NCLEX Questions

a client who has successfully adjusted to a colostomy declines the invitation to speak to a support group on the subject of alteration in body image; the client reports an extreme fear of public speaking. the nurse analyzes this information and determines that the client's fear would be considered which diagnosis?

a social phobia rationale social phobia focuses more on specific situations, such as fear of speaking, performing, or eating in public. agoraphobia is the fear of open spaces and the fear of being trapped in a situation from which there may not be an escape. agoraphobia also involves the possibility of experiencing a sense of helplessness or embarrassment. avoidance of such situations usually results in the reduction of social and professional interactions. claustrophobia is the fear of closed-in places. clients with hypochondriacal symptoms focus their anxiety on physical complaints and are preoccupied with their health.

A client asks the nurse why her newborn baby needs an injection of vitamin K. The nurse should make which statement to the client?

"Newborns are deficient in vitamin K. This injection prevents your baby from abnormal bleeding." 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 this fat-soluble vitamin. 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 bowel becomes colonized by bacteria as food is ingested. Vitamin K does not promote the development of immunity or prevent the infant from becoming jaundiced.

A client is receiving enteral feedings via a gastrostomy tube (G-tube). Which nursing measure is necessary when caring for this client?

Monitoring the skin around the stoma site for skin irritation Rationale: A gastrostomy tube is a tube inserted directly into the stomach for the purpose of providing direct enteral nutrition. Because of the surgical incision, occasionally gastric contents leak out onto the client's skin. Gastric contents are highly acidic and can cause major skin irritation, which may lead to infection. The nurse must monitor the insertion site for skin irritation. Option 1 is incorrect and generally the client with a G-tube is unable to tolerate oral intake. Antidiarrheal medications are not administered every day. Clean, not sterile, technique is needed in caring for the client.

A client with end stage kidney disease (ESKD) undergoes a surgical procedure to create an arteriovenous fistula for hemodialysis in the upper extremity. The nurse should take which actions when the client returns from surgery? Select all that apply.

monitor pain and administer analgesics // monitor bleeding and swelling at the site // check for audible bruit and palpable thrill at the fistula site rationale An arteriovenous fistula is created by connecting an artery and vein together in a limb to create a large caliber blood vessel with good blood flow for hemodialysis. Two needles, one inserted toward venous blood flow and one toward arterial blood flow, are inserted in the fistula during the hemodialysis treatment. The fistula must mature over time before it can be used for hemodialysis. Postoperatively, the nurse should observe the site for bleeding and swelling. The nurse determines that circulation is adequate in the fistula by feeling for a palpable thrill with the fingers and hearing an audible bruit with a stethoscope. The nurse asks the client to rate the pain in the surgical area and administers prescribed analgesics. Blood pressure is not assessed in the limb where the fistula was created because that procedure blocks the blood flow and may lead to thrombosis or clotting off of the fistula. Circulation should be assessed distal to the fistula. A "steal syndrome" is a possible complication of the arteriovenous fistula in which blood flow to the area distal to the fistula is inadequate. The nurse observes for signs of ischemia, such as coldness, cyanosis, and numbness, below the fistula and notifies the surgeon of ischemic changes if observed.

A nursing instructor asks a nursing student to describe accountability. Which statement by the student indicates an inaccurate description of accountability?

"Accountability can be delegated." rationale Accountability refers to the process of answering or being responsible for what occurs and carries legal implications for task performance. Accountability cannot be delegated; one must answer for the care given and for the care one asks others to complete.

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?

"Did the child have a sore throat or a fever within the past 2 months?" Rationale: Rheumatic fever (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 if the child has had a sore throat or an unexplained fever within the past 2 months.

The nurse has reinforced discharge instructions to the mother of an 18-month-old child following surgical repair of hypospadias. Which statement by the mother indicates a need for further teaching?

"I should carry my child by straddling the child on my hip." rationale Parent teaching following hypospadias repair includes restricting the child from activities that put pressure on the surgical site. Straddling the child on the hip will cause pressure on the surgical site. The parents should be instructed to use double diapers to hold the stent in place and should be instructed how to hold the child during the postoperative period. Fluids should be encouraged to maintain hydration. Toilet training should not be an issue during this stressful period.

A registered nurse has just hung a 250-mL bag of packed red blood cells (PRBCs) on a client. The licensed practical nurse assisting in caring for the client plans to remain with the client for at least how many minutes following the start of the infusion?

