSA levels are associated with prostate cancer. Testicular swelling without pain and a feeling of heaviness in the scrotum occur with testicular cancer as a result of the tumor growing. Back pain may indicate metastasis to the retroperitoneal lymph nodes.

The nurse is planning to feed an older client who is at risk for aspiration of food. During the meal how should the nurse position the client? 1. Upright in a chair 2. On the left side in bed 3. On the right side in bed 4. In a low-Fowler's position, with the legs elevated

1; Rationale: It is preferable to get clients out of bed and sitting in a chair for meals. This position facilitates chewing and swallowing and prevents the reflux of stomach contents and aspiration. The other options do not identify positions that will reduce the risk of aspiration.

The nurse is monitoring for signs of dehydration in a 1-year-old child who has been hospitalized for diarrhea and prepares to take the child's temperature. Which method of temperature measurement should be avoided? 1. Rectal 2. Axillary 3. Electronic 4. Tympanic

1; Rationale: Rectal temperature measurements should be avoided if diarrhea is present. The use of a rectal thermometer can stimulate peristalsis and cause more diarrhea. Axillary or tympanic measurements of temperature would be acceptable. Most measurements are performed via electronic devices.

The nurse is preparing to communicate with an older client who is hearing impaired. Which intervention should be implemented initially? 1. Stand in front of the client. 2. Exaggerate lip movements. 3. Obtain a sign-language interpreter. 4. Pantomime and write the client notes.

1; Rationale: The nurse should ensure that the hearing-impaired client can see the nurse when the nurse is speaking by providing adequate lighting and standing in front of the client. The nurse should enunciate words clearly, but not exaggerate lip movements. If the client is profoundly hearing impaired and uses signing, a sign-language interpreter should be obtained. If a client cannot understand by reading lips, the nurse should try using gestures, pantomiming, or writing notes.

A client is admitted to the emergency department, and a diagnosis of myxedema coma is made. Which action should the nurse prepare to carry out initially? 1. Warm the client. 2. Maintain a patent airway. 3. Monitor intravenous fluids. 4. Administer thyroid hormone.

2 Rationale: The initial nursing action would be to maintain a patent airway. Oxygen would be administered, followed by fluid replacement. The nurse would also keep the client warm, monitor intravenous fluids, and administer thyroid hormones.

The nurse is caring for an 18-month-old child who has been vomiting. Which is the appropriate position to place the child during naps and sleep time? 1. A supine position 2. A side-lying position 3. Prone, with the head elevated 4. Prone, with the face turned to the side

2 Rationale: The vomiting child should be placed in an upright or side-lying position to prevent aspiration. Options 1, 3, and 4 will place the child at risk for aspiration if vomiting occurs.

The medication prescribed is zidovudine, 0.2 g orally, three times daily. The medication label states zidovudine, 100-mg tablets. The nurse prepares to administer how many tablets for one dose?

2 tablets

When reinforcing dietary instructions to a client with irritable bowel syndrome whose primary symptom is alternating constipation and diarrhea, the nurse would tell the client that which foods are best to include in the diet for this disorder? Select all that apply. 1. Beans 2. Apples 3. Cabbage 4. Brussels sprouts 5. Whole-grain bread

2, Apples 5. Whole-grain bread Rationale: A high-fiber, high-residue diet is used for constipation, irritable bowel syndrome when the primary symptom is alternating constipation and diarrhea, and asymptomatic diverticular disease. High-fiber foods include fruits and vegetables and whole-grain products. Gas-forming foods such as beans, cabbage, and Brussels sprouts should be limited.

Methylergonovine is prescribed for a woman to treat postpartum hemorrhage. Before administration of methylergonovine, what is the priority nursing assessment? 1. Uterine tone 2. Blood pressure 3. Amount of lochia 4. Deep tendon reflexes

2; Rationale: Methylergonovine, an ergot alkaloid, is used to prevent or control postpartum hemorrhage by contracting the uterus. Methylergonovine causes continuous uterine contractions and may elevate the blood pressure. A priority assessment before the administration of the medication is to check the blood pressure. The HCP should be notified if hypertension is present. Although options 1, 3, and 4 may be components of the postpartum assessment, the correct option, blood pressure, is related specifically to the administration of this medication.

The client arrives at the prenatal clinic for her first prenatal assessment. The client tells the nurse that the first day of her last menstrual period (LMP) was October 20, 2019. Using Nägele's rule, the nurse determines the estimated date of birth is which date? 1. July 12, 2020 2. July 27, 2020 3. August 12, 2020 4. August 27, 2020

2; Rationale: The accurate use of Nägele's rule requires that the woman have a regular 28-day menstrual cycle. Subtract 3 months from the first day of the last menstrual period, add 7 days, and then adjust the year as appropriate. In this case, the first day of the LMP was October 20, 2019. When you subtract 3 months, you get July 20, 2019. If you add 7 days, you get July 27, 2019. Add 1 year to this, and you get the estimated date of birth: July 27, 2020.

The nurse is reinforcing discharge instructions to the parent of a 2-year-old child who has had an orchiopexy to correct cryptorchidism. Which statement by the parent indicates a need for further teaching? 1. "I'll check his temperature." 2. "I'll give him medication so he'll be comfortable." 3. "I'll let him decide when to return to his play activities." 4. "I'll check his voiding to be sure there are no problems."

3 Rationale: All vigorous activities should be restricted for 2 weeks after surgery to promote healing and prevent injury. This will prevent dislodging of the suture, which is internal. Normally, 2-year-old children will want to be very active. Therefore, allowing the child to decide when to return to his play activities may prevent healing and cause injury. The parents should be taught to monitor the child's temperature; provide analgesics, as needed; and monitor the urine output.

The nurse reinforces instructions to the mother about dietary measures for a 5-year-old child with lactose intolerance. The nurse should tell the mother that which supplement will be required as a result of the need to avoid lactose in the diet? 1. Fats and vitamin A 2. Zinc and vitamin C 3. Calcium and vitamin D 4. Thiamine and vitamin B

3 Rationale: Lactose intolerance is the inability to tolerate lactose, the sugar that is found in dairy products. Removing milk from the diet can provide relief from symptoms. Additional dietary changes may be required to provide adequate sources of calcium and vitamin D

A mother calls a neighborhood nurse and tells the nurse that her 3-year-old child has just ingested liquid furniture polish. Which action should the nurse instruct the mother to take first? 1. Induce vomiting. 2. Call an ambulance. 3. Call the poison control center. 4. Bring the child to the emergency department.

3; Rationale: If a suspected poisoning occurs, the poison control center should be contacted immediately. The nurse can assist the mother with contacting the poison control center. Vomiting should not be induced without instructions from the poison control center. Inducing vomiting is not done if the client is unconscious or the substance ingested is a strong corrosive or petroleum product. Bringing the child to the emergency department or calling an ambulance would delay treatment. The poison control center may advise the mother to bring the child to the emergency department; if this is the case, the mother should call an ambulance.

The mother of a 6-year-old child who has type 1 diabetes mellitus calls a clinic nurse and tells the nurse that the child has been sick. The mother reports that she checked the child's urine and it was positive for ketones. The nurse should instruct the mother to take which action? 1. Hold the next dose of insulin. 2. Come to the clinic immediately. 3. Encourage the child to drink liquids. 4. Administer an additional dose of regular insulin.

3; Rationale: When the child is sick, the mother should test for urinary ketones with each voiding. If ketones are present, liquids are essential to aid in clearing the ketones. The child should be encouraged to drink liquids. Bringing the child to the clinic immediately is unnecessary. Insulin doses should not be adjusted or changed.

A 16-year-old child is admitted to the hospital for acute appendicitis, and an appendectomy is performed. Which intervention is most appropriate to facilitate normal growth and development? 1. Encourage the child to rest and read. 2. Encourage the parents to room-in with the child. 3. Allow the family to bring in favorite computer games. 4. Allow the child to participate in activities with other individuals in the same age group when the condition permits.

4; Rationale: Adolescents are not often sure they want their parents with them when they are hospitalized. Because of the importance of the peer group, separation from friends is a source of anxiety. Ideally, the peer group will support the ill friend. The other options isolate the child from the peer group.

A pregnant client asks the nurse in the clinic when she will be able to start feeling the fetus move. The nurse responds by telling the mother that fetal movements will be noted between which weeks of gestation? 1. 6 and 8 weeks' gestation 2. 8 and 10 weeks' gestation 3. 10 and 12 weeks' gestation 4. 16 and 20 weeks' gestation

4; Rationale: Quickening is fetal movement that usually first occurs between 16 and 20 weeks' gestation. The expectant mother first notices subtle fetal movements during this time, and these gradually increase in intensity. Options 1, 2, and 3 are incorrect; these gestational time frames are too early for quickening.

The nurse is assisting with planning care for a postpartum woman who has small vulvar hematomas. To assist with reducing the swelling, the nurse should perform which action? 1. Check vital signs every 4 hours. 2. Measure the fundal height every 4 hours. 3. Prepare a heat pack for application to the area. 4. Prepare an ice pack for application to the area.

4; Rationale: The application of ice will reduce the swelling caused by hematoma formation in the vulvar area. Checking the vital signs and performing fundal massage every 4 hours and preparing a heat pack for the perineal area will not reduce swelling.

The nurse is assigned to care for a child after a myringotomy with the insertion of tympanostomy tubes. The nurse notes a small amount of reddish drainage from the child's ear after the surgery. On the basis of this finding, which action should the nurse take? 1. Document the findings. 2. Notify the registered nurse immediately. 3. Change the ear tubes so that they do not become blocked. 4. Check the ear drainage for the presence of cerebrospinal fluid.

1 Rationale: After a myringotomy with the insertion of tympanostomy tubes, the child is monitored for ear drainage. A small amount of reddish drainage is normal during the first few days after surgery. However, any heavy bleeding or bleeding that occurs after 3 days should be reported. The nurse would document the findings. Options 2, 3, and 4 are not necessary.

The nurse is instructing a mother of a 1-year-old child with strabismus about the treatment options. Which statement by the mother would indicate the need for further teaching? 1. "My child will outgrow this by the time he is 2 years old and be able to see just fine." 2. "I will have my child wear an eye patch over the good eye to help strengthen the weak eye." 3. "If this eye patch does not work I know that we will have to do surgery to correct my child's crossed eyes." 4. "There are a few causes of this condition and they tell me my child has crossed eyes because of a muscle imbalance."

1 Rationale: Although strabismus is considered a normal finding in young infants, it should not be present after 4 months of age, so the 1 year old will likely not outgrow the condition. The use of an eye patch helps to strengthen the weak eye and surgery may be required for the condition. A muscle imbalance or the paralysis of the extraocular muscles may be the cause or strabismus could be congenital.

The nurse reinforces instructions to the mother of a child who has been hospitalized with croup. Which statement made by the mother would indicate the need for further teaching? 1. "I will give my child cough syrup if a cough develops." 2. "During an attack, I will take my child to a cool location." 3. "I can give acetaminophen if my child develops a fever." 4. "I will be sure that my child drinks at least three to four glasses of fluids every day."

1 Rationale: Cough syrups and cold medicines are not to be given because they may dry and thicken secretions. During a croup attack, the child can be taken to a cool basement or garage. Acetaminophen is used if a fever develops. Adequate hydration of 500 mL to 1000 mL of fluids daily is important for thinning secretions.

The nurse reinforces home-care instructions to the parents of a child with celiac disease. Which food item should the nurse advise the parents to include in the child's diet? 1. Rice 2. Oatmeal 3. Rye toast 4. Wheat bread

1 Rationale: Dietary management is the mainstay of treatment for celiac disease. All wheat, rye, barley, and oats should be eliminated from the diet and replaced with corn and rice. Vitamin supplements, especially fat-soluble vitamins and folate, may be required during the early period of treatment to correct deficiencies. These restrictions are likely to be life long, although small amounts of grains may be tolerated after the gastrointestinal ulcerations have healed.

The nurse notes that a client with type 1 diabetes mellitus has lipodystrophy on both upper thighs. Which further information should the nurse obtain from the client during data collection? 1. Plan for injection rotation 2. Consistency of aspiration 3. Preparation of the injection site 4. Angle at which the medication is administered

1 Rationale: Lipodystrophy (i.e., the hypertrophy of subcutaneous tissue at the injection site) occurs in some diabetic clients when the same injection sites are used for prolonged periods of time. Thus clients are instructed to adhere to a rotating injection site plan to avoid tissue changes. Preparation of the site, aspiration, and the angle of insulin administration do not produce tissue damage

A child is diagnosed with scarlet fever. The nurse collects data regarding the child. Which is characteristic of scarlet fever? 1. Pastia's sign 2. Abdominal pain and flaccid paralysis 3. Dense pseudoformation membrane in the throat 4. Foul-smelling and mucopurulent nasal drainage

1 Rationale: Pastia's sign is a rash seen among children with scarlet fever that will blanch with pressure, except in areas of deep creases and in the folds of joints. The tongue is initially coated with a white furry covering with red projecting papillae (white strawberry tongue). By the fourth to fifth day, the white strawberry tongue sloughs off and leaves a red, swollen tongue (strawberry tongue). The pharynx is edematous and beefy red in color. Option 2 is associated with poliomyelitis. Options 3 and 4 are characteristics of diphtheria.

133. The nurse is collecting data from a client who is scheduled for surgery in 1 week in the ambulatory care surgical center. Which client data are pertinent and should be reported to the primary health care provider before the surgery? Select all that apply. 1. Is allergic to penicillin 2. Quit smoking 3 months earlier 3. History of tonsillectomy at the age of 7 years 4. Wonders if the surgery could cause incontinence 5. Takes daily multivitamin and calcium supplement. 6. History of deep venous thrombosis in right leg 10 years earlier

1, 2, 4, 6; Rationale: The nurse conducts an interview and reviews current health practices and health history preoperatively with clients. Specific client data that are likely to affect a surgery is communicated promptly. The nurse reports any client allergies, especially an antibiotic allergy to avoid an allergic reaction perioperatively. The fact that the client was a smoker until recently is pertinent because it may affect how the client tolerates and recovers from anesthesia. The nurse should communicate any client concerns about the effects of the surgery so that the matter can be discussed and understood clearly before the surgery (informed consent). A history of a deep venous thrombosis (DVT) is pertinent because of an increased risk for DVT after the planned surgery, and precautions should be prescribed. A history of a childhood tonsillectomy and routine vitamin and mineral supplementation are part of the client history but are not pertinent data that needs to be reported specifically.

The nurse is preparing to reposition a dependent client who weighs more than 250 lbs. Which interventions should the nurse use to move this client? Select all that apply. 1. Use a friction-reducing slide sheet. 2. Use a mechanical lift to move the client. 3. Place the client in Trendelenburg position. 4. Keep elbows close and work close to the body. 5. Administer oral pain medication 5 minutes before moving the client. 6. Obtain assistance of a second caregiver to assist with mechanical aids.

1, 2, 4, 6Rationale: Manually lifting or transferring clients can result in work-related injuries and back problems for health care workers. In addition, the shearing of the client's skin over bony prominences may occur when health care workers move clients independently. The nurse should get assistance from another caregiver, utilize correct body mechanics while utilizing mechanical aids such as a ceiling lift or friction-reducing slide sheet. Placing the client in Trendelenburg is not a useful technique for repositioning and could be harmful to the client because of the pressure this position places on the diaphragm. Administering oral pain medication is necessary, but oral medications need to be given at least 30 minutes before the activity to provide time for the medication to work and provide relief of pain.

The nurse is caring for a client with a health care associated infection caused by methicillin-resistant Staphylococcus aureus. Contact precautions are prescribed for the client. The nurse prepares to irrigate the wound and apply a new dressing. Which protective interventions should the nurse use to perform this procedure? Select all that apply. 1. Put on a mask. 2. Don gown and gloves. 3. Apply shoe protectors. 4. Wear a pair of protective goggles. 5. Have the client wear a mask and goggles.

1, 2, 4; Rationale: Contact precautions are in place, which include wearing gloves and a gown while providing care to the client. The mask and goggles are indicated because of the potential of splash contact during the wound irrigation procedure. Goggles are worn to protect the mucous membranes of the eye during interventions that may produce splashes of blood, body fluids, secretions, and excretions

Which home care instructions should the nurse plan to reinforce to the mother of a child with acquired immunodeficiency syndrome (AIDS)? Select all that apply. 1. Frequent hand washing is important. 2. The child should avoid exposure to other illnesses. 3. The child's immunization schedule will need revision. 4. Kissing the child on the mouth will never transmit the virus. 5. Clean up body fluid spills with bleach solution (10:1 ratio of water to bleach). 6. Fever, malaise, fatigue, weight loss, vomiting, and diarrhea are expected to occur and do not require special intervention.

1, 2, 5 Rationale: AIDS is a disorder that is caused by the human immunodeficiency virus (HIV) and is characterized by a generalized dysfunction of the immune system. Homecare instructions include the following: frequent hand washing; monitoring for fever, malaise, fatigue, weight loss, vomiting, diarrhea, altered activity level, and oral lesions and notifying the primary health care provider if these occur; monitoring for signs and symptoms of opportunistic infections; administering antiretroviral medications, as prescribed; avoiding exposure to other illnesses; keeping immunizations up to date; avoiding kissing the child on the mouth; monitoring the weight and providing a high-calorie, high-protein diet; washing eating utensils in the dishwasher; and avoiding the sharing of eating utensils. Gloves are worn for care, especially when in contact with body fluids or changing diapers. Diapers are changed frequently and away from food areas, and soiled disposable diapers are folded inward, closed with their tabs, and disposed of in a tightly covered plastic-lined container. Any body fluid spills are cleaned with a bleach solution made up of a 10:1 ratio of water to bleach.

The client is admitted to the hospital with a diagnosis of suspected Hodgkin's disease. Which signs and symptoms of the client are associated with Hodgkin's disease? Select all that apply. 1. Fatigue 2. Weakness 3. Joint pain 4. Weight gain 5. Night sweats 6. Enlarged lymph nodes

1, 2, 5, 6; Rationale: Hodgkin's disease (lymphoma) is a chronic, progressive neoplastic disorder of the lymphoid tissue that is characterized by the painless enlargement of lymph nodes with progression to extralymphatic sites, such as the spleen and liver. Other signs and symptoms include fatigue, weakness, weight loss, and night sweats. Weight gain and joint pain are not associated with Hodgkin's disease.

Which findings indicate to the nurse that placental separation has occurred? Select all that apply. 1. Lengthening of umbilical cord 2. Sudden trickle or spurt of blood 3. Fundus is boggy following separation 4. Change from globular to discoid shape 5. Fetal membranes are seen at the introitus

1, 2, 5; Rationale: As the placenta separates, it settles downward into the lower uterine segment, the umbilical cord lengthens, a sudden trickle or spurt of blood appears and fetal membranes may appear at the introitus. The fundus changes from discoid to globular shape. The fundus should not become boggy.

Which data indicate to the nurse that a client is experiencing effective coping following the loss of a spouse? Select all that apply. 1. Looks at old snapshots of family 2. Constantly neglects personal grooming 3. Visits the spouse's grave once a month 4. Visits the senior citizens' center once a month 5. Prefers to spend time alone and avoids contact with others

1, 3, 4 Rationale: Coping mechanisms are behaviors that are used to decrease stress and anxiety. Visiting a spouse's grave, visiting the senior citizens' center, and looking at snapshots of the family are effective coping mechanisms. Neglecting grooming and preferring to spend time alone and avoiding contact with others are behaviors that identify ineffective coping of the grieving process.

A 4-year-old child sustains a fall at home injuring the right arm and is brought to the emergency department by the mother. The nurse should perform which emergency actions in the care of the child? Select all that apply. 1. Elevate the right arm. 2. Apply warm packs to the right arm. 3. Check the neurovascular status of the right extremity. 4. Check the range of motion of the right arm and shoulder. 5. Determine the level of pain using a pediatric pain assessment tool.

1, 3, 5 Rationale: Emergency nursing actions to take for a child sustaining an extremity fracture include elevating the injured extremity, checking the extent of the injury including pain level, immobilizing the affected extremity, applying cold packs to the injured area, and monitoring the neurovascular status of the extremity.

The nurse is reinforcing instructions for a client in how to perform a testicular self-examination (TSE). Which instructions should the nurse include? Select all that apply. 1. Perform TSE after a shower or bath. 2. Perform TSE after emptying the bladder. 3. Perform TSE on the same day each month. 4. Observe for urethral discharge after performing TSE. 5. Perform TSE by rolling each testicle between the thumb and fingers.

1, 3, 5 Rationale: The nurse needs to teach the client how to perform a TSE. The nurse should instruct the client that the best time to perform a TSE is after a shower or bath when the hands are warm and soapy and the scrotum is warm. This will provide ease in palpating, and the client will be better able to identify any abnormalities. The nurse should instruct the client to select a day of the month and perform the examination on the same day each month to avoid forgetting to do the examination. TSE is done by the client rolling each testicle between the thumb and fingers. The client should seek medical attention if a lump, mass, or swelling of the testicle is detected. The bladder does not have to be empty to complete the examination. There is no connection between urethral discharge and TSE.

The licensed practical nurse (LPN) is assisting the registered nurse (RN) to create a teaching plan for the client receiving an antineoplastic medication. The LPN expects which information to be included? Select all that apply. 1. Rinse mouth after meals and use a soft toothbrush. 2. Notify the PHCP if the temperature is above 101° F (37.7° C). 3. Maintain oral hygiene and inspect the mouth for sores daily. 4. A sore throat is expected so the client should suck on soothing throat lozenges. 5. Consult with primary health care provider (PHCP) before receiving immunizations.

1, 3, 5; Rationale: Clients with cancer treated with antineoplastic medications must be aware of how to care for themselves and it is important that client teaching is included in the care plan. Because antineoplastic medications affect the bone marrow, clients are often anemic, have lower immunity, and may be at risk for bleeding. Oral hygiene is important and clients should inspect their mouths daily, rinse after meals, and use a soft toothbrush. The client should check with the PHCP before receiving any immunizations. The client should notify the PHCP for a low grade temperature such as 99.5°F (39.7° C) and a sore throat. These are often associated with low white blood cell counts.

The nurse is reviewing the laboratory results of a client who is receiving chemotherapy and notes that the platelet count is 10,000 mm3 (10 × 109/L). On the basis of this laboratory value, the nurse should perform which intervention? Select all that apply. 1. Monitor stools for occult blood. 2. Keep away from persons who have colds or feel ill. 3. Instruct the client not to bend over at the waist or lift. 4. Floss teeth and rinse mouth with mouthwash after every meal. 5. Instruct the client to blow nose very gently without blocking either nostril.

1, 3, 5; Rationale: Platelets or thrombocytes are necessary for a client to clot. A high risk of hemorrhage exists when the platelet count drops below 20,000 mm3 . Fatal central nervous system hemorrhage or massive GI hemorrhage can occur when the platelet count is less than 10,000 mm3. The nurse should monitor the client's stools for blood, both obvious and occult. The client should be very gentle if blowing the nose and not cause any pressure to build up in the head. The client needs to avoid epistaxis (nosebleed). The client should not bend over at the waist because this action would increase the pressure within the head and increase the risk for an intracerebral bleed. Clients with decreased immunity, which is not stated in the question, should avoid ill persons. The client should not floss the teeth and only use a soft toothbrush to avoid bleeding in the mouth.

A mother of a child with a diagnosis of intussusception calls the nurse into the hospital room because the child is screaming in pain. Which manifestations of perforation should the nurse report immediately? Select all that apply. 1. Fever 2. Ribbon-like stools 3. Increased heart rate 4. Hypoactive bowel sounds 5. Profuse projectile vomiting 6. Change in the level of consciousness

1, 3, 6; Rationale: The child with intussusception classically presents with severe abdominal pain that is crampy and intermittent and that causes the child to draw in his or her knees to the chest. The signs of perforation and shock are evidenced by fever, an increased heart rate, a change in the level of consciousness or blood pressure, and respiratory distress and need to be reported immediately. The options for hypoactive bowel sounds, profuse projectile vomiting, and ribbon-like stools are a part of the presentation picture of a child with intussusception but are not signs of shock.

The nurse is caring for a client with an internal radiation implant. The nurse should observe which principle? Select all that apply. 1. Pregnant women are not allowed into the client's room. 2. Limit the time with the client to 1 hour per 8-hour shift. 3. Wear a lead apron while delivering bedside care to the client. 4. Remove the dosimeter badge when entering the client's room. 5. Individuals less than 16 years old are allowed in the room if they stay 6 feet away from the client.

1, 3; Rationale: A client receiving treatment for cancer with internal radioactive implant is emitting radioactive beams and others in the environment must take precautions to avoid injury. Pregnant persons are not allowed in the room. Nurses delivering bedside care must wear a lead apron which will stop the radioactive beams. The time that the nurse spends in the room of a client with an internal radiation implant is 30 minutes per 8-hour shift. The dosimeter badge must be worn when in the client's room. Children less than 16 years old and pregnant women are not allowed in the client's room. These guidelines protect individuals from radiation exposure.

The school nurse prepares a list of home care instructions for the parents of school children who have been diagnosed with pediculosis capitis (head lice). Which should be included in the list? Select all that apply. 1. Siblings may also need treatment. 2. Use antilice sprays on all bedding and furniture. 3. Use a pediculicide shampoo and repeat treatment in 14 days. 4. Grooming items such as combs and brushes should not be shared. 5. Launder all the bedding and clothing in hot water and dry on high heat. 6. Vacuum floors, play areas, and furniture to remove any hairs that may carry live nits.

1, 4, 5, 6; Rationale: Bedding and linens should be washed with hot water and dried on a hot setting. Thorough home cleaning is necessary to remove any remaining lice or nits. Siblings may need to be treated and combs and brushes may need to be discarded or soaked in boiling water for 10 minutes. Antilice sprays are unnecessary. Additionally, they should never be used on bedding, furniture, or a child. The pediculicide product needs to be used as prescribed, and the parents are instructed to follow package instructions for timing the application and for contraindications for their use in children.

179. Which interventions are appropriate for the care of an infant? Select all that apply. 1. Provide swaddling. 2. Talk in a loud voice. 3. Provide the infant with a bottle of juice at naptime. 4. Hang mobiles with black-and-white contrast designs. 5. Caress the infant while bathing or during diaper changes. 6. Allow the infant to cry for at least 10 minutes before responding.

1, 4, 5; Rationale: Holding, caressing, and swaddling provide warmth and tactile stimulation for the infant. To provide auditory stimulation, the nurse should talk to the infant in a soft voice and should instruct the mother to also do so. Additional interventions include playing a music box, radio, or television or having a ticking clock or metronome nearby. Hanging a bright, shiny object within 20 cm to 25 cm of the infant's face in the midline and hanging mobiles with contrasting colors (e.g., black and white) provide visual stimulation. Crying is an infant's way of communicating; therefore, the nurse would respond to the infant's crying. The mother is taught to do so also. An infant or child should never be allowed to fall asleep with a bottle containing milk, juice, soda, or sweetened water because of the risk of nursing (bottle-mouth) caries.

The nurse is monitoring a client in preterm labor who is receiving intravenous magnesium sulfate. The nurse should monitor for which adverse effects of this medication? Select all that apply. 1. Flushing 2. Hypertension 3. Increased urine output 4. Depressed respirations 5. Extreme muscle weakness 6. Hyperactive deep tendon reflexes

1, 4, 5; Rationale: Magnesium sulfate is a central nervous system depressant and relaxes smooth muscle, including the uterus. It is used to halt preterm labor contractions and is used for preeclamptic clients to prevent seizure. Adverse effects include flushing, depressed respirations, depressed deep tendon reflexes, hypotension, extreme muscle weakness, decreased urine output, pulmonary edema, and elevated serum magnesium levels.

The nurse is applying a topical corticosteroid to a client with eczema. The nurse should apply the medication to which body area? Select all that apply. 1. Back 2. Axilla 3. Eyelids 4. Soles of the feet 5. Palms of the hands

1, 4, 5; Rationale: Topical corticosteroids can be absorbed into the systemic circulation. Absorption is higher from regions where the skin is especially permeable (scalp, axilla, face, eyelids, neck, perineum, genitalia), and lower from regions where permeability is poor (back, palms, soles). The nurse should avoid areas of higher absorption to prevent systemic absorption

The nurse is developing a plan of care for a client who is scheduled for surgery. The nurse should include which activities in the nursing care plan for the client on the day of surgery? Select all that apply. 1. Have the client void before surgery. 2. Avoid oral hygiene and rinsing with mouthwash. 3. Verify that the client has not eaten for the last 24 hours. 4. Determine that the client has signed the informed consent for the surgical procedure. 5. Report immediately any slight increase in blood pressure or pulse from the client's baseline vital signs.

1, 4; Rationale: The nurse caring for clients who will be having surgery must ensure that the client is properly identified and prepared according to the prescription(s) by the surgeon and anesthesiologist. The nurse should assist the client with voiding before surgery so that the bladder is empty at the beginning of the procedure. The nurse should verify that the client has signed the consent for the procedure. If the client has not signed a consent, no preoperative medications should be given, and the surgeon can obtain the consent before proceeding. Oral hygiene is allowed, but the client should not swallow any water. The client usually has a restriction of food and fluids for 8 hours before surgery rather than 24 hours (often NPO after midnight). A slight increase in blood pressure and pulse is common during the preoperative period; this is generally the result of anxiety. The nurse should verify what the normal blood pressure and pulse rate are for this client.

The nurse educator is asking the nursing student to recall the signs/symptoms of hypothyroidism. The nurse educator determines that the student understands this disorder if which are included in the student's response? Select all that apply. 1. Dry skin 2. Irritability 3. Palpitations 4. Weight loss 5. Constipation 6. Cold intolerance

1, 5, 6 Rationale: Signs of hypothyroidism include dry skin, hair, and loss of body hair; constipation; cold intolerance; lethargy and fatigue; weakness; muscle aches; paresthesia; weight gain; bradycardia; generalized puffiness and edema around the eyes and face; forgetfulness; menstrual disturbances; cardiac enlargement; and goiter. Irritability, palpitations, and weight loss are signs of hyperthyroidism.

The client with squamous cell carcinoma of the larynx is receiving bleomycin intravenously. The nurse caring for the client anticipates that which diagnostic study will be prescribed? Select all that apply. 1. Chest x-ray 2. Echocardiography 3. Electrocardiography 4. Cervical radiography 5. Pulmonary function studies

1, 5; Rationale: Bleomycin is an antineoplastic medication that can cause interstitial pneumonitis, which can progress to pulmonary fibrosis. During pulmonary fibrosis, the lung tissue becomes very scarred and hard. Pulmonary fibrosis is not reversible and the client is continuously short of breath. Pulmonary function studies and chest x-ray, along with hematological, hepatic, and renal function tests need to be monitored. The nurse needs to monitor lung sounds for dyspnea and adventitious sounds, which could indicate pulmonary toxicity. The medication needs to be discontinued immediately if pulmonary toxicity occurs. Cardiac studies such as an echocardiogram and electrocardiogram, and a cervical radiograph are unrelated to the specific use of this medication.

The nurse is assisting with developing a plan of care for the client with multiple myeloma. Which nursing intervention should be included to prevent renal failure for this client? Select all that apply. 1. Encouraging fluids 2. Providing frequent oral care 3. Coughing and deep breathing 4. Monitoring the red blood cell count 5. Monitoring serum calcium and uric acid levels

1, 5; Rationale: In order to prevent renal failure in the client with multiple myeloma, the nurse should encourage fluids and monitor serum calcium and uric acid levels. Hypercalcemia secondary to bone destruction is a priority concern in the client with multiple myeloma. The nurse should encourage fluids to maintain an output. Clients require about 3L fluid/day. The fluid is to dilute the calcium and uric acid, & to prevent protein from precipitating in the renal tubules. Oral care, coughing, and monitoring the rbc count are important, but are not specific to prevention of renal failure.

The nurse is planning to begin a continuous tube feeding on a client with a nasogastric (NG) tube. Which interventions should the nurse perform before initiating the feeding? Select all that apply. 1. Explain the procedure to the client. 2. Irrigate the NG tube with saline. 3. Aspirate all stomach contents and discard. 4. Elevate the head of the bed to 45 degrees. 5. Have a pair of scissors for emergency use at the bedside. 6. Ensure that the end of the NG tube is in the esophagus.

1,2,4; Rationale: When a tube feeding is initiated, the most important intervention is to make sure the NG tube is properly placed in the stomach to prevent aspiration. After explaining the procedure to the client and assessing placement of the tube, the nurse should irrigate the tube with saline to ensure flow well through the tube. When feeding is administered, the client is placed in a high Fowler's position for a bolus feeding and in a semi-Fowler's position (30-45 degrees) for a continuous feeding to allow gravity to help the flow of formula and to prevent reflux and aspiration. There is no need to aspirate contents because the formula has not been given and the contents are gastric secretions.

The nurse is told that an assigned client will have a fenestrated tracheostomy tube inserted. The nurse plans care knowing that which facts are true with the use of a fenestrated tracheostomy tube? Select all that apply. 1. Enables the client to speak 2. Is necessary for mechanical ventilation. 3. Must have the cuff deflated when capped 4. Eliminates the need for tracheostomy care 5. Prevents air from being inhaled through the tracheostomy opening

1,3; Rationale: A fenestrated trache tube is used when a client is being weaned from breathing through the tracheostomy to breathing normally through the nose and mouth. A fenestrated tube has a small opening in the outer cannula that allows some air to escape through the larynx; this type of tube enables the client to speak. The cuff of the tracheostomy tube must always be deflated before the fenestrated tube is capped. When the cuff is inflated, the tracheostomy tube can be used for mechanical ventilation. When the cuff is deflated and the cap is applied, the client can breathe around the tracheostomy tube.

The nurse is preparing to administer an intermittent tube feeding to a client with a nasogastric (NG) tube. The nurse checks the residual and obtains an amount of 200 mL. Which actions should the nurse take? Select all that apply. 1. Listen to the client's bowel sounds. 2. Document and discard the residual. 3. Offer the client sips of water to drink. 4. Question the client regarding nausea. 5. Determine whether the client has abdominal distension. 6. Hold the feeding after flushing the tubing with 30 mL saline.

1,4,5,6; Rationale: Large-volume aspirates in clients receiving intermittent tube feedings indicate delayed gastric emptying and place the client at risk for aspiration. The nurse should assess nausea, bowel sounds, and abdominal distention indicating possible bowel obstruction. When 200 mL of residual formula is obtained, the feeding is held and the RN is notified because this is an indication that the feeding is not being absorbed. The residual amount should be documented, but the residual aspirated is returned to the client to avoid electrolyte imbalance. There is no indication to give the client sips of water.

198. The nurse working in a prenatal clinic reviews a client's chart and notes that the primary health care provider documents that the client has a gynecoid pelvis. The nurse plans care understanding that which findings are characteristic of this type of pelvis? Select all that apply. 1. Round shape 2. Shallow depth 3. Narrow pubic arch 4. Diagonal conjugate measures 12.5 cm to 13 cm 5. Blunt, somewhat widely separated ischial spines

1,4,5; Rationale: A gynecoid pelvis is a normal female pelvis, and it is the most favorable for successful labor and birth. Characteristics of a gynecoid pelvis include a round shape, blunted ischial spines that are widely separated, a diagonal conjugate of at least 12.5 cm to 13 cm, a wide pelvic arch, and an adequate depth.

