NCLEX Question Trainer #3

The 8-year-old has been receiving chemotherapy for 6 months. The child asks, "Am I going to die?" Which response by the nurse is BEST? 1. "Are you afraid of dying?" 2. "Why do you ask that question?" 3. "Only God knows that answer." 4. "We won't leave you alone."

"Are you afraid of dying?" 1) CORRECT — encourages ventilation of thoughts and feelings regarding the concern 2) inappropriate 3) ignores the child's concern with dying 4) ignores the child's concern with dying

The client with newly diagnosed type 1 diabetes says to the nurse, "I know I have to take good care of my feet. When I buy new shoes, is there anything special I should do?" Which response by the nurse is best? 1. "It is best to buy new shoes in the morning." 2. "Have each foot measured every time you buy new shoes." 3. "Buy shoes a half-size larger than your foot size so the fit is roomy 4. "Buy vinyl shoes because they won't lose their shape easily."

"Have each foot measured every time you buy new shoes." 1) should buy shoes in the afternoon when feet are larger than in the morning 2) CORRECT — feet enlarge with age, break in shoes gradually rather than all at one time, have measurements for shoes taken while standing (feet are larger) 3) buy correct shoe size 4) leather shoes recommended because they "breathe," vinyl could cause foot to perspire and aggravate fungal infections

A client is admitted to the neurosurgery unit for the removal of a cerebellar tumor. The nurse expects the client to make which statement about symptoms? 1. "I have been having difficulty with my hearing." 2. "I lose my balance easily." 3. "I can't tell the difference between a sweet and sour taste." 4. "It is not easy for me to remember names and faces."

"I lose my balance easily." 1) temporal lobe contains auditory center, loss of hearing would involve CN VIII acoustic 2) CORRECT — cerebellum maintains balance 3) CN IX, glossopharyngeal responsible for differentiation of taste 4) not specific symptom of cerebellum dysfunction

Which client statement indicates to the nurse the client is using the defense mechanism of conversion? 1. "I love my family with all my heart, even though they don't love me." 2. "I was unable to take my final exams because I was unable to write." 3. "I don't believe I have diabetes. I feel perfectly fine." 4. "If my spouse was a better housekeeper I wouldn't have such a problem."

"I was unable to take my final exams because I was unable to write." 1) indicates reaction formation 2) CORRECT — client has converted the anxiety over school performance into a physical symptom that interferes with the ability to perform 3) indicates denial 4) indicates projection

The 11-year-old child falls off a bicycle and sustains a minor head injury. The injury is treated at the outpatient clinic. The nurse instructs the child's parent about care at home. The nurse determines further teaching is needed if the parent makes which statement? 1. "My child may have dizziness for 24 hours." 2. "My child can drink carbonated beverages if vomiting occurs." 3. "My child may report feeling nauseated." 4. "My child will probably have a headache."

"My child can drink carbonated beverages if vomiting occurs." 1) expected for at least 24 hours 2) CORRECT — vomiting is unexpected; should be reported to health care provider immediately; also unexpected is blurred vision, drainage from ear or nose, weakness, slurred speech, worsening headache 3) expected for at least 24 hours 4) expected for at least 24 hours; should not get more intense

The older client is hospitalized with a fractured left hip. While awaiting surgery, the client is placed in Buck's traction with a 7-pound weight. Which instruction about moving does the nurse give to encourage the client to participate in care? 1. "Pull up on the overhead trapeze while you push down on your right foot to lift your body." 2. "With your right arm, grasp the bedside rail on the opposite side and pull yourself over gently." 3. "I'll raise the head of the bed 45 degrees, and then you'll lean forward and rotate your hips to the left." 4. "Swing your right leg over your left leg and turn from your waist down, keeping your legs straight."

"Pull up on the overhead trapeze while you push down on your right foot to lift your body." 1) CORRECT — body must move as single, straight unit 2) turning or twisting from the waist down interferes with countertraction 3) prevents proper pull of weights 4) can't turn from side to side; can only move up and down

The client asks what the difference is between a gastric ulcer and duodenal ulcer. Which response does the nurse give? 1. "Gastric ulcers have an increased association with clients who experience greater psychological pressures." 2. "The pain of a duodenal ulcer usually occurs 2 to 4 hours after meals." 3. "Client with gastric ulcers often gain weight, as food alleviates the pain." 4. "Antacids are seldom prescribed for clients with duodenal ulcers."

"The pain of a duodenal ulcer usually occurs 2 to 4 hours after meals." 1) refers to duodenal ulcers 2) CORRECT — clients with duodenal ulcers experience pain after meals (e.g., midmorning and midafternoon) 3) clients with gastric ulcers may be malnourished because food may cause nausea or vomiting 4) antacids are given to duodenal ulcer clients

The office nurse reinforces the healthcare provider's explanation for a myelogram. Which statement correctly describes a pyelogram for the client? 1. "The test involves x-ray examination of the entire spinal column to determine the extent of myelin breakdown." 2. "The test injection of a contrast medium into a suspected ruptured vertebral disk, allowing radiographic visualization of the disk." 3. "The test involves a lumbar puncture with injection of contrast medium, allowing x-ray visualization of the vertebral canal." 4. "The test involves x-ray examination of the vertebral column following injection of air into the subarachnoid space."

"The test involves a lumbar puncture with injection of contrast medium, allowing x-ray visualization of the vertebral canal." 1) x-ray examination cannot determine the extent of myelin breakdown 2) no such procedure; injecting contrast medium into a ruptured disk would not allow visualization of the spinal column 3) CORRECT — contrast medium is injected into spinal subarachnoid space through a spinal puncture; identifies tumors, cysts, herniated vertebral disks 4) no such procedure; air is not injected into the subarachnoid space

The client is scheduled for electromyography (EMG). Which information does the nurse tell the client about the procedure? 1. "Your hair will be carefully washed prior to the procedure." 2. "This is a noninvasive procedure that takes about 30 minutes." 3. "A sedative will be given to you shortly before the procedure." 4. "You will not be allowed to eat 4 to 6 hours before the procedure."

"This is a noninvasive procedure that takes about 30 minutes." 1) performed on selected muscles, usually of the extremities 2) CORRECT—electrodes are attached to muscles, length of time for impulse transmission is measured 3) may impair test results 4) procedure does not involve general anesthesia or GI system

The nurse obtains a history from the parent of the 6-year-old child with a history of epilepsy. The child was admitted with uncontrolled seizures. It is MOST important for the nurse to ask which question? 1. "What part of the body was affected by the seizure?" 2. "What is the family history of seizure disorders?" 3. "What was your child doing before the seizure?" 4. "How long has it been since the last episode of seizures?"

"What was your child doing before the seizure?" 1) not most important question 2) should be included in detailed history, but will not prevent an immediate recurrence 3) CORRECT — seizure may result from triggering mechanism (loud noise, music, flickering light, prolonged reading, medications) 4) should be included in detailed history, but will not prevent an immediate recurrence

The client experiences inflammation due to rheumatoid arthritis. Which nursing statement is correct? 1. "If you are having a 'bad' day, postpone your exercises until the next day." 2. "Passive exercises are better for you than active exercises." 3. "When inflammation is severe, decrease the number of repetitions of the exercise." 4. "You can substitute your normal household tasks for your exercises to provide variety."

"When inflammation is severe, decrease the number of repetitions of the exercise." 1) consistency is important to maintain joint mobility 2) active exercises are better than passive or active-assistive exercises 3) CORRECT — should reduce repetitions when client experiences more pain 4) should do exercises that have been prescribed for client

The nurse responds to a train derailment. After making initial assessments, in what order should the nurse see these clients? 1. The young client with blood pulsating from a cut on the right leg 2. The pregnant client who states clothing is wet 3. The unconscious client with the right leg shorter than the left leg 4. The preschool child who is screaming and crying uncontrollably

1, 3, 2, 4 1) First (3) indicates arterial bleeding; apply direct pressure; high risk for shock. 2) Second (1) possible hip fracture; no indication of respiratory difficulty stated; client unconscious, may have other problems. 3) Third (4) requires further assessment; could be amniotic fluid or could be urine. 4) Last (2) stable client; no indications of any injuries.