15 minutes rationale The nurse must remain with the client for the first 15 minutes of a transfusion, which is the most frequent period during which a transfusion reaction may occur. This enables the nurse to quickly detect a reaction and intervene quickly.

A client complaining of not feeling well is seen in a clinic. The client is taking several medications for the control of heart disease and hypertension. These medications include a beta blocker, digoxin (Lanoxin), and a diuretic. A tentative diagnosis of digoxin toxicity is made. Which assessment data supports this diagnosis?

Double vision, loss of appetite, and nausea rationale Double vision, loss of appetite, and nausea are signs of digoxin toxicity. Additional signs of digoxin toxicity include bradycardia, difficulty reading, visual alterations such as green and yellow vision or seeing spots or halos, confusion, vomiting, diarrhea, decreased libido, and impotence.

The nurse is administering medications to a 6-year-old child with nephrotic syndrome. To reduce proteinuria, the nurse would expect which medication to be prescribed?

Furosemide (Lasix) rationale The child is usually placed on diuretic therapy with furosemide (Lasix) until protein loss is controlled. Enalapril is most commonly used to control hypertension. Corticosteroids, such as prednisone, may be prescribed to decrease inflammation. Corticosteroids also suppress the autoimmune response and stimulate vascular reabsorption of edema. Cyclophosphamide is an alkylating agent and may be used in maintaining remission.

The nurse performs an admission assessment on a client who visits a health care clinic for the first time. The client tells the nurse that propylthiouracil (PTU) is taken daily. The nurse continues to collect data from the client, suspecting that the client has a history of which disorder?

Graves' disease PTU inhibits thyroid hormone synthesis and is used to treat hyperthyroidism, or Graves' disease. Myxedema indicates hypothyroidism. Cushing's syndrome and Addison's disease are disorders related to adrenal function.

a nursing student is asked to discuss HIV during a clinical conference. the nursing student should include which correct item in the discussion?

HIV virus attacks the immune system by destroying T lymphocytes rationale the virus attacks the immune system by destroying T lymphocytes. children born to HIV-positive women test positive for HIV antibody, not HIV virus. this is actually a measure of maternal antibody and not indicative of true infection. T4 cells are depleted in number and cannot signal B cells to form protective antibodies to fight off the invading virus.

A breast-feeding mother of an infant with lactose intolerance asks the nurse about dietary measures. Which food should the nurse instruct the mother to avoid?

Hard cheeses Rationale: Breast-feeding mothers of an infant with lactose intolerance need to be encouraged to limit dairy products. Cheese is a dairy product. Alternative calcium sources include egg yolk; green, leafy vegetables; dried beans; cauliflower; and molasses.

Which is the primary goal that should be included in the plan of care for a child who has cerebral palsy?

Maximize the child's assets and minimize the limitations. rationale The goal of managing the child with cerebral palsy is early recognition and intervention to maximize the child's abilities. The cause of the disease cannot be eliminated. It is best to minimize emotional disturbances, if possible, but not to prevent them because it is healthy for the child to express emotions. Improvement of muscle control and coordination is a component of the plan, but the primary goal is to maximize the child's assets and minimize the limitations caused by the disease.

An oral powder form of nelfinavir (Viracept) is prescribed for a client with human immunodeficiency virus (HIV). The nurse reinforces instructions regarding the preparation of the medication and tells the client to mix the powder with which substance?

Milk rationale Nelfinavir is an antiviral medication used in the treatment of HIV infection when antiretroviral therapy is warranted. It is available in tablet and powder form. The powder form is prepared by mixing the dose with a small amount of water, milk, formula, soy milk, or dietary supplements. The powder is not mixed with acidic foods or juices such as apple juice or applesauce, orange juice, or grapefruit juice.

The nurse is suctioning a client through a tracheal tube. During the suctioning procedure, the nurse notes on the cardiac monitor that the heart rate has dropped 10 beats. Which should be the nurse's next action?

Stop the procedure and oxygenate the client. Rationale: During suctioning the nurse should monitor the client closely for complications including hypoxemia, drop in heart rate due to vagal stimulation, mucosal trauma, hypotension, and paroxysmal coughing. If complications develop, especially cardiac irregularities, the nurse should stop the procedure and oxygenate the client.