The nurse is providing endotracheal suctioning to a client who is mechanically ventilated when the client becomes restless and tachycardic. Which actions should the nurse take? Select all that apply. 1. Notify the RN. 2. Notify the Rapid Response Team. 3. Finish the suctioning as quickly as possible. 4. Discontinue suctioning until the client is stabilized. 5. Contact the respiratory department to suction the client.

1,4; Rationale: When suctioning a client with an endotracheal tube, the nurse removes the secretions and clears the airway. If a client becomes cyanotic or restless or develops tachycardia, bradycardia, or another abnormal heart rhythm, the nurse must discontinue suctioning until the client is stabilized. The nurse would also notify the RN. It is also important to monitor the vital signs and the pulse oximetry. If the client's condition continues to deteriorate, then the respiratory department and PHCP may need to be notified. There is no data in the question that indicates that the rapid response team needs to be notified.

89. The nurse is making a worksheet and listing the tasks that need to be performed for assigned adult clients during the shift. The nurse writes on the plan to check the intravenous (IV) of an assigned client who is receiving fluid replacement therapy how frequently? 1. Every hour 2. Every 2 hours 3. Every 3 hours 4. Every 4 hours

1. Every hour Rationale: Safe nursing practice includes monitoring an IV infusion at least once every 1 hour for an adult client. The remaining options do not provide time frames that are safe or acceptable.

The nursing instructor asks a nursing student to list the functions of the amniotic fluid. The student needs further teaching if which responses are made? Select all that apply. 1. Allows for fetal movement 2. Is a measure of kidney function 3. Surrounds, cushions, and protects the fetus 4. Maintains the body temperature of the fetus 5. Prevents large particles such as bacteria from passing to the fetus 6. Provides an exchange of nutrients and waste products between the mother and the fetus

197. 5,6; Rationale: The amniotic fluid surrounds, cushions, and protects the fetus. The placenta, not the amniotic fluid, prevents large particles such as bacteria from passing to the fetus, and the placenta provides an exchange of nutrients and waste products between the mother and the fetus. Amniotic fluid allows the fetus to move freely, it maintains the body temperature of the fetus, and it helps to measure kidney function, because the amount of fluid is based on the amount of urination from the fetus.

The nurse enters the nursing lounge and discovers that a chair is on fire. The nurse activates the alarm, closes the lounge door, and obtains the fire extinguisher to extinguish the fire. The nurse pulls the pin on the fire extinguisher. Which is the next action the nurse should perform? 1. Aim at the base of the fire. 2. Squeeze the handle on the extinguisher. 3. Sweep the fire from side to side with the extinguisher. 4. Sweep the fire from top to bottom with the extinguisher

1; Rationale: A fire can be extinguished by using a fire extinguisher. To use the extinguisher, the pin is pulled first. The extinguisher should then be aimed at the base of the fire. The handle of the extinguisher is squeezed, and the fire is extinguished by sweeping from side to side to coat the area evenly. Remember that the safety of anyone present is more important than extinguishing the fire.

The nurse is providing instructions to a new parent regarding the psychosocial development of the infant. Using Erikson's psychosocial development theory, which instruction should the nurse reinforce to the parents? 1. Allow the infant to signal a need. 2. Anticipate all of the needs of the infant. 3. Attend to the crying infant immediately. 4. Avoid the infant during the first 10 minutes of crying.

1; Rationale: According to Erikson, the caregiver should not try to anticipate the infant's needs at all times but rather allow the infant to signal his or her needs. If an infant is not allowed to signal a need, the infant will not learn how to control the environment. Erikson believed that a delayed or prolonged response to an infant's signal would inhibit the development of trust and lead to the mistrust of others. Therefore, the remaining options are incorrect.

The parent of a 3-year-old tells the nurse that the child is constantly rebelling and having temper tantrums. Which instruction should the nurse reinforce to the parent? 1. Set limits on the child's behavior. 2. Ignore the child when this behavior occurs. 3. Allow the behavior, because this is normal at this age period. 4. Punish the child every time the child says "no" to change the behavior.

1; Rationale: According to Erikson, the child focuses on independence between the ages of 1 and 3 years. Gaining independence often means that the child has to rebel against the parents' wishes. Saying things like "no" and "mine" and having temper tantrums are common during this period of development. Being consistent and setting limits on the child's behavior are necessary elements. Punishing the child every time the child says "no" is likely to produce a negative response.

A postpartum client is getting ready for discharge. The nurse suspects that the client needs further teaching related to breastfeeding when she makes which statement? 1. "I don't need birth control because I will be breastfeeding." 2. "I need to increase my caloric intake by 500 calories a day." 3. "I shouldn't use soap to wash my breasts because I will be breastfeeding." 4. "I need to be sure that I increase my fluid intake and take my prenatal vitamins while breastfeeding."

1; Rationale: Amenorrhea may occur during breastfeeding, but the client can still ovulate without menstruating. The caloric intake should be increased by 200 to 500 cal/day (per PHCP's prescription), and the diet should include additional fluids and prenatal vitamins, as prescribed. The use of soap on the breasts is avoided because it tends to remove natural oils, which can lead to cracked nipples.

A school-age child with type 1 diabetes mellitus has soccer practice three afternoons a week. The nurse reinforces instructions regarding how to prevent hypoglycemia during practice. Which should the nurse tell the child? 1. Drink a half a cup of orange juice before soccer practice. 2. Eat twice the amount that is normally eaten at lunchtime. 3. Take half of the amount of prescribed insulin on practice days. 4. Take the prescribed insulin at noontime rather than in the morning.

1; Rationale: An extra snack of 10 g to 15 g of carbohydrates eaten before activities and for every 30 to 45 minutes of activity will prevent hypoglycemia. A half cup of orange juice will provide the needed carbohydrates. The child or parents should not be instructed to adjust the amount or time of insulin administration, and meal amounts should not be doubled.

The nurse is reviewing the history and physical examination of a client who will be receiving asparaginase, an antineoplastic agent. The nurse consults with the registered nurse regarding the administration of the medication if which is documented in the client's history? 1. Pancreatitis 2. Diabetes mellitus 3. Myocardial infarction 4. Chronic obstructive pulmonary disease

1; Rationale: Asparaginase is a antineoplastic enzyme that is contraindicated if hypersensitivity exists in the case of pancreatitis, or if the client has a history of pancreatitis. The medication impairs pancreatic function, and pancreatic function tests should be performed before therapy begins and when a week or more has elapsed between the administration of doses. The client needs to be monitored for signs of pancreatitis, which include nausea, vomiting, and abdominal pain. The medication may be used for clients with a history of diabetes mellitus, myocardial infarction, or chronic obstructive pulmonary disease.

The clinic nurse is performing an admission assessment on a client and notes that the client is taking azelaic acid. The nurse determines that which client complaint may be associated with the use of this medication? 1. Itching 2. Euphoria 3. Drowsiness 4. Frequent urination

1; Rationale: Azelaic acid is a topical medication used to treat mild to moderate acne. Adverse effects include burning, itching, stinging, redness of the skin, and hypopigmentation of the skin in clients with a dark complexion. The effects noted in the other options are not specifically associated with this medication.

The nurse is reinforcing measures regarding the care of the newborn with a mother. To bathe the newborn, the mother should be taught which intervention? 1. Begin with the eyes and face. 2. Start with the dirtiest area first. 3. Begin with the feet and work upward. 4. Only wash the diaper area, because this is the only part of the baby that gets soiled.

1; Rationale: Bathing should start at the eyes and face, which are usually the cleanest areas. Next, the external portion of the ears and behind the ears are cleansed. The newborn's neck should be washed, because formula, breast milk, or lint will often accumulate in the folds of the neck. The hands and arms are then washed. The baby's legs are washed, with the diaper area being washed last.

The client is undergoing an amniocentesis at 16 weeks' gestation to detect the presence of biochemical or chromosomal abnormalities. Which instructions should the nurse reinforce to the client? 1. The bladder must be full during the examination. 2. The bladder must be empty during the examination. 3. She should not eat or drink anything 4 to 6 hours before the examination. 4. She will be given Rho(D) immune globulin because she is Rh positive.

1; Rationale: Before 20 weeks' gestation, the bladder must be kept full during amniocentesis to support the weight of the uterus. After 20 weeks' gestation, the bladder should be emptied to minimize the chance of puncturing the placenta or fetus. Rho(D) immune globulin is administered to Rh-negative women because of the risk of contact with the fetal blood during the examination. There are no fluid or food restrictions. Monitoring the fetal heart tones and the vital signs throughout and after the examination is an important intervention.

The nursing student is asked to describe the size of the uterus in a nonpregnant client. Which response indicates an understanding of the anatomy of this structure? 1. "The uterus weighs about 2 ounces." 2. "The uterus weighs about 2.2 pounds." 3. "The uterus has a capacity of about 50 milliliters." 4. "The uterus is round in shape and weighs approximately 1000 grams."

1; Rationale: Before conception, the uterus is a small, pear-shaped organ that is contained entirely in the pelvic cavity. Before pregnancy, the uterus weighs approximately 60 g (2 oz) and it has a capacity of about 10 mL (⅓ oz). At the end of pregnancy, the uterus weighs approximately 1000 g (2.2 lb) and it has a capacity that is sufficient for the fetus, the placenta, and the amniotic fluid.

The nurse should implement which activity to promote reminiscence among older clients? 1. Having storytelling hours 2. Setting up pet therapy sessions 3. Displaying calendars and clocks 4. Encouraging client participation in a pottery class

1; Rationale: Clients who like to retell stories or to describe past events need to be provided with the opportunity to do so. This phenomenon is called life review or reminiscence. In a sense, it is a way for the older client to relive and restructure life experiences, and it is a part of achieving ego identity. Displaying calendars and clocks indicates reality orientation techniques. Pet therapy and pottery classes describe socialization and physical activities.

210. The nurse is reviewing the record of a client who has just been told that her pregnancy test is positive. The nurse notes that the health care provider has documented the presence of Goodell's sign. The nurse determines that this sign is indicative of which change that occurs with pregnancy? 1. A softening of the cervix 2. The presence of fetal movement 3. The presence of human chorionic gonadotropin in the urine 4. A soft blowing sound that corresponds with the maternal pulse that is heard while auscultating the uterus

1; Rationale: During the early weeks of pregnancy, the cervix becomes softer as a result of pelvic vasoconstriction, which causes Goodell's sign. Cervical softening is noted by the examiner during a pelvic examination. Goodell's sign does not indicate the presence of fetal movement. Human chorionic gonadotropin is noted in maternal urine with a positive urine pregnancy test. A soft blowing sound that corresponds with the maternal pulse may be auscultated over the uterus; it is the result of blood circulating through the placenta.

The nursing instructor asks a nursing student to describe the procedure for administering erythromycin ointment to the eyes of a newborn. Which student statement indicates that further teaching is needed? 1. "I will flush the eyes after instilling the ointment." 2. "I will clean the newborn's eyes before instilling ointment." 3. "I need to administer the eye ointment within 1 hour after delivery." 4. "I will instill the eye ointment into each of the newborn's conjunctival sacs."

1; Rationale: Eye prophylaxis protects the newborn against Neisseria gonorrhoeae and Chlamydia trachomatis. The eyes are not flushed after instillation of the medication because the flush would wash away the administered medication. Options 2, 3, and 4 are correct statements regarding the procedure for administering eye medication to the newborn.

A client arrives to the surgical nursing unit after surgery. What should be the initial nursing action after surgery? 1. Assess patency of the airway. 2. Check tubes or drains for patency. 3. Check dressing for bleeding or drainage. 4. Obtain vital signs to compare with those recorded preoperatively.

1; Rationale: If the airway is not patent, immediate measures must be taken for the survival of the client. After checking the client's airway, the nurse would then check the client's vital signs, followed by the dressings, tubes, and drains.

Which statement by a nursing student about Kohlberg's theory of moral development indicates the need for further teaching about the theory? 1. "Individuals move through all six stages in a sequential fashion." 2. "Moral development progresses in relation to cognitive development." 3. "A person's ability to make moral judgments develops over a period of time." 4. "It provides a framework for understanding how individuals determine a moral code to guide his or her behavior."

1; Rationale: Kohlberg's theory states that individuals move through the six stages of development in a sequential fashion but that not everyone reaches stages 5 or 6 as part of their development of personal morality. The other options are correct statements regarding Kohlberg's theory.

A burn client is receiving treatments of topical mafenide acetate to the site of injury. The nurse monitors the client, knowing that which finding indicates the occurrence of a systemic effect? 1. Hyperventilation 2. Elevated blood pressure 3. Local rash at the burn site 4. Local pain at the burn site

1; Rationale: Mafenide acetate is a carbonic anhydrase inhibitor and can suppress renal excretion of acid, thereby causing acidosis. Clients receiving this treatment should be monitored for signs of an acid-base imbalance (hyperventilation). If this occurs, the medication will probably be discontinued for 1 to 2 days. Options 2 and 4 describe local rather than systemic effects. An elevated blood pressure may be expected from the pain that occurs with a burn injury.

The nurse observes a mother giving an oral iron supplement to her 6-year-old child with iron deficiency anemia. Which action by the mother indicates the need for further teaching? 1. The mother administered the iron with milk. 2. The mother administered the iron with water. 3. The mother administered the iron with apple juice. 4. The mother administered the iron with orange juice.

1; Rationale: Milk may affect absorption of the iron. Vitamin C increases the absorption of iron by the body. The mother should be instructed to administer the medication with a citrus fruit or a juice that is high in vitamin C. Water will not assist in absorption.

The nurse is talking to a pregnant client with human immunodeficiency virus (HIV) infection regarding care for the newborn after delivery. The client asks the nurse about the feeding options that are available. Which response should the nurse make to the client? 1. "You will need to bottle-feed your newborn." 2. "You will need to feed your newborn by nasogastric tube feeding." 3. "You will be able to breast-feed for 6 months and then will need to switch to bottle-feeding." 4. "You will be able to breast-feed for 9 months and then will need to switch to bottle-feeding."

1; Rationale: Perinatal transmission of HIV can occur during the antepartum period, during labor and birth, or in the postpartum period if the mother is breast-feeding. Clients who have HIV are advised not to breast-feed. There is no physiological reason why the newborn needs to be fed by nasogastric tube.

A mother brings her 3-week-old infant to a clinic for a phenylketonuria rescreening blood test. The test indicates a serum phenylalanine level of 0 mg/dL (0 mcmol/L). The nurse reviews this result and makes which interpretation? 1. It is negative. 2. It is a concern. 3. It is inconclusive. 4. It requires rescreening at age 6 weeks.

1; Rationale: Phenylketonuria is a genetic disorder that results in CNS damage from toxic levels of phenylalanine in the blood. It is characterized by blood levels greater than 20 mg/dL (1210 mcmol/L). The normal level is 0 mg/dL to 2 mg/dL (0-121 mcmol/L). A result of 0 mg/dL is a negative test result.

The nurse is caring for a postpartum client with a diagnosis of thrombophlebitis. The client suddenly complains of chest pain and dyspnea. The nurse should initially check which item? 1. Vital signs 2. Fundal height 3. Presence of calf pain 4. Level of consciousness (LOC)

1; Rationale: Pulmonary embolism is a complication of thrombophlebitis. Changes in the vital signs are one of the first things to occur with pulmonary embolism, because pulmonary blood flow is compromised. Fundal height is unrelated to the information in the question. Calf pain is an indicator of thrombophlebitis. Level of consciousness may change as the condition worsens; worsening would indicate hypoxia

The nursing instructor asks a nursing student to describe the process of quickening. Which statement indicates an understanding of this term? 1. "It is the fetal movement that is felt by the mother." 2. "It is the compressibility of the lower uterine segment." 3. "It is the irregular, painless contractions that occur throughout pregnancy." 4. "It is the soft blowing sound that can be heard when the uterus is auscultated."

1; Rationale: Quickening is fetal movement that appears usually at weeks 16 to 20, when the expectant mother first notices subtle fetal movements that gradually increase in intensity. A compressibility of the lower uterine segment occurs at about 6 weeks' gestation and is called Hegar's sign. Braxton Hicks contractions are irregular, painless contractions that may occur throughout pregnancy. A soft blowing sound that corresponds with the maternal pulse may be auscultated over the uterus; this is known as uterine souffle. This sound is the result of blood circulation to the placenta, and it corresponds with the maternal pulse.

The nurse is assigned to work in the delivery room and is assisting with caring for a client who has just delivered a newborn. The nurse is monitoring for signs of placental separation knowing that which indicates that the placenta has separated? 1. A change in the uterine contour 2. Sudden and sharp abdominal pain 3. A shortening of the umbilical cord 4. A decrease in blood loss from the introitus

1; Rationale: Signs of placental separation include the lengthening of the umbilical cord, a sudden gush of dark blood from the introitus, a firmly contracted uterus, and the uterus changing from a discoid to a globular shape. The client may experience vaginal fullness, but not sudden and sharp abdominal pain.

The nurse notes that the 4-hour postpartum client has cool, clammy skin and that she is restless and excessively thirsty. The nurse immediately notifies the registered nurse and then performs which action? 1. Checks the vital signs 2. Begins fundal massage 3. Encourages ambulation 4. Encourages the client to drink fluids

1; Rationale: Signs/symptoms of hypovolemia include cool, clammy, and pale skin; feelings of anxiety and restlessness; and thirst. The nurse should check the vital signs. The nurse does not ambulate the client or encourage fluids until specific prescriptions are given to do so. There is no information in the question to indicate the need for fundal massage.

The nurse is assigned to care for the client after a cesarean section. To prevent thrombophlebitis, the nurse should encourage the woman to take which priority action? 1. Ambulate frequently. 2. Wear support stockings. 3. Apply warm, moist packs to the legs. 4. Remain on bed rest, with the legs elevated.

1; Rationale: Stasis is believed to be a major predisposing factor for the development of thrombophlebitis. Because cesarean delivery poses a risk factor, the client should ambulate early and frequently to promote circulation and prevent stasis. Wearing support stockings, applying warm, moist packs to the legs and maintaining bed rest with legs elevated are implemented if thrombophlebitis occurs.

The nurse palpates the fundus and checks the character of the lochia of a postpartum client who is in the fourth stage of labor. Which lochia characteristic should the nurse expect to note? 1. Red 2. Pink 3. White 4. Serosanguineous

1; Rationale: The color of the lochia during the fourth stage of labor is bright red, and this may last from 1 to 3 days. The color of the lochia then changes to a pinkish-brown and occurs from day 4 to 10 postpartum. Finally, the lochia changes to a creamy white color that occurs from day 10 to 14 postpartum.

The nurse has inserted a nasogastric (NG) tube in a client and is checking for the correct placement of a NG tube. Which is the most reliable data to ensure that the end of the tube is in the stomach? 1. Placement is verified on x-ray. 2. The pH of the aspirated fluid is 5. 3. The aspirated fluid is bile green in color. 4. Air injection is auscultated in the left upper quadrant.

1; Rationale: The end of the NG tube should be in the stomach. An x-ray is the most reliable method of determining correct placement. The radiologist may recommend moving the tube backward or forward for a preferable placement. A low pH such as 4.5 of the fluid aspirated is likely to be from the stomach, but pH is affected by tube feeding formulas and prescribed proton-pump inhibitors. The characteristic bile green is highly suggestive that the tube is in the stomach. Auscultation of the air injection is not recommended as a reliable method to establish correct placement.

The nurse should monitor for which signs associated with respiratory distress syndrome (RDS) in a preterm newborn? 1. Tachypnea and retractions 2. Acrocyanosis and grunting 3. Hypotension and bradycardia 4. The presence of a barrel chest with acrocyanosis

1; Rationale: The newborn infant with RDS may present with clinical signs of cyanosis, tachypnea, apnea, nasal flaring, chest wall retractions, or audible grunts. Acrocyanosis is a bluish discoloration of the hands and feet that is associated with immature peripheral circulation, and it is not uncommon during the first few hours of life. Options 2, 3, and 4 do not indicate clinical signs of RDS.

The nurse is assigned to assist with caring for a client who has a chest tube. The nurse notes fluctuations of the fluid level in the water-seal chamber. Based on this observation, which action would be appropriate? 1. Continue to monitor. 2. Empty the drainage. 3. Encourage the client to deep breathe. 4. Encourage the client to hold his or her breath periodically.

1; Rationale: The presence of fluctuations in the fluid level in the water-seal chamber indicates a patent drainage system. With normal breathing, the water level rises with inspiration and falls with expiration. The apparatus and all connections must remain airtight at all times, and the drainage is never emptied because of the risk of disruption in the closed system, which can result in lung collapse. Encouraging the client to deep breathe is unrelated to this observation. The client is not told to hold his breath.

The parents of a 16-year-old child tell the nurse that they are concerned because the child sleeps until noon every weekend. Which is the most appropriate nursing response? 1. "Adolescents love to sleep late in the morning." 2. "The child shouldn't be staying up so late at night." 3. "If the child eats properly, that shouldn't be happening." 4. "The child should have a blood test to check for anemia."

1; Rationale: The sleep patterns of the adolescent vary some according to individual needs. However, in general, adolescents love to sleep late in the morning, but they should be encouraged to be responsible for waking themselves, particularly in time to get ready for school. Options 2, 3, and 4 are incorrect.

The nurse is reinforcing home-care instructions to the parents of a 3-year-old child with scabies. Which statement by a parent indicates the need for further teaching? 1. "I understand that I need to leave the scabicide on for 4 hours before washing it off." 2. "I will need to seal up all my child's nonwashable toys in a plastic bag for at least 4 days." 3. "I realize that everyone who has come in contact with my child will need to be treated for scabies." 4. "I know I need to wash all the clothing and bedding in hot water with detergent and dry in a hot dryer."

1; Rationale: The treatment for scabies involves applying a scabicide to cool, dry skin at least 30 minutes after bathing, which needs to be left on the skin for 8 to 14 hours, then washed off. The other statements are correct.

The nurse is reinforcing discharge instructions to the parents of a 2-year-old child who sustained accidental burns from a hot cup of coffee. The nurse determines that the parents have correctly understood the teaching when they make which statement? 1. "We will be sure not to leave hot liquids unattended." 2. "I guess my child needs to understand what the word 'hot' means." 3. "We will be sure that our child stays in his room when we work in the kitchen." 4. "We will install a safety gate as soon as we get home so that our child can't get into the kitchen."

1; Rationale: Toddlers, with their increased mobility and developing motor skills, can reach hot water, open fires, or hot objects placed on counters and stoves above their eye level. Parents should be encouraged to remain in the kitchen when preparing a meal and reminded to use the back burners of the stove. Pot handles should be turned inward and toward the middle of the stove. Hot liquids should never be left unattended, and the toddler should always be supervised. The other options do not reflect an adequate understanding of the principles of safety.

The nurse is monitoring an adult client for postoperative complications. Which is most indicative of a potential postoperative complication that requires further observation? 1. A urinary output of 20 mL/hour 2. A temperature of 37.6° C (99.6° F) 3. A blood pressure of 100/70 mm Hg 4. Serous drainage on the surgical dressing

1; Rationale: Urine output is maintained at a minimum of at least 30 mL/hour for an adult. An output of less than 30 mL/hour for each of 2 consecutive hours should be reported to the surgeon. A temperature more than 37° C (100° F) or less than 36.1° C (97° F) and a falling systolic blood pressure less than 90 mm Hg are to be reported. The client's preoperative or baseline blood pressure is used to make informed postoperative comparisons. Moderate or light serous drainage from the surgical site is considered normal.

The nurse is caring for a client who is receiving an intravenous (IV) infusion of an antineoplastic medication. During the infusion, the client complains of pain at the insertion site. During an inspection of the site, the nurse notes redness and swelling. The nurse should take which appropriate action? 1. Notify the registered nurse immediately. 2. Administer pain medication to reduce the discomfort. 3. Apply ice and maintain the infusion rate, as prescribed. 4. Elevate the extremity of the IV site, and slow the infusion.

1; Rationale: When antineoplastic medications are administered via IV, great care must be taken to prevent extravasation, the condition in which the medication escapes into the tissues surrounding the injection site, because pain, tissue damage, and necrosis can result. The nurse monitors for signs of extravasation, such as redness or swelling at the insertion site. If extravasation occurs, the RN needs to be notified at once and the infusion will be stopped. The nurse will contact the PHCP. Depending on the specific medication, actions are taken to counteract the negative effects. The medication may be aspirated out, ice or warmth applied, and the area infiltrated with a neutralizing agent specific to the medication.

A primigravida's membranes rupture spontaneously. Which action should the nurse take first? 1. Determine the fetal heart rate. 2. Prepare for immediate delivery. 3. Monitor the contraction pattern. 4. Note the amount, color, and odor of the amniotic fluid.

1; Rationale: When the membranes rupture, the nurse immediately assesses the fetal heart rate to detect changes associated with prolapse or the compression of the umbilical cord. Monitoring the contraction pattern and noting the amount, color, and odor of the amniotic fluid may be performed, but these would not be the first actions. There is no information in the question that indicates the need to prepare the client for immediate delivery.

After a precipitous delivery, the nurse notes that the new mother is passive and only touches her newborn briefly with her fingertips. The nurse should do which to help the woman process what has happened? 1. Support the mother in her reaction to the newborn. 2. Encourage the mother to breastfeed soon after birth. 3. Tell the mother that it is important to hold the newborn. 4. Document a complete account of the mother's reaction in the birth record.

1; Rationale: Women who have experienced precipitous labor and delivery often describe feelings of disbelief that their labor has progressed so rapidly. To assist the woman with understanding what has happened, it is best to support the mother in her reaction to the newborn. Encouraging the mother to breastfeed, telling the mother the importance of holding her newborn and documenting the maternal reaction to the birth do not acknowledge the mother's feelings.

An 18-month-old child is being discharged after surgical repair of hypospadias. Which postoperative nursing care measure should the nurse stress to the parents as they prepare to take this child home? 1. Leave diapers off to allow the site to heal. 2. Avoid tub baths until the stent has been removed. 3. Encourage toilet training to ensure that the flow of urine is normal. 4. Restrict the fluid intake to reduce urinary output for the first few days.

2 Rationale: After hypospadias repair, the parents are instructed to avoid giving the child a tub bath until the stent has been removed to prevent infection. Diapers are placed on the child to prevent the contamination of the surgical site. Toilet training should not be an issue during this stressful period. Fluids should be encouraged to maintain hydration.

The nurse is caring for a postoperative parathyroidectomy client. Which would require the nurse's immediate attention? 1. Incisional pain 2. Laryngeal stridor 3. Difficulty voiding 4. Abdominal cramps

2 Rationale: During the postoperative period, the nurse carefully observes the client for signs of hemorrhage, which causes swelling and the compression of adjacent tissue. Laryngeal stridor is a harsh, high-pitched sound heard during inspiration and expiration that is caused by the compression of the trachea and leads to respiratory distress. It is an acute emergency situation that requires immediate attention to avoid the complete obstruction of the airway.

The nurse collects a urine specimen preoperatively from a child with epispadias who is scheduled for surgical repair. The nurse reviews the child's record for the laboratory results of the urine test and would most likely expect to note which finding? 1. Hematuria 2. Bacteriuria 3. Glucosuria 4. Proteinuria

2 Rationale: Epispadias is a congenital defect that involves the abnormal placement of the urethral orifice of the penis. In clients with this condition, the urethral opening is located anywhere on the dorsum of the penis. This anatomical characteristic leads to the easy access of bacterial entry into the urine. Options 1, 3, and 4 are not characteristically noted with this condition.

A client who has been newly diagnosed with diabetes mellitus has been stabilized with daily insulin injections. Which teaching information should the nurse reinforce upon discharge? 1. Keep insulin vials refrigerated at all times. 2. Rotate the insulin injection sites systematically. 3. Increase the amount of insulin before unusual exercise. 4. Monitor the urine acetone level to determine the insulin dosage.

2 Rationale: Insulin dosages should not be adjusted or increased before unusual exercise. If acetone is found in the urine, it may possibly indicate the need for additional insulin. To minimize the discomfort associated with insulin injections, the insulin should be administered at room temperature. Injection sites should be systematically rotated from one area to another. The client should be instructed to give injections in one area, about 1 inch apart, until the whole area has been used and then to change to another site. This prevents dramatic changes in daily insulin absorption.

Isoniazid is prescribed for a 2-year-old child with a positive tuberculin skin test. The mother of the child asks the nurse how long the child will need to take the medication. Which time frame is the appropriate response to the mother? 1. 4 months 2. 9 months 3. 12 months 4. 18 months

2 Rationale: Isoniazid is given to prevent TB infection from progressing to active disease. A chest x-ray film is obtained before the initiation of preventive therapy. In infants and children, the recommended duration of isoniazid therapy is 9 months. For children with human immunodeficiency virus infection, a minimum of 12 months is recommended.

The nurse is assisting with gathering admission assessment data on a 2-year-old child who has been diagnosed with nephrotic syndrome. The nurse collects data knowing that which is a common characteristic associated with nephrotic syndrome? 1. Hypotension 2. Generalized edema 3. Increased urinary output 4. Frank, bright red blood in the urine

2 Rationale: Nephrotic syndrome is defined as massive proteinuria, hypoalbuminemia, and edema. The urine is dark, foamy, and frothy, but microscopic hematuria may be present. Frank, bright red blood in the urine does not occur. Urine output is decreased and the blood pressure is normal or slightly decreased.

The nurse reviews the home care instructions with a parent of a 3-year-old with pertussis. Which statement by the parent indicates a need for further teaching? 1. "I know that my child will make a loud whooping sound." 2. "I understand this whooping cough is viral and I have to let it run its course." 3. "I understand that I need to watch for respiratory distress signs with pertussis." 4. "I can reduce the environmental factors that can trigger coughing, like dust and smoke."

2 Rationale: Pertussis is caused by the bacteria Bordetella pertussis and treatment requires antimicrobial therapy. Symptoms of pertussis consist of a respiratory infection followed by increased severity of cough with a loud whooping on inspiration. The child may experience respiratory distress, and the parents should be instructed on reducing environmental factors that cause coughing spasms, such as dust, smoke, and sudden changes in temperature.

The nurse is reviewing the postoperative prescriptions for an infant with hydrocephalus, who came back from surgery with a ventriculoperitoneal shunt. Which of the primary health care provider's prescriptions does the nurse question? 1. Position the infant on the inoperative side 2. Keep the head of the bed elevated 45 degrees 3. Monitor for signs of infection and check dressings for drainage 4. Observe for irritability, a high shrill cry, lethargy, and poor feeding

2 Rationale: Postoperative management for infants with hydrocephalus who have undergone ventriculoperitoneal shunt should be flat in bed to avoid the rapid reduction of intracranial fluid. Observe for increased ICP, if it occurs elevate the head of the bed to 15 to 30 degrees to enhance gravity flow through the shunt. Position the infant on the inoperative side to prevent pressure on the shunt valve. Monitor for signs of infection and check dressings for drainage. A high shrill cry in an infant can be a sign of increased ICP.

The nurse inspects the skin of a client who is suspected of having psoriasis. Which finding should the nurse note if this disorder is present? 1. Oily skin 2. Silvery-white scaly lesions 3. Patchy hair loss and round, red macules with scales 4. The presence of wheal patches scattered about the trunk

2 Rationale: Psoriatic patches are covered with silvery white scales. There is no patchy hair loss or round, red macules with scales. The skin is dry and there is no presence of wheal patches scattered about the trunk

The nurse reinforces teaching to a client with diabetes mellitus regarding differentiating between hypoglycemia and ketoacidosis. The client demonstrates an understanding of the teaching by stating that glucose will be taken if which symptom develops? 1. Polyuria 2. Shakiness 3. Blurred vision 4. Fruity breath odor

2 Rationale: Shakiness is a sign of hypoglycemia, and it would indicate the need for food or glucose. Fruity breath odor, blurred vision, and polyuria are signs of hyperglycemia.

The nurse reinforces instructions to the mother of a child with croup about the measures to take if an acute spasmodic episode occurs. Which statement by the mother indicates the need for further teaching? 1. "I will take my child out into the humid night air." 2. "I will place a steam vaporizer in my child's bedroom." 3. "I will place a cool-mist humidifier in my child's bedroom." 4. "I will place my child in a closed bathroom and allow my child to inhale steam from the running water."

2 Rationale: Steam from warm running water in a closed bathroom and cool mist from a bedside humidifier are effective for reducing mucosal edema. Cool-mist humidifiers are recommended compared with steam vaporizers, which present a danger of scalding burns. Taking the child out into the humid night air may also relieve mucosal swelling. Remember, however, that a cold mist may precipitate bronchospasm.

The nurse was caring for an infant who had come to the nursing unit for observation and treatment of tetralogy of Fallot. The child suddenly becomes cyanotic and the oxygen saturation reading drops to 60%. The nurse should perform which action first? 1. Assist to administer morphine sulfate 2. Place the child in a knee-chest position. 3. Administer 100% oxygen by face mask. 4. Prepare to administer intravenous fluids.

2 Rationale: The child who is cyanotic with oxygen saturations dropping to 60% is having a hypercyanotic episode. Hypercyanotic episodes often occur among infants with tetralogy of Fallot. If a hypercyanotic episode occurs, the infant is placed in a knee-chest position immediately. The knee-chest position improves systemic arterial oxygen saturation by decreasing venous return so that smaller amounts of highly saturated blood reach the heart. Additional interventions include administering 100% oxygen by face mask, morphine sulfate, and intravenous fluids, as prescribed.

The nurse reinforces home-care instructions to the parents of a child with hepatitis regarding the care of the child and the prevention of the transmission of the virus. Which statement by a parent indicates a need for further teaching? 1. "Frequent hand washing is important." 2. "I need to provide a well-balanced, high-fat diet to my child." 3. "I need to clean contaminated household surfaces with bleach." 4. "Diapers should not be changed near any surfaces that are used to prepare food."

2 Rationale: The child with hepatitis should consume a well-balanced, low-fat diet to allow the liver to rest. Options 1, 3, and 4 are components of the homecare instructions to the family of a child with hepatitis.

The nurse reinforces instructions to a group of clients regarding measures that will assist with the prevention of skin cancer. Which statement by a client indicates the need for further teaching? 1. "I need to wear sunscreen when participating in outdoor activities." 2. "I need to avoid sun exposure before 10:00 am and after 4:00 pm." 3. "I need to wear a hat, opaque clothing, and sunglasses when in the sun." 4. "I need to examine my body monthly for any lesions that may be suspicious."

2 Rationale: The client should be instructed to avoid sun exposure between the hours of approximately 10:00 am and 4:00 pm. Sunscreen, a hat, opaque clothing, and sunglasses should be worn for outdoor activities. The client should be instructed to examine the body monthly for the appearance of any possible cancerous or precancerous lesions.

The nurse has reinforced homecare instructions to the parent of a child who is being discharged after cardiac surgery. Which statement by the parent indicates the need for further teaching? 1. "A balance of rest and exercise is important." 2. "I can apply lotion or powder to the incision if it is itchy." 3. "Activities during which the child could fall need to be avoided for 2 to 4 weeks." 4. "Large crowds of people need to be avoided for at least 2 weeks after this surgery."

2 Rationale: The mother should be instructed that lotions and powders should not be applied to the incision site because these items can affect the skin integrity and the healing process. Options 1, 3, and 4 are accurate instructions regarding home care after cardiac surgery.