The nurse cares for clients on a psychiatric unit and is suddenly faced with multiple issues. In which order does the nurse address these situations? 1. The client diagnosed with depression says to the nurse, "My plan is complete, and I'm ready to go." 2. The client diagnosed with bipolar disorder walks into he day room wearing only underwear. 3. The client with substance abuse reports harassment by another client. 4. The client diagnosed with schizophrenia tells the nurse the TV should be destroyed.

1, 3, 4, 2 1) fourth, the client wearing only underwear is not a harm to self or others initially 2) second, the client with substance abuse should be removed to quiet area, decrease environmental stimuli; may cause distraction for other clients 3) first, the client diagnosed with depression could indicate impending suicide; requires immediate follow-up 4) third, the client diagnosed with schizophrenia is experiencing command hallucination; protect from injury and destroying the TV

The nurse receives report from the previous shift. In which order should the nurse see these clients? 1. The client 1 day postop with an epidural catheter in place 2. The client diagnosed with type 1 diabetes scheduled for a cardiac catheterization at 1400 3. The client post coronary artery bypass graft having the atrioventricular wires removed at 1500 4. The client diagnosed with cardiomyopathy being evaluated for a heart transplant

1, 4, 2, 3 Strategy: Look for most unstable client and work towards most stable client First: most unstable client with epidural needs assessment for side effects of epidural and is fresh postop respiratory consideration. Second: client needing heart transplant will be unstable requires monitoring and early assessment; circulation consideration. Third: needs assessment of blood glucose and preoperative needs but falls behind respiratory and unstable circulation. Last: stable client.

The nurse in the pediatric office observes the child in the waiting room. The child can walk up and down steps, has a steady gait, can stand on one foot momentarily, and jumps with both feet. Which does the nurse identify as the child's chronological age? 1. 1 year old 2. 2 years old 3. 3 years old 4. 5 years old

3 years old 1) unable to walk up and down stairs with hand held until 18 months 2) unable to jump until 30 months 3) CORRECT — able to jump with both feet and stand on one foot momentarily at 30 months 4) behaviors are seen in younger child

The nurse receives report on these clients from the previous shift. In which order should the nurse see the clients? 1. The client scheduled to receive heparin and the aPTT is 70 seconds 2. The client receiving IV potassium infusion who reports burning at the IV site 3. The client receiving ciprofloxacin IV, reports a fine macular rash on the chest 4. The client receiving a blood transfusion who reports a dry mouth

3, 2, 1, 4 1) First (3) indicates hypersensitivity reaction; should stop medication and notify the health care provider. 2) Second (1) should decrease rate to prevent irritation of the vein, but hypersensitivity reaction requires first attention. 3) Third (4) lower limit of normal is 20 - 25 sec; upper limit of normal is 32 - 39 sec; aPTT is within therapeutic range; therapeutic levels increase aPTT 1.5 to 2 times control value; should give medication. 4) Last (2) not an immediate concern; routine transfusion evaluation.

The client with bipolar illness is extremely angry. The client tells the nurse, "I just found out my spouse has filed for divorce. I need to use the phone right now!" Which action by the nurse is most appropriate? 1. Allow the client to use the phone 2. Confront the client about the anger and inappropriate plan of action 3. Do not allow the client to use the phone because this is an involuntary admission 4. Set limits on the client's phone use because of the inability to control behavior

Allow the client to use the phone 1) CORRECT — client is able to use phone unless otherwise indicated by court order or health care provider's order 2) has not lost civil right to use phone 3) denies patient his civil rights 4) inappropriate

The elderly alcoholic client receives a long-acting benzodiazepine for 2 days for symptom management and reduction. The client states, "Get those bugs off of me and clean them out of here." The nurse knows the client is exhibiting symptoms of which problem? 1. A reaction to the sedative medication 2. A worsening course of the withdrawal syndrome 3. An exacerbation of the schizophrenia process 4. The process of aging and the effects of delirium

A worsening course of the withdrawal syndrome 1) client has been medicated with benzodiazepines and did not experience untoward reactions 2) CORRECT — client has most probably progressed to another level of abstinence withdrawal from polypharmacy chemical dependence; characteristic symptoms include tremors, increased heart rate, and fever, as well as psychological problems of confusion, delusions, and hallucinations 3) schizophrenic client usually experiences an episode of auditory hallucinations, not visual or tactile hallucinations 4) combination effect of the normal aging process and dementia could precipitate a similar reaction; however, the normal aging process does not produce delirium but rather dementia

The elderly client diagnosed with chronic schizophrenia is cared for in a partial hospitalization program. The client has been on long-term antipsychotic medication and recently developed symptoms of tardive dyskinesia. The nurse's documentation includes which finding? 1. Assessment of ADL ability 2. Mini-Mental Status Examination (MMSE) 3. Abnormal Involuntary Movement Scale (AIMS) 4. Modified Overt Aggression Scale (MOAS)

Abnormal Involuntary Movement Scale (AIMS) 1) assessment of client's abilities to complete the activities of daily living (ADLs) needs to be completed and revised with a client who is aging and chronically mentally ill but not related to tardive dyskinesia 2) measures cognitive function 3) CORRECT — most widely accepted examination to test for the presence of tardive dyskinesia 4) assessment tool for determining severity of aggression; usually utilized to determine nature, severity, and prevalence of aggression in an inpatient population

The nurse cares for the client with dementia. Which plan of care is MOST successful? 1. Teach new skills for adjusting to the aging process 2. Adjust the environment to meet the client's individual needs 3. Encourage competitive activities to keep the client physically strong 4. Provide unstructured activities with frequent changes to increase stimulation

Adjust the environment to meet the client's individual needs 1) unable to learn new skills 2) CORRECT — client with dementia does not have cognitive abilities to learn new skills or to adapt; environment must be adapted for client with attention to safety and predictability 3) requires skills the client with dementia does not have 4) requires skills the client with dementia does not have

The client diagnosed with bipolar disorder is in a manic phase with combative behavior. Which is the INITIAL PRIORITY nursing action? 1. Provide adequate hygiene and nutrition 2. Decrease environmental stimuli 3. Slowly involve the client in unit activities 4. Administer and monitor sedative and mood-stabilizing medications

Administer and monitor sedative and mood-stabilizing medications 1) is very important to ensure adequate hygiene and nutrition, but behavioral control and client/milieu safety are an initial priority 2) decreasing environmental stimulation is an additional strategy that, when utilized in conjunction with psychopharmacologic intervention, can reduce hyperactivity and aggressive acts; just decreasing environmental stimulation will not diminish client's internal sense of agitation and aggression 3) this action is inappropriate at this time 4) CORRECT — is most important to gain control with a physically aggressive client in manic phase; client has significant sympathetic nervous system stimulation and will require psychopharmacologic intervention with both sedative medications and mood-stabilizing agents

The nurse provides care for a client in a psychiatric facility. The client describes seeing snakes on the walls of the room. Which is an accurate nursing diagnosis? 1. Altered sensory perception 2. Long-term confusion 3. Impaired coping 4. Altered interaction

Altered sensory perception 1) CORRECT — reflects a pattern of altered perception, which is supported by the data that the client is having a hallucination, defined as a sensory perception for which no external stimuli exist 2) not relevant to the data 3) not relevant to the data 4) not relevant to the data

The client is diagnosed with an obsessive-compulsive ritual. The nurse recognizes the client is attempting to achieve with psychological status? 1. Control of other people 2. Increased self-esteem 3. Avoid severe levels of anxiety 4. Express and manage anxiety

Avoid severe levels of anxiety 1) inaccurate 2) inaccurate 3) CORRECT — obsessive-compulsive rituals are an attempt to avoid or alleviate increasing levels of anxiety; client is not trying to increase self-esteem or control others with the ritualistic behaviors; these behaviors do not have a significant impact on others; client does not want to repeat the act but feels compelled to do so 4) ritual is not a method of expressing anxiety but a strategy to avoid it

The client is admitted to the trauma intensive care unit (ICU) with a gunshot wound of the neck. The client is diagnosed with a spinal cord injury at the level of C4. The client is tearful, constantly reports discomfort, and requests to be suctioned. The nurse understands the client's attention-seeking behaviors may be due to which feelings? 1. Anger and frustration 2. Awareness of vulnerability 3. Increased social isolation 4. Increased sensory stimulation