A HCP has prescribed codeine sulfate for a client with a nonproductive cough to suppress the cough reflex. the nurse reinforces instructions given to the client about the medication and tells the client to monitor for which side effect?

constipation rationale a frequent side effect of codeine sulfate is constipation. additional side effects include drowsiness, nausea, and vomiting. urinary retention is also a concern and urine output should be monitored.

the nurse notes that meloxicam (Mobic) is prescribed for a client. the nurse anticipates the client to have which diagnosis?

osteoarthritis rationale meloxicam is used for the treatment of osteoarthritis. it is a medication with some cyclooxygenase (COX-2) selectively and has anaglesic, anti-inflammatory, and antipyretic actions

The nurse is working with an older client who has a diagnosis of depression. To work most effectively with this client, the nurse recalls that which information is accurate regarding depression and the older client? Select all that apply.

suicide is a frequent cause of death among the older population // some indications of dementia may actually originate as depression // depression in an older person is likely to have physical manifestations rationale Depression is treatable in an older client. The nurse should be aware of the implications of depression, such as physical manifestations, the possibility of dementia, and suicide risk. Depression is never a normal finding, regardless of the client's age.

the nurse is assigned to care for a client who has just returned to the nursing unit after having hemodialysis for the first time. the nurse monitors the client carefully for which signs and symptoms of disequilibrium syndrome?

vomiting and headaches rationale a complication that can occur during early dialysis is disequilibrium syndrome. this syndrome results from a high osmotic gradient in the brain following the rapid removal of fluid that can occur during hemodialysis. because solutes are not removed as quickly from the CSF and brain, fluid from the circulation shifts into the brain, causing cerebral edema. the client may exhibit nausea and vomiting, confusion, headaches, restlessness, twitching, muscle cramps, and seizures.

A client arrives at the emergency department following a burn injury that occurred in the basement at home, and an inhalation injury is suspected. Which prescription should the nurse anticipate for the client?

100% oxygen via a tight-fitting non-rebreather face mask Rationale: If inhalation injury is suspected, administration of 100% oxygen via a tight-fitting non-rebreather mask is prescribed until carboxyhemoglobin levels fall below 15%. In inhalation injuries, the oropharynx is inspected for evidence of erythema, blisters, or ulcerations. The need for endotracheal intubation is also assessed.

one unit of packed red blood cells is infusing into a client over a 4-hour period. the unit of blood contains 250 mL. the drop factor is 15 drops (gtt) per 1 mL. the nurse determines that the flow rate should be set at how many drops per minute?

16 drops per minute rationale total volume x gtt factor / time in minutes = gtt/min 250 mL x 15 gtt / 240 (4hr x 60 min) = 3750/240 = 16

A licensed practical nurse (LPN) asks an unlicensed assistive personnel (UAP) to gather supplies in preparation for administering a tepid bath to a child with a fever. The LPN intervenes if the UAP obtains which unnecessary item(s)?

A bottle of alcohol rationale Alcohol should never be used for bathing the child with a fever because it can cause rapid cooling, peripheral vasoconstriction, and chilling, thus elevating the temperature further. Washcloths can be used to squeeze water over the child's body. Towels are used to dry the child. Toys, especially water toys, can be used to provide distraction during the bath. Lightweight clothing should be placed on the child after the child is dried.

A licensed practical nurse (LPN), employed in the emergency department, prepares to assist in treating a child with an acetaminophen (Tylenol) overdose. The LPN checks the medication supply room, anticipating that which medication will be prescribed?

Acetylcysteine Rationale: Acetylcysteine is the antidote for acetaminophen overdose. It is administered orally with juice or cola or via a nasogastric tube. Vitamin K is the antidote for warfarin sodium (Coumadin). Protamine sulfate is the antidote for heparin. Edetate calcium disodium is used in the treatment of lead poisoning.

A client is scheduled for an endoscopic retrograde cholangiopancreatography (ERCP). The nurse includes which intervention in the plan of care for the client?

After the procedure, keep the client nothing by mouth (NPO) until the gag reflex returns. Rationale: An ERCP requires that a client is NPO for 12 hours before the procedure. Because an endoscope is inserted through the oral cavity, the throat is sprayed with an anesthetic and the client will be kept NPO until the gag reflex returns. Enemas are not needed. Radioactive isotopes are not used for this test. Contrast dye is injected via a catheter into the pancreatic or bile ductal systems.

The nurse is assigned to care for a client with a diagnosis of detached retina. Which finding would indicate that bleeding has occurred as a result of retinal detachment?