The nurse is reinforcing instructions to the parents of a child with scoliosis regarding the use of a brace. Which statement by a parent indicates the need for further teaching? 1. "I need to have my child wear a soft fabric under the brace." 2. "I will apply lotion under the brace to prevent skin breakdown." 3. "I need to encourage my child to perform the prescribed exercises." 4. "I need to avoid applying powder under the brace, because it will cake."

2 Rationale: The use of either lotions or powders should be avoided because they can become sticky or cake under the brace, thus causing irritation. Options 1, 3, and 4 are appropriate statements regarding the care of a child with a brace.

The nurse is assigned to care for a client with herpes zoster. Based on an understanding of the cause of this disorder, the nurse determines that this definitive diagnosis was made by which diagnostic test? 1. Positive patch test 2. Positive culture results 3. Abnormal biopsy results 4. Wood's light examination indicative of infection

2 Rationale: With the classic presentation of herpes zoster, the clinical examination is diagnostic. However, a viral culture of the lesion provides the definitive diagnosis. Herpes zoster (shingles) is caused by a reactivation of the varicella-zoster virus, the virus that causes chickenpox. A patch test is a skin test that involves the administration of an allergen to the surface of the skin to identify specific allergies. A biopsy would provide a cytological examination of tissue. In a Wood's light examination, the skin is viewed under ultraviolet light to identify superficial infections of the skin.

The medication prescribed is metoclopramide hydrochloride 10 mg intramuscularly times one dose. The medication label reads metoclopramide hydrochloride 5 mg/mL. The nurse prepares how much medication to administer the dose?

2 mL

The medication prescribed is digoxin 0.25 mg orally, daily. The medication label reads digoxin 0.125 mg/tablet. The nurse should prepare how many tablet(s) to administer the dose?

2 tablet(s)

The medication prescribed is levodopa 1 g orally, daily. The medication label states levodopa, 500-mg tablets. The nurse prepares to administer how many tablets at the evening dose?

2 tablet(s)

A child with rubeola (measles) is being admitted to the hospital. When preparing for the admission of the child, which precautions should be implemented? Select all that Apply. 1. Enteric 2. Contact 3. Airborne 4. Protectiveicon 5. Neutropenic

2, 3 Rationale: Rubeola is transmitted via airborne particles or direct contact with infectious droplets. Airborne precautions and contact precautions are required; a mask and gloves are worn by those who come in contact with the child. Gowns and gloves are not indicated. Articles that are contaminated should be bagged and labeled. Options 1, 4, and 5 are not indicated for rubeola.

The nurse caring for an infant with congenital heart disease is monitoring the infant closely for signs of heart failure (HF). The nurse should observe for which early sign of HF? Select all that apply. 1. Cough 2. Irritability 3. Scalp diaphoresis 4. Tachypnea, tachycardia 5. Slow and shallow breathing

2, 3, 4 Rationale: The early signs of HF include tachycardia, tachypnea, profuse scalp sweating, fatigue, irritability, sudden weight gain, and respiratory distress. A cough may occur with HF as a result of mucosal swelling and irritation, but it is not an early sign. Slow and shallow breathing is not associated with heart failure.

The nurse is assigned to care for a child who is scheduled for an appendectomy. Which prescriptions does the nurse anticipate to be prescribed? Select all that apply. 1. Administer a Fleet enema. 2. Initiate an intravenous line. 3. Maintain nothing-by-mouth status. 4. Administer intravenous antibiotics. 5. Administer preoperative medications. 6. Place a heating pad on the abdomen to decrease pain.

2, 3, 4, 5 Rationale: During the preoperative period, enemas or laxatives should not be administered. In addition, heat should not be applied to the abdomen. Any of these interventions can cause the rupture of the appendix and resultant peritonitis. Intravenous fluids would be started, and the child should receive nothing by mouth while awaiting surgery. Antibiotics are usually administered because of the risk of perforation. Preoperative medications are administered as prescribed.

. The nurse is reinforcing home-care instructions to a client and family regarding care after left cataract surgery with lens implant. Which statements made by the client indicate an understanding of the instructions? Select all that apply. 1. "I will bend over to tie my shoes." 2. "I will not sleep lying on my left side." 3. "I will sit at the table to eat breakfast." 4. "I will sit in my recliner with my feet elevated." 5. "I will not lift anything heavier than 10 pounds." 6. "I will resume my exercise routine including pushups."

2, 3, 4, 5; Rationale: After cataract surgery, the client should not assume positions that will increase the intraocular pressure. This could lead to injury to the surgical site and damage the lens implant. The client should not sleep on the side of the body that was operated on. The client may resume activities such as sitting upright at a table or sitting in a recliner with the feet elevated. The client should not lift anything heavier than 10 lbs. The client should not perform activities that would increase the pressure within the eye, such as bending over to tie shoes or performing pushups.

The nurse notes the physical assessment findings for a client with a diagnosis of possible meningitis. Which findings should the nurse expect to observe because of meningeal irritation? Select all that apply. 1. Pupils are unequal and react slowly to light. 2. The client reports stiffness and soreness in the neck area. 3. The client reports pain in the vertebral column and passively flexes the hip and knee in response to neck flexion. 4. The client flexes a leg at the hip and knee and reports pain in the vertebral column when the leg is extended.

2, 3, 4; Rationale: Meningitis is the inflammation of the meninges, the membranes covering the brain and spinal cord. It is caused by organisms such as bacteria, viruses, or fungi. The client with meningitis experiences discomfort when pressure is placed on certain areas that irritate the inflamed meninges. Neck stiffness (nuchal rigidity) is an early sign of meningitis. A positive Brudzinski's sign is observed if the supine client passively flexes the hip and knee in response to neck flexion by the examiner and the client reports pain in the vertebral column. Kernig's sign also tests for meningeal irritation and is positive when the client flexes the legs at the hip and knee and complains of pain along the vertebral column when the leg is extended. Unequal pupils and slowed pupillary response to light is a sign of increased intracranial pressure. This may occur in clients who are critically ill, but it is not a sign of meningeal irritation. Decorticate posturing is abnormal flexion and is noted when the client's upper arms are flexed and held tightly to the sides of the body and the legs are extended and internally rotated. This posturing occurs with severe brain damage and the client requires emergency medical attention.

The health education nurse provides instructions to a group of clients regarding measures that will assist with preventing skin cancer. Which instructions should the nurse provide? Select all that apply. 1. Sunscreen should be applied every 8 hours. 2. Use sunscreen when participating in outdoor activities. 3. Wear a hat, opaque clothing, and sunglasses when in the sun. 4. Avoid sun exposure in the late afternoon and early evening hours. 5. Examine your body monthly for any lesions that may be suspicious.

2, 3, 5; Rationale: The client should be instructed to avoid sun exposure between the hours of brightest sunlight: 10 AM to 4 PM. Sunscreen, a hat, opaque clothing, and sunglasses should be worn for outdoor activities. The client should be instructed to examine the body monthly for the appearance of any cancerous or precancerous lesions. Sunscreen should be reapplied every 2 to 3 hours and after swimming or sweating; otherwise, the duration of protection is reduced.

The nurse obtains the vital signs on a postoperative client who just returned to the nursing unit. The client's blood pressure (BP) is 100/60 mm Hg, the pulse is 90 beats per minute, and the respiration rate is 20 breaths per minute. On the basis of these findings, which actions should the nurse take? Select all that apply. 1. Ask if the client is thirsty and assist with drinking a glass of water. 2. Ask how the client feels and inquire about any feelings of dizziness. 3. Review the client record to determine time and type of analgesia last received. 4. Review the client record to determine whether the client has voided postoperatively. 5. Assist the client to perform leg exercises and then recheck the blood pressure and pulse rate. 6. Review the client record to note the vital signs taken in the Post Anesthesia Care Unit (PACU).

2, 3, 6 Rationale: In a clinical situation, the nurse must evaluate the vital signs of each postoperative client individually. If complications such as hemorrhage or shock are developing, early intervention is extremely important. Determining how the client feels and asking about dizziness lets the nurse evaluate how the client is tolerating these vital signs. Accessing the medical record to determine the most recent analgesic administration is pertinent because hypotension is a frequent side/adverse effect of analgesics, especially opioids. Reviewing the client's record gives the nurse data on the client's vital signs during and after surgery in the PACU, and the nurse can evaluate whether there has been a change. Giving the client oral fluids is an intervention if the client has a fluid volume deficit and this has not been established. Oral fluids would not correct the problem as quickly as administering IV fluids would. Collecting data about the client voiding is not directly related to the vital signs. Encouraging leg exercises is a correct postoperative intervention, but is not appropriate for evaluating the vital signs.

The nurse caring for a child who sustained a burn injury plans care based on which pediatric considerations associated with this injury? Select all that apply. 1. Scarring is less severe in a child than in an adult. 2. A delay in growth may occur after a burn injury. 3. An immature immune system presents an increased risk of infection for infants and young children. 4. Fluid resuscitation is unnecessary unless the burned area is more than 25% of the total body surface area. 5. The lower proportion of body fluid to body mass in a child increases the risk of cardiovascular problems. 6. Infants and young children are at increased risk for protein and calorie deficiency because they have smaller muscle mass and less body fat than adults.

2, 3, 6; Rationale: Pediatric considerations in the care of a burn victim include the following: Scarring is more severe in a child than in an adult. A delay in growth may occur after a burn injury. An immature immune system presents an increased risk of infection for infants and young children. The higher proportion of body fluid to body mass in a child increases the risk of cardiovascular problems. Burns involving more than 10% of total body surface area require some form of fluid resuscitation. Infants and young children are at increased risk for protein and calorie deficiencies because they have smaller muscle mass and less body fat than adults.

The nurse is checking a client's surgical incision and notes an increase in the amount of drainage, a separation of the incision line, and the appearance of underlying tissue. Which actions should the nurse take to deal with this event? Select all that apply. 1. Turn the client to the side with the knees bent. 2. Apply a sterile dressing soaked with normal saline to the wound. 3. Notify the registered nurse (RN) and primary health care provider (PHCP) at once. 4. Explain to the client that obesity is a risk factor and weight loss should be a future goal 5. Gently explore the wound with a cotton-tipped applicator to determine whether evisceration has occurred.

2, 3; Rationale: Wound dehiscence is the separation of the wound edges at the suture line. Signs and symptoms include increased drainage and the appearance of underlying tissues. It usually occurs as a complication 6 to 8 days after surgery. The client should be instructed to remain quiet and avoid coughing or straining, and he or she should be positioned to prevent further stress on the wound. Sterile dressings soaked with sterile normal saline should be used to cover the wound. The registered nurse (RN) and primary health care provider (PHCP) need to be notified. The client should assume a low Fowlers position with knees bent to avoid further stress on the incision. Obesity is a risk factor for dehiscence, but now is not the appropriate time for this teaching. The nurse should not explore the incision because this may actually cause evisceration, a more serious complication.

A pregnant client is receiving magnesium sulfate for the management of preeclampsia. The nurse determines that the client is experiencing toxicity from the medication if which findings are noted during assessment? Select all that apply. 1. Proteinuria of 3 + 2. Respirations of 10 breaths/minute 3. Presence of deep tendon reflexes 4. Urine output of 20 mL in an hour 5. Serum magnesium level of 6 mEq/L (3 mmol/L)

2, 4 Rationale: Magnesium toxicity can occur from magnesium sulfate therapy. Signs of magnesium sulfate toxicity relate to the central nervous system depressant effects of the medication and include respiratory depression, loss of deep tendon reflexes, and a sudden decline in fetal heart rate and maternal heart rate and blood pressure. Urine output should be at least 25 mL to 30 mL per hour. Therapeutic serum levels of magnesium are 4 mEq/L to 7 mEq/L (2 to 3.5 mmol/L). Proteinuria of 3 + is an expected finding in a client with preeclampsia.

The nurse checks the postoperative client for signs of infection. Which observations are indicative of a potential infection? Select all that apply. 1. Slight redness along the incision 2. The presence of purulent drainage 3. A temperature of 98.8° F (37.1° C) 4. The client states that he feels cold. 5. The client states that the incision itches. 6. Tender firmness palpable around the incision

2, 6; Rationale: A wound infection occurs when healing is delayed and pathogens such as bacteria grow in the wound. Signs and symptoms of a wound infection include warmth, redness, swelling, and tenderness of skin around the incision. The client may have fever and chills. Purulent material may exit from drains or from separated wound edges. Infection may be caused by poor aseptic technique or a wound that was contaminated before surgical exploration; it appears 3 to 6 days after surgery. Slight redness along an incision is a sign of inflammation and should be monitored to determine whether it progresses. A temperature of 98.8° F (37.1° C) is not an abnormal finding in a postoperative client. Itching around a wound may be from irritation or dryness and is not associated with infection. The fact that a client feels cold is not indicative of an infection, although chills and fever are signs of infection. The room temperature may be too cold for client comfort.

A LPN is preparing to assist a RN with removing a nasogastric tube from the client. Which interventions should be included in the procedure? Select all that apply. 1. Remove the air from the balloon. 2. Explain the procedure to the client. 3. Ask the client to take a deep breath and hold. 4. Pull the tube out in one continuous steady motion. 5. Remove the device or tape securing the tube from the nose.

2,3,4,5; Rationale: Before removing the tube, the client should be told about the procedure and review the instructions. The tape or securing device needs to be removed from the client's nose. When the NG tube is removed, the client is instructed to take and hold a deep breath. This will close the epiglottis, and the airway will be temporarily obstructed during the tube removal. This allows for the easy withdrawal of the tube through the esophagus into the nose. The tube is removed with one very smooth, continuous pull. There is no balloon that needs to be deflated on a NG tube.

The nurse is assisting in planning care for a client with a chest tube. The nurse should suggest to include which interventions in the plan? Select all that apply. 1. Pin the tubing to the bed linens. 2. Be sure all connections remain airtight. 3. Be sure all connections are taped and secure. 4. Monitor closely for tubing that is kinked or obstructed. 5. Empty the drainage from the drainage collection chamber daily.

2,3,4; Rationale: The chest tube system must be maintained as a closed system in order for the air to be removed by suction and for the lungs to reexpand to a normal state. The connections should be air tight (no leaks), and all connections should be tapes and secure. It is important that the tubes to the suction and the tubes without kinks or obstructions. Chest-tube tubing is never pinned to the bed linens because this presents the risk of accidental dislodgment of the tube when the client moves. The chest tube system is not opened and emptied because a closed system must be maintained; if the system is opened, air pressure causes air to rush in, and lung collapse can occur.

The nurse is assigned to assist the primary health care provider with the removal of a chest tube. Which interventions should the nurse anticipate performing during this process? Select all that apply. 1. Reinforce instructions to breathe deeply while the tube is removed. 2. Cover the site with an occlusive dressing after the tube is removed. 3. Clamp the chest tube near the insertion site just before the removal. 4. Raise the drainage system to the level of the chest tube insertion site. 5. Have the client perform the Valsalva maneuver as the chest tube is pulled out.

2,5; Rationale: A chest tube is removed when the lung has fully reexpanded or there is limited drainage. When the chest tube is removed, the client is asked to perform a Valsalva maneuver, the tube is quickly withdrawn, and an occlusive dressing is taped in place. An alternative instruction is to ask the client to take a deep breath and hold the breath while the tube is removed. After the tube is removed, the client should take deep breaths to ensure adequate lung expansion. The tube is not usually clamped before it is removed, and the drainage apparatus must always be lower than the chest tube site.

A contraction stress test is scheduled for the client. The woman asks the nurse about the test. Which response describes the most accurate description of the test? 1. "Uterine contractions are stimulated by Leopold's maneuvers." 2. "The uterus is stimulated to contract by either small amounts of oxytocin or by nipple stimulation." 3. "An internal fetal monitor is attached, and you will walk on a treadmill until contractions begin." 4. "Small amounts of oxytocin are administered during internal fetal monitoring to stimulate uterine contractions."

2; Rationale: A contraction stress test assesses placental oxygenation and function and determines the fetus's ability to tolerate labor, as well as its well-being. The test is performed if the nonstress test result is abnormal. During the stress test, the fetus is exposed to the stressor of contractions to assess the adequacy of placental perfusion under simulated labor conditions. An external fetal monitor is applied to the mother, and a 20- to 30-minute baseline strip is recorded. The uterus is stimulated to contract, either by the administration of a dilute dose of oxytocin or by having the mother use nipple stimulation, until three palpable contractions with a duration of 40 seconds or more during a 10-minute period have occurred.

The nurse has a teaching session with a malnourished client regarding iron supplementation to prevent anemia during pregnancy. Which statement indicates successful learning? 1. "Iron supplements will give me diarrhea." 2. "The iron is needed for the red blood cells." 3. "Meat does not provide iron and should be avoided." 4. "My body has all the iron it needs and I don't need to take supplements."

2; Rationale: A nutritional supplement that is commonly needed during pregnancy for the red blood cells is iron. Anemia in pregnancy is primarily caused by iron deficiency. Iron supplements usually cause constipation. Meats are an excellent source of iron. Iron for the fetus comes from the maternal serum.

The nurse is caring for an older client who is reminiscing about past life experiences in a positive manner. The nurse plans care with the understanding that this behavior indicates which? 1. A mental status alteration 2. A normal psychosocial response 3. A need for psychiatric consultation 4. A sensory deficit requiring social activities

2; Rationale: According to Erikson, the later years of life are from 65 years of age until death. The adult reminisces about past life experiences, often viewing them in a positive way. The adult needs to feel good about his or her accomplishments, see successes in his or her life, and feel that he or she has made a contribution to society.

After delivery the nurse checks the height of the uterine fundus. Which position of the fundus should the nurse expect to note? 1. To the right of the abdomen 2. At the level of the umbilicus 3. About 4 cm above the level of the umbilicus 4. One fingerbreadth above the symphysis pubis

2; Rationale: After delivery, the uterine fundus should be at the level of the umbilicus or 1 to 3 fingerbreadths below it and in the midline of the abdomen. If the fundus is 4 cm above the umbilicus, this may indicate that there are blood clots in the uterus that need to be expelled by fundal massage. If the fundus is noted to the right of the abdomen, it may indicate a full bladder. By about 10 days postpartum, the uterus will be in the symphysis pubis area.

A client in preterm labor (31 weeks) who is dilated to 4 cm has been started on magnesium sulfate and her contractions have stopped. If the client's labor can be inhibited for the next 48 hours, the nurse anticipates a prescription for which medication? 1. Nalbuphine 2. Betamethasone 3. Rho(D) immune globulin 4. Dinoprostone vaginal insert

2; Rationale: Betamethasone, a glucocorticoid, is given to increase the production of surfactant to stimulate fetal lung maturation. It is administered to clients in preterm labor at 28 to 32 weeks of gestation if the labor can be inhibited for 48 hours. Nalbuphine is an opioid analgesic. Rho(D) immune globulin is given to Rh-negative clients to prevent sensitization. Dinoprostone vaginal insert is a prostaglandin given to ripen and soften the cervix and to stimulate uterine contractions.

The nurse is describing the process of fetal circulation to a client during a prenatal visit. The nurse should tell the client that fetal circulation consists of which components? 1. Two umbilical veins and one umbilical artery 2. Two umbilical arteries and one umbilical vein 3. Arteries that carry oxygenated blood to the fetus 4. Veins that carry deoxygenated blood to the fetus

2; Rationale: Blood pumped by the fetus's heart leaves the fetus through two umbilical arteries. After the blood is oxygenated, it is then returned by one umbilical vein. The umbilical arteries carry deoxygenated blood and waste products from the fetus, and the umbilical vein carries oxygenated blood and provides oxygen and nutrients to the fetus

The nurse is reinforcing instructions to a pregnant client regarding measures to prevent heartburn. The nurse should instruct the client to take which best measure? 1. Eliminate between-meal snacks. 2. Drink decaffeinated coffee and tea. 3. Lie down for 30 minutes after eating. 4. Substitute salt in cooking for other spices.

2; Rationale: Caffeine, like spices, may cause heartburn and needs to be avoided. Spices tend to trigger heartburn. Eating smaller, more frequent portions is preferable to eating three large meals to control heartburn. Lying down after meals is likely to lead to the reflux of stomach contents and cause heartburn. Salt leads to the retention of fluid.

The nurse is caring for a client after a mastectomy. Which finding would indicate that the client is experiencing a complication that may become a chronic problem related to the surgery? 1. Pain at the incisional site 2. Arm edema on the operative side 3. Sanguineous drainage in the Jackson Pratt drain 4. Complaints of decreased sensation near the operative site

2; Rationale: Clients who undergo mastectomy for breast cancer, especially those with axillary node resection, may develop chronic lymphedema or excessive swelling in the arm and hand. Lymphedema is a complication that may develop immediately after mastectomy, months, or even years after surgery. Slight edema may occur in the immediate postoperative period, but should decrease especially if the client rests with the arm supported on a pillow. Women should avoid injury to the arm on the affected side and not allow venipunctures or blood pressures to be taken in that arm.

The nurse is monitoring for bleeding in a child after surgery to remove a brain tumor. The nurse checks the head dressing for the presence of blood and notes a colorless drainage on the back of the dressing. Which nursing action is appropriate? 1. Reinforce the dressing. 2. Notify the registered nurse (RN). 3. Document the findings and continue to monitor. 4. Circle the area of drainage and continue to monitor.

2; Rationale: Colorless drainage on the dressing would indicate the presence of cerebrospinal fluid and should be reported to the RN immediately; the RN would then contact the primary health care provider. The colorless drainage should also be checked for evidence of cerebrospinal fluid; one method is to check for the presence of glucose using a dipstick. Options 1, 3, and 4 are incorrect and delay required immediate interventions.

The perinatal client is admitted to the obstetrical unit during an exacerbation of a heart condition. When planning for the nutritional requirements of the client, the nurse should consult with the dietitian to ensure which dietary measure? 1. A low-calorie diet to ensure the absence of weight gain 2. A diet that is high in fluids and fiber to decrease constipation 3. A diet that is low in fluids and fiber to decrease blood volume 4. Unlimited sodium intake to increase the circulating blood volume

2; Rationale: Constipation causes the client to use Valsalva's maneuver. This causes blood to rush to the heart and overload the cardiac system. The absence of weight gain is not recommended during pregnancy. Diets that are low in fluid and fiber cause a decrease in blood volume, which in turn deprives the fetus of nutrients. Too much sodium could cause an overload to the circulating blood volume and contribute to the cardiac condition.

The emergency department nurse receives a telephone call and is informed that a tornado has hit a local residential area and numerous casualties have occurred. The victims will be brought to the emergency department. Which should be the initial nursing action? 1. Prepare the triage rooms. 2. Activate the agency emergency response plan. 3. Obtain additional supplies from the central supply department. 4. Obtain additional nursing staff to assist with treating the casualties.

2; Rationale: During a widespread disaster, many people will be brought to the emergency department for treatment. Health care institutions are required to have an emergency response plan in place and perform practice drills. The initial nursing action should be to activate the emergency response plan. The plan entails the other options, which include preparing triage rooms to take casualties, and obtaining sufficient supplies and medical personnel.

212. The nurse is collecting data from a pregnant client who is currently at 28 weeks' gestation. At her prior prenatal visit, her fundal height measured 22 cm. The nurse measures the fundal height at this visit in centimeters and should expect which finding? 1. 22 cm 2. 26 cm 3. 32 cm 4. 40 cm

2; Rationale: During the second and third trimesters (18-30 weeks' gestation), the fundal height in centimeters approximately equals the fetus's age in weeks plus or minus 2 cm. In addition, at this point in the pregnancy, in a 4 week period, the fundal height should increase approximately 4 cm. At 14 to 16 weeks' gestation, the fundus can be located halfway between the symphysis pubis and the umbilicus. At 20 to 22 weeks' gestation, the fundus is at the umbilicus, and at term, the fundus is at the xiphoid process.

A woman in active labor has contractions every 2 to 3 minutes that last for 45 seconds. The fetal heart rate between contractions is 100 beats per minute. On the basis of these findings which is the priority nursing action? 1. Monitor the maternal vital signs. 2. Notify the registered nurse (RN) immediately. 3. Continue monitoring labor and the fetal heart rate. 4. Encourage relaxation and breathing techniques between contractions.

2; Rationale: Fetal bradycardia between contractions may indicate the need for immediate medical management. The nurse should immediately contact the RN, who then contacts the health care provider. Monitoring maternal vital signs, labor progress, and encouraging relaxation and breathing techniques will delay necessary and immediate interventions.

The nursing instructor asks a student nurse to describe osteogenic sarcoma. Which statement by the student indicates the need to further research the disease? 1. "The femur is the most common site of this sarcoma." 2. "The child does not experience pain at the primary tumor site." 3. "If a weight-bearing limb is affected, then limping is a clinical manifestation." 4. "The symptoms of the disease during the early stage are almost always attributed to normal growing pains."

2; Rationale: Osteogenic sarcoma is the most common bone tumor in children. A clinical manifestation of osteogenic sarcoma is progressive, insidious, intermittent pain at the tumor site. By the time these children receive medical attention, they may be in considerable pain from the tumor. Options 1, 3, and 4 are accurate regarding osteogenic sarcoma.

The client is admitted to the labor suite complaining of painless vaginal bleeding. The nurse assists with the examination of the client, knowing that which routine labor procedure is contraindicated? 1. Leopold's maneuvers 2. A manual pelvic examination 3. Hemoglobin and hematocrit evaluation 4. External electronic fetal heart rate monitoring

2; Rationale: Painless vaginal bleeding is a sign of possible placenta previa. Digital examination of the cervix is contraindicated because it can lead to maternal and fetal hemorrhage. Leopold's maneuvers can reveal a nonengaged presenting part or malpresentation, both of which often accompany placenta previa because of the placenta filling the lower uterine segment. Hemoglobin and hematocrit values help estimate the amount of blood loss. External electronic fetal monitoring is crucial for evaluating the status of the fetus, which is at risk for severe hypoxia. Options 1, 3, and 4 are procedures that would not place the client at further risk.

The nurse is assigned to assist with caring for a client who has been admitted to the labor unit. The client is 9 cm dilated and is experiencing precipitous labor. Which is the priority nursing action? 1. Prepare for an oxytocin infusion. 2. Keep the client in a side-lying position. 3. Prepare the client for epidural anesthesia. 4. Encourage the client to start pushing with the contractions

2; Rationale: Precipitous labor progresses quickly, with frequent contractions and short periods of relaxation between them. This does not allow for the maximal reperfusion of the placenta with oxygenated blood. Priority care of this client includes the promotion of fetal oxygenation. A side-lying position can assist with providing blood flow to the uterus by preventing vena cava and abdominal aorta compression. Further stimulation with oxytocin is contraindicated. There may not be enough time to administer epidural anesthesia before delivery with such quick progression. Pushing with contractions is not indicated, especially with this type of labor. The controlled delivery of the fetus is essential to prevent maternal and fetal injury.

The nurse is collecting data from a client who is pregnant with twins. The client has a healthy 5-year-old child who was delivered at 38 weeks, and she tells the nurse that she does not have a history of any type of abortion or fetal demise. The nurse should document which as the GTPAL for this client? 1. G = 3, T = 2, P = 0, A = 0, L = 1 2. G = 2, T = 1, P = 0, A = 0, L = 1 3. G = 1, T = 1, P = 1, A = 0, L = 1 4. G = 2, T = 0, P = 0, A = 0, L = 1

2; Rationale: Pregnancy outcomes can be described with the GTPAL acronym: G = gravidity (number of pregnancies); T = term births (number born after 37 weeks); P = preterm births (number born before 37 weeks' gestation); A = abortions/miscarriages (number of abortions/miscarriages); L = live births (number of live births or living children). Therefore, a woman who is pregnant with twins and who already has a child has a gravida of 2. Because the child was delivered at 38 weeks, the number of preterm births is 0, and the number of term births is 1. The number of abortions is 0, and the number of live births is 1.

The nurse is caring for a client who is in labor. The nurse rechecks the client's blood pressure and notes that it has dropped. To decrease the incidence of supine hypotension, the nurse should encourage the client to remain in which position? 1. Squatting 2. Side-lying 3. Tailor sitting 4. Semi-Fowler's

2; Rationale: Pressure from the enlarged uterus on the aorta and the vena cava when the woman is supine can result in hypotension. This can be relieved by having the woman lie on her side. Squatting, tailor sitting and semi-Fowler's position are incorrect because they would not prevent hypotension.

The nurse is preparing to administer beractant to a premature infant who has respiratory distress syndrome. The nurse plans to administer the medication by which route? 1. Intradermal 2. Intratracheal 3. Subcutaneous 4. Intramuscular

2; Rationale: Respiratory distress syndrome is a serious lung disorder caused by immaturity and the inability to produce surfactant, resulting in hypoxia and acidosis. It is common in premature infants and may occur as a result of lung immaturity caused by surfactant deficiency. The mainstay of treatment is the administration of exogenous surfactant, which is administered by the intratracheal route. Options 1, 3, and 4 are not routes of administration for this medication.

A couple comes to the family planning clinic and asks about sterilization procedures. Which question by the nurse helps determine whether this method of family planning is appropriate? 1. "Have either of you ever had surgery?" 2. "Do you plan to have any other children?" 3. "Do either of you have diabetes mellitus?" 4. "Do either of you have problems with high blood pressure?"

2; Rationale: Sterilization is a method of contraception for couples who have completed their families. It should be considered a permanent end to fertility because reversal surgery is not always successful. The nurse would ask the couple about their plans for having children in the future. Options 1, 3, and 4 are unrelated to this procedure

The nurse is assisting with caring for a client who is receiving intravenous fluids and who has sustained full-thickness burn injuries of the back and legs. The nurse understands that which would provide the most reliable indicator for determining the adequacy of the fluid resuscitation? 1. Vital signs 2. Urine output 3. Mental status 4. Peripheral pulses

2; Rationale: Successful or adequate fluid resuscitation in the adult is signaled by stable vital signs, adequate urine output, palpable peripheral pulses, and a clear sensorium. The most reliable indicator for determining the adequacy of fluid resuscitation is the urine output. For an adult, the hourly urine volume should be 30 mL to 50 mL.

The client with metastatic breast cancer is receiving tamoxifen. The nurse specifically monitors which laboratory value while the client is taking this medication? 1. Glucose level 2. Calcium level 3. Potassium level 4. Prothrombin time

2; Rationale: Tamoxifen may increase calcium, cholesterol, and triglyceride levels. Before the initiation of therapy, a complete blood count, platelet count, and serum calcium levels should be assessed. These blood levels, along with cholesterol and triglyceride levels, should be monitored periodically during therapy. The nurse should assess for hypercalcemia while the client is taking this medication. Signs of hypercalcemia include increased urine volume, excessive thirst, nausea, vomiting, constipation, hypotonicity of muscles, and deep bone and flank pain. Tamoxifen does not increase glucose or potassium levels, or increase the prothrombin time.

Upon palpation of the fontanel of a 3-month-old newborn, the nurse notes that the anterior fontanel has not closed and is soft and flat. Which action should the nurse take? 1. Increase oral fluids. 2. Document the findings. 3. Notify the registered nurse. 4. Elevate the head of the bed to 90 degrees.

2; Rationale: The anterior fontanel is diamond shaped and located on the top of the head. It should be soft and flat in a normal infant, and it normally closes by 12 to 18 months of age. The posterior fontanel closes by 2 to 3 months of age. Therefore, because the findings are normal, the nurse should document the findings.

The nurse in the newborn nursery receives a telephone call to prepare for the admission of a neonate born at 43 weeks' gestation with Apgar scores of 1 and 4. When planning for the admission of this infant, which is the nurse's highest priority? 1. Turning on the apnea and cardiorespiratory monitor 2. Connecting the resuscitation bag to the oxygen outlet 3. Setting up the intravenous line with 5% dextrose in water 4. Setting the radiant warmer control temperature at 36.5° C (97.6° F)

2; Rationale: The highest priority during the admission to the nursery of a newborn with low Apgar scores is airway support, which would involve preparing respiratory resuscitation equipment. The remaining options are also important, although they are of lower initial priority. The newborn infant will be placed on a cardiorespiratory monitor. Setting up an intravenous line with 5% dextrose in water would provide circulatory support and may be prescribed. The radiant warmer will provide an external heat source, which is necessary to prevent further respiratory distress.

A pregnant human immunodeficiency virus (HIV)-positive woman delivers a baby. The nurse provides guidance to help the client make decisions regarding newborn care. Which statement by the woman indicates that additional guidance is needed? 1. "I will be sure to wash my hands before feeding the newborn." 2. "I will breastfeed, especially for the first 6 weeks postpartum." 3. "I will be sure to wash my hands before and after bathroom use." 4. "I will administer the prescribed antiviral medication to the newborn for the first 6 weeks after delivery."

2; Rationale: The mode of perinatal transmission of HIV to the fetus or neonate of an HIV-positive woman can occur during the antenatal, intrapartal, or postpartum periods. HIV transmission can occur during breastfeeding; thus, HIV-positive clients need to bottle-feed their neonates. Antiviral medications will be prescribed for the neonate for the first 6 weeks of life. The principles related to hand washing need to be taught to the mother.

The nurse is assisting in caring for a post-term neonate immediately after admission to the nursery. The priority nursing action should be to monitor which clinical parameter? 1. Urinary output 2. Blood glucose level 3. Total bilirubin level 4. Hemoglobin and hematocrit levels

2; Rationale: The most common metabolic complication in the post-term newborn is hypoglycemia, which can produce central nervous system abnormalities and cognitive impairment if it is not corrected immediately. Urinary output, although important, is not the highest priority action. The polycythemia contributes to increased bilirubin levels, usually beginning on the second day after delivery. Hemoglobin and hematocrit levels are monitored, because the post-term neonate may exhibit polycythemia; however, this also does not require immediate attention.

The nurse is assigned to assist with caring for a neonate born to a mother who is human immunodeficiency virus (HIV)-positive. The nurse understands that which should be included in the plan of care? 1. Monitoring the neonate's vital signs routinely 2. Maintaining standard precautions at all times while caring for the neonate 3. Instructing breastfeeding mothers regarding the treatment of their nipples with an antifungal cream 4. Initiating a referral to evaluate for blindness, deafness, learning, or behavioral problems in the neonate

2; Rationale: The neonate born to a mother who is HIV-positive must be cared for with strict attention to standard precautions. This prevents the transmission of the infection from the neonate, if he or she is infected, to others, and it prevents the transmission of other infectious agents to the possibly immunocompromised neonate. The mother should not breastfeed, unless the primary health care provider has specific recommendations about doing so. Monitoring vital signs and referring for sensory/cognitive problems are not care measures specifically associated with the care of a potentially AIDS-infected neonate.

The nurse obtains a prescription to restrain a client using a belt (safety) restraint and instructs the unlicensed assistive personnel (UAP) to apply the restraint. Which observation, if made by the nurse, indicates unsafe application of the restraint? 1. A safety knot is made in the restraint strap. 2. The restraint straps are safely secured to the side rails. 3. The restraint strap does not tighten when force is applied against it. 4. The restraint is secure, and the client is able to turn from back to side.