Awareness of vulnerability 1) is not accurate for situation 2) CORRECT — is experiencing an increased awareness of physical vulnerability due to the spinal cord injury; fosters increased dependency needs that are real due to the injury; is trying to determine who is consistent and trustworthy for meeting significant physical needs 3) is not accurate for situation 4) is not accurate for situation

The parent brings a 9-month-old infant to the pediatric office with a fever of 102.2° F (39° C) and frequent vomiting. The nurse expects to find which reflex? 1. Babinski reflex 2. Moro reflex 3. Tonic neck reflex 4. Grasp reflex

Babinski reflex 1) CORRECT — stroking outer sole of foot upward causes toes to hyperextend and fan and great toe to dorsiflex; disappears after 1 year of age 2) sudden jarring causes extension and abduction of extremities and fanning of fingers with index finger and thumb forming a C shape; disappears after 3 to 4 months 3) when head is turned to side, arm and leg extend on that side, and opposite arm and leg flex; disappears by age 3 to 4 months 4) touching palms of hands or soles of feet causes flexion of hands and toes; palmar grasp disappears after 3 months of age, plantar grasp lessens by 8 months of age

The nurse cares for the client after an electroconvulsive therapy (ECT) treatment. The nurse reports which observation to the healthcare provider? 1. Headache 2. Disruption in short- and long-term memory 3. Transient confusional state 4. Backache

Backache 4) CORRECT — client undergoing ECT needs to be instructed about what could be experienced during and after ECT; expected effects include headache, disrupted memory (short- and long-term), and general confused state; backache is not a usual effect; thorough description of the pain in relation to severity, duration, location, and what makes pain better needs to be assessed and reported to the health care provider

The client has a three-way indwelling urinary catheter following a transurethral resection. Which finding causes the nurse to infuse the irrigating solution rapidly? 1. The urinary output is increased 2. Bright-red drainage or clots are present 3. Dark-brown drainage is present 4. The client reports pain

Bright-red drainage or clots are present 1) not a reason to infuse irrigating solution rapidly 2) CORRECT — nurse should irrigate three-way urinary catheter rapidly when bright-red drainage or clots are present; nurse should decrease irrigation rate to about 40 gtt/min when the drainage clears 3) not an indication to infuse irrigating solution rapidly 4) not an indication to infuse irrigating solution rapidly

The client is admitted for a series of tests to verify the diagnosis of Cushing's syndrome. Which nursing assessment finding supports this diagnosis? 1. Buffalo hump 2. Intolerance to heat 3. Hyperglycemia 4. Hypernatremia 5. Intolerance to cold 6. Irritability

Buffalo hump, hyperglycemia, & hypernatremia 1) CORRECT — hypersecretion of adrenal hormones; other indications include weight gain, moon face, purple striae, osteoporosis, mood swings, and high susceptibility to infections 2) indication of hyperthyroidism 3) CORRECT — hypersecretion of adrenal hormones; other indications include weight gain, moon face, purple striae, osteoporosis, mood swings, and high susceptibility to infections 4) CORRECT — hypersecretion of adrenal hormones; other indications include weight gain, moon face, purple striae, osteoporosis, mood swings, and high susceptibility to infections 5) indication of hypothyroidism 6) indication of hypoparathyroidism

The client receives aminophylline IV. The client has clear lung sounds and unlabored breathing. Which is the MOST important nursing action if the client's IV infiltrates? 1. Apply warm soaks to the infiltration site, start a new IV, and continue IV medications 2. Wait 2 hours, reassess the client, and restart the IV if the client has wheezing or labored breathing 3. Restart the IV and continue the previous medication schedule 4. Call the healthcare provider and recommend the IV medication be changed to PO

Call the healthcare provider and recommend the IV medication be changed to PO 1) continued IV medication may not be necessary based on the current assessment 2) health care provider should be notified if IV medications are not infusing as scheduled 3) client has improved breathing, so IV medications may not be indicated 4) CORRECT — before a new IV is started on this client, health care provider should be called and PO medications recommended

The nurse observes the student nursing care for the client. The student nurse wears a gown and gloves in addition to following standard precautions. The nurse determines care is appropriate if the student nurse performs which activity? 1. Gives isoniazid to a client with TB 2. Administers an IM injection to a client with rubella 3. Delivers a food tray to a client with hepatitis 4. Changes the dressing for a client with a draining abscess

Changes the dressing for a client with a draining abscess 1) requires airborne precautions, particulate respirator 2) requires droplet precautions; nurse should wear a mask 3) requires standard precautions 4) CORRECT — requires contact precautions

Which is the MOST appropriate nursing action to take before administering captopril? 1. Check the client's apical pulse for 60 seconds 2. Check the client's BP 3. Check the client's urine output 4. Check the client's temperature

Check the client's BP 1) important, but not a priority 2) CORRECT — captopril is an antihypertensive that necessitates assessment of BP before administration 3) important, but not a priority 4) unnecessary to assess prior to the administration of the medication

The child has a closed transverse fracture of the right ulna. Which nursing action before the application of a cast is most important? 1. Check the radial pulses bilaterally and compare 2. Evaluate the skin temperature and tissue turgor in the area 3. Assess sensation of each foot while the child closes the eyes 4. Apply baby powder to decrease skin irritation under the cast

Check the radial pulses bilaterally and compare 1) CORRECT — assess neurovascular status, check pain, pallor, paralysis, paresthesia, pulselessness 2) assessment; temperature indicates decreased circulation but is subjective and not most important 3) assessment; upper (not lower) extremity fracture 4) implementation; should not be done because it would increase skin irritation

The parent of a toddler recovering from surgery is concerned because the client is restless and overactive. Which action will the nurse take? 1. Direct the LPN to obtain the client's vital signs 2. Ask the parent if the client's sutures are still intact 3. Telling nursing assistive personnel to take the client for a walk 4. Check to see when pain medication was last provided

Check to see when pain medication was last provided 1) There is no indication that there are any problems with the client's vital signs. 2) It is not the parent's responsibility to assess the surgical site and condition of the sutures. 3) The client should be assessed first before ambulating. 4) CORRECT - Young children typically become restless and overactive in response to pain. Grimacing, clenching teeth, rocking, and aggressive behavior may also be observed.

The client is to have an intravenous pyelogram (IVP). Nursing management includes which action? 1. A fat-free meal the evening before the examination and radiopaque tablets at bedtime 2. Placement of a retention urinary catheter to facilitate dilation of the bladder sphincter 3. Cleansing enemas the evening before to provide for adequate visualization of the urinary tract 4. Explaining the importance of following directions regarding voiding during the test

Cleansing enemas the evening before to provide for adequate visualization of the urinary tract 1) fat-free meal is associated with a gallbladder series 2) a retention indwelling catheter may be in place, but not for the purpose of dilating the bladder sphincter 3) CORRECT — because of the need to visualize the abdominal area, cleansing enemas the evening before an IVP are usually ordered 4) there are few directions the client needs to follow during the test

A newborn client at 32 weeks' gestation weighs 4 lb 10 oz (2.12 kg) and has mottling of the skin and acrocyanosis with irregular respirations of 60 breaths per minute. Which newborn problem does the nurse suspect this client is experiencing? 1. Hypoglycemia 2. Cold stress 3. Birth asphyxia 4. Hypovolemia

Cold stress 1) Newborn hypoglycemia is a blood glucose level less than 25 mg/dL (1.4 mmol/L). Symptoms include cyanosis, apnea, tachypnea, irregular respirations, diaphoresis, jitteriness, weak cry, lethargy, convulsions, and coma. 2) CORRECT — Mottling of the skin, acrocyanosis, and irregular respirations at the rate of 60 breaths per minute are symptoms of cold stress. 3) Meconium-stained amniotic fluid is associated with birth asphyxia. 4) Symptoms of shock occur in hypovolemia.