Complaints of a burst of black spots or floaters rationale Complaints of a sudden burst of black spots or floaters indicate that bleeding has occurred as a result of the detachment. Options 1, 2, and 3 are not specifically associated with bleeding as a result of detached retina.

The nurse carries out a standard prescription for a stat electrocardiogram (ECG) on a client who has an episode of chest pain. The nurse should take which action next?

Give sublingual nitroglycerin (Nitrostat) per the health care provider's prescriptions. rationale After completing the stat ECG, the nurse should administer a nitroglycerin tablet to dilate the coronary arteries and relieve ischemic pain. The nurse should not wait to see whether pain resolves on its own but should determine whether the pain is relieved with nitroglycerin. The nurse should do a repeat ECG if it is prescribed. The nurse should report the episode of pain to the health care provider but should administer the nitroglycerin before doing so.

The nurse is checking a dark-skinned client for the presence of petechiae. Which body area is best for the nurse to check in this client?

Oral mucosa Rationale: In a dark-skinned client, petechiae are best observed in the conjunctivae and oral mucosa. Cyanosis is best noted on the palms of the hands and soles of the feet. Jaundice would best be noted in the sclera of the eye.

After a precipitate delivery, the nurse notes that a new mother is passive and only touches her newborn briefly with her fingertips. The nurse should do which action first to help the woman process what has happened?

Support the mother no matter what her reaction is to the newborn. Rationale: There may be many reactions to the birth of a baby. The mother may be exhausted, in pain, stunned by the rapid nature of the delivery, or may be following her cultural norms. The mother may want to process what has happened and will need time to assimilate all that occurred. The new mother requires support, and the nurse needs to provide a nurturing and accepting attitude.

Which intervention should be implemented for the older client with presbycusis who has a hearing loss?

Use low-pitched tones. 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 softly or slowly is not helpful.

the nurse is performing nasotracheal suctioning of a client. the nurse determines that the client is adequately tolerating the procedure if which observation is made?

coughing occurs while suctioning rationale the nurse monitors for adverse effects of suctioning, which include cyanosis, excessively rapid or slow heart rate, or the sudden development of bloody secretions. if they occur, the nurse stops suctioning and reports these signs to the HCP immediately. coughing is a normal response to suctioning for the client with an intact cough reflex and does not indicate that the client cannot tolerate the procedure.

the nurse is caring for a client with gout who is taking colchicine (Colcrys). the client has been instructed to restrict the diet to low-purine foods. which food should the nurse instruct the client to avoid while taking this medication/

scallops rationale Colchicine is a medication used for clients with gout to inhibit the reabsorption of uric acid by the kidney and promote excretion of uric acid in the urine. uric acid is produced when purine is catabolized. clients are instructed to modify their diet and limit excessive purine intake. high-purine foods to avoid or limit include organ meats, roe, sardines, scallops, anchovies, broth, mincemeat, herring, shrimp, mackerel, gravy, and yeast

The spouse of a client admitted to the hospital for alcohol withdrawal says to the nurse, "I should get out of this bad situation." The most helpful response by the nurse should be which?

"What do you find difficult about this situation?" Rationale: The most helpful response is the one that encourages the client to problem solve. Giving advice implies that the nurse knows what is best and can also foster dependency. The nurse should not agree with the client, nor should the nurse request that the client provide explanations.

A female victim of a sexual assault is being seen in the crisis center. The client states that she still feels "as though the rape just happened yesterday," even though it has been a few months since the incident. Which nursing response is appropriate?

"Tell me more about what causes you to feel like the rape just occurred." rationale this allows the client to express her ideas and feelings more fully and portrays an unhurried, nonjudgmental, supportive attitude. Clients need to be reassured that their feelings are normal and that they may freely express their concerns in a safe environment.

The nursing student demonstrates understanding of the pathophysiology of reflex tachycardia in the client taking an antihypertensive medication by making which statement?

"When blood pressure begins to decrease, the heart responds with tachycardia as a compensatory mechanism to raise the blood pressure." rationale Reflex tachycardia can be produced by dilation of arterioles or veins. The mechanism of reflex tachycardia is as follows: (1) arteriolar dilation causes a direct decrease in arterial pressure; (2) baroreceptors in the aortic arch and carotid sinus sense the drop in pressure and relay this information to the vasomotor center of the medulla; and (3) in an attempt to bring blood pressure back up, the medulla sends impulses along sympathetic nerves instructing the heart to beat faster.

a pediatric client with a ventricular septal defect repair is placed on a maintenance dose of digoxin (Lanoxin). the safe dose is 0.03 mg/kg/day and the clients weight is 7.2 kg. the HCP prescribes the digoxin to be given twice daily. how many digoxin should the nurse administer to the client at each dose?