2; Rationale: The restraint strap is secured to the bed frame (never to the side rail) to avoid accidental injury in case the side rail is released. The nurse recognizes that tying the strap to the side rail is not correct and unsafe. A half-bow or safety knot should be used when applying a restraint, because it does not tighten when force is applied against it and allows for the quick and easy removal of the restraint in case of an emergency. The belt restraint should be secure, and one to two fingers should easily slide between the restraint and the client's skin. The client should be able to turn from back to side while in the restraint. A purpose of a restraint is to remind the client not to get out of bed alone.

The nurse reinforces instructions to the parents of a child with leukemia regarding measures related to monitoring for infection. Which statement by the parents indicates the need for further teaching? 1. "I need to use proper hand-washing techniques." 2. "I need to take my child's rectal temperature daily." 3. "I need to inspect my child's skin daily for redness." 4. "I need to inspect my child's mouth daily for lesions."

2; Rationale: The risk of injury to the fragile mucous membranes is so great in the child with leukemia that only oral, axillary, or temporal or tympanic temperatures should be taken. Rectal abscesses can easily occur in damaged rectal tissue, so no rectal temperatures should be taken. In addition, oral temperatures should be avoided if the child has oral ulcers. Options 1, 3, and 4 are appropriate teaching measures.

The nursing student is preparing a conference on Freud's psychosexual stages of development, specifically the anal stage. Which appropriately relates to this stage? 1. Gratification of self 2. Beginning of toilet training 3. Tapering off of conscious biological and sexual urges 4. Association with pleasurable and conflicting feelings about the genital organs

2; Rationale: Toilet training generally occurs during this period. According to Freud, the child gains pleasure from both the elimination and retention of feces. Self-gratification relates to the oral stage. Tapering off of conscious biological and sexual urges relates to the latency period. Association with pleasurable and conflicting feelings about genital organs relates to the phallic stage.

When caring for a 3-year-old child, the nurse should provide which toy for the child? 1. A puzzle 2. A wagon 3. A golf set 4. A miniature farm set

2; Rationale: Toys for the toddler must be strong, safe, and too large to swallow or place in the ear or nose. Toddlers need supervision at all times. Push-pull toys, large balls, large crayons, trucks, and dolls are some appropriate toys. A puzzle, with large pieces only, may be appropriate. A miniature farm set and a golf set may contain items that the child could swallow.

The nurse is assigned to assist with caring for a client with abruptio placentae who is experiencing vaginal bleeding. The nurse collects data from the client, knowing that abruptio placentae is accompanied by which additional finding? 1. Soft abdomen on palpation 2. Uterine tenderness on palpation 3. No complaints of abdominal pain 4. Lack of uterine irritability or tetanic contractions

2; Rationale: Vaginal bleeding in a pregnant client is most often caused by placenta previa or a placental abruption. Uterine tenderness accompanies abruptio placentae, especially with a central abruption and trapped blood behind the placenta. The abdomen will feel hard and board-like during palpation as the blood penetrates the myometrium and causes uterine irritability. A sustained tetanic contraction can occur if the client is in labor and the uterine muscle cannot relax.

Isotretinoin is prescribed for a client with severe acne. Before the administration of this medication, the nurse anticipates that which laboratory test will be prescribed? 1. Potassium level 2. Triglyceride level 3. Hemoglobin A1C 4. Total cholesterol level

2;Rationale: Isotretinoin can elevate triglyceride levels. Blood triglyceride levels should be measured before treatment and periodically thereafter until the effect on triglycerides has been evaluated. There is no indication that isotretinoin affects potassium, hemoglobin A1C, or total cholesterol levels

Which laboratory result would verify the diagnosis of bacterial meningitis? 1. Clear cerebrospinal fluid with high protein and low glucose levels 2. Cloudy cerebrospinal fluid with low protein and low glucose levels 3. Cloudy cerebrospinal fluid with high protein and low glucose levels 4. Decreased pressure and cloudy cerebrospinal fluid with a high protein level

3 Rationale: A diagnosis of meningitis is made by testing the cerebrospinal fluid (CSF) obtained by lumbar puncture. In the case of bacterial meningitis, findings usually include increased pressure, cloudy cerebrospinal fluid, a high protein level, and a low glucose level.

An infant returns to the nursing unit after the surgical repair of a cleft lip located on the right side of the lip. Which is the best position to place this infant at this time? 1. A flat position 2. A prone position 3. On his or her left side 4. On his or her right side

3 Rationale: After the repair of a cleft lip, the infant should be positioned on the side opposite to the repair to prevent contact of the suture lines with the bed linens. In this case it is best to place the infant on the left side. Additionally, the flat or prone position can result in aspiration if the infant vomits.

The nurse instructs a mother of a child who has seizures regarding seizure precautions. Which statement by the mother indicates a need for further teaching? 1. "I will make my child wear a medical identification alert bracelet." 2. "I know that my child will need to have a companion when swimming." 3. "I will need to give antiseizure medications when my child has a seizure." 4. "I will have my child wear a bike helmet when riding a bike or skateboarding."

3 Rationale: Antiseizure medications are given on a routine basis to prevent a seizure, they are not rescue medications given at the time of a seizure. Padding the side rails, having a child wear a medical alert bracelet, swimming with a companion, and wearing a protective helmet while riding a bike or skateboarding are just a few of the precautions that are discussed with families.

The nurse is assigned to care for a child who is in skeletal traction. The nurse needs to avoid which action when caring for the child? 1. Keeping the weights hanging freely 2. Ensuring that the ropes are in the pulleys 3. Placing the bed linens on the traction ropes 4. Ensuring that the weights are out of the child's reach

3 Rationale: Bed linens should not be placed on the traction ropes because of the risk of disrupting the traction apparatus. Options 1, 2, and 4 are appropriate measures when caring for a child who is in skeletal traction.

The nurse is reinforcing instructions to a client with diabetes mellitus who is recovering from diabetic ketoacidosis (DKA) regarding measures to prevent a recurrence. Which instruction is important for the nurse to emphasize? 1. Eat six small meals daily. 2. Test the urine ketone level. 3. Monitor blood glucose level frequently. 4. Receive appropriate follow-up health care.

3 Rationale: Client education after DKA should emphasize the need for home glucose monitoring four to five times per day. It is also important to instruct the client to notify the PHCP when illness occurs. The presence of urinary ketones indicates that DKA has already occurred. The client should eat well-balanced meals with snacks, as prescribed.

The nurse is working in the emergency department and is caring for a child who has been diagnosed with epiglottitis. Which is an indication that the child may be experiencing airway obstruction? 1. Retractions and coughing 2. Nasal flaring and bradycardia 3. Tripod positioning and dyspnea 4. A low-grade fever and complaints of a sore throat

3 Rationale: Clinical manifestations that are suggestive of airway obstruction include tripod positioning (leaning forward supported by the hands and arms with the chin thrust out and the mouth open), nasal flaring, tachycardia, retractions, and dyspnea. Epiglottitis is the bacterial form of croup with symptoms of a high fever, sore throat, and an absence of spontaneous cough.

The mother of a child with juvenile idiopathic arthritis calls the nurse because the child is experiencing a painful exacerbation of the disease. The mother asks the nurse if the child should perform range-of-motion (ROM) exercises at this time. The nurse should make which response to the mother? 1. "Avoid all exercise during painful periods." 2. "The ROM exercises must be performed every day." 3. "Have the child perform simple isometric exercises during this time." 4. "Administer additional pain medication before performing the ROM exercises."

3 Rationale: During painful episodes, hot or cold packs, splinting, and positioning the affected joint in a neutral position help to reduce the pain. Although resting the extremity is appropriate, it is important to begin simple isometric or tensing exercises as soon as the child is able. These exercises do not involve joint movement.

The nurse is caring for a client after a thyroidectomy and notes that calcium gluconate is prescribed. The nurse determines that this medication has been prescribed for which reason? 1. Treat thyroid storm. 2. Prevent cardiac irritability. 3. Treat hypocalcemic tetany. 4. Stimulate the release of parathyroid hormone.

3 Rationale: Hypocalcemia can develop after thyroidectomy if the parathyroid glands are accidentally removed or injured during surgery. Manifestations develop 1 to 7 days after surgery. If the client develops numbness and tingling around the mouth, fingertips, or toes, or muscle spasms or twitching, the PHCP is notified immediately. Calcium gluconate should be accessible for the client who underwent thyroidectomy.

The nurse provides dietary instructions to a client with diabetes mellitus regarding the prescribed diabetic diet. Which statement made by the client indicates the need for further teaching? 1. "I'll eat a balanced meal plan." 2. "I need to drink diet soft drinks." 3. "I need to buy special dietetic foods." 4. "I will snack on fruit instead of cake."

3 Rationale: It is important to emphasize to the client and family that they are not eating a diabetic diet, but rather following a balanced meal plan. Adherence to nutrition principles is an important component of diabetic management, and an individualized meal plan should be developed for the client. It is not necessary for the client to purchase special dietetic foods.

A 6-month-old infant receives a diphtheria, tetanus, and acellular pertussis (DTaP) immunization at the well-baby clinic. The parent returns home and calls the clinic to report that the infant has developed swelling and redness at the site of injection. Which instruction by the nurse is appropriate? 1. Monitor the infant for a fever. 2. Bring the infant back to the clinic. 3. Apply an ice pack to the injection site. 4. Leave the injection site alone, because this always occurs.

3 Rationale: Occasionally tenderness, redness, or swelling may occur at the site of the injection. This can be relieved with cool packs for the first 24 hours and followed by warm or cool compresses if the inflammation persists. It is not necessary to bring the infant back to the clinic. Option 1 may be an appropriate intervention, but it is not specific to the question

The nurse is told that an assigned client is suspected of having methicillin-resistant Staphylococcus aureus (MRSA). Which precautions should the nurse institute during the care of the client? 1. Wear gloves only. 2. Wear a mask and gloves. 3. Wear a gown and gloves. 4. Avoid touching the client's clothes.

3 Rationale: The Centers for Disease Control and Prevention recommends the wearing of gowns and gloves when in close contact with a person who has methicillin-resistant Staphylococcus aureus (MRSA). Masks are not necessary. Transmission via clothing and other inanimate objects is uncommon. Methicillin-resistant Staphylococcus aureus (MRSA) is contagious and is spread to others by direct contact with infected skin or infected articles.

The nurse reinforces home care instructions to the parents of a child with a brace for scoliosis. Which statement by a parent indicates a need for further teaching? 1. "I will inspect the skin under the brace for redness or breakdown." 2. "I will encourage my child to do their exercises to maintain strength." 3. "I understand that my child needs to wear this brace for 12 hours a day." 4. "I understand that this brace is not a cure for scoliosis, it only slows the progression of the curvature."

3 Rationale: The brace needs to be worn from 16 to 23 hours a day. Braces are not curative, they slow the progression of the curvature. The skin under the brace needs to be inspected for any redness or breakdown. The child should continue to perform prescribed exercise to help maintain and strengthen the spinal and abdominal muscles.

The nurse is assisting with preparing a teaching plan for the client with diabetes mellitus regarding proper foot care. Which instruction should be included in the plan of care? 1. Soak the feet in hot water. 2. Avoid using soap to wash the feet. 3. Apply a moisturizing lotion to dry feet, but not between the toes. 4. Always have a podiatrist cut your toenails; never cut them yourself.

3 Rationale: The client should use a moisturizing lotion on his or her feet, but should avoid applying the lotion between the toes. The client should also be instructed not to soak the feet and to avoid hot water to prevent burns. The client may cut the toenails straight across and even with the toe itself, but he or she should consult a podiatrist if the toenails are thick or hard to cut or if his or her vision is poor. The client should be instructed to wash the feet daily with a mild soap.

The child with cryptorchidism is being discharged after orchiopexy, which was performed on an outpatient basis. The nurse should reinforce instructions to the parents about which priority care measure? 1. Measuring intake and output 2. Administering anticholinergics 3. Preventing infection at the surgical site 4. Applying cold, wet compresses to the surgical site

3 Rationale: The most common complications associated with orchiopexy are bleeding and infection. The parents are instructed in postoperative homecare measures, including the prevention of infection, pain control, and activity restrictions. The measurement of intake and output is not required. Anticholinergics are prescribed for the relief of bladder spasms; they are not necessary after orchiopexy. Cold, wet compresses are not prescribed. The moisture from a wet compress presents a potential for infection.

The nurse provides information to the parent of a 2-week-old infant who was diagnosed with clubfoot at the time of birth. Which statement by the parent indicates the need for further teaching regarding this disorder? 1. "I understand treatment needs to be started as soon as possible." 2. "I realize my child will require follow-up care until full grown." 3. "I need to bring my child back to the clinic in 1 month for a new cast." 4. "I need to come to the clinic every week with my child for the casting."

3 Rationale: Treatment for clubfoot is started as soon as possible after birth. Serial manipulation and casting are performed at least weekly. If sufficient correction is not achieved within 3 to 6 months, surgery is usually indicated. Because clubfoot can recur, all children with the condition require long-term interval follow-up until they reach skeletal maturity to ensure an optimal outcome.

262. A client asks the nurse why her newborn baby needs an injection of vitamin K (phytonadione). The nurse should make which statement to the client? 1. "Your newborn needs vitamin K to develop immunity." 2. "The vitamin K will protect your newborn from becoming jaundiced." 3. "Newborns are deficient in vitamin K. This injection prevents your baby from abnormal bleeding." 4. "Newborns have sterile bowels. The vitamin K will give the bowel the necessary bacteria."

3 Rationale: Vitamin K is necessary for the body to synthesize coagulation factors, and it is administered to the newborn infant to prevent abnormal bleeding. It promotes the liver's formation of the clotting factors II, VII, IX, and X. Newborn infants are deficient in vitamin K because the bowel does not have the bacteria necessary for synthesizing. The normal flora in the intestinal tract produces vitamin K, but the newborn's bowel does not support the normal production of vitamin K until bacteria have adequately colonized it.

The nurse assists to prepare a teaching plan regarding the administration of eardrops for the parents of a 2-year-old child with otitis media. Which should be included in the plan? 1. Wear gloves when administering the eardrops. 2. Pull the ear up and back before instilling the eardrops. 3. Pull the earlobe down and back before instilling the eardrops. 4. Hold the child in a sitting position when administering the eardrops.

3 Rationale: When administering eardrops to a child who is younger than 3 years old, the ear should be pulled down and back. For children who are older than 3 years old, the ear is pulled up and back. Gloves do not need to be worn by the parents, but hand washing needs to be performed before and after the procedure. The child should be in a side-lying position with the affected ear facing upward to facilitate the flow of medication down the ear canal by gravity.

The client with carcinoma of the lung develops the syndrome of inappropriate antidiuretic hormone (SIADH) as a complication of the cancer. Besides treatment of the lung cancer, the nurse anticipates that which interventions may be prescribed to treat the SIADH? Select all that apply. 1. Increase fluid intake 2. Decreased sodium intake 3. Institute safety measures 4. Frequent monitoring of sodium blood levels 5. Gather data about the neurological status frequently 6. Medication that is antagonistic to antidiuretic hormone (ADH)

3, 4, 5, 6; Rationale: Syndrome of inappropriate ADH (SIADH) is a condition in which excessive amounts of water are reabsorbed by the kidney and put into the systemic circulation. The increased water causes hyponatremia (decreased serum sodium levels) and some degree of fluid retention. SIADH is a potential complication associated with cancer, especially small cell lung cancer. SIADH is managed by treating the condition and its cause. The SIADH induces low sodium blood levels and results in altered neurological states, including confusion and unresponsiveness. Treatment of SIADH includes fluid restriction, increased sodium intake, and a medication with a mechanism of action that is antagonistic to ADH, such as demeclocycline

A newborn has just been circumcised and is being discharged home in 2 hours. Which instructions should be provided by the nurse to the parents? Select all that apply. 1. Use only baby wipes to cleanse the penis. 2. Remove the yellow exudate which forms by 24 hours post circumcision. 3. Do not wash penis with soap until the circumcision is healed, which takes 5 to 6 days. 4. Change diaper every 4 hours or more often to inspect the penis for drainage or infection. 5. Monitor the circumcision; penis may appear reddened with small amount of bloody drainage shortly after the procedure

3, 4, 5; Rationale: The glans penis is normally dark red. Use only water to cleanse the glans penis until complete healing has occurred around day 5 to 6. Diapers should be changed at least every 4 hours to inspect the glans penis for drainage or signs of infection. After circumcision, a small amount of bloody drainage is expected. Baby wipes may contain alcohol and should not be used to cleanse the glans penis. During the normal healing process, the glans becomes covered with a yellow exudate. This exudate should not be removed. If excessive bleeding is noted from the circumcision, the parent should be instructed to apply gentle pressure to the site of bleeding with a sterile gauze pad. If the bleeding is not controlled, the primary health care provider is notified because a blood vessel may need to be ligated.

The nurse is assisting with creating a plan of care for a client with pancytopenia as a result of chemotherapy. The nurse should suggest including which in the plan of care? Select all that apply. 1. Restricting all visitors 2. Restricting fluid intake 3. Restricting fresh fruits and vegetables in the diet 4. Applying a face mask to the client if outside the client room. 5. Inserting an indwelling urinary catheter to prevent skin breakdown

3, 4; Rationale: A client who is experiencing pancytopenia (decrease in all blood cells types: red, white, and platelets) is at high risk for infection because of significantly low immunity. The client should not eat fresh fruits and vegetables because they are at a potential for ingesting bacteria. All foods should be cooked thoroughly. The client should wear a mask when outside of the room to avoid potential infection spread from persons in the hallways. Not all visitors are restricted, but the client is protected from people with known infections. Fluids should be encouraged because dehydration increases the risk for infection. Invasive measures such as an indwelling urinary catheter should be avoided to prevent infection.

The nurse is reinforcing discharge instructions to a client with cancer of the prostate after a suprapubic prostatectomy. The nurse should reinforce which discharge instruction? Select all that apply. 1. Avoid driving a car for 1 week. 2. Restrict fluid intake to prevent incontinence. 3. Take the prescribed stool softener every day. 4. Avoid lifting objects heavier than 20 pounds for 6 weeks. 5. Inspect the incision on the scrotum every day for any redness. 6. Notify the primary health care provider (PHCP) if small blood clots are noticed during urination.

3, 4; Rationale: A suprapubic approach involves a lower abdominal incision to remove the prostate to treat prostate cancer. The nurse will reinforce instructions about the incision activity, medications, and when to contact the urologist. The client should take the prescribed stool softener because constipation will lead to straining and cause pain and tension on the surgical site. The client should avoid lifting more than 20 pounds for 6 weeks to avoid tension on the surgical site. Driving a car and sitting for long periods of time are restricted for at least 3 weeks. A daily fluid intake of 2 L to 2.5 L per day (unless contraindicated) should be maintained to limit clot formation and prevent infection. The incision is not on the scrotum but in the lower abdominal area. Small pieces of tissue or blood clots can be passed during urination for up to 2 weeks after surgery and do not need to be reported.

109. The nurse should institute which interventions for a client diagnosed with Clostridium difficile? Select all that apply. 1. Wear a mask if within 3 feet of the client. 2. Place a mask on the client when client is outside the room. 3. Wear gloves and gown while in the room caring for the client. 4. Use soap and water, not alcohol-based hand rub, for hand hygiene. 5. Keep the door of the room shut except when entering or exiting the client's room.

3, 4; Rationale: Contact precautions are necessary for colonization or infection with a multidrug-resistant organism. This includes enteric infection with Clostridium difficile. Measures used to prevent the spread of C. difficile are wearing gowns and gloves while in the room (not just during care) because the spores are on surfaces in the room. Washing with soap and water for hand hygiene is indicated because alcohol-based sanitizers are ineffective against the spores. The use of a mask by the nurse, or the client when outside the client's room, is unnecessary because C. difficile is not transmitted by the respiratory route. The door does not need to be kept shut

The nurse is reviewing the postoperative primary health care provider's (PHCP'S) prescriptions for a 3-week-old infant with Hirschsprung's disease admitted to the hospital for surgery. Which prescriptions documented in the child's record should the nurse question? Select all that apply. 1. Measure abdominal girth daily. 2. Monitor strict intake and output. 3. Take temperature measurements rectally. 4. Start clear liquid diet after 8 hours postoperative. 5. Maintain IV fluids until the child tolerates oral intake. 6. Monitor the surgical site for redness, swelling, and drainage

3, 4; Rationale: Postoperative management of Hirschsprung's disease includes taking vital signs, but avoiding taking the temperature rectally. The client needs to remain NPO (nothing by mouth) status until bowel sounds return or flatus is passed, usually within 48 to 72 hours. The other options are correct postoperative management

A client returns to the clinic for follow-up treatment after a skin biopsy of a suspicious lesion that was performed 1 week ago. The biopsy report indicates that the lesion is a melanoma. The nurse understands that which characteristics describe this type of a lesion? Select all that apply. 1. Metastasis is rare. 2. It is encapsulated. 3. It is highly metastatic. 4. It is characterized by local invasion. 5. Lesion is a nevus that has changed in color.

3, 5 Rationale: Melanomas are pigmented malignant lesions that originate in the melanin-producing cells of the epidermis. The lesion is a nevus that changes in color. This skin cancer is highly metastatic and a person's survival depends on early diagnosis and treatment. Basal cell carcinomas arise in the basal cell layer of the epidermis. Early malignant basal cell lesions often go unnoticed, and although metastasis is rare, underlying tissue destruction can progress to include vital structures. Squamous cell carcinomas are malignant neoplasms of the epidermis. They are characterized by local invasion and the potential for metastasis.

The nurse is assisting with caring for a client after a craniotomy. Which are the positions that can be used for the client? Select all that apply. 1. Prone position 2. Supine position 3. Semi-Fowler's position 4. Dorsal recumbent position 5. With the foot of the bed flat 6. With the foot of the bed elevated 30 degrees

3, 5; Rationale: After a craniotomy, the client is at risk for developing complications of increased intracranial pressure and cerebral edema. The head of the bed is elevated 30 degrees (semi-Fowler's position), and the client's head is maintained in a midline, neutral position to facilitate venous drainage. The foot of the bed should be flat because flexion at the hips will impair venous drainage. Blocking venous drainage increases the risk for increased intracranial pressure and cerebral edema. Remember there are no valves in the veins that drain the head.

The nurse should implement which interventions for a child older than 2 years with type 1 diabetes mellitus who has a blood glucose level of 60 mg/dL ? Select all that apply. 1. Administer regular insulin. 2. Encourage the child to ambulate. 3. Give the child a teaspoon of honey. 4. Provide electrolyte replacement therapy intravenously. 5. Wait 30 minutes and confirm the blood glucose reading. 6. Prepare to administer glucagon subcutaneously if unconsciousness occurs.

3, 6; Rationale: The nurse should confirm hypoglycemia with a blood glucose reading. Glucose is administered orally immediately; rapid-releasing glucose is followed by a complex carbs and protein, such as a slice of bread or a peanut butter cracker. An extra snack is given if the next meal is not for 30 minutes+ or if activity is planned. If the child becomes unconscious, cake frosting or glucose paste is squeezed onto the gums, glucose level is retested in 15 minutes; if the reading remains low, give additional glucose. If the child remains unconscious, admin. of glucagon may be necessary.

The nurse is assisting with monitoring the functioning of a chest-tube drainage system in a client who just returned from the recovery room after a thoracotomy with wedge resection. Which findings should the nurse expect to note? Select all that apply. 1. Excessive bubbling in the water-seal chamber 2. Vigorous bubbling in the suction-control chamber 3. 50 mL of drainage in the drainage-collection chamber 4. The drainage system is maintained below the client's chest. 5. An occlusive dressing is in place over the chest-tube insertion site. 6. Fluctuation of water in the tube of the water-seal chamber during inhalation and exhalation

3,4,5,6; Rationale: In a thoracotomy the lung is opened and exposed, and a wedge resection is the removal of part of the lung. The chest tube is placed during the surgery to remove fluid and air so the remaining lung can reinflate. The bubbling of water in the water-seal chamber should be gentle and indicates air drainage from the client. This is usually seen when intrathoracic pressure is greater than atmospheric pressure, and it may occur during exhalation, coughing, or sneezing. The fluctuation of water in the tube in the water-seal chamber during inhalation and exhalation is expected. An absence of fluctuation may indicate that the chest tube is obstructed, the lung has reexpanded, or no more air is leaking into the pleural space. Gentle (not vigorous) bubbling should be noted in the suction-control chamber. A total of 50 mL of drainage is not excessive in a client returning to the nursing unit from the recovery room; however, drainage of more than 70 mL/hour to 100 mL/hour is considered excessive and requires RN and PHCP notification. The chest-tube insertion site is covered with an occlusive (airtight) dressing to prevent air from entering the pleural space. Positioning the drainage system below the client's chest allows gravity to drain the pleural space. .

The nurse is preparing to care for a dying client and several family members are at the client's bedside. Which therapeutic techniques should the nurse use when communicating with the family? Select all that apply. 1. Discourage reminiscing. 2. Make the decisions for the family. 3. Encourage expression of feelings, concerns, and fears. 4. Explain everything that is happening to all family members. 5. Touch and hold the client's or family member's hand if appropriate. 6. Be honest and let the client and family know that they will not be abandoned by the nurse.

3,5,6; Rationale: The nurse must determine whether there is a spokesperson for the family and how much the client and family want to know. The nurse needs to allow the family and client the opportunity for informed choices and assist with the decision-making process if asked. The nurse should encourage expression of feelings, concerns, and fears and reminiscing. The nurse needs to be honest and let the client and family know that they will not be abandoned. The nurse should touch and hold the client's or family member's hand, if appropriate.

An adult client was burned as a result of an explosion. The burn initially affected the client's entire face (the anterior half of the head) and the upper half of the anterior torso, and there were circumferential burns to the lower half of both arms. The client's clothes caught on fire and the client ran, which caused subsequent burn injuries of the posterior surface of the head and the upper half of the posterior torso. According to the rule of nines, what is the extent of this client's burn injury?

36% Rationale: According to the rule of nines, with the initial burn, the anterior half of the head equals 4.5%, the upper half of the anterior torso equals 9%, and the lower halves of both arms equal 9%. The subsequent burn included the posterior half of the head, which equals 4.5%, and the upper half of the posterior torso, which equals 9%. This totals 36%.

The nurse notes that a 6-year-old child does not recognize that objects exist even when the objects are outside of the visual field. Based on this observation, which action should the nurse take? 1. Move the objects in the child's direct field of vision. 2. Teach the child how to visually scan the environment. 3. Report the observation to the primary health care provider. 4. Provide additional lighting for the child during play activities.

3; Rationale: According to Jean Piaget's theory of cognitive development, it is normal for the infant or toddler not to recognize that objects continue to be in existence, even if out of the visual field; however, this is abnormal for a 6-year-old. If a 6-year old child does not recognize that objects still exist even when outside the visual field, the child is not progressing normally through the developmental stages. The nurse should report this finding to the health care provider. Options 1, 2, and 4 delay necessary follow-up and treatment.

A child remarks, "I share my toys and snacks with my friends so they will like me more." The nurse determines the child is in which stage of moral development? 1. Egocentric judgment 2. Law-and-order orientation 3. Good boy-nice girl orientation 4. Social contract and legalistic orientation

3; Rationale: According to Kohlber's theory of moral development, during the good boy-nice girl orientation, the child acts in a way to please other people. Sharing is an example of this behavior. A child in the egocentric judgment stage has no awareness of right or wrong. A person in the law-and-order orientation stage obeys laws to maintain social order. During the social contract and legalistic orientation stage, a person is aware that others may have another set of values and opinions

A pregnant client is seen in the health care clinic for a regular prenatal visit. The client tells the nurse that she is experiencing irregular contractions. The nurse determines that the client is experiencing Braxton Hicks contractions. Based on this finding, which nursing action is appropriate? 1. Contact the health care provider. 2. Instruct the client to maintain bed rest for the remainder of the pregnancy. 3. Tell the client that these are common and they may occur throughout the pregnancy. 4. Call the maternity unit and inform them that the client will be admitted in a prelabor condition.

3; Rationale: Braxton Hicks contractions are irregular, painless contractions that may occur intermittently throughout pregnancy. Because Braxton Hicks contractions may occur and are normal in some pregnant women during pregnancy, options 1, 2, and 4 are unnecessary and inappropriate actions.

The nurse is collecting data from a pregnant client when the client asks the nurse about the purpose of the fallopian tubes. Which is the accurate response the nurse should make? 1. The organ of copulation 2. Where the fetus develops 3. Where fertilization occurs 4. The organ that secretes estrogen and progesterone

3; Rationale: Each fallopian tube is a hollow muscular tube that transports a mature oocyte for final maturation and fertilization. Fertilization typically occurs near the boundary between the ampulla and the isthmus of the tube. The vagina is the organ of copulation, and the fetus develops in the uterus. Estrogen is a hormone that is produced by the ovarian follicles, the corpus luteum, the adrenal cortex, and the placenta during pregnancy. Progesterone is a hormone that is secreted by the corpus luteum of the ovary, the adrenal glands, and the placenta during pregnancy.

The nurse is reinforcing teaching to a pregnant woman about the physiological effects and hormonal changes that occur during pregnancy. The woman asks the nurse about the purpose of estrogen. The nurse bases the response on which purpose of estrogen? 1. It maintains the uterine lining for implantation. 2. It stimulates the metabolism of glucose and converts glucose to fat. 3. It stimulates uterine development to provide an environment for the fetus and stimulates the breasts to prepare for lactation. 4. It prevents the involution of the corpus luteum and maintains the production of progesterone until the placenta is formed.

3; Rationale: Estrogen stimulates uterine development to provide an environment for the fetus and it stimulates the breasts to prepare for lactation. Progesterone maintains the uterine lining for implantation and relaxes all smooth muscle. Human placental lactogen stimulates the metabolism of glucose and converts the glucose to fat. Human chorionic gonadotropin prevents the involution of the corpus luteum and maintains the production of progesterone until the placenta is formed.

The nurse is reviewing the laboratory results of a client with leukemia who has received a regimen of chemotherapy. Which laboratory finding is indicative of the massive cell destruction that occurs with the chemotherapy? 1. Anemia 2. Decreased platelets 3. Increased uric acid level 4. Decreased leukocyte count

3; Rationale: Hyperuricemia, elevated levels of uric acid, is especially common after treatment for leukemias and lymphomas, because the therapy results in massive cell destruction and the release of uric acid. Anemia (low red blood cell count), low platelet levels, and low white blood cell counts are associated with the bone marrow abnormalities that are a part of the leukemias and lymphoma disease process.

The nurse is observing a parent and child interacting in the clinic waiting room. The child begins to bounce on the couch. The parent removes the child from the couch stating firmly, "Couches are for sitting, not for jumping." The parent then gives the child a toy to play with on the carpet. The child plays with the toy until called by the nurse. The nurse determines the child is acting within which Kohlberg stage of moral development? 1. Egocentric judgment 2. Law-and-order orientation 3. Punishment-obedience stage 4. Good boy-nice girl orientation

3; Rationale: In stage 1 (ages 2-3 years; punishment-obedience orientation), children cannot reason as mature members of society because they are too young to do so. A child obeys rules to avoid punishment. It is appropriate for a parent to explain limitations, and to provide distractions. In the egocentric stage, an infant has no concept of right or wrong. A child who is in the law-and-order orientation stage obeys laws to maintain social order. In the good boy-nice girl orientation stage, a child behaves in a way to avoid displeasing others.

The parent of a 4-year-old child expresses concern because her hospitalized child has started sucking his thumb. The mother states that this behavior began 2 days after hospital admission. Which is the appropriate nursing response? 1. "Your child is acting like a baby." 2. "The doctor will need to be notified." 3. "This is common during hospitalization" 4. "A 4-year-old is too old for this type of behavior."

3; Rationale: In the hospitalized preschooler, it is best to accept regression, such as thumb sucking if it occurs, because it is most often caused by the stress of the hospitalization. Parents may be overly concerned about regression and should be told that their child may continue the behavior at home. There is no need to call the health care provider. Telling the parents the child is acting like a baby or being too old to act this way is inappropriate.

. The nurse is caring for a 5-year-old child who has been placed in traction after a fracture of the femur. Which is the most appropriate activity for this child? 1. Blocks 2. A music video 3. A 10-piece puzzle 4. Large picture books

3; Rationale: In the preschooler, play is simple and imaginative, and it includes activities such as dressing up, paints, crayons, and simple board and card games. Ten-piece puzzles are also appropriate and aid with fine motor development. Blocks are most appropriate for the toddler. A music video is most appropriate for the adolescent. Large picture books are most appropriate for the infant.

A child has fluid volume deficit. The nurse collects data and determines that the child is improving and the deficit is resolving if which finding is noted? 1. The child has no tears. 2. Urine specific gravity is 1.030. 3. Capillary refill is less than 2 seconds. 4. Urine output is less than 1 mL/kg/hour.

3; Rationale: Indicators that fluid volume deficit is resolving would be capillary refill less than 2 seconds, specific gravity of 1.002 to 1.025, urine output of at least 1 mL/kg/hour, and adequate tear production. A capillary refill time less than 2 seconds is the only indicator that the child is improving. Urine output of less than 1 mL/kg/hour, a specific gravity of 1.030, and no tears would indicate that the deficit is not resolving.

A client with severe acne is seen in the clinic and the primary health care provider (PHCP) prescribes isotretinoin. The nurse reviews the client's medication record and would contact the PHCP if the client is also taking which medication? 1. Digoxin 2. Phenytoin 3. Vitamin A 4. Furosemide

3; Rationale: Isotretinoin is a metabolite of vitamin A and can produce generalized intensification of isotretinoin toxicity. Because of the potential for increased toxicity, vitamin A supplements should be discontinued before isotretinoin therapy. There are no contraindications associated with digoxin, phenytoin, or furosemide.

The nurse applies wrist restraints, prescribed to prevent a client from pulling out a nasogastric tube. How should the nurse determine that the restraints are not too constrictive? 1. Observe the skin in the wrist area for redness. 2. Check the temperature of the skin in the hands. 3. Place two fingers under the restraint to determine snugness. 4. Remove the restraint and exercise the extremity in 2 hours.

3; Rationale: Limb restraints are often prescribed to prevent clients from pulling out tubes and injuring themselves. The restraint is prescribed for 24 hours, and the nurse must verify that the restraint is protecting the client from self-injury but not too constrictive to impair circulation or harm the skin. Limb restraints are made with padding to protect the client's skin. The nurse determines the tightness of the wrist restraint by placing two fingers under the restraint. Observing the skin and checking the temperature of the skin is not as thorough or accurate as checking the tightness of the restraint manually. Restraints need to be removed at least every 2 hours, but this does not evaluate how tight the restraint is around the wrist.

After episiotomy and the delivery of a newborn, the nurse performs a perineal check on the mother. The nurse notes a trickle of bright red blood coming from the perineum. The nurse checks the fundus and notes that it is firm. Which determination should the nurse make? 1. This is a normal expectation after episiotomy. 2. The mother should be allowed bathroom privileges only. 3. The bright red bleeding is abnormal and should be reported. 4. The perineal assessment should be performed more frequently.

3; Rationale: Lochial flow should be distinguished from bleeding that originates from a laceration or an episiotomy, which is usually brighter red than lochia and presents as a continuous trickle of bleeding, even though the fundus of the uterus is firm. This bright red bleeding is abnormal and needs to be reported. Therefore, the other options are incorrect interpretations.