The parent of the 7-year-old child is dying. The nurse anticipates the child will have which concept of death? 1. Death is punishment for the child's actions 2. Death is inevitable and irreversible 3. Death is temporary and gradual 4. Death as a concept based on past experience

Death is punishment for the child's actions 1) CORRECT - 7-year-olds see death as a punishment 2) by age of 9, most children begin to develop an adult concept of death and begin to understand that death is irreversible 3) is a preschool child's concept of death 4) is an adolescent's concept of death

The nurse cares for the elderly client receiving IV fluids of 0.9% NaCl at 125 mL/h into the left arm. During a routine assessment, the nurse finds the client has distended neck veins, shortness of breath, and crackles in both lung bases. Which action does the nurse take FIRST? 1. Decrease the IV rate to 20 mL/h and notifies the healthcare provider 2. Decreases the IV rate to 100 mL/h and continues to monitor the client 3. Discontinues the IV and starts oxygen at 6 L/min 4. Assesses for infiltration of the IV solution

Decreases the IV rate to 20 mL/h and notifies the healthcare provider 1) CORRECT — 20 mL/h (KVO - keep vein open) will keep access open 2) need to notify health care provider; rate still too much since client is in fluid overload 3) IV line may be necessary; diuretics may be ordered 4) description indicates circulatory overload, not infiltration

The client is returned to the unit after surgery with a cuffed tracheostomy tube in place. The nurse knows the purpose of the cuff on the tracheostomy tube includes which reason? 1. Guarantees secure placement of the tracheostomy in the airway 2. Prevents ischemia of the tracheal wall by distributing the pressure applied to it 3. Decreases the chance of aspiration into the trachea 4. Protects the trachea from ischemia and edema

Decreases the chance of aspiration into the trachea 1) inaccurate, not the purpose of the cuff on a tracheostomy tube 2) complication of using a cuffed tracheostomy tube 3) CORRECT — seals trachea, helps to prevent aspiration 4) trauma from overinflated tube may cause edema

The nurse provides care for a 2-day-old client. The neonate will not take formula from the parent or the nurse. Which is the priority nursing diagnosis? 1. Swallowing difficulty 2. Failure to thrive 3. Dehydration 4. Altered bonding

Dehydration 1) no information about swallowing provided in the stem 2) failure to thrive is impaired growth fluid volume is of greater concern 3) CORRECT — the priority is fluid volume for a neonate 4) no information about bonding provided in the stem

The nurse assesses the client with severe bilateral peripheral edema. Which is the BEST way for the nurse to determine the degree of edema in a limb? 1. Measure both limbs with the tape measure and compare 2. Depress the skin and rank the degree of pitting 3. Describe the swelling in the affected area 4. Pinch the skin and note how quickly it returns to normal

Depress the skin and rank the degree of pitting 1) is not the best way to evaluate for peripheral edema 2) CORRECT — severity of edema is characterized by grading it 1+ (2-mm pitting) to 4+ (8-mm pitting) 3) not as objective 4) is used for evaluating hydration

The parent brings 10-year-old and 3-year-old children to the pediatric office. The young child reports dysuria. The healthcare provider orders a catheterized urine specimen. The nurse takes which action? 1. Describes the procedure to the child in short, concrete terms while taking calmly. 2. Allows the child to play with the equipment during the procedure 3. Involves the older sibling in explaining the procedure 4. Shows the child a diagram of the urinary system

Describes the procedure to the child in short, concrete terms while taking calmly 1) CORRECT — children this age need simple explanations 2) might contaminate the equipment; must be a sterile procedure 3) not likely to listen to sibling 4) not appropriate for this age

The nurse prepares a dopamine infusion for the client. Which action does the nurse take FIRST? 1. Evaluates the urine output 2. Obtains the client's weight 3. Determines the patency of the IV line 4. Measures pulmonary artery pressures

Determines the patency of the IV line 1) not a critical assessment at this time 2) contains correct information but is not a priority 3) CORRECT — if extravasation occurs, there is sloughing of the surrounding skin and tissue; patent IV line is essential to prevent serious adverse effects 4) not a critical assessment at this time

The nurse teaches a health class to a group of senior citizens. Which behavior does the nurse emphasize to facilitate regular bowel elimination? 1. Avoid strenuous activity 2. Eat more foods with increased bulk 3. Decrease fluid intake to decrease urinary losses 4. Use oral laxatives so a bowel pattern emerges

Eat more foods with increased bulk 1) regular exercise program facilitates bowel elimination 2) CORRECT — fiber contained in whole grains, legumes, vegetables, fruits, seeds, nuts, bulk promotes peristalsis 3) normal fluid intake of 1,500 mL/day facilitates bowel elimination 4) laxatives used as last resort because they become habit-forming

The nurse in the outpatient clinic assists with the application of a cast to the left arm of the preschool-aged child. After the cast is applied, the nurse takes which action FIRST? 1. Petals the edges of the cast to prevent irrigation 2. Elevates the child's left arm on two pillows 3. Applies cool, humidified air to dry the cast 4. Asks the client to move the fingers to maintain mobility

Elevates the child's left arm on two pillows 1) done when cast is completely dry, prevents crumbling of plaster into cast 2) CORRECT — minimizes swelling, elevated for first 24 to 48 hours, protects from pressure and flattening of cast 3) would delay drying of cast 4) maintaining mobility of fingers not most important after application of cast

A client suspects she is pregnant because the last menstrual period began May 8 and ended May 12. Which estimated date of birth will the nurse calculate for this client? 1. February 1 2. February 15 3. February 19 4. March 14

February 15 1) February 1 is incorrect using Naegele's rule to determine EDB. When using the Naegele's rule, the nurse adds 7 calendar days to the date of the client's last menstrual period and then subtracts 3 months. This EDB subtracts 7 days from, instead of adding 7 days to, the first day of the last menstrual period. 2) CORRECT — When using the Naegele's rule, the nurse adds 7 calendar days to the date of the client's last menstrual period and then subtracts 3 months. For example, May 8 plus 7 days is May 15 minus 3 months is February 15th. 3) February 19 is incorrect using Naegele's rule to determine EDB. When using the Naegele's rule, the nurse adds 7 calendar days to the date of the client's last menstrual period and then subtracts 3 months. This EDB uses the date of the last day, not first day, of the last menstrual cycle. 4) The day of March 14 is an incorrect calculation for the estimated date of birth based upon the client's last menstrual period.

The client is receiving imipramine. It is important for the nurse to instruct the client to immediately report which symptoms? 1. Fever 2. Dry mouth 3. Increased fatigue 4. Vomiting and diarrhea 5. Staggering gait 6. Sore throat

Fever, dry mouth, increased fatigue, vomiting and diarrhea, & sore throat 1) CORRECT— imipramine is a tricyclic antidepressant and hyperthermia can be a side effect. 2) CORRECT— imipramine is a tricyclic antidepressant and dry mouth is a side effect. 3) CORRECT— imipramine is a tricyclic antidepressant and increased fatigue is a side effect. 4) CORRECT— imipramine is a tricyclic antidepressant and N/V/D are side effects. 5) Staggering gait is not a side effect of this medication 6) CORRECT— imipramine is a tricyclic antidepressant and a sore throat can be a side effect.

The client has a neurological disorder. Which nursing assessment is MOST helpful to determine subtle changes in the client's level of consciousness? 1. Client posturing 2. Glasgow coma scale 3. Client thinking pattern 4. Occurrence of hallucinations

Glasgo coma scale 1) indicates increased intracranial pressure 2) CORRECT — Glasgow coma scale score best evaluates changes in a client's level of consciousness by evaluating eye-opening, motor, and verbal responses 3) more appropriate for the psychiatric client 4) more appropriate for the psychiatric client

The client is diagnosed with obsessive-compulsive disorder manifested by the compulsion of hand-washing. The nurse knows which behavior BEST describes the client's need for repetitive acts of hand-washing? 1. Hand-washing represents an attempt to manipulate the environment to make it more comfortable. 2. Hand-washing externalizes the anxiety from a source within the body to an acceptable substitute outside the body 3. Hand-washing helps the client avoid undesirable thoughts and maintain some control over guilt and anxiety 4. Hand-washing helps maintain the client in an active state to resist the effects of depression

Hand-washing helps the client avoid undesirable thoughts and maintain some control over guilt and anxiety 1) not a manipulation on the client's part 2) not an accurate statement regarding the compulsive behavior of this client 3) CORRECT — compulsive behavior is an unconscious attempt to control and/or relieve the tension and anxiety the client is experiencing 4) client is not subject to depression but to high levels of anxiety