When reinforcing teaching about signs and symptoms of ovarian cancer with a community group of women, the nurse emphasizes which sign/symptom as being a typical manifestation of the disease recognized by persons diagnosed with the condition? 1. Pelvic cramping 2. Sharp abdominal pain 3. Abdominal distention or fullness 4. Postmenopausal vaginal bleeding

3; Rationale: Ovarian cancer is the leading cause of death from gynecological cancers and occurs in women older than 50 years. The most common sign and symptom of ovarian cancer is abdominal distention or fullness. Less common are vague symptoms of urinary frequency and urgency, and GI symptoms such as a change in bowel habits. Pelvic cramping, sharp abdominal pain, or postmenopausal vaginal bleeding are not the most typical signs and symptoms.

The nurse monitors the 3-day postoperative client who underwent abdominal surgery. Vital signs are: temperature: 37.9° C (100.2° F), pulse104 beats per minute, respirations 22 breaths per minute, blood pressure 128/74 mmHg. Oxygen saturation is 93% on room air. The client feels tired and has a productive cough. Fine crackles are audible in the bases of the lungs posteriorly. The nurse considers the client has developed which postoperative problem? 1. Hypoxia 2. Atelectasis 3. Pneumonia 4. Fluid overload

3; Rationale: Pneumonia is a postoperative condition caused by inflammation and infection in the lungs. Frequently it results from shallow breathing that leads to atelectasis (the alveoli partially collapse and eventually become fluid-filled). This fluid is good medium for bacteria. Pneumonia usually occurs 3 to 7 days postoperatively. Signs and symptoms include fever, productive cough, painful breathing, and an increased respiratory effort and rate. Fine crackles may be audible over the lung area involved. Treatment includes coughing up the purulent sputum, deep breathing, antibiotics, and adequate hydration.

The nurse caring for a child with aplastic anemia is reviewing the laboratory results and notes a white blood cell (WBC) count of 6000 mm3 (6 × 109/L) and a platelet count of 20,000 mm3 (20 × 109/L). Which nursing intervention should be incorporated into the plan of care? 1. Encourage naps. 2. Encourage a diet high in iron. 3. Encourage quiet play activities. 4. Maintain strict isolation precautions.

3; Rationale: Precautionary measures to prevent bleeding should be taken when a child has a low platelet count. These include no injections, no rectal temperatures, the use of a soft toothbrush, quiet activities, and abstinence from contact sports or activities that could cause an injury. Strict isolation would be required if the WBC count was low. Naps and a diet high in iron are unrelated to the risk of bleeding.

Silver sulfadiazine is prescribed for a client with a partial-thickness burn and the nurse provides teaching about the medication. Which statement made by the client indicates a need for further teaching about the treatments? 1. "The medication is an antibacterial." 2. "The medication will help heal the burn." 3. "The medication is likely to cause stinging initially." 4. "The medication should be applied directly to the wound."

3; Rationale: Silver sulfadiazine is an antibacterial that has a broad spectrum of activity against gram-negative bacteria, gram-positive bacteria, and yeast. It is applied directly to the wound to assist in healing. It does not cause stinging when applied.

132. The nurse is caring for a client who is scheduled for surgery. The client states concern about the surgical procedure. How should the nurse initially address the clients concerns? 1. Tell the client that preoperative fear is normal. 2. Explain all nursing care and possible discomfort that may result. 3. Ask the client to discuss information known about the planned surgery. 4. Provide explanations about the procedures involved in the planned surgery.

3; Rationale: The client is concerned about having surgery and needs to discuss it. This will offer the client the opportunity to verbalize his or her current and specific understanding. Explanations should begin with the information that the client knows. Option 1 is a block to communication and minimizes the client's feelings. Giving unsolicited explanations may produce additional anxiety and not address the real concerns of the client.

A nursing student is assigned to a client in labor. The nursing instructor asks the student to describe fetal circulation, specifically the ductus venosus. The instructor determines that the student understands the structure of the ductus venosus if the student states which about the ductus venosus? 1. Connects the pulmonary artery to the aorta 2. Is an opening between the right and left atria 3. Connects the umbilical vein to the inferior vena cava 4. Connects the umbilical artery to the inferior vena cava

3; Rationale: The ductus venosus connects the umbilical vein to the inferior vena cava. The foramen ovale is a temporary opening between the right and left atria. The ductus arteriosus joins the aorta and the pulmonary artery.

A Spanish-speaking client arrives at the triage desk in the emergency department and states to the nurse, "No speak English, need interpreter." Which action should the nurse take? 1. Have one of the client's family members interpret. 2. Have the Spanish-speaking triage receptionist interpret. 3. Seek an interpreter from the hospital's interpreter services. 4. Obtain a Spanish-English dictionary and attempt to triage the client.

3; Rationale: The nurse should have a professional hospital-based interpreter translate for the client. English-speaking family members may not appropriately understand what is asked of them and may paraphrase what the client is actually saying. Also, client confidentiality and accurate information may be compromised when a family member or a nonhealth care provider acts as interpreter. Using a Spanish-English dictionary is time-consuming and not the best action; accurate interpretation is best done by a professional hospital-based interpreter.

An older client has been prescribed digoxin. The nurse determines that which age-related change would place the client at risk for digoxin toxicity? 1. Decreased salivation and gastrointestinal motility 2. Decreased muscle strength and loss of bone density 3. Decreased lean body mass and glomerular filtration rate 4. Decreased cardiac output and decreased efficiency of blood return to the heart

3; Rationale: The older client is at risk for medication toxicity because of decreased lean body mass and an age-associated decreased glomerular filtration rate. Although the other changes identify age-related changes that occur in the older client, they are not specifically associated with this risk

The nurse enters a client's room and finds that the wastebasket is on fire. The nurse quickly assists the client out of the room. Which is the next nursing action? 1. Call for help. 2. Extinguish the fire. 3. Activate the fire alarm. 4. Confine the fire by closing the room door.

3; Rationale: The order of priority in the event of a fire is to rescue the clients who are in immediate danger. The next step is to activate the fire alarm. The fire is then confined by closing all doors. Finally, the fire is extinguished.

The parents of a 2-year-old arrive at the hospital to visit their child. The child is in the play room and ignores the parents during the visit. The nurse tells the parents that this behavior in a 2-year-old child indicates which characteristic about the child? 1. The child is withdrawn. 2. The child is upset with the parents. 3. The child is exhibiting a normal pattern. 4. The child has adjusted to the hospitalized setting.

3; Rationale: The toddler is particularly vulnerable to separation. A toddler often shows anger at being left by ignoring the parent or pretending to be more interested in play than in going home. The parents of hospitalized toddlers are frequently distressed by such behavior. The toddler normally engages in parallel play and plays alongside (but not with) other children.

The nurse is administering a cleansing enema to a client with a fecal impaction. Before administering the enema, the nurse asks the client to assume a left Sims' position. The nurse explains that this positioning is preferred because of which reason? 1. The nurse is right-handed. 2. The rectal sphincter will relax. 3. The enema will flow into the bowel easily. 4. The client is more likely to retain the enema solution.

3; Rationale: When administering an enema, the client is placed in a left Sims' position so that the enema solution can flow by gravity in the natural direction of the colon. The anatomy of the colon consists of ascending on the right, transverse across, with descending on the left leading to the sigmoid and rectum. If the client lies on the left side, the enema solution will flow easily into the bowel. The hand dominance of the nurse is not a factor. The nurse assists the client to relax the rectal sphincter by asking the client to take a deep breath. The nurse assists the client to retain the enema solution by administering the enema slowly. The nurse should also use teach-back to determine client's understanding about the reason for the enema.

The nurse is inserting an indwelling urinary catheter into a male client. As the catheter is inserted into the urethra, urine begins to flow into the tubing. When should the nurse inflate the balloon? 1. Immediately inflate the balloon. 2. Insert the catheter 2.5 cm to 5 cm and inflate the balloon. 3. Advance the catheter to the bifurcation and inflate the balloon. 4. Insert the catheter until resistance is met and inflate the balloon.

3; Rationale: When inserting an indwelling catheter, the nurse should ensure the balloon is in the bladder before inflating it. If the balloon is inflated in the urethra of the male client, trauma may occur. When catheterizing a male client, the nurse observes the tubing for the flow of urine and then continues to advance the catheter to the point of bifurcation and then inflates the balloon. The nurse then pulls the catheter back until slight resistance is felt and applies a tube holder onto the thigh to hold the catheter in place.

The nurse is assisting with caring for a client with abruptio placentae. While caring for the client, the nurse notes that the client begins to develop signs of shock. The nurse should take which action first? 1. Monitor the urinary output. 2. Monitor the maternal pulse. 3. Turn the client onto her side. 4. Monitor the maternal blood pressure.

3; Rationale: With a pregnant client who is in shock, the nurse should want to increase perfusion to the placenta to minimize fetal distress. A simple way to do this that requires no equipment is to turn the mother on her side. This increases blood flow to the placenta by relieving pressure from the gravid uterus on the great vessels. The nurse should immediately contact the registered nurse, who then contacts the health care provider. The other options should follow quickly.

The nurse has provided instructions to the mother of a child who has been diagnosed with bacterial conjunctivitis. Which statement by the mother would indicate the need for further teaching? 1. "I need to wash my hands frequently." 2. "I need to clean the eye, as prescribed." 3. "I need to give the eye drops, as prescribed." 4. "I need to use hot compresses to relieve the eye irritation."

4

The nurse is monitoring the daily weight of an infant with heart failure (HF). Which finding alerts the nurse to suspect fluid accumulation and thus the need to notify the registered nurse? 1. Bradypnea 2. Diaphoresis 3. Decreased blood pressure (BP) 4. A weight gain of 1 lb in 1 day

4 Rationale: A weight gain of 0.5 kg (1 lb) in 1 day is a result of the accumulation of fluid. The nurse should monitor the urine output, monitor for evidence of facial or peripheral edema, check the lung sounds, and report the weight gain. Tachypnea and an increased BP would occur with fluid accumulation. Diaphoresis is a sign of HF, but it is not specific to fluid accumulation and it usually occurs with exertional activities.

A child is brought to the emergency room and the mother reports that the child accidentally swallowed paint thinner after mistaking it for water. The nurse should perform which action first? 1. Begin resuscitation. 2. Terminate exposure to the poison. 3. Take measures to prevent absorption of the poison. 4. Check the circulation, airway, and breathing status of the child.

4 Rationale: Actions to take in the case of a child swallowing poison include assessing the child and treating the child first, not the poison. Circulation, airway and breathing, and vital signs need to be assessed. Resuscitation measures would be initiated if the assessment indicates a need. The next step is to terminate exposure to the poison, such as emptying the mouth of pills or other materials or flushing the skin with water. Then identify the poison, if possible, and take measures to prevent absorption of the poison, such as administering the antidote if known. Transport the child to an emergency department for further treatment.

The nurse is reviewing instructions to a parent of a 6-year-old on how to prevent influenza. Which statement by the parent indicates a need for further teaching? 1. "I will get a flu shot and I will have my child get a flu shot too." 2. "I will avoid having my child come into contact with sick children." 3. "I will have my child wash her hands frequently during the flu season." 4. "I will not let my child play with other children who have the flu unless they are taking acetaminophen."

4 Rationale: Children who have influenza should be kept home and away from other children until they are fever-free without the use of antipyretics. Influenza may be prevented with the annual vaccine, by avoiding other children who are sick, and with frequent hand washing.

The nurse is instructing the mother of a child with cystic fibrosis (CF) about the appropriate dietary measures. Which meal best illustrates the most appropriate diet for a client with cystic fibrosis (CF)? 1. Veggie salad and a caramel apple 2. Strawberry jelly sandwich and pretzels 3. Plate of nachos and cheese and a cupcake 4. Chicken tenders and a baked potato with butter

4 Rationale: Children with CF are managed with a high-calorie, high-protein diet. Pancreatic enzyme replacement therapy is undertaken, and fat-soluble vitamin supplements are administered. Fats are not restricted unless steatorrhea cannot be controlled by increased levels of pancreatic enzymes. Chicken tenders and a baked potato with butter provide a high-calorie and high-protein meal that includes fat.

A child is diagnosed with Reye's syndrome. The nurse assists with developing a nursing care plan for the child and should include which intervention in the plan? 1. Assess hearing loss 2. Monitor urine output 3. Change body position every 2 hours 4. Provide a quiet atmosphere with dimmed lighting

4 Rationale: Decreasing stimuli in the environment by providing a quiet environment with dimmed lighting would decrease the stress on the cerebral tissue and neuron responses. Hearing loss and urine output are not affected. Changing the body position every 2 hours would not affect the cerebral edema directly. The child should be positioned with the head elevated to decrease the progression of the cerebral edema and promote drainage of cerebrospinal fluid.

When the nurse is reinforcing instructions to a client who has been newly diagnosed with type 1 diabetes mellitus, which statement by the client would indicate that teaching has been effective? 1. "I will stop taking my insulin if I'm too sick to eat." 2. "I will decrease my insulin dose during times of illness." 3. "I will adjust my insulin dose according to the level of glucose in my urine." 4. "I will notify my primary health care provider if my blood glucose level is consistently greater than 250

4 Rationale: During illness, the client should monitor the blood glucose level, and he or she should notify the PHCP if the level is greater than 250 mg/dL (13.9 mmol/L). Insulin should never be stopped. In fact, insulin may need to be increased during times of illness. Doses should not be adjusted without the PHCP's advice.

The client arrives at the emergency department after a burn injury that occurred in their home basement and an inhalation injury is suspected. Which should the nurse anticipate as being prescribed for the client? 1. Oxygen via nasal cannula at 10 L 2. Oxygen via nasal cannula at 15 L 3. 100% oxygen via an aerosol mask 4. 100% oxygen via a tight-fitting, nonrebreather face mask

4 Rationale: If an inhalation injury is suspected, the administration of 100% oxygen via a tight-fitting, nonrebreather face mask is prescribed until the carboxyhemoglobin level falls below 15%. With inhalation injuries, the oropharynx is inspected for evidence of erythema, blisters, or ulcerations. The need for endotracheal intubation is also determined. Options 1, 2, and 3 are incorrect

The mother of a toddler with mumps asks the nurse what she needs to watch for in her child with this disease. The nurse bases the response on the understanding that mumps is which type of communicable disease? 1. Skin rash caused by a virus 2. Skin rash caused by a bacteria 3. Respiratory disease caused by virus involving the lymph nodes 4. Respiratory disease caused by a virus involving the parotid gland

4 Rationale: Mumps is caused by a paramyxovirus that causes swelling from the parotid gland, causing jaw and ear pain. It is transmitted via direct contact or droplets spread from an infected person, salive from infected saliva, and possibly by contact with urine. Airborne and contact precautions are indicated during the period of communicability. Options 1, 2, and 3 are incorrect.

A child has a basilar skull fracture. Which primary health care provider's prescription should the nurse question? 1. Restrict fluid intake. 2. Insert an indwelling urinary catheter. 3. Keep an intravenous (IV) line patent. 4. Suction via the nasotracheal route as needed.

4 Rationale: Nasotracheal suctioning is contraindicated in a child with a basilar skull fracture. Because of the location of the injury, the suction catheter may be introduced into the brain. Fluids are restricted to prevent fluid overload. The child may require a urinary catheter for the accurate monitoring of I&O. An IV line is maintained to administer fluids or medications, if necessary.

A health care provider has prescribed oxygen as needed for a 10-month-old infant with heart failure (HF). In which situation should the nurse administer the oxygen to the child? 1. When the child is sleeping 2. When changing the child's diapers 3. When the mother is holding the child 4. When drawing blood for electrolyte levels

4 Rationale: Oxygen administration may be prescribed for the infant with HF for stressful periods, especially during bouts of crying or invasive procedures. Drawing blood is an invasive procedure that would likely cause the child to cry.

The nurse reinforces instructions to the parent of a child with meningococcal meningitis. Which statement by the parent indicates a need for further teaching? 1. "I can give my child acetaminophen for fever." 2. "I will watch for any hearing loss that may occur." 3. "I know that I will need to watch for any rash that my child may develop." 4. "I will need to get my other children the pneumococcal vaccine, but not the baby yet, he is only 3 months."

4 Rationale: Pneumococcal conjugate vaccine is recommended for all children beginning at age 2 months to protect against meningitis, streptococcal pneumococci can cause many bacterial infections, including meningitis. Options 1, 2, and 3 are correct.

The nurse is told that a child with rheumatic fever (RF) will be arriving to the nursing unit for admission. Which question should the nurse ask the family to elicit information specific to the development of RF? 1. "Has the child complained of back pain?" 2. "Has the child complained of headaches?" 3. "Has the child had any nausea or vomiting?" 4. "Has the child had a sore throat or a fever within the past 2 months?"

4 Rationale: RF characteristically presents 2 to 6 weeks after an untreated or partially treated group A β-hemolytic streptococcal infection of the upper respiratory tract. Initially, the nurse determines whether the child has had a sore throat or an unexplained fever within the past 2 months. Options 1, 2, and 3 are unrelated to RF.

A client arrives at the emergency department and has experienced frostbite to the right hand. What should the nurse expect to find when inspecting the client's hand? 1. A pink, edematous hand 2. Fiery red skin with edema in the nail beds 3. Black fingertips surrounded by an erythematous rash 4. A white color of the skin which is insensitive to touch

4 Rationale: The findings related to frostbite include a white or blue skin color and skin that is hard, cold, and insensitive to touch. As thawing occurs, so does flushing of the skin, the development of blisters or blebs, or tissue edema. Gangrene can develop in 9 to 15 days.

The nurse provides homecare instructions to the parents of a child with heart failure regarding the procedure for the administration of digoxin. Which statement by a parent indicates the need for further teaching? 1. "I will not mix the medication with food." 2. "If more than one dose is missed, I will call the doctor." 3. "I will take my child's pulse before administering the medication." 4. "If my child vomits after medication administration, I will repeat the dose."

4 Rationale: The parents need to be instructed that if the child vomits after the digoxin is administered, they are not to repeat the dose. Options 1, 2, and 3 are accurate instructions regarding the administration of this medication. Additionally, the parents should be instructed that if a dose is missed and it is not noticed until 4 hours or more later, the dose should not be administered.

A child is diagnosed with infectious mononucleosis. The nurse reinforces homecare instructions to the parents about the care of the child. Which instruction should the nurse provide to the parents? 1. Maintain the child on bed rest for 2 weeks. 2. Maintain respiratory precautions for 1 week. 3. Notify the pediatrician if the child develops a fever. 4. Notify the pediatrician if the child develops abdominal or left shoulder pain.

4 Rationale: The parents need to be instructed to notify the pediatrician if abdominal pain (especially in the left upper quadrant) or left shoulder pain occurs, because this may indicate splenic rupture. Children with enlarged spleens are also instructed to avoid contact sports until the splenomegaly resolves. Bed rest is not necessary and children usually self-limit their activity. Respiratory precautions are not required, although transmission can occur via direct intimate contact or contact with infected blood. Fever is treated with acetaminophen

The nurse is collecting data regarding a client after a thyroidectomy and notes the development of a hoarse and weak voice. Which nursing action is appropriate? 1. Check for signs of bleeding. 2. Administer calcium gluconate. 3. Notify the registered nurse immediately. 4. Reassure the client that this is usually a temporary condition.

4 Rationale: Weakness and hoarseness of the voice can occur as a result of trauma to the laryngeal nerve. If this develops, the client should be reassured that the problem will subside in a few days. Unnecessary talking should be discouraged. It is not necessary to notify the registered nurse immediately. These signs do not indicate bleeding or the need to administer calcium gluconate.

The evening nurse reviews the nursing documentation in the client's chart and notes that the day nurse has documented that the client has a stage 2 pressure injury in the sacral area. What should the nurse expect to find when checking the client's sacral area? 1. Intact skin 2. The presence of tunneling 3. A deep, crater-like appearance 4. Partial-thickness skin loss of the epidermis

4 Rationale: With a stage 2 pressure injury, the skin is not intact. There is partial-thickness skin loss of the epidermis or dermis. The ulcer is superficial and it may look like an abrasion, blister, or shallow crater. The skin is intact with a stage 1 pressure injury. A deep, crater-like appearance occurs during stage 3 and tunneling develops during stage 4.

The nurse is assisting a primary health care provider (PHCP) during an examination of an infant with hip dysplasia. The PHCP performs the Ortolani maneuver. Which data should the nurse expect to note during the examination? 1. Full range of motion of the legs 2. Marked asymmetry on the affected side 3. The unstable femoral head pops out of the acetabulum 4. The dislocated femoral head pops back into the acetabulum

4 Rationale: With the Ortolani maneuver, the examiner reduces the dislocated femoral head back into the acetabulum. A positive Ortolani maneuver is a palpable clunk as the femoral head moves over the acetabular ring. Options 1 and 2 are data collection techniques for the identification of the clinical manifestations of hip dysplasia, but they do not describe the Ortolani maneuver. When performing the Barlow maneuver, the examiner pushes the unstable femoral head out of the acetabulum.

The parents of a child recently diagnosed with cerebral palsy ask the nurse about the disorder. The nurse bases the response on the understanding that cerebral palsy is which type of condition? 1. An infectious disease of the central nervous system 2. An inflammation of the brain as a result of a viral illness 3. A congenital condition that results in moderate to severe retardation 4. A chronic disability characterized by impaired muscle movement and posture

4 Rationale: Cerebral palsy is a chronic disability characterized by impaired movement and posture resulting from an abnormality in the extrapyramidal or pyramidal motor system. Meningitis is an infectious process of the central nervous system. Encephalitis is an inflammation of the brain that occurs as a result of viral illness or central nervous system infection. Down syndrome is an example of a congenital condition that results in moderate to severe retardation.

The nurse reviews measures to prevent tick bites with a parent of a child with Rocky Mountain spotted fever. Which statement by the parent indicates a need for further teaching? 1. "I will have my child wear long sleeves and long pants to keep covered up." 2. "I will have my child stay on well-worn paths and not stray into tall grass." 3. "I will check my child for ticks after being exposed to a high-risk tick-infected area." 4. "I will have my child wear dark colored clothing so the tick will not be attracted to the colors."

4 Rationale: Protection from tick bites includes wearing light colored clothing to make the ticks more visible if they get on the child. Prevention of Rocky Mountain spotted fever includes measures to take to protect getting tick bites and includes wearing long-sleeved shirts, long pants tucked into socks, and a hat. Checking for ticks on children after they have been exposed to a high-risk area and using insect repellents containing diethyltoluamide and permethrins are also measures to take.

The nurse is reinforcing instructions to a client receiving external radiation therapy. The nurse determines that the client needs further teaching if the client states an intention to take which action? Select all that apply. 1. Eat a high-protein diet. 2. Avoid exposure to sunlight. 3. Wash the skin with a mild soap and pat it dry. 4. Apply pressure on the radiated area to prevent bleeding. 5. Avoid standing within 6 feet of persons under the age of 18 years.

4, 5 Rationale: The client should avoid pressure on the radiated area and wear loose-fitting clothing to prevent a disruption in the skin integrity. A client receiving external radiation is not radioactive and does not need to avoid other persons, including young people. A diet high in protein assists in the healing process. Avoiding sunlight and washing the skin with gentle soap and patting dry will assist with preventing skin disruption.

The nurse is preparing to care for a newborn who is receiving phototherapy. Which measures should be implemented? Select all that apply. 1. Avoid stimulation. 2. Decrease fluid intake. 3. Expose all of the newborn's skin. 4. Monitor the skin temperature closely. 5. Reposition the newborn every 2 hours. 6. Cover the newborn's eyes with shields or patches.

4, 5, 6; Rationale: Phototherapy is the use of intense fluorescent lights to reduce serum bilirubin levels in the newborn. Injury from treatment can occur. Interventions include exposing as much of the newborn's skin as possible; however, the genital area is covered. The newborn's eyes are also covered with shields or patches to ensure that the eyelids are closed. The shields or patches are removed at least once per shift to inspect the eyes for infection or irritation and to allow for eye contact. The nurse measures the quantity of light every 8 hours, monitors the skin temperature closely, and increases fluids to compensate for water loss. The newborn will have loose green stools and green-colored urine. The newborn's skin color is monitored with the fluorescent light turned off every 4 to 8 hours, and he or she is monitored for bronze baby syndrome, which is a grayish-brown discoloration of the skin.

The nurse is collecting data from a client who has been diagnosed with placenta previa. Which findings should the nurse expect to note? Select all that apply. 1. Uterine rigidity 2. Uterine tenderness 3. Severe abdominal pain 4. Bright red vaginal bleeding 5. Soft, relaxed, nontender uterus

4, 5; Rationale: Painless bright red vaginal bleeding during the second or third trimester of pregnancy is a sign of placenta previa. The client will have a soft and relaxed nontender uterus. In clients with abruptio placentae, severe abdominal pain is present. Uterine tenderness accompanies placental abruption. Additionally, with abruptio placentae, the abdomen will feel hard and board-like during palpation as the blood penetrates the myometrium and causes uterine irritability.

The nurse provides skin care instructions to the client who is receiving external radiation therapy. Which statement by the client indicates the need for further teaching? Select all that apply. 1. "I will handle the area gently." 2. "I will wear loose-fitting clothing." 3. "I will avoid the use of deodorants." 4. "I will limit sun exposure to 1 hour daily." 5. "I will apply moisturizer with a cotton tipped applicator for itching. "

4, 5; Rationale: The client needs to be instructed to avoid exposure to the sun because of the risk of burns, resulting in altered tissue integrity. No lotions, ointments, or medications should be applied to the skin unless prescribed by the radiologist.

The nurse is preparing to assist the health care provider to test the extraocular movements in a client and muscle weakness in the eyes. The nurse anticipates that which physical assessment technique will be done? 1. Testing using the Ishihara chart 2. Testing using a Snellen eye chart 3. Testing the corneal light reflexes 4. Testing the six cardinal positions of gaze

4. Testing the six cardinal positions of gaze Rationale: Testing the six cardinal positions of gaze is done to check for muscle weakness in the eyes. The client is asked to hold the head steady, then to follow movement of an object through the positions of gaze. The client should follow the object in a parallel manner with the two eyes. The Ishihara chart is used to detect color blindness. A Snellen eye chart is used to determine visual acuity and cranial nerve II (optic nerve) functioning. Testing the corneal light reflex, shining a penlight in the eyes of a client gazing straight ahead, should demonstrate the corneal reflection in the exact position in each eye and parallel alignment.

The client with small cell lung cancer is being treated with etoposide and the nurse is assisting with caring for the client during administration. The client gets up to use the bathroom and is dizzy and very weak. The nurse understands these symptoms are likely as a result of which side/adverse effect that is specifically associated with this medication? 1. Alopecia 2. Chest pain 3. Pulmonary fibrosis 4. Orthostatic hypotension

4; Rationale: A side effect specific to etoposide is orthostatic hypotension. The client's blood pressure is monitored during the infusion. Hair loss occurs with nearly all antineoplastic medications. Chest pain and pulmonary fibrosis are unrelated to this medication.

The parents of an 8-year-old child tell the nurse that they are concerned about the child because the child seems to be more attentive to friends than anyone else. Which is the appropriate nursing response? 1. "You need to be concerned." 2. "You need to monitor the child's behavior closely." 3. "You need to praise the child more often to stop this behavior." 4. "At this age, the child is developing his or her own personality."

4; Rationale: According to Erikson, at ages 7 to 12 years, the child begins to move toward receiving support from peers and friends and away from that of parents. The child also begins to develop special interests that reflect his or her own developing personality instead of those of the parents. Therefore, the other options identify incorrect responses.

After a client undergoes a liver biopsy, the nurse places the client in the prescribed right-side lying position. The nurse understands that the purpose of this intervention is to accomplish which? 1. Promote bile flow 2. Limit client discomfort 3. Promote hepatic glucose storage 4. Limit bleeding from the biopsy site

4; Rationale: After a liver biopsy, the client is assisted with assuming a right side-lying position with a small pillow or folded towel under the puncture site for at least 3 hours to apply pressure and limit bleeding from the biopsy site. The liver produces bile that flows through the common bile duct; client discomfort may be decreased; and the liver does store glucose as glycogen, but this is not the purpose of the right side-lying position.

The nurse has just administered ibuprofen to a child with a temperature of 38.8° C (102° F). The nurse should also take which action? 1. Withhold oral fluids for 8 hours. 2. Sponge the child with cold water. 3. Plan to administer salicylate in 4 hours. 4. Remove excess clothing and blankets from the child.

4; Rationale: After administering ibuprofen, excess clothing and blankets should be removed. The child can be sponged with tepid water, but not cold water because the cold water can cause shivering, which increases metabolic requirements above those already caused by the fever. Aspirin is not administered to a child with fever because of the risk of Reye's syndrome. Fluids should be encouraged to prevent dehydration.

The nurse is assigned to care for a client who has a chest tube. The nurse is told to monitor the client for crepitus (subcutaneous emphysema). Which method should be used to monitor the client for crepitus? 1. Auscultating the posterior breath sounds 2. Asking the client about pain upon inspiration 3. Placing the hands over the rib area and observing expansion 4. Palpating the skin around the chest and neck for a crackling sensation

4; Rationale: Air caught under the skin in the subcutaneous tissues is known as crepitus or subcutaneous emphysema. It presents as a "puffed-up" appearance that is caused by the leakage of air into the subcutaneous tissues. it feels like bubble wrap when palpated.

During a prenatal visit, the nurse is explaining dietary management to a client with diabetes mellitus. The nurse determines that the teaching has been effective when the client makes which statement? 1. "I can eat more sweets now because I need more calories." 2. "I need more fat in my diet so that the baby can gain enough weight." 3. "I need to eat a high-protein, low-carbohydrate diet now to control my blood glucose." 4. "I need to increase the fiber in my diet to control my blood glucose and prevent constipation."

4; Rationale: An increase in calories is needed during pregnancy, but concentrated sugars should be avoided because they may cause hyperglycemia. Per health care provider recommendations, fat intake should be 20% to 30% of the total calories. In addition, the client with diabetes needs about 50% to 60% of her caloric intake from carbohydrates and about 12% to 20% from protein. High-fiber foods will control blood glucose levels and prevent constipation.

A licensed practical nurse (LPN) attends a session about bioterrorism agents including anthrax. Which statement by an attendee demonstrates the need for further teaching about anthrax? 1. Anthrax is treated with antibiotic medications. 2. The most lethal form of anthrax is contacted by inhalation of the spores. 3. Anthrax can be transmitted by consumption of meat from an infected animal. 4. Anthrax bacteria produces a neurotoxin leading to a serious, possibly fatal paralysis.

4; Rationale: Anthrax is caused by Bacillus anthracis, and it can be contracted through the digestive system, abrasions in the skin, or inhalation. Antibiotics are administered. Botulism is caused by a neurotoxin that causes severe paralysis and can be fatal.

The client at 28 weeks' gestation is Rh negative and Coombs antibody negative. The nurse determines that the client understands what the nurse has taught her about Rh sensitization when the client makes which statement? 1. "I know I can never have another child." 2. "I am glad I won't have to have these shots if I have another child." 3. "I will have to have an injection once a month until the baby is born." 4. "I will tell the nurse at the hospital that I had an Rh shot during pregnancy."

4; Rationale: As described in the question, it is accepted practice to administer Rho(D) immune globulin to an Rh-negative woman at 28 weeks' gestation, with a second injection within 72 hours of delivery. This prevents sensitization, which could jeopardize a future pregnancy. For subsequent pregnancies or abortions, the injections must be repeated, because the immunity is passive. Options 1, 2, and 3 are inaccurate information.

A topical corticosteroid is prescribed by the health care provider for a child with atopic dermatitis (eczema). Which instruction should the nurse give the parent about applying the cream? 1. Apply the cream over the entire body. 2. Apply a thick layer of cream to affected areas only. 3. Avoid cleansing the area before application of the cream. 4. Apply a thin layer of cream and rub it into the area thoroughly.

4; Rationale: Atopic dermatitis is a superficial inflammatory process involving primarily the epidermis. A topical corticosteroid may be prescribed and should be applied sparingly (thin layer) and rubbed into the area thoroughly. The affected area should be cleaned gently before application. A topical corticosteroid should not be applied over extensive areas. Systemic absorption is more likely to occur with extensive application.

The nurse should plan which to encourage autonomy in the client who is a resident in a long-term care facility? 1. Choosing meals 2. Decorating the room 3. Scheduling haircut appointments 4. Allowing the client to choose social activities

4; Rationale: Autonomy is the personal freedom to direct one's own life as long as it does not impinge on the rights of others. An autonomous person is capable of rational thought. This individual can identify problems, search for alternatives, and choose solutions that allow for continued personal freedom as long as the rights and property of others are not harmed. The loss of autonomy—and, therefore, independence—is a very real fear among older clients. The correct option is the only choice that allows the client to be a decision maker.

The nurse suspects that the client has a pulmonary embolism. Which is the most important nursing action? 1. Monitor the vital signs. 2. Elevate the head of the bed. 3. Increase the intravenous flow rate. 4. Administer oxygen by face mask, as prescribed.

4; Rationale: Because pulmonary circulation is compromised in the presence of an embolus, cardiorespiratory support is initiated by oxygen administration. Monitoring vital signs and elevating the head of the bed may be components of the plan of care, but they are not the most important actions from the options provided. The nurse should not increase the intravenous rate without a prescription from the PHCP to do so.

The nurse is caring for a client with circumferential burns of both legs. Which leg position is appropriate for this type of a burn? 1. A dependent position 2. Elevation of the knees 3. Flat, without elevation 4. Elevation above the level of the heart

4; Rationale: Circumferential burns of the extremities may compromise circulation. Elevating injured extremities above the level of the heart and performing active exercise help to reduce dependent edema formation. Options 1, 2, and 3 are incorrect.

A mother is breastfeeding her newborn baby and experiences breast engorgement. The nurse should encourage the mother to do which to provide relief of the engorgement? 1. Breastfeed only during the daytime hours. 2. Apply cold compresses to the breast before feeding. 3. Avoid the use of a bra while the breasts are engorged. 4. Massage the breasts before feeding to stimulate let-down.

4; Rationale: Comfort measures for breast engorgement include massaging the breasts before feeding to stimulate let-down, wearing a supportive and well-fitting bra at all times, taking a warm shower or applying warm compresses just before feeding, and alternating breasts during feeding.

While assisting with the measurement of fundal height, the client at 36 weeks' gestation states that she is feeling lightheaded. On the basis of the nurse's knowledge of pregnancy, the nurse determines that this is most likely a result of which reason? 1. A full bladder 2. Emotional instability 3. Insufficient iron intake 4. Compression of the vena cava

4; Rationale: Compression of the inferior vena cava and aorta by the uterus may cause supine hypotension syndrome during pregnancy. Having the woman turn onto her left side or elevating the right buttock during fundal height measurement will prevent or correct the problem. Options 1, 2, and 3 are not the cause of the problem described in the question.

The nurse caring for a client with abruptio placentae is monitoring the client for signs of disseminated intravascular coagulopathy (DIC). The nurse should suspect DIC if which is observed? 1. Rapid clotting times 2. Pain and swelling of the calf of one leg 3. Laboratory values that indicate increased platelets 4. Petechiae, oozing from injection sites, and hematuria

4; Rationale: DIC is a state of diffuse clotting in which clotting factors are consumed, which leads to widespread bleeding. Platelet counts are decreased, because they are consumed by the process. Coagulation studies show no clot formation (clotting times are thus prolonged), and fibrin plugs may clog the microvasculature diffusely rather than in an isolated area.

An adolescent client with type 1 diabetes mellitus is admitted to the emergency department for treatment of diabetic ketoacidosis. Which assessment findings should the nurse expect to note? 1. Sweating and tremors 2. Hunger and hypertension 3. Cold, clammy skin and irritability 4. Fruity breath odor and decreasing level of consciousness

4; Rationale: DKA is a complication of diabetes mellitus that develops when a severe insulin deficiency occurs. Hyperglycemia occurs with diabetic ketoacidosis. Signs of hyperglycemia include fruity breath odor and a decreasing level of consciousness.

The nurse is caring for a postpartum client. At 4 hours postpartum, the client's temperature is 102° F (38.9° C). Which is the appropriate nursing action? 1. Apply cool packs to the abdomen. 2. Continue to monitor the temperature. 3. Remove the blanket from the client's bed. 4. Notify the registered nurse (RN), who will then contact the primary health care provider (PHCP).

4; Rationale: During the first 24 hours postpartum, the mother's temperature may be elevated as a result of dehydration. However, if the temperature is more than 2° F above normal, this may indicate infection, and the PHCP will need to be notified. Applying cool packs to the abdomen is an inappropriate action, and, additionally, this action requires a prescription. The remaining options may be a component of care but are not the most appropriate based on the data in the question.

The nurse administers erythromycin ointment (0.5%) to the newborn's eyes and the mother asks the nurse why this is done. The nurse should give which response to the client? 1. Prevents cataracts in the neonate born to a woman who is susceptible to rubella 2. Protects the neonate's eyes from possible infections acquired while hospitalized 3. Minimizes the spread of microorganisms to the neonate from invasive procedures during labor 4. Prevents ophthalmia neonatorum from occurring after delivery to a neonate born to a woman with an untreated gonococcal infection

4; Rationale: Erythromycin ophthalmic ointment 0.5% is used as a prophylactic treatment for ophthalmia neonatorum, which is caused by the bacteria Neisseria gonorrhoeae. The preventive treatment of gonorrhea is required by law. Options 1, 2, and 3 are not the purposes of administering this medication to the newborn.

The nurse is providing an education class to healthy older adults. Which exercise will best promote health maintenance? 1. Gardening every day for an hour 2. Sculpting once a week for 40 minutes 3. Cycling three times a week for 20 minutes 4. Walking three to five times a week for 30 minutes

4; Rationale: Exercise and activity are essential for health promotion and maintenance in the older adult and for achieving an optimal level of functioning. One of the best exercises for an older adult is walking, with the goal of progressing to 30-minute sessions three to five times each week. Gardening for an hour each day may not be practical. Not all clients have access to sculpting, and performing the activity once a week for 40 minutes would not provide enough activity. Cycling three times a week for 20 minutes would not provide enough activity, and not all clients have access to cycling.

A pregnant woman has a positive history of genital herpes, but she has not had lesions during her pregnancy. The nurse plans to provide which information to the client? 1. "You will be isolated from your newborn after delivery." 2. "There is little risk to your baby during your pregnancy, birth, and after delivery." 3. "Vaginal deliveries can reduce neonatal infection risk, even if you have an active lesion at birth." 4. "You will be evaluated at the time of delivery for herpetic genital tract lesions. If they are present, a cesarean delivery will be needed."

4; Rationale: If herpetic genital lesions are present at the time of delivery, a cesarean delivery will be necessary to reduce the risk of infecting the neonate. In the absence of herpetic genital lesions, a vaginal delivery may be indicated, unless there are other reasons for performing a cesarean delivery. Maternal isolation is not necessary, but potentially exposed neonates should be cultured on the day of delivery.

A health care provider prescribes an intravenous (IV) solution of 5% dextrose and half-normal saline (0.45%) with 40 mEq of potassium chloride for a child with hypotonic dehydration. The nurse performs which priority assessment before administering this IV prescription? 1. Obtains a weight 2. Takes the temperature 3. Takes the blood pressure 4. Checks the amount of urine output

4; Rationale: In hypotonic dehydration, electrolyte loss exceeds water loss. The priority assessment before administering potassium chloride intravenously would be to assess the status of the urine output. Potassium chloride should never be administered in the presence of oliguria or anuria. If the urine output is less than 1 mL/kg/hour to 2 mL/kg/hour, potassium chloride should not be administered. Although options 1, 2, 3 are appropriate assessments for a child with dehydration, these assessments are not related specifically to the IV administration of potassium chloride.

The nurse determines a child is in the "preoperational" phase of Piaget's cognitive developmental theory when the child makes which statement? 1. "I know all of my multiplication tables by memory." 2. "The ball is gone," when a ball disappears out of sight. 3. "I'll use a map to help me find my way in a new town." 4. "The moon follows me, and goes to bed when I go to bed."

4; Rationale: In the preoperational stage, the child is demonstrating egocentric thinking by believing the moon's actions revolve around the child. In the sensorimotor stage, a child does not believe an object exists if it is not in sight. A child in the concrete operations stage is able to classify, order, and sort facts, such as the multiplication tables. A child in the formal operations stage is able to solve more complex problems, such as using a map to determine location and directions.

The nurse is assigned to care for the client during the postpartum period. The client asks the nurse what the term involution means. Which description should the nurse give to the client? 1. The inverted uterus returning to normal 2. The gradual reversal of the uterine muscle into the abdominal cavity 3. The descent of the uterus into the pelvic cavity, which occurs at a rate of 2 cm/day 4. The progressive descent of the uterus into the pelvic cavity, which occurs at a rate of approximately 1 cm/day

4; Rationale: Involution is the progressive descent of the uterus into the pelvic cavity. After birth, descent occurs at a rate of approximately 1 fingerbreadth or 1 cm per day. The other options do not accurately describe involution.

Leopold's maneuvers will be performed on a pregnant client. The client asks the nurse about the procedure. Which information should the nurse provide to the client about Leopold's maneuvers? 1. The maneuvers measure the height of the maternal fundus. 2. The maneuvers determine the "lie" and "attitude" of the fetus. 3. The maneuvers are a systematic method for palpating the fetus through the maternal back. 4. The maneuvers are a systematic method for palpating the fetus through the maternal abdominal wall.

4; Rationale: Leopold's maneuvers comprise a systematic method for palpating the fetus through the maternal abdominal wall. Options 1, 2, and 3 are incorrect descriptions.

Methylergonovine is prescribed for a client with postpartum hemorrhage. Before administering the medication, the nurse contacts the primary health care provider (PHCP) who prescribed the medication if which condition is documented in the client's medical history? 1. Hypotension 2. Hypothyroidism 3. Diabetes mellitus 4. Peripheral vascular disease

4; Rationale: Methylergonovine is an ergot alkaloid used to treat postpartum hemorrhage. Ergot alkaloids are contraindicated in clients with significant cardiovascular disease, peripheral vascular disease, hypertension, preeclampsia, or eclampsia. These conditions are worsened by the vasoconstrictive effects of the ergot alkaloids. Options 1, 2, and 3 are not contraindications related to the use of ergot alkaloids.

The nurse reinforces instructions to the parents of a child with sickle cell anemia regarding the precipitating factors related to pain crisis. Which, if identified by a parent as a precipitating factor, indicates the need for further teaching? 1. Stress 2. Trauma 3. Infection 4. Fluid overload

4; Rationale: Pain crisis may be precipitated by infection, dehydration, hypoxia, trauma, or general stress. The mother of a child with sickle cell disease should encourage a fluid intake of 1.5 to 2 times the daily requirement to prevent dehydration.

The nurse is assisting in performing pediculosis capitis (head lice) checks. Which finding indicates that a child has a "positive" head check? 1. Maculopapular lesions behind the ears 2. Lesions in the scalp that extend to the hairline or neck 3. White flaky particles throughout the entire scalp region 4. White sacs attached to the hair shafts in the occipital area

4; Rationale: Pediculosis capitis is an infestation of the hair and scalp with lice. The nits are visible and attached firmly to the hair shaft near the scalp. The occiput is an area in which nits can be seen. Maculopapular lesions behind the ears or lesions that extend to the hairline or neck are indicative of an infectious process, not pediculosis. White flaky particles are indicative of dandruff.

A child with type 1 diabetes mellitus is brought to the emergency department by the mother, who states that the child has been complaining of abdominal pain and has been lethargic. Diabetic ketoacidosis is diagnosed. Anticipating the plan of care, the nurse prepares to administer which type of intravenous (IV) infusion? 1. Potassium infusion 2. NPH insulin infusion 3. 5% dextrose infusion 4. Normal saline infusion

4; Rationale: Rehydration is the initial step in resolving dka. Normal saline is the initial IV rehydration fluid. NPH insulin is never administered by the IV route. Dextrose solutions are added to the treatment when the blood glucose level decreases to an acceptable level. Intravenously administered potassium may be required, depending on the potassium level, but would not be part of the initial treatment.

Rho(D) immune globulin is prescribed for a client after delivery and the nurse provides information to the client about the purpose of the medication. The nurse determines that the woman understands the purpose if the woman states that it will protect her next baby from which condition? 1. Having Rh-positive blood 2. Developing a rubella infection 3. Developing physiological jaundice 4. Being affected by Rh incompatibility

4; Rationale: Rh incompatibility can occur when an Rh-negative mother becomes sensitized to the Rh antigen. Sensitization may develop when an Rh-negative woman becomes pregnant with a fetus who is Rh positive. During pregnancy and at delivery, some of the fetus's Rh-positive blood can enter the maternal circulation, causing the mother's immune system to form antibodies against Rh-positive blood. Administration of Rho(D) immune globulin prevents the mother from developing antibodies against Rh-positive blood by providing passive antibody protection against the Rh antigen.

Silver sulfadiazine is prescribed for a client with a burn injury. Which laboratory finding requires the need for monitoring by the nurse? 1. Glucose level of 99 mg/dL (5.5 mmol/L) 2. Platelet level of 300,000 mm3 (300 × 109/L) 3. Magnesium level of 1.5 mEq/L (0.75 mmol/L) 4. White blood cell count of 3000 mm3 (3.0 × 109/L)

4; Rationale: Silver sulfadiazine is used for the treatment of burn injuries. Adverse effects of this medication include rash and itching, blue-green or gray skin discoloration, leukopenia, and interstitial nephritis. The nurse should monitor a complete blood count, particularly the white blood cells, frequently for the client taking this medication. If leukopenia develops, the PHCP is notified and the medication is usually discontinued. The white blood cell count noted in option 4 is indicative of leukopenia. The other laboratory values are not specific to this medication, and are also within normal limits.

The camp nurse asks the children preparing to swim in the lake if they have applied sunscreen. The nurse reminds the children that chemical sunscreens are most effective when applied at which times? 1. Immediately before swimming 2. 5 minutes before exposure to the sun 3. Immediately before exposure to the sun 4. At least 30 minutes before exposure to the sun

4; Rationale: Sunscreens are most effective when applied at least 30 minutes before exposure to the sun so that they can penetrate the skin. All sunscreens should be reapplied after swimming or sweating.

Tamoxifen is prescribed for the client with metastatic breast carcinoma. The nurse understands that which is the primary action of this medication? 1. Increase DNA and RNA synthesis. 2. Promote the biosynthesis of nucleic acids. 3. Increase estrogen concentration and estrogen response. 4. Compete with estradiol for binding to estrogen in tissues containing high concentrations of receptors.

4; Rationale: Tamoxifen is an antineoplastic medication that competes with estradiol for binding to estrogen in tissues containing high concentrations of receptors. Tamoxifen reduces DNA synthesis and estrogen response

The nurse is planning to reinforce instructions about cord care to a new mother. The nurse should plan to tell the mother which about cord care? 1. Alcohol is the only agent used to clean the cord. 2. It takes 21 days for the cord to dry up and fall off. 3. Cord care is done only at birth to control bleeding. 4. The process of keeping the cord clean and dry will decrease bacterial growth

4; Rationale: The cord should be kept clean and dry to decrease bacterial growth; this includes keeping the diaper folded below the cord to keep urine away from the cord. The cord should be cleansed two to three times a day. It usually falls off within 7 to 14 days. Agents other than alcohol may be prescribed to clean the cord.

The client received epidural anesthesia during labor and had a forceps delivery after pushing for 2 hours. At 6 hours postpartum, the client's systolic blood pressure (BP) dropped 20 points, the diastolic BP dropped 10 points, and her pulse is 120 beats per minute. The client is very anxious and restless. The nurse is told that the client has a vulvar hematoma. Based on this diagnosis, the nurse should plan which action? 1. Reassure the client 2. Apply perineal pressure 3. Monitor fundal height 4. Prepare the client for surgery

4; Rationale: The information provided in the question indicates that the client is experiencing blood loss. Surgery would be indicated for this complication to stop the bleeding. Reassuring the client, applying perineal pressure, and monitoring the fundal height do not assist with controlling the bleeding in this emergency situation.

The nurse reinforces home care instructions to the parents of a 3-year-old child who has been hospitalized with hemophilia. Which statement by a parent indicates the need for further teaching? 1. "I will supervise my child closely." 2. "I will pad the corners of the furniture." 3. "I will remove household items that can easily fall over." 4. "I will avoid immunizations and dental hygiene treatments for my child."

4; Rationale: The nurse needs to stress the importance of immunizations, dental hygiene, and routine well-child care. Options 1, 2, and 3 are appropriate statements. The parents are also provided instructions regarding measures to take in the event of blunt trauma (especially trauma that involves the joints), and they are instructed to apply prolonged pressure to superficial wounds until the bleeding has stopped.

The client asks the nurse about the purpose of the placenta. The nurse plans to respond to the client knowing which about the placenta? 1. Cushions and protects the fetus 2. Maintains the body temperature of the fetus 3. Surrounds the fetus and allows for fetal movement 4. Provides an exchange of nutrients and waste products between the mother and the fetus

4; Rationale: The placenta provides an exchange of nutrients and waste products between the mother and the fetus. The amniotic fluid surrounds, cushions, and protects the fetus and allows for fetal movement. The amniotic fluid also maintains the body temperature of the fetus.

226. The client is in her second trimester of pregnancy. She complains of frequent low back pain and ankle edema at the end of the day. The nurse should recommend which measure to help relieve both discomforts? 1. Lie on the left side with the feet dorsiflexed. 2. Soak the feet in hot water after performing 10 pelvic tilt exercises. 3. Lie on the right side with the feet elevated on a pillow and a heating pad on the back. 4. Lie on the floor with the legs elevated onto a couch or padded chair, with the hips and knees at a right angle.

4; Rationale: The position described in option 4 will produce the posture of the pelvic tilt while countering gravity as the force that leads to the edema of the lower extremities. Although the other options may seem useful, options 2 and 3 identify heat, which should be prescribed by the health care provider (HCP). Option 1 will not relieve back pain and ankle edema.

150. A client has just returned to a nursing unit after an above-knee amputation of the right leg. The nurse should plan to place the client in which position? 1. Prone 2. Reverse Trendelenburg's 3. Supine, with the residual limb flat on the bed 4. Supine, with the residual limb supported with pillows

4; Rationale: The residual limb is usually supported on pillows for the first 24 hours following surgery to promote venous return and decrease edema. After the first 24 hours, the residual limb usually is placed flat on the bed to reduce hip contracture. Edema also is controlled by limb-wrapping techniques. In addition, it is important to check the surgeon's prescription(s) regarding positioning following amputation.

The nurse is providing discharge instructions to the parents of a 14-year-old child who is undergoing radiation for Hodgkin's disease. Which statement by a parent indicates the need for further teaching? 1. "I need to watch for diarrhea, so my child does not get dehydrated." 2. "I think that once my child's hair starts to fall out that I can keep a hat on him." 3. "I understand that the radiation will cause nausea and vomiting and I need to keep my child hydrated." 4. "I will need to keep my child's skin from flaking, so we will be allowing showers every 2 or 3 days."

4; Rationale: The side effects of radiation therapy include dry or moist desquamation (peeling of the skin) and the intervention includes washing the skin daily, using mild soap, applying a lubricant as prescribed. Options 1, 2, and 3 are appropriate statements.

The nurse is assigned to assist with caring for a client who is being admitted to the birthing center in early labor. During admission, which action should the nurse take initially? 1. Estimate the fetal size. 2. Check pelvic adequacy. 3. Administer an analgesic. 4. Determine the maternal and fetal vital signs.

4; Rationale: To evaluate a woman's physical well-being, her temperature, pulse, respirations, and blood pressure (as well as the fetal heartbeat) are checked. Administering an analgesic is incorrect because it would be too premature for an analgesic; medication given too early tends to slow or stop labor contractions. Estimating fetal size and pelvic adequacy should have been previously performed by the health care provider during prenatal visits

The client who is being prepared for a cesarean delivery is brought to the delivery room. To maintain the optimal perfusion of oxygenated blood to the fetus, the nurse should place the client in which position? 1. Prone position 2. Semi-Fowler's position 3. Trendelenburg's position 4. Supine position with a wedge under the right hip

4; Rationale: Vena cava and descending aorta compression by the pregnant uterus impede blood return from the lower trunk and extremities, thereby decreasing cardiac return, cardiac output, and blood flow to the uterus and subsequently to the fetus. The best position to prevent this would be side-lying, with the uterus displaced off of the abdominal vessels. Positioning for abdominal surgery necessitates a supine position; however, a wedge placed under the right hip provides for the displacement of the uterus. A prone or semi-Fowler's position is not practical for this type of abdominal surgery. Trendelenburg's position places pressure from the pregnant uterus on the diaphragm and lungs, thus decreasing respiratory capacity and oxygenation.

The client with ovarian cancer is being treated with vincristine. The nurse monitors the client, knowing that which adverse effect is specific to this medication? 1. Diarrhea 2. Hair loss 3. Chest pain 4. Extremity numbness

4; Rationale: Vincristine is a vinca alkaloid antineoplastic (miotic inhibitor) medication that has an adverse effect, specifically peripheral neuropathy. Peripheral neuropathy can be manifested as numbness and tingling in the fingers and toes. Depression of the Achilles tendon reflex may be the first clinical sign indicating peripheral neuropathy. Constipation, rather than diarrhea, is most likely to occur with this medication, although diarrhea may occur occasionally. Hair loss occurs with nearly all the antineoplastic medications. Chest pain is unrelated to this medication.

The nurse is assigned to assist with caring for a client with esophageal varices who had a Sengstaken-Blakemore tube inserted because other treatment measures were unsuccessful. The nurse should check the client's room to ensure that which priority item is at the bedside? 1. An obturator 2. A Kelly clamp 3. An irrigation set 4. A pair of scissors

4; Rationale: When the client has a Sengstaken-Blakemore tube, a pair of scissors must be kept at the client's bedside at all times. If the gastric balloon of the tube ruptures, the tube will move upward and potentially occlude the client's airway. The client needs to be observed for sudden respiratory distress. If this occurs, the RN is notified immediately, and the balloon lumens will be cut.

142. The nurse is assigned to assist with caring for a client after cardiac catheterization performed through the left femoral artery. The nurse should plan to maintain bed rest for this client in which position? 1. High Fowler's position 2. Supine with no head elevation 3. Left lateral (side-lying) position 4. Supine with head elevation no greater than 30 degrees

4; rationale: After cardiac catheterization, the extremity into which the catheter was inserted is kept straight for the prescribed time period to prevent arterial occlusion or bleeding and hematoma. With a femoral approach, the client's affected extremity is kept straight and the head elevated no more than 30 degrees (some PHCPs prefer a lower head position or the flat position) until hemostasis is adequately achieved. The client may turn from side to side. Bathroom privileges are not allowed during the immediate postcatheterization period. High Fowler's (90-degree elevation), flat, and side lying on the puncture site are not effective in preventing complications or allowing for client comfort.

The nurse monitors a 5-year-old child admitted to the hospital for a neuroblastoma for signs and symptoms related to the location of the tumor in the adrenal gland. Which descriptions would the nurse expect to be documented in the child's record specific to this tumor? Select all that apply. 1. Respiratory impairment 2. Anorexia and weight loss 3. Pallor, weakness, irritability 4. Supraorbital ecchymosis and periorbital edema 5. Firm, nontender, irregular mass in the abdomen 6. Urinary frequency or retention from compression on the bladder

5, 6; Rationale: The signs and symptoms of a neuroblastoma depend on the location of the tumor. When the tumor is found on the adrenal gland, the findings will be consistent with a firm, nontender, irregular mass in the abdomen. This will likely cause some degree of urinary frequency or retention from compression on the ureter, or kidney.

The medication prescribed is heparin 5000 units subcutaneously, every 12 hours. The medication vial reads heparin 10,000 units/mL. The nurse prepares how many milliliters to administer one dose?

0.5mL

The medication prescribed is prochlorperazine 5 mg intramuscularly, every 4 hours as needed. The medication label states prochlorperazine 10 mg/mL. The nurse prepares how much medication to administer the dose?

0.5mL

After a tonsillectomy, the child begins to vomit bright red blood. Which is the initial nursing action? 1. Turn the child to the side. 2. Notify the registered nurse (RN). 3. Administer the prescribed antiemetic. 4. Maintain NPO (nothing by mouth) status.

1 Rationale: After a tonsillectomy, if bleeding occurs, the child is turned to the side and the RN or PHCP is notified. An NPO status would be maintained, and an antiemetic may be prescribed; however, the initial nursing action would be to turn the child to the side.

The nurse is checking a client's record for probable signs of pregnancy. Which are the probable signs of pregnancy that the nurse should note? Select all that apply. 1. Ballottement 2. Chadwick's sign 3. Uterine enlargement 4. Braxton Hicks contractions 5. Outline of fetus via radiography or ultrasound 6. Fetal heart rate detected by a nonelectronic device

1, 2, 3, 4; Rationale: The probable signs of pregnancy include uterine enlargement; Hegar's sign, Goodell's sign, Chadwick's sign, ballottement, Braxton Hicks contractions; and a positive pregnancy test that measures for human chorionic gonadotropin. Positive signs of pregnancy include a fetal heart rate that is detected by an electronic device (Doppler transducer) at 10 to 12 weeks' gestation and by a nonelectronic device (fetoscope) at 20 weeks' gestation; active fetal movements that are palpable by the examiner; and an outline of the fetus via radiography or ultrasound.

The nurse assists to create a nursing care plan for the child with an arm cast and should include which interventions in the plan? Select all that apply. 1. Instruct parents to keep the cast clean and dry. 2. Monitor the extremity for circulatory impairment. 3. Instruct the child not to stick objects down the cast. 4. Ensure that rough cast materials are cut off to keep smooth. 5. Notify the registered nurse (RN) immediately if circulatory impairment occurs.

1, 2, 3, 5 Rationale: The cast should have not rough edges, but cutting the cast is not appropriate, the edges can be covered with waterproof adhesive tape to ensure a smooth cast edge. Instruct the parents and the child to keep the cast clean and dry, and not to stick objects down the cast. Monitoring for circulatory impairment is important.

The nurse is planning care for a child with hemolytic-uremic syndrome (HUS). The child has been anuric and will be receiving peritoneal dialysis treatment. The nurse should plan to include which interventions in the care of the child? Select all that apply. 1. Provide adequate nutrition. 2. Restriction of fluids, as prescribed 3. Institute measures to prevent infection. 4. Monitoring the arteriovenous (AV) fistula 5. Administer blood products to treat severe anemia. 6. Anticipate the child will have central nervous system involvement.

1, 2, 3, 5, 6 Rationale: HUS is thought to be associated with bacterial toxins, chemicals, and viruses that cause acute kidney injury in children. A child with HUS who is undergoing peritoneal dialysis for the treatment of anuria will be prescribed fluid restrictions. The treatment also involves providing adequate nutrition, preventing infection and anticipating CNS involvement which may include seizure, stupor, and coma. Peritoneal dialysis does not require an AV fistula (only hemodialysis does).

The nurse is assisting with caring for a client with cancer who is receiving cisplatin. Which adverse effects are associated with this medication? Select all that apply. 1. Tinnitus 2. Ototoxicity 3. Hyperkalemia 4. Hypercalcemia 5. Nephrotoxicity 6. Hypomagnesemia

1, 2, 5, 6; Rationale: Cisplatin is an alkylating medication. Alkylating medications are cell cycle phase nonspecific and affect the synthesis of DNA by causing its cross-linking to inhibit cell reproduction. Cisplatin may cause ototoxicity, tinnitus, hypokalemia, hypocalcemia, hypomagnesemia, and nephrotoxicity. Amifostine may be administered before cisplatin to reduce the potential for renal toxicity.

The nurse is assigned to care for a client who is in early labor. When collecting data from the client, which should the nurse check first? 1. Baseline fetal heart rate 2. Intensity of contractions 3. Maternal blood pressure 4. Frequency of contractions

1; Rationale: The nurse should first determine the baseline fetal heart rate. Although options 2, 3, and 4 are components of the data collection process, the fetal heart rate is the priority.

The nurse is performing a neurovascular check on a hospitalized child who had a cast applied to the lower leg. The child complains of tingling in the toes distal to the fracture site. Which action should the nurse take? 1. Elevate the extremity. 2. Document the findings. 3. Notify the registered nurse (RN). 4. Ambulate the child with crutches.

3 Rationale: Reduced sensation to touch or complaints of numbness or tingling at a site distal to the fracture may indicate poor tissue perfusion. This finding should be reported to the registered nurse or PHCP. Options 1, 2, and 4 are inappropriate and would delay the required and immediate interventions.

An opioid analgesic is administered to a client in labor. The nurse assigned to care for the client ensures that which medication is readily available if respiratory depression occurs? 1. Naloxone 2. Morphine sulfate 3. Betamethasone 4. Meperidine hydrochloride

1; Rationale: Opioid analgesics may be prescribed to relieve moderate to severe pain associated with labor. Opioid toxicity can occur and cause respiratory depression. Naloxone is an opioid antagonist, which reverses the effects of opioids and is given for respiratory depression. Morphine sulfate and meperidine hydrochloride are opioid analgesics. Betamethasone is a corticosteroid administered to enhance fetal lung maturity.

The nurse notes hypotonia, irritability, and a poor sucking reflex in a full-term newborn after admission to the nursery. The nurse suspects fetal alcohol syndrome (FAS) and is aware that which additional sign is consistent with FAS? 1. A length of 19 inches 2. Abnormal palmar creases 3. A birth weight of 6 pounds and 14 ounces 4. A head circumference that is appropriate for gestational age

2; Rationale: Features of newborn infants who are diagnosed with FAS include craniofacial abnormalities, intrauterine growth restriction, cardiac abnormalities, abnormal palmar creases, and respiratory distress. Options 1, 3, and 4 are normal findings in the full-term newborn infant.

55. The registered nurse (RN) reviews the results of the arterial blood gas (ABG) values with the licensed practical nurse (LPN) and tells the LPN that the client is experiencing respiratory acidosis. The LPN should expect to note which on the laboratory result report? 1. pH 7.50, Pco2 52 mm Hg 2. pH 7.35, Pco2 40 mm Hg 3. pH 7.25, Pco2 50 mm Hg 4. pH 7.50, Pco2 30 mm Hg

3. pH 7.25, Pco2 50 mm Hg Rationale: The normal pH is 7.35 to 7.45, and the normal Pco2 value is 35 mm Hg to 45 mm Hg (35 to 45 mm Hg). In respiratory acidosis, the pH is down, and the Pco2 is up. Therefore, the pH of 7.25 and the Pco2 of 50 mm Hg (50 mm Hg) option is the only one that reflects an acidotic condition. Options with an elevated pH (options 1 and 4) indicate an alkalotic condition. Option 2 identifies normal values for pH and Pco2.

The pregnant woman complains of being awakened frequently by leg cramps. The nurse reinforces instructions to the client's partner and should tell the client to perform which measure? 1. Dorsiflex the client's foot while flexing the knee. 2. Plantarflex the client's foot while flexing the knee. 3. Dorsiflex the client's foot while extending the knee. 4. Plantarflex the client's foot while extending the knee.

3; Rationale: Leg cramps often occur when the pregnant woman stretches her leg and plantar flexes her foot. Dorsiflexion of the foot while extending the knee stretches the gastrocnemius muscle, prevents the muscle from contracting, and halts the cramping. Therefore, the remaining options are incorrect.

A client with type 1 diabetes mellitus calls the nurse to report recurrent episodes of hypoglycemia. Which statement by the client indicates a correct understanding of Humulin N insulin and exercise? 1. "I should not exercise after lunch." 2. "I should not exercise after breakfast." 3. "I should not exercise in the late evening." 4. "I should not exercise in the late afternoon."

4 Rationale: A hypoglycemic reaction may occur in response to increased exercise. Clients should avoid exercise during the peak time of insulin. Humulin N insulin peaks between 6 and 14 hours; therefore, late-afternoon exercise would occur during the peak of the medication.

The medication prescribed is morphine sulfate 6 mg subcutaneously. The medication label states morphine sulfate 10 mg/1 mL. The nurse plans to prepare how much medication to administer the dose?

0.6 mL

The medication prescribed is haloperidol, 4 mg intramuscularly, immediately. The medication label states 5 mg/1 mL. The nurse prepares how much medication to administer the dose?

0.8mL

A child is diagnosed with chicken pox. The nurse collects data regarding the child. Which finding is characteristic of chicken pox? 1. Macular rash on the trunk and scalp 2. Pseudomembrane formation in the throat 3. Maculopapular or petechial rash on the extremities 4. Small, red spots with a bluish-white center and red base

1 Rationale: A macular rash that first appears on the trunk and scalp and then moves to the face and the extremities is a characteristic of chicken pox. Pseudomembrane formation in the throat is characteristic of diphtheria. A maculopapular or petechial rash primarily on the extremities is characteristic of Rocky Mountain spotted fever. Small red spots with a bluish-white center and red base are known as Koplik spots and are characteristic of measles.

The nurse is providing instructions to a parent of a child with patent ductus arteriosus (PDA). Which statement by the parent would indicate a need for further teaching? 1. "I know that my child will outgrow this problem, just give him time." 2. "I know that I need to be alert for signs of heart failure with this defect until it is repaired." 3. "The doctors tell me that my child has a heart murmur caused by the ductus not closing after birth." 4. "As I understand it, my child may have to have his defect closed, either during a catheterization or by surgery."

1 Rationale: A patent ductus arteriosus (PDA) is caused by a failure of the ductus to close within the first weeks of life. The infant may be asymptomatic or show signs of heart failure. The defect may be closed during cardiac catheterization or may require surgery. A characteristic machine-like murmur is present with PDA.

The nurse is assigned to care for a child who is suspected of having glomerulonephritis. The nurse reviews the child's record and notes that which findings are associated with the diagnosis of glomerulonephritis? Select all that apply. 1. Headache 2. Hypotension 3. Red-brown urine 4. Periorbital edema 5. Increased urine output 6. A low blood urea nitrogen (BUN) level

1, 3, 4 Rationale: Signs of glomerulonephritis include headache, abdominal or flank pain, gross hematuria resulting in dark, smoky, cola-colored or red-brown urine and periorbital edema or facial edema. Clients are hypertensive and have decreased urine output. BUN levels may be elevated.

A child with a diagnosis of a hernia has been scheduled for a surgical repair in 2 weeks. The nurse reinforces instructions to the parents about the signs of possible incarcerated hernia. The nurse tells the parents that which manifestation requires primary health care provider (PHCP) notification by the parents? 1. Pain 2. Diarrhea 3. Constipation 4. Increased flatus

1 Rationale: The parents of a child with a hernia need to be instructed about the signs of an incarcerated hernia. These signs include irritability, tenderness at the site of the hernia, anorexia, abdominal distension, and difficulty defecating. The parents should be instructed to contact the PHCP immediately if an incarcerated hernia is suspected. These signs may lead to a complete intestinal obstruction and gangrene. Diarrhea, increased flatus and constipation are not associated with an incarcerated hernia

The nurse is monitoring a pregnant client with gestational hypertension (GH) who is at risk for preeclampsia. The nurse should check the client for which signs of preeclampsia? Select all that apply. 1. Proteinuria 2. Hypertension 3. Low-grade fever 4. Increased pulse rate 5. Increased respiratory rate

1, 2; Rationale: Signs of preeclampsia are hypertension and proteinuria. A low-grade fever, increased pulse rate, and increased respiratory rate are not associated with preeclampsia.

The medication prescription states to administer acetaminophen 650 mg orally for a temperature of more than 38° C. The medication bottle states acetaminophen 325 mg tablets. The nurse takes the client's temperature and notes that it is 101° F. The nurse plans to take which action? 1. Administer two tablets. 2. Administer three tablets. 3. Do not administer at this time. 4. Check the client's temperature in 30 minutes.

1. Administer two tablets.

The primary health care provider (PHCP) has prescribed an antibiotic for a child. The average adult dose is 500 mg. The child has a body surface area (BSA) of 0.63 m2. What is the dose for the child?

182.0 mg Rationale: When calculating pediatric dosages that are specified for adults, calculate the child's dose using the formula that incorporates BSA values. Standard adult BSA value is 1.73 m2, the child's BSA is 0.63 m2.

The medication prescription reads phenytoin 0.2 g orally, twice daily. The medication label states 100-mg capsules. The nurse prepares how many capsule(s) to administer one dose?

2 capsule(s)

The nurse is preparing to administer a medication through a nasogastric (NG) tube that is connected to suction. Which interventions should be included to accurately administer the medication? Select all that apply. 1. Position the client supine to assist with medication absorption. 2. Clamp the NG tube for 30 minutes after medication administration. 3. Before medication administration, verify correct placement of tube. 4. Flush the NG tube with saline before and after medication administration. 5. Discontinue the suction from the tube during administration of medication.

2,3,4,5; Rationale: Oral medications are sometimes administered to a client who is prescribed suction through a nasogastric (NG) tube. The nurse must verify that the tube has correct placement by checking drainage characteristics and pH to avoid aspiration of the medication into the trachea. The NG tube should be flushed with saline before and after medication administration to facilitate delivery and promote absorption. The suction must be stopped during administration and then the tube is clamped for 30 minutes afterward. The client should be in an upright position at least 30 degrees, but higher is better to avoid aspiration. Medications should not be given in the supine position.

. The intravenous prescription is 1000 mL of 0.9% NaCl (normal saline) to run over 12 hours. The drop factor is 15 gtts/1 mL. The nurse plans to adjust the flow rate to how many gtts/minute?

21 gtts/minute

The intravenous prescription is 3000 mL of 5% dextrose in water (D5W) to run over a 24-hour period. The drop factor is 10 gtts/1 mL. The nurse plans to adjust the flow rate to how many gtts/minute?

21 gtts/minute

Morphine sulfate, 2.5 mg, is prescribed for a child. The safe pediatric dose is 0.05 mg/kg/dose to 0.1 mg/kg/dose. The child weighs 50 kg. Which statement accurately describes the prescribed dosage for this child? 1. The dose is too low. 2. The dose is too high. 3. The dose is within the safe dosage range. 4. There is not enough information to determine the safe dosage range.