The client has orders for cefoxitin 2 g IV piggyback in 100 mL 5% dextrose in water. The primary IV is 5% dextrose in lactated Ringer's and is infusing by gravity. It is most important for the nurse to take which action? 1. Administer the medication slowly, at 20 to 25 mL/h. 2. Change the primary IV solution 3. Hang the piggyback infusion bag higher than the primary infusion bag 4. Obtain an infusion pump prior to administration

Hang the piggyback infusion bag higher than the primary infusion bag 1) antibiotic should be administered within 1 hour 2) unnecessary for safe infusion 3) CORRECT — when using a gravity drip, piggyback fluid level needs to be higher than primary infusion 4) unnecessary for safe infusion

The nurse assesses the client's neurosensory cerebella functioning. Which assessment technique is correct? 1. Test the client's deep tendon reflexes to observe for weakness 2. Check the client's pupils with a penlight and observe for constriction 3. Have the client's stand with eyes closed and observe for swaying 4. Ask the client to show the teeth and stick out the tongue

Have the client's stand with eyes closed and observe for swaying 1) general central nervous system response, not sensory involvement 2) evaluates for increased intraocular pressure 3) CORRECT — coordination is governed by the cerebellum; this test evaluates neurosensory status 4) evaluates the facial and hypoglossal nerves

The nurse plans a diet for a child diagnosed with cystic fibrosis (CF). Which dietary requirements should be considered by the nurse? 1. High-protein 2. Low-sodium 3. High-calorie 4. Low-protein 5. Low-carbohydrate 6. High-sodium

High-protein & high-calorie 1) CORRECT — impaired intestinal absorption due to cystic fibrosis necessitates a diet high in protein and calories 2) no need to reduce sodium 3) CORRECT — impaired intestinal absorption due to cystic fibrosis necessitates a diet high in protein and calories 4) need high protein for growth and because of loss of nutrients 5) the level of carbohydrate is not as important as increased calories 6) sodium should not be elevated

The client is treated in the telemetry unit for cardiac disease. The client receives propranolol hydrochloride 20 mg PO at 09:00. When the nurse enters the room to give the medication to the client, the nurse finds the client wheezing with a nonproductive cough and shortness of breath. Initially the nurse takes which action? 1. Holds the medication and counts the respirations 2. Holds the medication and calls the healthcare provider 3. Takes an apical pulse and then gives the medication 4. Gives the medication as ordered

Holds the medication and counts the respirations 1) CORRECT — adverse effects include increased airway resistance; client is experiencing bronchospasm; should assess and then call the health care provider 2) should assess the client's condition first 3) client is experiencing an adverse effect; medication should not be given 4) medication should be held; client is experiencing an adverse effect

The neonate weighing 7 lb 4 oz with Apgar scores of 7 and 8 at 1 and 5 minutes, respectively. Because the infant's mother is diagnosed with type 1 diabetes, the nurse knows the infant is at greatest risk for developing which problem? 1. Hypovolemia 2. Hypoglycemia 3. Hyperglycemia 4. Cold stress

Hypoglycemia 1) no change in blood volume for infant of diabetic mother 2) CORRECT — fetus produces increased insulin to match mother's increased glucose level during pregnancy; infant continues to have high insulin output after birth, resulting in hypoglycemia 3) infant would be at risk of hypoglycemia due to increased insulin production 4) thermal receptors in skin are stimulated due to cold environment; increases metabolic rate; infant needs to maintain normal body temperature while producing minimal amount of heat generated from metabolic processes; not expected with diabetic mother

The 25-year-old primigravida is diagnosed with type 1 diabetes mellitus. The nurse reviews the insulin regimen with the client. The nurse explains insulin needs will change in which way? 1. Increase during pregnancy and decrease after delivery 2. Decrease during pregnancy and increase after delivery 3. Increase during pregnancy and remain increased after delivery 4. Decrease during pregnancy and fluctuate after delivery

Increase during pregnancy and decrease after delivery 1) CORRECT — needs increase during pregnancy due to hormonal interference in glucose metabolism 2) needs increase during pregnancy due to hormonal interference in glucose metabolism 3) insulin needs will decrease after delivery 4) insulin needs increase during pregnancy

The nurse obtains the client's temperature of 103° F (39.4° C). The nurse knows body compensatory mechanisms include which mechanism? 1. Decreased respiratory rate and bradycardia 2. Normal BP and pulse 3. Increased respiratory rate and tachycardia 4. Diaphoresis with cool, clammy skin

Increased respiratory rate and tachycardia 1) respirations and heart rate will increase with fever 2) blood pressure and pulse usually increase with fever 3) CORRECT — hyperthermia increases the oxygen requirements, which results in faster breathing as well as an increase in the pulse rate 4) diaphoresis may occur, but the skin will be warm

The client is admitted for regulation of insulin dosage. The client takes 15 units of isophane insulin at 08:00 every day. At 16:00, which nursing observations indicate a complication from the insulin? 1. Acetone odor to the breath 2. Irritability 3. Polyuria 4. Tachycardia 5. Headache 6. Diaphoresis

Irritability, tachycardia, & diaphoresis 1) related to hyperglycemia. 2) CORRECT— isophane insulin is an intermediate-acting insulin that peaks from 8 to 12 hours after administration; this is when signs and symptoms of hypoglycemia will occur. 3) related to hyperglycemia. 4) CORRECT— isophane insulin is an intermediate-acting insulin that peaks from 8 to 12 hours after administration; this is when signs and symptoms of hypoglycemia will occur. 5) related to hyperglycemia. 6) CORRECT— isophane insulin is an intermediate-acting insulin that peaks from 8 to 12 hours after administration; this is when signs and symptoms of hypoglycemia will occur.

The nurse teaches nutrition classes at the community center. Which food does the nurse encourage the low-income client to eat to satisfy essential protein needs? 1. Legumes 2. Red meat 3. Seafood 4. Cheese

Legumes 1) CORRECT — legumes are an economical source rich in protein 2) high in protein, but more expensive to purchase 3) high in protein, but more expensive to purchase 4) high in protein, but more expensive to purchase

The client is admitted to the hospital for a hemiglossectomy with lymph node dissection. The client's preoperative care includes frequent oral hygiene with normal saline. The nurse knows the purpose of this treatment includes which reason? 1. Minimizes the bacterial count in the mouth 2. Softens the mucous membranes of the tongue before surgery 3. Stimulates the microcirculation of the mouth 4. Hydrates the tissues of the gums

Minimizes the bacterial count in the mouth 1) CORRECT — destroys bacteria found in mouth, reduces the chance of infection 2) is not the action of saline 3) circulation is unaffected by a mouth rinse 4) has slight drying effect on mucous membranes

The nurse cares for the elderly client diagnosed with dementia. Which nursing action is BEST? 1. Place the client in soft hand restraints or chair restraints 2. Monitor wandering behaviors during a 7-day period 3. Keep the lounge's television volume on a low level 4. Encourage a diet high in protein, iron, and vitamins

Monitor wandering behaviors during a 7-day period 1) do not restrain unless all other options have been exhausted 2) CORRECT — appropriate assessment to determine if client wanders during specific times of the day; assess before implementing 3) need to prevent sensory overload; should assess first 4) offer well-balanced diet

The client takes phenelzine. The nurse observes the client eat another client's lunch. After a few minutes, the client reports headache, nausea, and rapid heartbeat, and begins to vomit. The nurse anticipates administering which medication? 1. Buspirone 2. Fluoxetine 3. Prochlorperazine 4. Nifedipine

Nifedipine 1) antianxiety; adverse effects include light-headedness, confusion, hypotension, palpitations 2) SSRI antidepressant; adverse effects include palpitation, bradycardia, nausea and vomiting 3) antiemetic; adverse effect include drowsiness, orthostatic hypotension 4) CORRECT — antihypertensive; client experiencing hypertensive crisis due to ingesting tyramine; adverse effects include dizziness, headache, nervousness

The nurse cares for the child who is in Buck's traction. The nurse notes the foot of the uninjured leg feels warmer to touch than that of the broken leg. The nurse takes which action? 1. Records the observation 2. Encourages the child to move the foot 3. Covers the colder foot with a sock 4. Notifies the healthcare provider