3

The nurse reviews the record of a child who was just seen by the primary health care provider (PHCP). The PHCP has documented a diagnosis of suspected aortic stenosis. Which specific sign/symptom of aortic stenosis should the nurse anticipate? 1. Pallor 2. Hyperactivity 3. Exercise intolerance 4. Gastrointestinal disturbances

3 Rationale: The child with aortic stenosis shows signs of exercise intolerance, chest pain, and dizziness when standing for long periods. Pallor may be noted, but it is not specific to this type of disorder alone. Options 2 and 4 are not related to this disorder.

The client is receiving external radiation to the neck for cancer of the larynx. The nurse monitors the client knowing that which are side/adverse effects of the external radiation? Select all that apply. 1. Dyspnea 2. Diarrhea 3. Sore throat 4. Constipation 5. Red and dry skin over neck

3, 5; Rationale: External radiation is used to treat cancer in a specific area by emission of ionizing radiation beams that destroy cancer cells and have minimal damage to the surrounding normal cells. The client receiving external radiation experiences both general side/adverse effects such as fatigue, nausea, anorexia and localized side/adverse effects in the specific area receiving radiation. A client who is receiving radiation to the larynx is most likely to experience a sore throat and dry, reddened skin in the throat area. Diarrhea or constipation occur with radiation to the gastrointestinal (GI) tract. Dyspnea may occur with lung involvement.

The licensed practical nurse (LPN) enters a client's room and finds the client lying on the bathroom floor. The LPN calls the registered nurse, who checks the client thoroughly and then assists the client back into bed. The LPN completes an incident report, and the nursing supervisor and primary health care provider (PHCP) are notified of the incident. Which is the next nursing action regarding the incident? 1. Place the incident report in the client's chart. 2. Make a copy of the incident report for the PHCP. 3. Document a complete entry in the client's record concerning the incident. 4. Document in the client's record that an incident report has been completed.

3. Document a complete entry in the client's record concerning the incident. -Rationale: The incident report is confidential and privileged information, and it should not be copied, placed in the chart, or have any reference made to it in the client's record. The incident report is not a substitute for a complete entry in the client's record concerning the incident.

101. While collecting data related to the cardiac system on a client, the nurse hears a murmur. Which best describes the sound of a heart murmur? 1. Lub-dub sounds 2. Scratchy, leathery heart noise 3. Gentle, blowing or swooshing noise 4. Abrupt, high-pitched snapping noise

3. Gentle, blowing or swooshing noise Rationale: A heart murmur is an abnormal heart sound and is described as a gentle, blowing, swooshing sound. It occurs from increased or abnormal blood flow through the valves of the heart. Lub-dub sounds are normal and represent the S1 (first heart sound) and S2 (second heart sound), respectively. A pericardial friction rub is described as a scratchy, leathery heart sound that occurs with pericarditis. A click is described as an abrupt, high-pitched snapping sound.

52. The nurse is caring for a client with a diagnosis of chronic obstructive pulmonary disease (COPD). The nurse should monitor the client for which acid-base imbalance? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

3. Respiratory acidosis Rationale: Respiratory acidosis most often occurs as a result of primary defects in the function of the lungs or changes in normal respiratory patterns from secondary problems. Chronic respiratory acidosis is most commonly caused by chronic obstructive pulmonary disease (COPD). Acute respiratory acidosis also occurs in clients with COPD when superimposed respiratory infection or concurrent respiratory disease increases the work of breathing. The remaining options are not likely to occur unless other conditions complicate the COPD.

Sulfisoxazole 1 g orally four times daily, is prescribed for an adolescent with a urinary tract infection. The medication label reads, "250-mg tablets." The nurse has determined that the prescribed dose is safe. How many tablets per dose should the nurse administer to the adolescent?

4 mL

A clear liquid diet has been prescribed for a client with gastroenteritis. Which item is appropriate to offer to the client? 1. Soft custard 2. Orange juice 3. Clam chowder 4. Fat-free beef broth

4. Fat-free beef broth Rationale: A clear liquid diet consists of foods that are relatively transparent. Soft custard and orange juice would be included in a full liquid diet because they are opaque, not clear. Clam chowder is opaque and also includes pieces of clams, thus eliminating it from a full liquid diet.

The nurse is caring for a client with leukemia and notes that the client has poor skin turgor and flat neck and hand veins. The nurse suspects hyponatremia. Which additional sign/symptom should the nurse expect to note in this client if hyponatremia is present? 1. Intense thirst 2. Slow bounding pulse 3. Dry mucous membranes 4. Postural blood pressure changes

4. Postural blood pressure changes Postural blood pressure changes occur in the client with hyponatremia. Intense thirst and dry mucous membranes are seen in clients with hypernatremia. A slow, bounding pulse is not indicative of hyponatremia. In a client with hyponatremia, a rapid, thready pulse is noted.

The primary health care provider (PHCP) has prescribed phenobarbital sodium, 25 mg orally twice daily, for a child with febrile seizures. The medication label reads as follows: "Phenobarbital sodium, 20 mg/5 mL." The nurse has determined that the dose prescribed is a safe dose for the child. How many milliliters per dose should the nurse administer to the child?

6.25mL

The client is hospitalized for the insertion of an internal cervical radiation implant. While giving care, the nurse finds the radiation implant in the bed. Which is the immediate nursing action? 1. Reinsert the implant into the vagina. 2. Call the primary health care provider (PHCP). 3. Pick up the implant with gloved hands and flush it down the toilet. 4. Pick up the implant with long-handled forceps and place into a lead container.

4; Rationale: A lead container and long-handled forceps should be kept in the client's room at all times during internal radiation therapy. If dislodged, the implant must be handled carefully to limit radiation exposure to the client and all persons in the environment. If the implant becomes dislodged, the nurse should pick up the implant with long-handled forceps and place it into the lead container. A radioactive implant is specifically placed inside the client to kill the cancer while limiting damage to adjacent tissues and organs. Touching the implant with gloves and flushing this down the toilet exposes the nurse and the environment to unsafe levels of radiation.

The nurse is assisting with caring for a postpartum client who is experiencing uterine hemorrhage. When planning to meet the psychosocial needs of the client, the nurse should plan which action? 1. Maintain strict bed rest 2. Monitor the vital signs every 2 hours 3. Perform firm fundal massage every 2 hours 4. Keep the client and her family members informed of her progress

4; Rationale: Keeping the client and her family informed about her condition will help minimize fear and apprehension. Maintaining strict bed rest, monitoring vital signs, and performing fundal massage every 2 hours address physiological needs.

The nurse reinforces instructions to a client to increase the amount of riboflavin in the diet. The nurse should tell the client to select which food item that is high in riboflavin? 1. Milk 2. Tomatoes 3. Citrus fruits 4. Green, leafy vegetables

1. Milk Rationale: Food sources of riboflavin include milk, lean meats, fish, and grains. Tomatoes and citrus fruits are high in vitamin C. Green leafy vegetables are high in folic acid.

The nurse is assigned to care for four clients. When planning client rounds, which client should the nurse check first? 1. A client in skeletal traction 2. A client who is dependent on a ventilator 3. A postoperative client preparing for discharge 4. A client admitted during the previous shift with a diagnosis of gastroenteritis

2. A client who is dependent on a ventilator Rationale: The airway is always a priority, and the nurse first checks the client on a ventilator.

The nurse is caring for a client with hyperparathyroidism and notes that the client's serum calcium level is 13 mg/dL (3.25 mmol/L). Which prescribed medication should the nurse plan to assist in administering to the client? 1. Calcitonin 2. Calcium chloride 3. Calcium gluconate 4. Large doses of vitamin D

1. Calcitonin Rationale: The normal serum calcium level is 9 to 10.5 mg/dL (2.2.5-2.75 mmol/L). This client is experiencing hypercalcemia. Calcium gluconate and calcium chloride are medications used for the treatment of tetany, which occurs as a result of acute hypocalcemia. In hypercalcemia, large doses of vitamin D need to be avoided. Calcitonin, a thyroid hormone, decreases the plasma calcium level by inhibiting bone resorption and lowering the serum calcium concentration.

The nurse takes a client's temperature before giving a blood transfusion. The temperature is 100° F (37.7° C) orally. The nurse reports the finding to the registered nurse (RN) and anticipates that which action will take place? 1. The transfusion will begin as prescribed. 2. The transfusion will begin after the administration of an antihistamine. 3. The transfusion will begin after the administration of 650 mg of acetaminophen. 4. The blood will be held, and the primary health care provider (PHCP) will be notified

4. The blood will be held, and the primary health care provider (PHCP) will be notified Rationale: If the client has a temperature of 100° F (37.7° C) or more, the unit of blood should be held until the primary health care provider (PHCP) is notified and has the opportunity to give further prescriptions. The other options are incorrect actions.

The nurse is providing dietary instructions to a client with gout. The nurse should tell the client to avoid which food item? 1. Scallops 2. Chocolate 3. Cornbread 4. Macaroni products

1Scallops Rationale: Scallops should be omitted from the diet of a client who has gout because of the high purine content. The food items identified in the remaining options have negligible purine content and may be consumed by the client with gout.

The nurse reviews a client's electrolyte results and notes that the potassium level is 5.4 mEq/L (5.4 mmol/L). What should the nurse look for on the cardiac monitor as a result of this laboratory value? 1. ST elevation 2. Peaked P waves 3. Prominent U waves 4. Narrow, peaked T waves

4 Rationale: A serum potassium level of 5.4 mEq/L is indicative of hyperkalemia. Cardiac changes include a wide, flat P wave; a prolonged PR interval; a widened QRS complex; and narrow, peaked T waves.

A client who is receiving a blood transfusion pushes the call light for the nurse. When entering the room, the nurse notes that the client is flushed, dyspneic, and complaining of generalized itching. How should the nurse correctly interpret these findings? 1. Bacteremia 2. Fluid overload 3. Hypovolemic shock 4. Transfusion reaction

4. Transfusion reaction Rationale: The signs and symptoms exhibited by the client are consistent with a transfusion reaction. With bacteremia, the client would have a fever, which is not part of the clinical picture presented. With fluid (circulatory) overload, the client would have crackles in addition to dyspnea. There is no correlation between the signs mentioned in the question and hypovolemic shock. The signs identified in the question are indicative of an allergic reaction, which is one type of blood transfusion reaction.

A client with diabetes mellitus has a blood sample drawn for the determination of a fasting blood glucose level. When reviewing the client's results, the nurse determines that which requires a call to the primary health care provider for intervention? 1. 75 mg/dL (4.2 mmol/L) 2. 92 mg/dL (5.3 mmol/L) 3. 120 mg/dL (6.9 mmol/L) 4. 240 mg/dL (13.7 mmol/L)

. 4240 mg/dL (13.7 mmol/L) Rationale: The normal fasting blood glucose level is 70 mg/dL to 100 mg/dL (4-6 mmol/L) in the adult client. Values above the normal range should be evaluated to determine whether further intervention is needed. The most critical value is 240 mg/dL (13.7 mmol/L).

The nurse is caring for a client with a diagnosis of cancer who is immunosuppressed. The nurse would suggest to the registered nurse the need for implementing neutropenic precautions if the client's white blood cell count was which value? 1. 2000 mm3 (2.0 × 109/L) 2. 5800 mm3 (5.8 × 109/L) 3. 8400 mm3 (6.4 × 109/L) 4. 11,500 mm3 (11.5 × 109/L)

1. 2000 mm3 (2.0 × 109/L) Rationale: The normal white blood cell count ranges from 5000 mm3 to 10,000 mm3 (5-10 × 109/L). The client who has a decrease in the number of circulating white blood cells is immunosuppressed. The nurse implements neutropenic precautions when the client's values fall sufficiently below the normal level. The specific value for implementing neutropenic precautions usually is determined by agency policy. The remaining options are normal values.

A client has been admitted to the hospital for urinary tract infection and dehydration. The nurse determines that the client has received adequate volume replacement if the blood urea nitrogen level drops to which value? 1. 3 mg/dL (1.05 mmol/L) 2. 15 mg/dL (5.25 mmol/L) 3. 29 mg/dL (10.15 mmol/L) 4. 35 mg/dL (12.25 mmol/L)

2 Rationale: The normal blood urea nitrogen level is 6 mg/dL to 20 mg/dL (2.1-7.1 mmol/L). Values of 29 mg/dL mg/dL (10.15 mmol/L) and 35 mg/dL (12.25 mmol/L) reflect continued dehydration. A value of 3 mg/dL (1.05 mmol/L) reflects a lower than normal value, which may occur with fluid volume overload, among other conditions.

The nurse notes documentation that a client has conductive hearing loss. The nurse plans care knowing that this kind of hearing loss can be caused by which circumstances? Select all that apply. 1. A defect in the cochlea 2. Acute otitis media with effusion 3. A defect in the 8th cranial nerve 4. A defect in the sensory fibers that lead to the cerebral cortex 5. A physical obstruction to the transmission of sound waves

2, 5 Rationale: A conductive hearing loss is as a result of a physical obstruction to the transmission of sound waves. Acute otitis media with effusion, a fluid buildup in the middle ear, can block the transmission of sound waves. A sensorineural hearing loss occurs as a result of a pathological process in the inner ear, a defect in the 8th cranial nerve, or a defect of the sensory fibers that lead to the cerebral cortex.

88. The nurse is assigned to care for a client with a peripheral intravenous (IV) infusion. The nurse is providing hygiene care to the client and should avoid which while changing the client's hospital gown? 1. Using a hospital gown with snaps at the sleeves 2. Disconnecting the IV tubing from the catheter in the vein 3. Checking the IV flow rate immediately after changing the hospital gown 4. Putting the bag and tubing through the sleeve, followed by the client's arm

2. Disconnecting the IV tubing from the catheter in the vein Rationale: The tubing should not be removed from the IV catheter. With each break in the system, there is an increased chance of introducing bacteria into the system, which can lead to infection. Using gowns with snaps and inserting the IV bag and tubing through the sleeve of the gown first are appropriate. The flow rate should be checked immediately after changing the hospital gown, because the position of the roller clamp may have been affected during the change.

35. The nurse is reading the primary health care provider's (PHCP's) progress notes in the client's record and sees that the PHCP has documented "insensible fluid loss of approximately 800 mL daily." Which client is at risk for this loss? 1. The client with a draining wound 2. The client with a urinary catheter 3. The client with a fast respiratory rate 4. The client with a nasogastric tube to low suction

3 Rationale: Sensible losses are those that the person is aware of, such as those that occur through wound drainage, gastrointestinal (GI) tract losses, and urination. Insensible losses may occur without the person's awareness. Insensible losses occur daily through the skin and the lungs.

A client is diagnosed with cancer and is told that surgery followed by chemotherapy will be necessary. The client states to the nurse, "I have read a lot about complementary therapies. Do you think I should try any?" The nurse should respond by making which appropriate statement? 1. "I would try anything that I could if I had cancer." 2. "No, because it will interact with the chemotherapy." 3. "Tell me what you know about complementary therapies." 4. "You need to ask your primary health care provider about it."

3. "Tell me what you know about complementary therapies." Rationale: Complementary (alternative) therapies include a wide variety of treatment modalities that are used in addition to conventional treatment to treat a disease or illness. These therapies complement conventional treatment, but they should be approved by the person's primary health care provider (PHCP) to ensure that the treatment does not interact with prescribed therapy.

. The nurse is caring for a group of clients who are taking herbal medications at home. Which client should be given instructions with regard to avoiding the use of herbal medications? 1. A 60-year-old male client with rhinitis 2. A 24-year-old male client with a lower back injury 3. A 10-year-old female client with a urinary tract infection 4. A 45-year-old female client with a history of migraine headaches

3. A 10-year-old female client with a urinary tract infection Rationale: Children should not be given herbal therapies, especially in the home and without professional supervision.

The nurse is planning to reinforce nutrition instructions to an African American client. When reviewing the plan, the nurse is aware that which food may be a common dietary practice of clients with African American heritage? 1. Raw fish 2. Red meat 3. Fried foods 4. Rice as the basis for all meals

3. Fried foods Rationale: African American food preferences usually include chicken, pork, greens, rice, and fried foods. Asian Americans eat raw fish, rice, and soy sauce. Hispanic Americans prefer beans, fried foods, spicy foods, chili, and carbonated beverages. European Americans prefer carbohydrates and red meat.

87. The nurse is doing a routine assessment of a client's peripheral intravenous (IV) site. The nurse notes that the site is cool, pale, and swollen and that the IV has stopped running. The nurse determines that which has probably occurred? 1. Phlebitis 2. Infection 3. Infiltration 4. Thrombosis

3. Infiltration Rationale: An infiltrated IV is one that has dislodged from the vein and is lying in subcutaneous tissue. The pallor, coolness, and swelling are the result of IV fluid being deposited into the subcutaneous tissue. When the pressure in the tissues exceeds the pressure in the tubing, the flow of the IV solution will stop. The other options identify complications that are likely to be accompanied by warmth at the site rather than coolness.

An adult female client has a hemoglobin level of 10.8 g/dL (108 g/L). The nurse interprets that this result is most likely caused by which condition noted in the client's history? 1. Dehydration 2. Heart failure 3. Iron deficiency anemia 4. Chronic obstructive pulmonary disease

3. Iron deficiency anemia Rationale: The normal hemoglobin level for an adult female client is 12 g/dL to 16 g/dL (120-160 g/L). Iron deficiency anemia can result in lower hemoglobin levels. Dehydration may increase the hemoglobin level by hemoconcentration. Heart failure and chronic obstructive pulmonary disease may increase the hemoglobin level as a result of the body's need for more oxygen-carrying capacity.

91. The nurse has been instructed to remove an intravenous (IV) line. The nurse removes the catheter by withdrawing the catheter while applying pressure to the site with which item? 1. Band-Aid 2. Alcohol swab 3. Betadine swab 4. Sterile 2 × 2 gauze

4. Sterile 2 × 2 gauze Rationale: A dry, sterile dressing such as sterile 2 × 2 gauze is used to apply pressure to the site while the catheter is discontinued and removed. This material is absorbent, sterile, and nonirritating to the site. A Band-Aid may be used to cover the site after hemostasis has occurred. An alcohol swab or Betadine would irritate the opened puncture site and would not stop the blood flow.

The nurse who is caring for a client with kidney failure notes that the client is dyspneic and crackles are heard when listening to breath sounds in the lungs. Which additional sign/symptom should the nurse expect to note in this client? 1. Rapid weight loss 2. Flat hand and neck veins 3. A weak and thready pulse 4. An increase in blood pressure

4 Rationale: Impaired cardiac or kidney function can result in fluid volume excess. Findings associated with fluid volume excess include cough, dyspnea, crackles, tachypnea, tachycardia, an elevated blood pressure, a bounding pulse, an elevated central venous pressure, weight gain, edema, neck and hand vein distention, an altered level of consciousness, and a decreased hematocrit level.

The nurse is reviewing the health records of assigned clients. The nurse should plan care knowing that which client is at risk for a potassium deficit? 1. The client with Addison's disease 2. The client with metabolic acidosis 3. The client with intestinal obstruction 4. The client receiving nasogastric suction

4 Rationale: Potassium-rich gastrointestinal (GI) fluids are lost through GI suction, which places the client at risk for hypokalemia. The client with intestinal obstruction, Addison's disease, and metabolic acidosis is at risk for hyperkalemia.

The nurse is assigned to care for four clients. When planning client rounds, which client should the nurse collect data from first? 1. A client scheduled for a chest x-ray 2. A client requiring daily dressing changes 3. A postoperative client preparing for discharge 4. A client receiving oxygen who is having difficulty breathing

4. A client receiving oxygen who is having difficulty breathing The airway is always a priority, and the nurse would attend to the client who has been experiencing an airway problem first. The clients described in options 1, 2, and 3 would have intermediate priority.

The nurse reviews electrolyte values and notes a sodium level of 130 mEq/L (130 mmol/L). The nurse expects that this sodium level would be noted in a client with which condition? 1 . The client with watery diarrhea 2. The client with diabetes insipidus 3. The client with an inadequate daily water intake 4. The client with the syndrome of inappropriate secretion of antidiuretic hormone

4. The client with the syndrome of inappropriate secretion of antidiuretic hormone Rationale: Hyponatremia is a serum sodium level less than 135 mEq/L (135 mmol/L). Hyponatremia can occur secondary to syndrome of inappropriate secretion of antidiuretic hormone (SIADH). The client with an inadequate daily water intake, watery diarrhea, or diabetes insipidus is at risk for hypernatremia.

Which of these clients is/are most likely to develop fluid (circulatory) overload? Select all that apply. 1. A premature infant 2. A 101-year-old man 3. A client with heart failure 4. A client with diabetes mellitus 5. A client receiving renal dialysis 6. 29-year-old client with pneumonia

1. A premature infant 2. A 101-year-old man 3. A client with heart failure 5. A client receiving renal dialysis Rationale: Clients with cardiac, respiratory, renal, or liver diseases and older and very young clients cannot tolerate an excessive fluid volume. The risk of fluid (circulatory) overload exists with these clients.

The nurse has completed diet teaching for a client who has been prescribed a low-sodium diet to treat hypertension. The nurse determines that there is a need for further teaching when the client makes which statement? 1. "This diet will help lower my blood pressure." 2. "Fresh foods such as fruits and vegetables are high in sodium." 3. "This diet is not a replacement for my antihypertensive medications." 4. "The reason I need to lower my salt intake is to reduce fluid retention." Answers

2. "Fresh foods such as fruits and vegetables are high in sodium." Rationale: A low-sodium diet is used as an adjunct to antihypertensive medications for the treatment of hypertension. Sodium retains fluid, which leads to hypertension secondary to increased fluid volume. Fresh foods such as fruits and vegetables are low in sodium.

. The nurse is reviewing the health records of assigned clients. The nurse should plan care knowing that which client is at risk for fluid volume deficit? 1. The client with cirrhosis 2. The client with a ileostomy 3. The client with heart failure 4. The client with decreased kidney function

2. The client with a ileostomy Rationale: Causes of a fluid volume deficit include vomiting, diarrhea, conditions that cause increased respirations or increased urinary output, insufficient intravenous fluid replacement, draining fistulas, ileostomy, and ileostomy. A client with cirrhosis, heart failure (HF), or decreased kidney function is at risk for fluid volume excess. Test-Taking Strategy: Focus on the subject, fluid volume deficit. Read the question carefully, and note that it asks for the client who is at risk for a deficit. Read each option, and think about the fluid imbalance that can occur in each client. Clients with cirrhosis, HF, and decreased kidney function all retain fluid. The only condition that can cause a fluid volume deficit is the condition noted in the correct option. Review: causes of fluid volume deficit.

The client asks the nurse about various herbal therapies available for the treatment of insomnia. The nurse should encourage the client to discuss the use of which product with the primary health care provider? 1. Garlic 2. Valerian 3. Lavender 4. Glucosamine

2. Valerian Rationale: Valerian has been used to treat insomnia, hyperactivity, and stress. It has also been used to treat nervous disorders such as anxiety and restlessness. Garlic is used as an antioxidant and to lower cholesterol levels. Lavender is used as an antiseptic and fragrance for a mild sedative effect. Glucosamine is an amino acid that assists with the synthesis of cartilage.

The nurse is attending an agency orientation meeting about the nursing model of practice implemented in the facility. The nurse is told that the nursing model is a team nursing approach. The nurse determines that which describes the team-based model of nursing practice? 1. A task approach method is used to provide care to clients. 2. Managed care concepts and tools are used when providing client care. 3. Nursing staff are led by the nurse when providing care to a group of clients. 4. A single registered nurse is responsible for providing nursing care to a group of clients

3. Nursing staff are led by the nurse when providing care to a group of clients. Rationale: In team nursing, nursing personnel are led by the nurse when providing care to a group of clients. Option 1 identifies functional nursing. Option 2 identifies a component of case management. Option 4 identifies primary nursing.

A client who was receiving a blood transfusion has experienced a transfusion reaction. The nurse sends the blood bag that was used for the client to which area? 1. The pharmacy 2. The laboratory 3. The blood bank 4. The risk-management department

3. The blood bank Rationale: The nurse prepares to return the blood transfusion bag containing any remaining blood to the blood bank. This allows the blood bank to complete any follow-up testing procedures that are needed after a transfusion reaction has been documented. The remaining options are incorrect.

The nurse arrives at work and is told to report (float) to the pediatric unit for the day because the unit is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the pediatric unit. Which is the appropriate nursing action? 1. Call the hospital lawyer. 2. Call the nursing supervisor. 3. Refuse to float to the pediatric unit. 4. Report to the pediatric unit and identify tasks that can be safely performed.

4. Report to the pediatric unit and identify tasks that can be safely performed. Rationale: Floating is an acceptable legal practice used by hospitals to solve their understaffing problems. Legally the nurse cannot refuse to float unless a union contract guarantees that the nurse can only work in a specified area or the nurse can prove a lack of knowledge for the performance of assigned tasks. When faced with this situation, the nurse should identify potential areas of harm to the client.

An older woman is brought to the emergency department. When caring for the client, the nurse notes old and new ecchymotic areas on both of the client's arms and buttocks. The nurse asks the client how the bruises were sustained. The client, although reluctant, tells the nurse in confidence that her daughter frequently hits her if she gets in the way. Which is the appropriate nursing response? 1. "I have a legal obligation to report this type of abuse." 2. "I promise I won't tell anyone, but let's see what we can do about this." 3. "Let's talk about ways that will prevent your daughter from hitting you." 4. "This should not be happening. If it happens again, you must call the emergency department."

1. "I have a legal obligation to report this type of abuse." Rationale: Confidential issues are not to be discussed with nonmedical personnel or with the client's family or friends without the client's permission. Clients should be assured that information is kept confidential unless it places the nurse under a legal obligation. The nurse must report situations related to child, older adult abuse, and other types of abuse, depending on state laws; gunshot wounds; stabbings; and certain infectious diseases.

A client with a history of cardiac disease is due for a morning dose of furosemide. Which serum potassium level, if noted in the client's laboratory report, should be reported before administering the dose of furosemide? 1. 3.2 mEq/L (3.2 mmol/L) 2. 3.8 mEq/L (3.8 mmol/L) 3. 4.2 mEq/L (4.2 mmol/L) 4. 4.8 mEq/L (4.8 mmol/L)

1. 3.2 mEq/L (3.2 mmol/L) Rationale: The normal serum potassium level in the adult is 3.5 mEq/L to 5.0 mEq/L (3.5-5.0 mmol/L). The correct option is the only value that falls below the therapeutic range. Administering furosemide to a client with a low potassium level and a history of cardiac problems could precipitate ventricular dysrhythmias. The remaining options are within the normal range.

The nurse employed in a long-term care facility is planning the client assignments for the shift. Which client should the nurse assign to the unlicensed assistive personnel (UAP)? 1. A client who requires a 24-hour urine collection 2. A client who requires twice-daily dressing changes 3. A client with diabetes mellitus who requires daily insulin and the reinforcement of dietary measures 4. A client who has been placed on a bowel management program and requires rectal suppositories and a daily enema

1. A client who requires a 24-hour urine collection Rationale: The nurse must determine the most appropriate assignment on the basis of the skills of the staff member and the needs of the client. The assignment of tasks needs to be implemented on the basis of the job description of the individual, the individual's level of clinical competence, and state law. Options 2, 3, and 4 involve care that requires the skill of a licensed nurse. A UAP is not licensed.

The nurse is recording a nursing hands-off (end-of-shift) report for a client. Which information needs to be included? 1. As-needed medications given that shift 2. Normal vital signs that have been normal since admission 3. All of the tests and treatments the client has had since admission 4. Total number of scheduled medications that the client received on that shift

1. As-needed medications given that shift Rationale: The nursing hands-off (end-of-shift) report needs to be an efficient and accurate account of the client's condition during the last shift. It needs to include pertinent information about the client, such as tests and treatments; as-needed medications given or therapies performed during the past 24 hours, including the client's response to them; changes in the client's condition; scheduled tests and treatments; current problems; and any other special concerns. It is not necessary to include the total number of medications given or a list of all the tests and treatments that the client has had since admission. Only significant vital signs need to be included.

A client experiences cardiac arrest. The nurse leader quickly responds to the emergency and assigns clearly defined tasks to the work group. In this situation, the nurse is implementing which leadership style? 1. Autocratic 2. Situational 3. Democratic 4. Laissez-faire

1. Autocratic Rationale: Autocratic leadership is an approach in which the leader retains all authority and is primarily concerned with task accomplishment. It is an effective leadership style to implement in an emergency or crisis situation. The leader assigns clearly defined tasks and establishes one-way communication with the work group, and he or she makes all decisions independently. Situational leadership is a comprehensive approach that incorporates the leader's style, the maturity of the work group, and the situation at hand. Democratic leadership is a people-centered approach that is primarily concerned with human relations and teamwork. This leadership style facilitates goal accomplishment and contributes to the growth and development of the staff. Laissez-faire leadership is a permissive style in which the leader gives up control and delegates all decision making to the work group.

A low-sodium diet has been prescribed for a client with hypertension. Which food selected from the menu by the client indicates an understanding of this diet? 1. Baked turkey 2. Tomato soup 3. Boiled shrimp 4. Chicken gumbo

1. Baked turkey Rationale: Regular soup (1 cup) contains 900 mg of sodium. Fresh shellfish (1 oz) contains 50 mg of sodium. Poultry (1 oz) contains 25 mg of sodium.

The nurse is preparing an intravenous (IV) solution and tubing for a client who requires IV fluids. While preparing to prime the tubing, the tubing drops and hits the top of the medication cart. The nurse should plan to take which action? 1. Change the IV tubing. 2. Wipe the tubing with Betadine. 3. Scrub the tubing with an alcohol swab. 4. Scrub the tubing before attaching it to the IV bag.

1. Change the IV tubing. Rationale: The nurse should change the IV tubing. The tubing has become contaminated, and, if used, it could result in a systemic infection in the client. Wiping or scrubbing the tubing is insufficient to prevent systemic infection.

The nurse is reviewing the client's health record and notes that the client elicited a positive Romberg sign. Based on this finding, the nurse should institute which intervention? Select all that apply. 1. Collect data to determine factors for fall risk. 2. Close the blinds and turn off the overhead light. 3. Instruct the client to ask for assistance when getting up to walk. 4. Teach the client to lift legs high while walking, as if walking over planks. 5. Ensure the client is upright when eating and swallows twice after each bite.

1. Collect data to determine factors for fall risk. 3. Instruct the client to ask for assistance when getting up to walk. Rationale: In the Romberg test, the client is asked to stand with the feet together, the arms at the sides, and to close the eyes and hold the position. Normally the client can maintain posture and balance. A positive Romberg is a vestibular neurological sign that is found when a client elicits a loss of balance when closing the eyes. This may occur with cerebellar ataxia, loss of proprioception, and loss of vestibular function. The nurse should determine the client's risk for falling by collecting data. Because the client has difficulty maintaining balance, the nurse should instruct the client to ask for assistance when getting up or walking. Decreasing the light in the environment is done if a client has photophobia (sensitive to light). Clients with a shuffling gait as with Parkinson's disease should lift their legs high when walking. Clients experiencing dysphagia, which often occurs with stroke, should eat sitting upright and perform double swallowing.

The nurse enters a client's room and notes that the client's lawyer is present and that the client is preparing a living will. The living will requires that the client's signature be witnessed, and the client asks the nurse to witness the signature. Which is the appropriate nursing action? 1. Decline to sign the will. 2. Sign the will as a witness to the signature only. 3. Call the hospital lawyer before signing the will. 4. Sign the will, clearly identifying credentials and employment agency.

1. Decline to sign the will. Rationale: Living wills are required to be in writing and signed by the client. The client's signature either must be witnessed by specified individuals or notarized. Many states prohibit any employee from being a witness, including the nurse in a facility in which the client is receiving care.

73. A hospitalized client is a lacto-vegetarian. Which food item should the nurse remove from the meal tray? 1. Eggs 2. Milk 3. Cheese 4. Broccoli

1. Eggs Rationale: Lacto-vegetarians eat milk, cheese, and dairy foods but avoid meat, fish, poultry, and eggs.

The nurse is assisting to perform a focused data collection process on a client who is complaining of symptoms of a cold, a cough, and lung congestion. Which should the nurse include for this type of data collection? Select all that apply. 1. Listening to lung sounds 2. Obtaining the client's temperature 3. Checking the strength of peripheral pulses 4. Obtaining information about the client's respirations 5. Performing a musculoskeletal and neurological examination 6. Asking the client about a family history of any illness or disease

1. Listening to lung sounds 2. Obtaining the client's temperature 4. Obtaining information about the client's respirations Rationale: A focused data collection process is centered around a limited or short-term problem, such as the client's complaint. Because the client is complaining of symptoms of a cold, a cough, and lung congestion, the nurse would focus on the respiratory system and the presence of an infection. A complete data collection includes a complete health history and physical examination and forms a baseline database. Checking the strength of peripheral pulses relates to a vascular assessment, which is not related to this client's complaints. A musculoskeletal and neurological examination also is not related to this client's complaints. However, strength of peripheral pulses and a musculoskeletal and neurological examination would be included in a complete data collection. Likewise, asking the client about a family history of any illness or disease would be included in a complete assessment.

. A nursing student is asked to identify the practices and beliefs of the Amish society. Which should the student identify? Select all that apply. 1. Many choose not to have health insurance. 2. They believe that health is a gift from God. 3. The authority of women is equal to that of men. 4. They remain secluded and avoid helping others. 5. They use both traditional and alternative health care, such as healers, herbs, and massage. 6. Funerals are conducted in the home without a eulogy, flower decorations, or any other display. Caskets are plain and simple, without adornment.

1. Many choose not to have health insurance. 2. They believe that health is a gift from God. 5. They use both traditional and alternative health care, such as healers, herbs, and massage. 6. Funerals are conducted in the home without a eulogy, flower decorations, or any other display. Caskets are plain and simple, without adornment. Rationale: The Amish society maintains a culture that is distinct and separate from the non-Amish society, and some members generally remain separate from the rest of the world, both physically and socially. Family life has a patriarchal structure, and although the roles of women are considered equally important to those of men, they are very unequal in terms of authority. Amish society rejects materialism and worldliness. Members value living simply, and they may choose to avoid technology, such as electricity and cars. They highly value responsibility, generosity, and helping others, and they often work as farmers, builders, quilters, and homemakers. The Amish use traditional health care and alternative health care, such as healers, herbs, and massage. They believe that health is a gift from God but that clean living and a balanced diet help maintain it. They may choose not to have health insurance and instead maintain mutual aid funds for those members who need help with medical costs. Funerals are conducted in the home without a eulogy, flower decorations, or any other display. Caskets are plain and simple, without adornment. At death, women are usually buried in their bridal dresses.

50. The nurse is caring for a client with severe diarrhea. The nurse monitors the client closely, understanding that this client is at risk for developing which acid-base disorder? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

1. Metabolic acidosis Rationale: Intestinal secretions high in bicarbonate may be lost through enteric drainage tubes, an ileostomy, or diarrhea. The decreased bicarbonate level creates the actual base deficit of metabolic acidosis. The remaining options are unlikely to occur in a client with severe diarrhea.

90. The nurse is checking the insertion site of a peripheral intravenous (IV) catheter. The nurse notes the site to be reddened, warm, painful, and slightly edematous in the area of the vein proximal to the IV catheter. The nurse interprets that this is likely the result of which? 1. Phlebitis of the vein 2. Infiltration of the IV line 3. Hypersensitivity to the IV solution 4. An allergic reaction to the IV catheter material

1. Phlebitis of the vein Rationale: Phlebitis at an IV site results in discomfort at the site and redness, warmth, and swelling proximal to the IV catheter. The IV catheter should be removed, and a new IV line should be inserted at a different site. The remaining options are incorrect; the signs and symptoms in the question are not associated with these conditions.