Notifies the healthcare provider 1) ignores possibility the elastic bandage is too tight 2) does not relieve the circulation problem 3) does not relieve the circulation problem 4) CORRECT — assessment indicates the elastic bandage is too tight and needs readjusting

The client has an irregular pulse rate of 81 and a potassium level of 3.0 mEq/L (3.0 mmol/L). The client has digoxin ordered. Which nursing action is BEST? 1. Give the digoxin 2. Hold the digoxin 3. Notify the healthcare provider 4. Recheck the pulse

Notify the healthcare provider 1) although the pulse is normal, level of potassium must be considered 2) notify health care provider about low potassium 3) CORRECT — hypokalemia can precipitate digoxin toxicity; health care provider should be called to obtain order for potassium supplement 4) notify health care provider about the potassium level

The infant is admitted with vomiting and diarrhea. The infant's anterior fontanelle is depressed and the temperature is 103.2° F (39.5° C). Which nursing action is most appropriate? 1. Obtain daily weights and evaluate weight loss 2. Observe the infant's ability to take in fluids 3. Place a full bottle of pediatric electrolyte solution at the bedside 4. Start an intravenous infusion

Observe the infant's ability to take in fluids 1) assessment; correct information, but is not what the question asks for 2) CORRECT — assessment; will assist in determining if hydration can be done through oral fluids alone 3) implementation; does not do anything to improve the situation; placing a full bottle at the bedside doesn't guarantee the infant is taking fluids 4) implementation; would be implemented later

The nurse cares for the multipara client who delivered an infant 1 hour ago. The nurse observes the client's breasts are soft, the uterus is boggy to the right of the midline and 2cm below the umbilicus, and there is moderate lochia rubra. It is MOST important for the nurse to take which action? 1. Perform a straight catheterization 2. Offer the client the bedpan 3. Put the baby to breast 4. Massage the uterine fundus

Offer the client the bedpan 1) encourage the client to void before catheterizing 2) CORRECT — boggy uterus deviated to right indicates full bladder, encourage client to void 3) will increase uterine tone, but the problem is a full bladder 4) findings indicate a full bladder

The client is admitted with irritable bowel syndrome. The nurse anticipates the client's history will reflect which information? 1. Pattern of alternating diarrhea and constipation 2. Chronic diarrhea stools occurring 10 to 12 times per day 3. Diarrhea and vomiting with severe abdominal distention 4. Bloody stools with increased cramping after eating

Pattern of alternating diarrhea and constipation 1) CORRECT — condition is often called spastic bowel disease; no inflammation is present 2) refers to inflammatory bowel disease such as ulcerative colitis or Crohn's disease 3) refers to inflammatory bowel disease such as ulcerative colitis or Crohn's disease 4) bloody stools do not occur with irritable bowel syndrome

The client has a diagnosis of a ruptured lumbar disc. The nurse anticipates which assessment finding? 1. Sensation loss in an upper extremity 2. Clonic jerks in the affected foot 3. Paresthesia in the affected leg 4. Chorea in the upper and lower extremities

Paresthesia in the affected leg ) results from cervical lesions 2) can occur in a person who has been paralyzed from a spinal cord injury 3) CORRECT — lumbar lesions can cause paresthesia, pain, muscle weakness, and atrophy in the lower extremities 4) is a sign of Huntington chorea, resulting from atrophy of parts of the brain

The client has been taking propranolol 40 mg bid and furosemide 40 mg daily for several months. Two weeks ago, the health care provider added verapamil 80 mg tid to the client's medication regimen. It is MOST important for the nurse to assess the client for which symptom? 1. Tachycardia 2. Diarrhea 3. Peripheral edema 4. Impotence

Peripheral edema 1) will cause bradycardia 2) usually causes constipation 3) CORRECT — verapamil is a calcium channel blocker, depresses myocardial contractility, decreases work of ventricles and O2 demand, dilates coronary arteries; when used with other antihypertensives can cause hypotension and heart failure 4) not most important or frequent adverse effect

The nurse cares for the client one day after a thoracotomy. Nursing actions in the care plan include turn, cough, and deep breathe Q2H. Which does the nurse understand to be the purpose of this nursing action? 1. Promote ventilation and prevent respiratory alkalosis 2. Increase oxygenation and removal of secretions 3. Increase pH and facilitate and balance of bicarbonate 4. Prevent respiratory alkalosis by increasing oxygenation

Promote ventilation and prevent respiratory alkalosis 1) CORRECT — primary purpose of this nursing measure is to improve and/or maintain good gas exchange, especially removal of carbon dioxide in order to prevent respiratory acidosis 2) promoting ventilation and preventing respiratory acidosis is better because it refers to ventilation rather than oxygenation 3) increasing the pH is not desirable 4) respiratory alkalosis is not prevented by this nursing measure

The nurse provides care for a client who has had an above-knee amputation (AKA) with an immediate prosthetic fitting. It is IMPORTANT for the nurse to take which action? 1. Assess drainage from site drains 2. Observe dressings for signs of excessive bleeding 3. Elevate the residual limb for no less than 40 hours 4. Provide cast care on the affected extremity

Provide cast care on the affected extremity 1) drains not usually used with amputations 2) rigid cast dressing frequently used to create a socket for prosthesis 3) elevation of extremity for this length of time is unnecessary; rigid cast dressing prevents swelling 4) CORRECT — cast applied to provide uniform compression, prevents pain and contractures

The nurse cares for the client on suicide precautions. The client verbalizes other options besides suicide, appears to be responding to antidepressant medication, is sleeping and eating better, and has indicated a willingness to interact more with family members. Based on this data, which nursing action is MOST important? 1. Recommend the healthcare provider decrease the client's medication dosage. 2. Recommend the treatment team reevaluates the client's treatment plan. 3. Give the client privileges to walk around the hospital alone. 4. Ask the family to begin planning for the client's discharge.

Recommend the treatment team reevaluate the client's treatment plan. 1) may reverse the client's progress 2) CORRECT — data suggest the client is beginning to benefit from treatment; entire treatment team should share data and make a decision about the suicide precautions so that restrictions are changed gradually on the basis of a full-data picture 3) may be the team's decision, but not until a thorough review of the case is completed 4) premature

The client has just indicated a wish to commit suicide. The client then asks the nurse not to tell anyone. Which action by the nurse is BEST? 1. Encourage the client not to do anything without thinking it through carefully. 2. Explain to the client that anything told to the nurse is kept strictly confidential 3. Reports this to staff members in order to protect the client. 4. Encourage the client to tell the nurse more about what is being felt.

Report this to staff members in order to protect the client 1) does not answer client's immediate concern or give client accurate information about what the nurse will do 2) does not answer client's immediate concern or give client accurate information about what the nurse will do 3) CORRECT — nurse must let the client know this information will be shared with the staff so the client's safety can be preserved 4) does not answer client's immediate concern or give client accurate information about what the nurse will do

The client is diagnosed with a hiatal hernia. Which information is the nursing assessment MOST likely to reveal? 1. A bulge in the lower right quadrant 2. Pain at the umbilicus radiating down into the groin 3. A burning sensation in the midepigastric area each day before lunch 4. Reports of awakening at night with heartburn

Reports of awakening at night with heartburn 1) suggests an inguinal hernia 2) suggests an inguinal hernia 3) pain usually does not develop during the day with an empty stomach 4) CORRECT — classic symptom of hiatal hernia associated with reflux

The nurse cares for a client with a diagnosis of Guillain-Barre syndrome. Which symptoms support this diagnosis? 1. Respiratory failure 2. Pulmonary congestion 3. Hypertension 4. Flaccid paralysis 5. Hemiplegia 6. Urinary retention

Respiratory failure, flaccid paralysis, & urinary retention 1) CORRECT— classic symptoms include respiratory failure and flaccidity due to paralysis of the muscles and urinary retention due to loss of sensation. 2) not a symptom. 3) not a symptom; may have hypotension. 4) CORRECT— classic symptoms include respiratory failure and flaccidity due to paralysis of the muscles and urinary retention due to loss of sensation. 5) paralysis is whole body, not one sided as in CVA. 6) CORRECT— classic symptoms include respiratory failure and flaccidity due to paralysis of the muscles and urinary retention due to loss of sensation.

The nurse cares for the client receiving a continuous tube feeding. Which nursing action is MOST appropriate? 1. Rinse the bag and change the formula every 4 hours 2. Rinse the bag and change the formula every shift 3. Rinse the bag and change the formula every 12 hours 4. Rinse the bag and change the formula every 2 hours

Rinse then bag and change the formula every 4 hours 1) CORRECT — there is an increased growth of organisms after 4 hours 2) inappropriate due to increased organism growth 3) inappropriate due to increased organism growth 4) not a necessary action to maintain asepsis

The young adult is immobilized for trauma to the spinal cord. The client has periods of diaphoresis, a draining abdominal wound, and diarrhea. On the basis of the nursing assessment, which is the MOST important nursing diagnosis? 1. Risk for constipation related to immobilization 2. Risk for impaired skin integrity related to immobilization and secretions 3. Risk for infection related to involuntary bowel secretions 4. Risk for fluid volume excess related to secretions

Risk for impaired skin integrity related to immobilization and secretions 1) constipation is not a problem because the client has diarrhea 2) CORRECT — skin is very susceptible to breakdown because of immobility and bodily secretions; needs numerous nursing interventions to prevent this 3) not most important 4) may be at risk of deficient fluid volume due to diarrhea and secretions

The nurse cares for the client who has just had a prosthetic hip implant. The nurse places the client in which position? 1. With the affected hip internally rotated and flexed 2. With the affected hip adducted when turned 3. In the supine position with the knees elevated 90 degrees 4. Side-lying with the affected hip in a position of abduction

Side-lying with the affected hip in a position of abduction 1) flexion beyond 60 degrees, adduction and internal rotation should be avoided in the early postoperative period 2) flexion beyond 60 degrees, adduction and internal rotation should be avoided in the early postoperative period 3) flexion beyond 60 degrees, adduction and internal rotation should be avoided in the early postoperative period 4) CORRECT — position of abduction should be maintained

The client has partial-thickness and full-thickness burns over 75% of the body. The nurse is most concerned if which symptom is observed? 1. Epigastric pain 2. Restlessness 3. Tachypnea 4. Lethargy

Tachypnea 1) insignificant for burn client 2) may be due to pain 3) CORRECT — body responds to early hypovolemic shock by adrenergic stimulation; vasoconstriction compensates for the loss of fluid, resulting in cool, clammy skin, tachycardia, tachypnea, and pale color 4) may be due to pain

The older client diagnosed with pneumonia is admitted to the medical/surgical unit. Which other client does the nurse place with the older client? 1. The 20-year-old in traction for multiple fractures of the left lower leg 2. The 35-year-old with recurrent fever of unknown origin 3. The 50-year-old recovering alcoholic with cellulitis of the right foot 4. The 89-year-old with Alzheimer's disease awaiting long term care facility placement

The 50-year-old recovering alcoholic with cellulitis of the right foot 1) clients with fractures are considered "clean"; don't place with an infectious client 2) don't know the cause of the fever 3) CORRECT - generalized nonfollicular infection that involves deeper connective tissue; both clients have infections 4) elderly are high risk for developing pneumonia

The nurse assists a nursing assistive personnel (NAP) in providing a bed bath to the comatose client with incontinence. The nurse intervenes if which action is noted? 1. The NAP answers the phone while wearing gloves 2. The NAP log rolls the client to provide back care 3. The NAP places an incontinence pad under the client 4. The NAP positions the client on the left side, head elevated

The NAP answers the phone while wearing gloves 1) CORRECT — contaminated gloves should be removed before answering the phone 2) correct way to roll a client to maintain proper alignment 3) appropriate to use incontinence pad for this client 4) appropriate position to prevent aspiration and protect the airway

The school nurse observes a group of preschool children in the playroom. The nurse recognizes which activity as appropriate behavior for the 5-year-old client? 1. The child plays with a large truck with another child 2. The child talks on a toy telephone and imitates same-sex parent 3. The child works on a puzzle with several other children 4. The child holds and cuddles a large stuffed animal

The child talks on a toy telephone and imitates same-sex parent 1) cooperative play ocurs in school-aged children 2) CORRECT — imitative behavior seen at this age 3) too advanced for this age 4) too regressed for this age

The client is learning to self-administer insulin. Which observation indicates to the nurse the client needs further teaching? 1. The client draws up the short-acting insulin first, then the intermediate-acting insulin 2. The client gently rotates the insulin bottle before withdrawing the dose 3. The client rotates injection sites following the guide on the printed diagram 4. The client administers the insulin while it is still cold from the refrigerator

The client administers the insulin while it is still cold from the refrigerator 1) when mixing short-acting insulin with other types of insulin, the client should draw up the clear (short-acting [regular]) before the cloudy (intermediate-acting) 2) bottle of insulin should never be vigorously shaken, but rather gently mixed 3) imperative to rotate injection sites to avoid tissue irritation/infection and ensure proper absorption 4) CORRECT — insulin should be administered at room temperature; temperature extremes should be avoided

The charge nurse makes client assignments on the maternity unit. The RN has been reassigned to the maternity unit from outpatient surgery. Which client does the charge nurse assign to the RN? 1. The client at 16 weeks gestation admitted with hyperemsis and receiving IV fluids 2. The client at 26 weeks in premature labor and receiving terbutaline 3. The client at 32 weeks gestation with a placenta prevue and ruptured membranes 4. The client at 37 weeks gestation with severe preeclampsia and epigastric pain

The client at 16 weeks gestation admitted with hyperemesis and receiving IV fluids 1) CORRECT — monitor IV therapy, administer antiemetics and nutritional supplements 2) monitor client's response to medication and the status of the fetus 3) prepare for delivery, closely monitor fetal response 4) indicates impending seizures, prepare for delivery

The nurse reviews client assignments on a medical surgical unit. The nurse determines the assignment is appropriate if the nurse assistive personnel provides care for which client? 1. The client diagnosed with AIDS dementia complex and who requires a urine specimen 2. The client reporting postop pain after repair of a torn rotator cuff 3. The client diagnosed with GI bleeding due to a duodenal ulcer and who is receiving packed cells 4. The client diagnosed with type 1 diabetes and who is receiving prednisone for a herniated disk

The client diagnosed with AIDS dementia complex and who requires a urine specimen 1) CORRECT — standard, unchanging procedure 2) assign to the RN 3) assign to the RN 4) assign to the RN

The nurse cares for the client after right cataract surgery. The nurse intervene if which observation is made? 1. Client is in the supine position 2. The head of the bed is elevated 30 degrees 3. The client is lying on the right side 4. An eye shield is over the right eye

The client is lying on the right side 1) appropriate position 2) decreases swelling and pain 3) CORRECT — client should not be positioned with operative side in a dependent position or against the bed 4) shield is appropriate

The client is diagnosed with right-sided weakness. The nurse instructs the client how to walk down stairs using a cane. Which client behavior indicates the teaching is successful? 1. The client puts the right leg on the step, then the cane, followed by the left leg. 2. The client leads with the cane, followed by the right leg and then the left leg. 3. The client advances the right leg, followed by the left leg and the cane. 4. The client puts the cane on the step and advances the left leg, followed by the right leg.