62. Several laboratory tests are prescribed for a client, and the nurse reviews the results of the tests. Which laboratory test results should the nurse report? Select all that apply. 1. Platelets 35,000 mm3 (35 × 109/L) 2. Sodium 150 mEq/L (150 mmol/L) 3. Potassium 5.0 mEq/L (5.0 mmol/L) 4. Segmented neutrophils 40% (0.40) 5. Serum creatinine, 1 mg/dL (88.3 mcmol/L) 6. White blood cells, 3000 mm3 (3.0 × 109/L)

1. Platelets 35,000 mm3 (35 × 109/L) 2. Sodium 150 mEq/L (150 mmol/L) 4. Segmented neutrophils 40% (0.40) 6. White blood cells, 3000 mm3 (3.0 × 109/L) Rationale: The normal values include the following: platelets 150,000 mm3 to 400,000 mm3 (150-400 × 109/L); sodium 135 mEq/L to 145 mEq/L (135-145 mmol/L); potassium, 3.5 mEq/L to 5.0 mEq/L (3.5-5.0 mmol/L); segmented neutrophils 60% to 70% (0.60-0.70); serum creatinine, 0.6 mg/dL to 1.3 mg/dL (53-115 mcmol/L); and white blood cells 5000 mm3 to 10,000 mm3 (5.0-10.0 × 109/L). The platelet level noted is low; the sodium level noted is high; the potassium level noted is normal; the segmented neutrophil level noted is low; the serum creatinine level noted is normal; and the white blood cell level is low.

The nurse reviews the client's serum calcium level and notes that the level is 8.0 mg/dL (2.0 mmol/L). The nurse understands that which condition would cause this serum calcium level? 1. Prolonged bed rest 2. Adrenal insufficiency 3. Hyperparathyroidism 4. Excessive ingestion of vitamin D

1. Prolonged bed rest Rationale: The normal serum calcium level is 9 to 10.5 mg/dL (2.25-2.75 mmol/L). A client with a serum calcium level of 8.0 mg/dL (2.0 mmol/L) is experiencing hypocalcemia. The excessive ingestion of vitamin D, adrenal insufficiency, and hyperparathyroidism are causative factors associated with hypercalcemia. Although immobilization can initially cause hypercalcemia, the long-term effect of prolonged bed rest is hypocalcemia.

The nurse consults with a dietitian regarding the dietary preferences of an Asian American client. Which food should the nurse suggest to include in the diet plan? 1. Rice 2. Fruits 3. Red meat 4. Fried foods

1. Rice Rationale: Asian American food preferences usually include raw fish, rice, and soy sauce. African American food preferences include chicken, pork, greens, rice, and fried foods. Hispanic Americans prefer beans, fried foods, spicy foods, chili, and carbonated beverages. European Americans prefer carbohydrates and red meat.

Which identifies accurate nursing documentation notations? Select all that apply. 1. The client slept through the night. 2. Abdominal wound dressing is dry and intact without drainage. 3. The client seemed angry when awakened for vital sign measurement. 4. The client appears to become anxious when it is time for respiratory treatments. 5. The client's left lower medial leg wound is 3 cm in length without redness, drainage, or edema.

1. The client slept through the night. 2. Abdominal wound dressing is dry and intact without drainage. 5. The client's left lower medial leg wound is 3 cm in length without redness, drainage, or edema. Rationale: Factual documentation contains descriptive, objective information about what the nurse sees, hears, feels, or smells. The use of inferences without supporting factual data is not acceptable because it can be misunderstood. The use of vague terms, such as seems or appears, is not acceptable because these words suggest the nurse is stating an opinion.

A nurse lawyer provides an education session to the nursing staff regarding client rights with emphasis on invasion of client rights. The nurse lawyer asks a staff nurse to identify a situation that represents an example of invasion of client privacy. Which situation, if identified by the student, indicates an understanding of a violation of this client right? 1. Threatening to place a client in restraints 2. Performing a surgical procedure without consent 3. Taking photographs of the client without consent 4. Telling the client that he or she cannot leave the hospital

1. Threatening to place a client in restraints Rationale: invasion of privacy takes place when an individual's private affairs are intruded on unreasonably. Threatening to place a client in restraints constitutes assault. Performing a surgical procedure without consent is an example of battery. Not allowing a client to leave the hospital constitutes false imprisonment

A client is scheduled for blood to be drawn from the radial artery for an arterial blood gas (ABG) determination. The nurse assists with performing Allen's test before drawing the blood to determine the adequacy of which? 1. Ulnar circulation 2. Carotid circulation 3. Femoral circulation 4. Brachial circulation

1. Ulnar circulation Rationale: Before performing a radial puncture to obtain an arterial specimen for ABG values, Allen's test should be performed to determine adequate ulnar circulation. Failure to assess collateral circulation could result in severe ischemic injury to the hand if damage to the radial artery occurs with arterial puncture. The remaining options are not associated with this test.

81. The nurse is assisting with caring for a client who will receive a unit of blood. Just before the infusion, it is most important for the nurse to check which item? 1. Vital signs 2. Skin color 3. Oxygen saturation 4. Latest hematocrit level

1. Vital signs Rationale: A change in the vital signs may indicate that a transfusion reaction is occurring. The nurse assesses the client's vital signs before the procedure to obtain a baseline every 15 minutes for the first half hour after beginning the transfusion and every half hour thereafter. Skin color, oxygen saturation, and most recent hematocrit may be checked but are not the most important.

63. The nurse is caring for a client who takes ibuprofen for pain. The nurse is gathering information on the client's medication history and determines it is necessary to consult with the registered nurse if the client is also taking which medications? Select all that apply. 1. Warfarin 2. Glimepiride 3. Amlodipine 4. Simvastatin 5. Hydrochlorothiazide

1.Warfarin 2. Glimepiride 3. Amlodipine Rationale: NSAIDs can amplify the effects of anticoagulants; therefore these medications should not be taken together. Hypoglycemia may result for the client taking ibuprofen if the client is concurrently taking an oral hypoglycemic agent such as glimepiride; these medications should not be combined. A high risk of toxicity exists if the client is taking ibuprofen concurrently with a calcium-channel blocker such as amlodipine; therefore this combination should be avoided. There is no known interaction between ibuprofen and simvastatin or hydrochlorothiazide.

The nurse is planning the client assignments for the day. Which is the most appropriate assignment for the unlicensed assistive personnel (UAP)? 1. A client who requires wound irrigation 2. A client who requires frequent ambulation 3. A client who is receiving continuous tube feedings 4. A client who requires frequent vital signs after a cardiac catheterization

2. A client who requires frequent ambulation Rationale: The nurse must determine the most appropriate assignment on the basis of the skills of the staff member and the needs of the client. In this case the most appropriate assignment for the UAP would be to care for the client who requires frequent ambulation. The UAP is skilled in this task. The client who had a cardiac catheterization will require specific monitoring in addition to that of the vital signs. Wound irrigations and tube feedings are not performed by unlicensed personnel.

A licensed practical nurse is explaining the appropriate methods for measuring an accurate temperature to an unlicensed assistive personnel (UAP). Which method, if noted by the UAP as being an appropriate method, indicates the need for further teaching? 1. Taking a rectal temperature for a client who has undergone nasal surgery 4. Leaving the rate of the heparin infusion as is 3. Taking an axillary temperature on a client who has just consumed hot coffee 4. Taking a temporal temperature on the neck behind the ear on a client who is diaphoretic

2 Rationale: An oral temperature should be avoided if the client has nasal congestion. One of the other methods of measuring the temperature should be used according to the equipment available. Taking a rectal temperature for a client who has undergone nasal surgery is appropriate. Other, less invasive measures should be used if available; if not available, a rectal temperature is acceptable. Taking an axillary temperature on a client who just consumed coffee is also acceptable; however, the axillary method of measurement is the least reliable, and other methods should be used if available. If temporal equipment is available and the client is diaphoretic, it is acceptable to measure the temperature on the neck behind the ear, avoiding the forehead.

The nurse is educating a new nurse about mass casualty events (disasters). Which statement by the new nurse indicates a need for further teaching? Select all that apply. 1. "An event is termed a mass casualty when it overwhelms local medical capabilities." 2. "Mass casualty events do not require an increase in the number of staff that are needed." 3. "A mass casualty event occurs only within the heath care facility and could endanger staff." 4. "Mass casualty events may require the collaboration of many local agencies to handle the situation." 5. "A mass casualty event occurs if a fight between visitors occurs in the emergency department."

2. "Mass casualty events do not require an increase in the number of staff that are needed." 3. "A mass casualty event occurs only within the heath care facility and could endanger staff." 5. "A mass casualty event occurs if a fight between visitors occurs in the emergency department." Rationale: Mass casualty events, also known as disasters, overwhelm local medical capabilities and may require the collaboration of multiple agencies and health care facilities to handle the crises. This type of event can occur in the health care facility or outside of it. Fights in the emergency department are not termed mass casualty events but are agency security and local enforcement issues. Mass casualty events almost always require an increase in staffing to ensure safe client care.

93. A client is going to be transfused with a unit of packed red blood cells (PRBCs). The nurse understands that it is necessary to remain with the client for what time period after the transfusion is started? 1. 5 minutes 2. 15 minutes 3. 30 minutes 4. 45 minutes

2. 15 mins Rationale: The nurse must remain with the client for the first 15 minutes of a transfusion, which is the most likely time that a transfusion reaction will occur. This enables the nurse to detect a reaction and intervene quickly. The nurse engages in safe nursing practice by obtaining coverage for the other clients during this time. Five minutes is too short of a time period, while 30 and 45 minutes are lengthy time periods.

The nurse finds the client lying on the floor. The nurse calls the registered nurse, who checks the client and then calls the nursing supervisor and the primary health care provider to inform them of the occurrence. The nurse completes the incident report for which purpose? 1. Providing clients with necessary stabilizing treatments 2. A method of promoting quality care and risk management 3. Determining the effectiveness of interventions in relation to outcomes 4. The appropriate method of reporting to local, state, and federal agencies

2. A method of promoting quality care and risk management Rationale: Proper documentation of unusual occurrences, incidents, accidents, and the nursing actions taken as a result of the occurrence are internal to the institution or agency. Documentation on the incident report allows the nurse and administration to review the quality of care and determine any potential risks present.

54. The nurse is caring for a client with respiratory insufficiency. The arterial blood gas (ABG) results indicate a pH of 7.50 and a Pco2 of 30 mm Hg (30 mm Hg), and the nurse is told that the client is experiencing respiratory alkalosis. Which additional laboratory value should the nurse expect to note? 1. A sodium level of 145 mEq/L (145 mmol/L) 2. A potassium level of 3.0 mEq/L (3.0 mmol/L) 3. A magnesium level of 1.3 mEq/L (0.65 mmol/L) 4. A phosphorus level of 3.0 mg/dL (0.97 mmol/L)

2. A potassium level of 3.0 mEq/L (3.0 mmol/L) Rationale: Signs/symptoms of respiratory alkalosis include tachypnea, change in mental status, dizziness, pallor around the mouth, spasms of the muscles of the hands, and hypokalemia. The remaining options identify normal laboratory results

67. A licensed practical nurse is caring for a postoperative client who is receiving demand-dose hydromorphone via a patient-controlled analgesia (PCA) pump for pain control. The nurse enters the client's room and finds the client drowsy and records the following vital signs: temperature 36.2° C (97.2° F) orally, pulse 52 beats per minute, blood pressure 101/58 mm Hg, respiratory rate 11 breaths per minute, and SpO2 of 93% on 3 liters of oxygen via nasal cannula. Which action should the nurse take first? 1. Document the findings. 2. Attempt to arouse the client. 3. Contact the registered nurse immediately. 4. Check the medication administration history on the PCA pump.

2. Attempt to arouse the client. Rationale: The primary concern with opioid analgesics is respiratory depression and hypotension. Based on the findings, the nurse should suspect opioid overdose. The nurse should first attempt to arouse the client and then reassess the vital signs. The vital signs may begin to normalize once the client is aroused because sleep can also cause decreased heart rate, BP, respiratory rate, and oxygen saturation. The nurse should also check to see how much medication has been taken via the PCA pump and should continue to monitor the client closely to determine whether further action is needed. The nurse should notify the registered nurse as the next step after attempting to arouse the client. The nurse would also then document the findings after all data is collected, the client is stabilized, and if an abnormality still exists after arousing the client.

The nurse is instructing a client on how to decrease the intake of calcium in the diet. The nurse should tell the client that which food item is least likely to contain calcium? 1. Milk 2. Butter 3. Spinach 4. Collard greens

2. Butter Rationale: Butter comes from milk fat and does not contain significant amounts of calcium. Milk, spinach, and collard greens are calcium-containing foods and should be avoided by the client on a calcium-restricted diet.

A client with heart disease is instructed regarding a low-fat diet. The nurse determines that the client understands the diet if the client states to avoid which food item? 1. Apples 2. Cheese 3. Oranges 4. Skim milk

2. Cheese Rationale: Fruits, vegetables, and skim milk contain minimal amounts of fat. Cheese is high in fat.

A client with a burn injury is transferred to the nursing unit, and a regular diet has been prescribed. The nurse encourages the client to eat which dietary items to promote wound healing? 1. Veal, potatoes, gelatin, and orange juice 2. Chicken breast, broccoli, strawberries, and milk 3. Peanut butter and jelly sandwich, cantaloupe, and tea 4. Spaghetti with tomato sauce, garlic bread, and ginger ale

2. Chicken breast, broccoli, strawberries, and milk Rationale: Protein and vitamin C are necessary for wound healing. Poultry and milk are good sources of protein. Broccoli and strawberries are good sources of vitamin C. Peanut butter is a source of niacin. Gelatin and jelly have no nutrient value. Spaghetti is a complex carbohydrate.

The nurse is assisting with caring for a client who is receiving a unit of packed red blood cells (PRBCs). The nurse should tell the client that it is most important to report which sign(s) immediately? 1. Sore throat or earache 2. Chills, itching, or rash 3. Unusual sleepiness or fatigue 4. Mild discomfort at the catheter site

2. Chills, itching, or rash Rationale: The client is told to report chills, itching, or rash immediately, because these could be signs of a possible transfusion reaction. Mild discomfort at the catheter site may be indicative of a problem, or it could result from the size of the IV catheter required to infuse the blood product. Sore throat, earache, sleepiness, and fatigue are unrelated to a transfusion reaction.

A client with atrial fibrillation who is receiving maintenance therapy of warfarin sodium has a prothrombin time (PT) of 35 (35) seconds and an international normalized ratio (INR) of 3.5. On the basis of these laboratory values, the nurse anticipates which prescription? 1. Adding a dose of heparin sodium 2. Holding the next dose of warfarin 3. Increasing the next dose of warfarin 4. Administering the next dose of warfarin

2. Holding the next dose of warfarin Rationale: The normal PT is 11 seconds to 12.5 seconds (conventional therapy and SI units). The normal INR is 0.81 to 1.2 (conventional therapy and SI units); 2 to 3 for standard warfarin therapy, which is used for the treatment of atrial fibrillation, and 3 to 4.5 for high-dose warfarin therapy, which is used for clients with mechanical heart valves. A therapeutic PT level is 1.5 to 2 times higher than the normal level. Because the values of 35 seconds and 3.5 are high, the nurse should anticipate that the client would not receive further doses at this time. Therefore, the prescriptions noted in the remaining options are incorrect.

The nurse is caring for a client with a diagnosis of hyperparathyroidism. Laboratory studies are performed and the serum calcium level is 12.0 mg/dL (3.0 mmol/L). Based on this laboratory value, the nurse should take which action? 1. Document the value in the client's record. 2. Inform the registered nurse of the laboratory value. 3. Place the laboratory result form in the client's record. 4. Reassure the client that the laboratory result is normal.

2. Inform the registered nurse of the laboratory value. Rationale: The normal serum calcium level ranges from 9 to 10.5 mg/dL (2.25-2.75 mmol/L). The client is experiencing hypercalcemia and the nurse would inform the registered nurse of the laboratory value. Because the client is experiencing hypercalcemia, the remaining options are incorrect actions.

49. The nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client closely for which acid-base disorder that is most likely to occur in this situation? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

2. Metabolic alkalosis Rationale: The loss of gastric fluid via nasogastric suction or vomiting causes a metabolic condition. This also results in an alkalotic condition as a result of the loss of hydrochloric acid through gastrointestinal fluid losses. Also, the options denoting a respiratory problem—respiratory acidosis and alkalosis—can be easily eliminated.

The nurse is assisting with collecting data from an African American client admitted to the ambulatory care unit who is scheduled for a hernia repair. Which information about the client is of lowest priority during the data collection? 1. Respiratory 2. Psychosocial 3. Neurological 4. Cardiovascular

2. Psychosocial Rationale: The psychosocial data is the lowest priority during the initial admission data collection. In the African American culture, it is considered intrusive to ask personal questions during the initial contact or meeting. Additionally, respiratory, neurological, and cardiovascular data include physiological assessments that would be priority.

An antihypertensive medication has been prescribed for a client with hypertension. The client tells the nurse that she would like to take an herbal substance to help lower her blood pressure. Which statement by the nurse is most important to provide to the client? 1. "Herbal substances are not safe and should never be used." 2. "I will teach you how to take your blood pressure so that it can be monitored closely." 3. "You will need to talk to your primary health care provider (HCP) before using an herbal substance." 4. "If you take an herbal substance, you will need to have your blood pressure checked frequently."

3. "You will need to talk to your primary health care provider (HCP) before using an herbal substance." Rationale: Although herbal substances may have some beneficial effects, not all herbs are safe to use. Clients who are being treated with conventional medication therapy should be advised to avoid herbal substances with similar pharmacological effects, because the combination may lead to an excessive reaction or unknown interaction effects. Therefore, the nurse would advise the client to discuss the use of the herbal substance with the HCP.

A client with a diagnosis of asthma is admitted to the hospital with respiratory distress. Which signs should the nurse expect to note in the health record when collecting data related to the respiratory system for this client? 1. Stridor and cyanotic lip 2. Diminished breath sounds and fever 3. Wheezes and use of accessory muscles 4. Pleural friction rub and inspirational chest pain

3. Wheezes and use of accessory muscles Rationale: Asthma is a respiratory disorder characterized by recurring episodes of dyspnea, constriction of the bronchi, and wheezing. Wheezes are described as high-pitched musical sounds heard when air passes through an obstructed or narrowed lumen of a respiratory passageway. Clients with respiratory distress use other chest muscles to breathe. Muscle retraction is observed at the sternum and between the ribs. Stridor is a harsh crowing sound noted with an upper airway obstruction and often signals a life-threatening emergency. Cyanosis is bluish coloration of the lips occurring as a result of poor oxygenation of the circulating blood. Diminished lung sounds are heard over lung tissue where poor oxygen exchange is occurring. Fever (elevated temperature) occurs with a respiratory infection such as pneumonia. A pleural friction rub is heard in individuals with pleurisy (inflammation of the pleural surfaces) and often causes chest discomfort with inspiration.

36. The nurse is reviewing the health records of assigned clients. The nurse should plan care knowing that which client is at the least likely risk for the development of third-spacing? 1. The client with sepsis 2. The client with cirrhosis 3. The client with kidney failure 4. The client with diabetes mellitus

4 Rationale: Fluid that shifts into the interstitial space and remains there is referred to as third-space fluid. Common sites for third-spacing include the abdomen, pleural cavity, peritoneal cavity, and pericardial sac. Third-space fluid is physiologically useless because it does not circulate to provide nutrients for the cells. Risk factors include liver or kidney disease, major trauma, burns, sepsis, wound healing, major surgery, malignancy, malabsorption syndrome, malnutrition, alcoholism, and older age.

A licensed practical nurse is precepting a student assigned to care for a client with chronic pain. Which statement, if made by the student, indicates the need for further teaching regarding pain management? 1. "I will be sure to ask my client what their pain level is on a scale of 0 to 10." 2. "I know that I should follow-up after giving medication to make sure it is effective." 3. "I know that pain in the older client might manifest as sleep disturbance or depression." 4. "I will be sure to cue in to any indicators that the client may be exaggerating their pain."

4. "I will be sure to cue in to any indicators that the client may be exaggerating their pain." Rationale: Pain is a highly individual experience, and the nurse should not assume that the client is exaggerating the pain. Rather, the nurse should frequently assess the pain and intervene accordingly through the use of both nonpharmacological and pharmacological interventions. The nurse should assess pain using a number-based scale or a picture-based scale for clients who cannot verbally describe their pain to rate the degree of pain. The nurse should follow-up with the client after giving medication to ensure the medication is effective in managing the pain. Pain experienced by the older client may be manifested differently than pain experienced by members of other age groups, and they may have sleep disturbances, changes in gait and mobility, decreased socialization, and depression; the nurse should be aware of this attribute of this population.

The nurse employed in an emergency department is assigned to assist with the triage of clients arriving to the emergency department. The nurse should assign priority to which client? 1. A client complaining of muscle ache, headache, and malaise 2. A client who twisted their ankle when they fell in-line skating 3. A client with a minor laceration on the index finger sustained while cutting an eggplant 4. A client with chest pain who states that they just ate pizza that was made with a very spicy sauce

4. A client with chest pain who states that they just ate pizza that was made with a very spicy sauce Rationale: In an emergency department, triage involves classifying clients according to their need for care, and it includes establishing priorities of care, the type of illness, the severity of the problem, and the resources available to govern the process. Clients with trauma, chest pain, severe respiratory distress, cardiac arrest, limb amputation, or acute neurological deficits, and those who sustained a chemical splash to the eyes are classified as emergent, and these clients are the number 1 priority. Clients with conditions such as simple fractures, asthma without respiratory distress, fever, hypertension, abdominal pain, or renal stones have urgent needs, and these clients are classified as the number 2 priority. Clients with conditions such as minor lacerations, sprains, or cold symptoms are classified as nonurgent, and they are the number 3 priority.

95. The nurse is assisting with caring for a client who has received a transfusion of platelets. The nurse determines that the client is benefiting most from this therapy if the client exhibits which finding? 1. An increased hematocrit level 2. An increased hemoglobin level 3. A decline of the temperature to normal 4. A decrease in oozing from puncture sites and gums

4. A decrease in oozing from puncture sites and gums Rationale: Platelets are necessary for proper blood clotting. The client with insufficient platelets may exhibit frank bleeding or the oozing of blood from puncture sites, wounds, and mucous membranes. The client's temperature would decline to normal after the infusion of granulocytes if those transfused cells were then instrumental in fighting infection in the body. Increased hemoglobin and hematocrit levels would be seen when the client has received a transfusion of red blood cells.

The nurse is preparing to assist a client of Orthodox Jewish faith with eating lunch. A kosher meal is delivered to the client. Which nursing action is appropriate when assisting the client with the meal? 1. Unwrapping the eating utensils for the client 2. Replacing the plastic utensils with metal utensils 3. Carefully transferring the food from paper plates to glass plates 4. Allowing the client to unwrap the utensils and prepare his own meal for eating

4. Allowing the client to unwrap the utensils and prepare his own meal for eating Rationale: Kosher meals arrive on paper plates and with plastic utensils sealed. Primary health care providers should not unwrap the utensils or transfer the food to another serving dish. Although the nurse may want to be helpful by assisting the client with the meal.

53. Which clients would the nurse determine is at risk for development of metabolic alkalosis? Select all that apply. 1. Client with emphysema 2. Client who is hyperventilating 3. Client with chronic kidney disease 4. Client who has been vomiting for 2 days 5. Client receiving oral furosemide 40 mg daily 6. Client admitted with acetylsalicylic acid overdose

4. Client who has been vomiting for 2 days 5. Client receiving oral furosemide 40 mg daily Rationale: Metabolic alkalosis is caused by any condition that creates the acid-base imbalance through either an increase in bases or a deficit of acids, such as the client who has been vomiting for 2 days and the client receiving furosemide daily. Recall that clients with emphysema and hyperventilation are at risk for a respiratory acid-base disturbance. Chronic kidney disease and aspirin overdose will result in metabolic acidosis.

The nurse learns in report that a client is exhibiting Cheyne-Stokes respirations. Based on this data, which action is most appropriate for the nurse to take initially? 1. Listen to the client's heart sounds 2. Determine whether the client has a pulse deficit 3. Instruct the client to use an incentive spirometer 4. Determine the client's ability to follow verbal commands

4. Determine the client's ability to follow verbal commands Rationale: Cheyne-Stokes respirations, rhythmic respirations with periods of apnea, occur with disorders affecting the respiratory center of the pons in the cns such as a metabolic dysfunction in the cerebral hemisphere or basal ganglia. The nurse should initially obtain data about neurological functioning, starting with determining the client's ability to respond to verbal stimuli. Listening to heart is secondary to determining the neurological status.

A client brought to the emergency department states that he has accidentally been taking two times his prescribed dose of warfarin for the past week. After noting that the client has no evidence of obvious bleeding, the nurse plans to assist the registered nurse with which action? 1. Administering an antidote. 2. Drawing a sample for type and crossmatch and transfuse the client. 3. Drawing a sample for an activated partial thromboplastin time (aPTT) level. 4. Drawing a sample for prothrombin time (PT) and international normalized ratio (INR).

4. Drawing a sample for prothrombin time (PT) and international normalized ratio (INR). Rationale: The action that the nurse should take is to draw a sample for PT and INR level to determine the client's anticoagulation status and risk for bleeding. These results will provide information as to how to best treat this client (e.g., if an antidote such as vitamin K or a blood transfusion is needed). The aPTT monitors the effects of heparin therapy.

46. A client has the following laboratory values: a pH of 7.55, an level of 22 mEq/L (22 mmol/L), and a Pco2 of 30 mm Hg (30 mm Hg). Which action should the nurse plan to take? 1. Perform Allen's test. 2. Prepare the client for dialysis. 3. Administer insulin as prescribed. 4. Encourage the client to slow down breathing.

4. Encourage the client to slow down breathing. Rationale: The client is experiencing respiratory alkalosis based on the laboratory results of a high pH and a low Pco2 level. Interventions for respiratory alkalosis are the voluntary holding of breath or slowed breathing and the rebreathing of exhaled CO2 by methods such as using a paper bag or a rebreathing mask as prescribed. Performing Allen's test would be incorrect, because the blood specimen has already been drawn, and the laboratory results have been completed. Dialysis and insulin administration are interventions for metabolic acidosis.

The nurse is caring for a client with a suspected diagnosis of hypercalcemia. Which sign/symptom would be an indication of this electrolyte imbalance? 1. Twitching 2. Positive Trousseau's sign 3. Hyperactive bowel sounds 4. Generalized muscle weakness

4. Generalized muscle weakness Rationale: Generalized muscle weakness is seen in clients with hypercalcemia. Twitching, positive Trousseau's sign, and hyperactive bowel sounds are signs of hypocalcemia.

A client is having problems with blood clotting. Which food item should the nurse encourage the client to eat? 1. Legumes 2. Citrus fruits 3. Vegetable oils 4. Green, leafy vegetables

4. Green, leafy vegetables Rationale: Green, leafy vegetables are high in vitamin K, which acts as a catalyst for facilitating blood-clotting factors. Legumes are high in folic acid and thiamine. Citrus fruits are high in vitamin C, which helps with wound healing. Vegetable oil is high in vitamin E, which acts as an antioxidant.

The nurse is caring for a client who has been taking diuretics on a long-term basis. Which finding should the nurse expect to note as a result of this long-term use? 1. Gurgling respirations 2. Increased blood pressure 3. Decreased hematocrit level 4. Increased specific gravity of the urine

4. Increased specific gravity of the urine Rationale: Clients taking diuretics on a long-term basis are at risk for fluid volume deficit. Findings of fluid volume deficit include increased respiration and heart rate, decreased central venous pressure, weight loss, poor skin turgor, dry mucous membranes, decreased urine volume, increased specific gravity of the urine, dark-colored and odorous urine, an increased hematocrit level, and an altered level of consciousness. Gurgling respirations, increased blood pressure, and decreased hematocrit as a result of hemodilution are seen in a client with fluid volume excess.

51. The nurse observes that a client with diabetic ketoacidosis is experiencing abnormally deep, regular, rapid respirations. How should the nurse correctly document this observation in the medical record? 1. Apnea 2. Bradypnea 3. Cheyne stokes 4. Kussmaul's respirations

4. Kussmaul's respirations Rationale: Abnormally deep, regular, and rapid respirations observed in the client with diabetic ketoacidosis are documented as Kussmaul's respirations. During apnea, respirations cease for several seconds. During bradypnea, respirations are regular but abnormally slow. Cheyne stokes respirations gradually become more shallow and are followed by periods of apnea (no breathing), with repetition of the pattern.

A client is receiving a continuous intravenous infusion of heparin sodium to treat deep vein thrombosis. The client's activated partial thromboplastin (aPTT) time is 65 seconds. The licensed practical nurse reviews the laboratory results with the registered nurse, anticipating that which action is needed? 1. Discontinuing the heparin infusion 2. Increasing the rate of the heparin infusion 3. Decreasing the rate of the heparin infusion 4. Leaving the rate of the heparin infusion as is

4. Leaving the rate of the heparin infusion as is Rationale: The normal aPTT varies between 28 seconds and 35 seconds, depending on the type of activator used in testing. The therapeutic dose of heparin for treatment of deep vein thrombosis is to keep the aPTT between 1.5 and 2.5 times normal. This means that the client's value should not be less than 40 seconds or greater than 87.5 seconds. Thus the client's aPTT is within the therapeutic range, and the dose should remain unchanged.

The nurse has delegated several nursing tasks to staff members. Which is the nurse's primary responsibility after the delegation of tasks? 1. Document that the task was completed. 2. Assign the tasks that were not completed to the next nursing shift. 3. Allow each staff member to make judgments when performing the tasks. 4. Perform follow-up with each staff member regarding the performance and outcome of the task.

4. Perform follow-up with each staff member regarding the performance and outcome of the task Rationale: The ultimate responsibility for a task lies with the person who delegated it. Therefore, it is the nurse's primary responsibility to follow-up with each staff member regarding the performance of the task and the outcomes related to implementing the task. Not all staff members have the education, knowledge, and ability to make judgments about tasks being performed. The nurse documents that the task has been completed, but this would not be done until follow-up was implemented and outcomes were identified. It is not appropriate to assign the tasks that were not completed to the next nursing shift.

A client with a history of gastrointestinal bleeding has a platelet count of 300,000 mm3 (300 × 109/L). The nurse should take which action after seeing the laboratory results? 1. Report the abnormally low count. 2. Report the abnormally high count. 3. Place the client on bleeding precautions. 4. Place the normal report in the client's medical record.

4. Place the normal report in the client's medical record. Rationale: A normal platelet count ranges from 150,000 mm3 to 400,000 mm3 (150-400 × 109/L). The nurse should place the report containing the normal laboratory value in the client's medical record. A platelet count of 300,000 mm3 (300 × 109/L) is not an elevated count. The count also is not low; therefore, bleeding precautions are not needed.

A client with diabetes mellitus has a glycosylated hemoglobin A1C level of 9%. On the basis of this test result, the nurse plans to reinforce teaching the client about the need for which measure? 1. Avoiding infection 2. Taking in adequate fluids 3. Preventing and recognizing hypoglycemia 4. Preventing and recognizing hyperglycemia

4. Preventing and recognizing hyperglycemia Rationale: The normal reference range for the glycosylated hemoglobin A1C (HgbA1C) is 4.0% to 6.0%. This test measures the amount of glucose that has become permanently bound to the red blood cells from circulating glucose. Elevations in the blood glucose level will cause elevations in the amount of glycosylation. Thus the test is useful in identifying clients who have periods of hyperglycemia that are undetected in other ways. Therefore, an HgbA1C of 9% is elevated. Elevations indicate continued need for teaching related to the prevention of hyperglycemic episodes.

A client has died, and the nurse asks a family member about the funeral arrangements. The family member refuses to discuss the issue. Which is the appropriate nursing action? 1. Show acceptance of feelings. 2. Provide information needed for decision making. 3. Suggest a referral to a mental health professional. 4. Remain with the family member without discussing funeral arrangements.

4. Remain with the family member without discussing funeral arrangements. Rationale: The family member is exhibiting the first stage of grief (denial), and the nurse should remain with the family member. Option 1 is an appropriate intervention for the acceptance or reorganization and restitution stage. Option 2 may be an appropriate intervention for the bargaining stage. Option 3 may be an appropriate intervention for depression.

The nurse observes that a client received pain medication 1 hour ago from another nurse, but the client still has severe pain. The nurse has previously observed this same occurrence several times. Based on the nurse practice act, the observing nurse should plan to take which action? 1. Report the information to the police. 2. Call the impaired nurse organization. 3. Talk with the nurse who gave the medication. 4. Report the information to a nursing supervisor.

4. Report the information to a nursing supervisor. Rationale: Nurse practice acts require reporting the suspicion of impaired nurses. The state board of nursing has jurisdiction over the practice of nursing and may develop plans for treatment and supervision. This suspicion needs to be reported to the nursing supervisor, who will then report to the board of nursing. Options 1 and 2 are inappropriate. Option 3 may cause a conflict.

47. The nurse is told that the arterial blood gas (ABG) results indicate a pH of 7.50 and a Pco2 of 32 mm Hg (32 mm Hg). The nurse determines that these results are indicative of which acid-base disturbance? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

4. Respiratory alkalosis Rationale: The normal pH is 7.35 to 7.45. If a respiratory condition exists, an opposite relationship will be seen between the pH and the Pco2, as is seen in the correct option. If an alkalotic condition exists, the pH is increased. During an acidotic condition, the pH is decreased so both metabolic acidosis and respiratory acidosis can be eliminated. Metabolic alkalosis can also be eliminated because both pH and are increased above normal values with this condition.

A Hispanic American mother brings her child to the clinic for an examination. Which is most important when gathering data about the child? 1. Avoiding eye contact 2. Using body language only 3. Avoiding speaking to the child 4. Touching the child during the examination

4. Touching the child during the examination rationale: In the Hispanic American culture, eye behavior is significant. It is believed that the "bad/evil eye" can be given to a child if a person looks at and admires a child without touching the child. Therefore, touching the child during the examination is very important. Although avoiding eye contact indicates respect and attentiveness, this is not the most important intervention. Avoiding speaking to the child and using body language only are not therapeutic interventions.

An unconscious client, bleeding profusely, is brought to the emergency department after a serious accident. Surgery is required immediately to save the client's life. With regard to informed consent for the surgical procedure, which is the best action? 1. Call the nursing supervisor to initiate a court order for the surgical procedure. 2. Try calling the client's spouse to obtain telephone consent before the surgical procedure. 3. Ask the friend who accompanied the client to the emergency department to sign the consent form. 4. Transport the client to the operating department immediately without obtaining an informed consent.

4. Transport the client to the operating department immediately without obtaining an informed consent. Rationale:Generally there are only two instances in which the informed consent of an adult client is not needed. One instance is when an emergency is present and delaying treatment for the purpose of obtaining informed consent would result in injury or death to the client. The second instance is when the client waives the right to give informed consent.