The client leads with the cane, followed by the right leg and then the left leg 1) to go down stairs, advance weak leg and cane first; to go up stairs, advance strong leg, then weak leg and cane 2) CORRECT — to go down stairs, advance cane and weak leg, then strong leg; memory trick: the good goes up, the bad goes down 3) should advance cane and weak leg first 4) weaker leg and cane advance first

The nurse cares for the client several days after an above-knee amputation (AKA). Which symptom is characteristic of an infected residual limb wound? 1. The client is anxious and restless 2. There is a small amount of dark drainage on the dressing 3. The client reports persistent pain at the operative site 4. The skin is cool above the operative site

The client reports persistent pain at the operative site 1) may be due to changes in body image or pain 2) expected, not indicative of an infection 3) CORRECT — pain is characteristic of inflammation and infection 4) warm skin above the operative site would indicate infection

The healthcare provider orders morphine sulfate 8mg IM Q3 to 3 hours for pain PRN. In which situation does the nurse consider withholding the medication until further assessment is completed? 1. The client's reports acute pain from a partial-thickness burn affecting the lower left leg 2. The client's BP is 140/90, pulse is 90, and respiration is 28 3. The client's level of consciousness fluctuates from alert to lethargic 4. The client exhibits restlessness, anxiety, and cold and clammy skin

The client's level of consciousness fluctuates from alert to lethargic 1) morphine is used for moderate to severe pain; the nurse should give the medication 2) BP slightly elevated, respirations elevated, may be the result of pain; the nurse should give the medication 3) CORRECT — morphine depresses CNS, especially respiratory center in medulla 4) may be the result of pain

The nurse checks for placement of a NG tube prior to initiating a tube feeding for the client. Which result indicates the tube feeding can begin? 1. A small amount of white mucus is aspirated from the NG tube 2. The contents aspirated from the NG tube have a pH of 3 3. No bubbles are seen when the nurse inverts the NG tube in water 4. The client says the NG tube can be felt in the back of the throat

The contents aspirated from the NG tube have a pH of 3 1) mucus may be from the lungs 2) CORRECT— stomach contents are acidic 3) not a safe way to check placement 4) not a reliable indication

The nurse checks the incision of the client 48 hours after surgery for a hernia repair. Which finding indicates a possible complication? 1. There is swelling under the sutures 2. There is crusting around the incision line 3. The incision line is red 4. The incision line is approximated

The incision line is red 1) slight swelling is expected during healing 2) slight crusting of incision line is normal 3) CORRECT — should be pink, not red; indicates possible infection; other signs include increased warmth, tenderness, pain, and purulent or odorous drainage 4) shows healing is taking place

The nurse administers Rho(D) immune globulin to prevent complications in which client situation? 1. The baby is Rh-negative, the mother is Rh-negative, and the father is Rh-positive. 2. The mother is Rh-negative, the baby is Rh-positive, and there is a negative direct Coombs. 3. The mother is Rh-positive and previously sensitized, and the baby is Rh-negative. 4. The mother is Rh-positive, the baby is Rh-negative, and there is a history of one incomplete pregnancy.

The mother is Rh-negative, the baby is Rh-positive, and there is a negative direct Coombs. 1) if both mother and baby are Rh-negative, there is no problem 2) CORRECT — Rho(D) immune globulin is given to an Rh-negative mother who delivers an Rh-positive baby when the baby has a negative Coombs test 3) medication is not given if the mother has been sensitized by a previous pregnancy 4) there is no incompatibility here because Rh-positive mothers are not at risk for Rh incompatibility; only Rh-negative mother with Rh-positive fetus

The nurse supervises care given to clients a medical surgical unit. The nurse intervene if which activity is observed? 1. The nurse and client wear masks during a dressing change for the central catheter used for total parenteral nutrition 2. The nurse injects insulin through a single-lumen percutaneous central catheter for the client receiving total parenteral nutrition 3. The nurse applies lip balm to the lips immediately after performing a blood draw to obtain a specimen 4. The nurse wears a disposable particulate respiratory when administering rifampin to the client with TB

The nurse applies lip balm to the lips immediately after performing a blood draw to obtain a specimen 1) appropriate procedure, prevents airborne contamination 2) insulin is the only medication that can be given, compatible with TPN 3) CORRECT — applying lip balm or handling contact lenses is prohibited in work areas where exposure to bloodborne pathogens may occur 4) use airborne precautions for TB, private room with negative air pressure, minimum of six exchanges per hour

The nurse cares for the male client diagnosed with urinary tract problems. A prostate-specific antigen (PSA) and acid phosphatase test are to be done. Which statement best describes the rationale for doing these tests? 1. These tests are valuable screening tests for prostatic cancer 2. The level of PSA is decreased in clients with renal calculi 3. The tests reflect the level of renal involvement in acid-base problems 4. The level of PSA is elevated in clients in early-stage kidney failure

These tests are valuable screening tests for prostatic cancer 1) CORRECT — PSA test has replaced acid phosphatase test in screening for prostatic cancer; test must be drawn before digital rectal exam, as manipulation of the prostate will abnormally increase PSA value 2) inaccurate information about a PSA 3) inaccurate information about a PSA 4) inaccurate information about a PSA

The nurse cares for the elderly client who is admitted with confusion, mood lability, impaired communication, and lethargy. Which order from the healthcare provider does the nurse question? 1. Dexamethasone suppression test 2. Thyroid studies 3. Drug toxicology screen 4. Trendelenburg test

Trendelenburg test 1) may be ordered to determine adrenal gland function 2) may be ordered to check for an endocrine cause for the symptoms before the diagnosis of dementia is made 3) may be ordered to see if the client's symptoms are caused by excessive use of medications or alcohol 4) CORRECT— test is used with a client who may have varicose veins, which have no relationship to the symptoms described in this situation

The 6-month-old infant has had all of the required immunizations for that age. The nurse knows this includes which immunizations? 1. Three doses of diphtheria, tetanus, and pertussis vaccine 2. Measles, mumps, and rubella vaccine 3. One dose of rotavirus 4. Varicella vaccine

Three of diphtheria, tetanus, and pertussis vaccine 1) CORRECT — the first dose of the DTaP may be given at 2 months of age; the second is given around 4 months; the third is given around 6 months 2) MMR is given at 12-15 months 3) rotavirus is given at 2, 4, and 6 months 4) varicella is given at 12 to 15 months

The client has a total laryngectomy with a permanent tracheostomy. The nurse plans nutritional intake for the next 3 days. Which action is necessary for the nurse to consider regarding the client's nutrition? 1. To facilitate healing of the surgical area, a nasogastric tube may be utilized and tube feedings may be implemented. 2. The client will be unable to maintain any oral intake as long as the tracheostomy is in place. 3. Nutritional and/or gastric feedings will not be attempted for approximately 3 weeks to decrease the incidence of aspiration. 4. Because the client is dependent on the ventilator, nutritional intake will be delayed.

To facilitate healing of the surgical area, a nasogastric tube may be utilized and tube feedings may be implemented. 1) CORRECT — tube feedings frequently started as the initial nutritional intake; prevents trauma to suture area 2) although client has permanent tracheotomy, will be able to eat normally after area has healed 3) nutritional intake will begin when bowel sounds return and client can tolerate intake 4) client is not dependent on ventilator

The nurse cares for the client admitted with a diagnosis of acute hypoparathyroidism. It is MOST important for the nurse to have which items available? 1. Tracheostomy set 2. Cardiac monitor 3. IV monitor 4. Heating pad

Tracheostomy set 1) CORRECT — tracheostomy set is the most important for the client's safety due to risk for laryngospasm 2) nice to have, but not the most important 3) nice to have, but not the most important 4) unnecessary

The nurse conducts a physical examination of the client suspected to have bulimia. Which nursing observation MOST likely indicates bulimia? 1. Edema of the lower extremities 2. The presence of lanugo 3. Ulcerated oral mucous membranes 4. Dry, yellowish colored skin

Ulcerated oral mucous membranes 1) common with anorexia 2) seen with anorexia 3) CORRECT — due to frequent vomiting 4) bulimics are normal in appearance

The client receives tetracycline. The nurse indicates which information in the teaching plan? 1. Take the medication with milk or antacids to decrease GI problems 2. The medication should always be taken with meals 3. Use a maximum-protection sunscreen when outdoors. 4. Crackers and juice will help decrease gastric irritation

Use a maximum-protection sunscreen when outdoors 1) tetracycline should never be taken with milk or antacids because these inhibit the medication's action 2) should take with full glass of water at least 1 hour before or 2 hours after meals 3) CORRECT — because of problems related to photosensitivity, client should wear sunscreen, wide-brimmed hats, and long sleeves when at risk for sun exposure 4) should take with full glass of water at least 1 hour before or 2 hours after meals

The teenage client diagnosed with anorexia nervosa is admitted to the hospital. Which behavior does the nurse expects the client to present? 1. View appearance as "skinny." 2. Be hypoactive and withdrawn 3. Want to discuss and plan meals 4. Have a close relationship with a parent

Want to discuss and plan meals 1) usually view the appearance as fat 2) inaccurate for client with anorexia nervosa 3) CORRECT — display a marked preoccupation with food 4) inaccurate for client with anorexia nervosa