0.1 mg rationale calculate the dosage by weight first; therefore 0.03 mg/day x 7.2 kg = 0.21 mg/day next, note that the HCP prescribes digoxin to be given twice daily; therefore 2 doses in 24 hours will be administered, and 0.21 mg/day divided by 2 doses = 0.1 mg for each dose

a client is complaining of abdominal pain and nausea. the prescription is as follows; give meperidine (Demerol) 25 mg intramuscularly, hydroxyzine (Vistaril) 25 mg IM stat. hydroxyzine is available 50 mg/mL demerol is available in 25 mg/0.5 mL. the nurse should combine the doses in one syringe for administration to the ventrogluteal muscle. how many mL should the nurse administer in total?

1 mL rationale desired / available x quantity = mL per dose 25 / 50 mg x 1 mL = 0.5mL (Vistaril) 25 mg / 50 mg x 0.5 mL = 0.5 mL (Demerol) 0.5 + 0.5 = 1 mL

The nurse is caring for a group of clients. Which client is most likely to have a serum phosphorus level of 2.0 mg/dL?

A client with a history of alcoholism Rationale: The normal serum phosphorus level is 2.7 to 4.5 mg/dL, so a value of 2.0 mg/dL is indicative of hypophosphatemia. Causative factors include decreased nutritional intake and malnutrition. A poor nutritional state is associated with alcoholism. Hypoparathyroidism, chemotherapy, and vitamin D intoxication are causative factors of hyperphosphatemia.

An older client is transferred to the nursing unit following a graft to a stage 4 pressure ulcer. Which combination of dietary items should the nurse encourage the client to eat to promote wound healing?

Chicken breast, broccoli, strawberries, 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.

A client enters the ambulatory clinic, stating she has just been stung by a bee. Her vital signs are stable, and she has no previously known allergy to bee stings. The "stinger" is still visible in her arm. What should be the nurse's first action?

Use the edge of a sterile surgical tool to scrape out the stinger. Rationale: Using the edge of a sterile surgical tool to scrape out the stinger will not likely squeeze any bee venom into the tissue. Tweezers likely would squeeze additional venom into the tissues. Applying warm compresses likely would cause additional absorption because of vasodilation. An occlusive dressing would not prevent tissue absorption and would not assist in removal of the stinger.

A client with multiple sclerosis is receiving diazepam (Valium), and the home care nurse reinforces instructions to the client regarding the side effects of the medication. The nurse tells the client that which is a side effect of this medication?

Incoordination Rationale: Incoordination and drowsiness are common side effects resulting from this medication

a client newly admitted to the mental health unit describes a recent history of emotional turmoil. the client exhibits symptoms and has some loss of physical functioning. the nurse determines that this client is exhibiting signs compatible with which?

somatization disorder rationale a somatization disorder is characterized by multiple physical complaints involving numerous body systems; the cause of the complaints is presumed to be psychological.

the LPN is assisting in the care of a client who is receiving Pitocin (oxytocin) to induce labor. the LPN plans to notify the RN immediately if which is noted?

the uterus becomes hyperstimulated rationale induction of labor is the initiation of labor through mechanical or pharmacological means. oxytocin is a synthetic hormone that stimulates uterine contractions and is a medication commonly used to induce labor. a major danger associated with this medication is hyperstimulation of uterine contractions, which decreases placental perfusion and causes fetal distress. for this reason, the oxytocin infusion must be discontinued if signs of uterine hyperstimulation occur. early decelerations of the fetal heart rate are a reassuring sign and do not indicate fetal distress.

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?

"I will give my child cough syrup if a cough develops." 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 to 1000 mL of fluids daily is important for thinning secretions.

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 of the 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 is preparing to get a client with tetraplegia (quadriplegia) out of bed into a chair. The nurse places which item on the seat of the chair as the best device for pressure relief?

Water pad rationale The client who cannot independently shift weight should have a pressure relief pad in place under the buttocks to prevent skin breakdown. The best products for use in providing pressure relief are those that equalize the client's weight on the device. These include foam, water, gel, or alternating air pads. A plastic-lined pad absorbs moisture but provides no pressure relief. A pillow provides cushion but does not redistribute weight equally. An air ring relieves pressure in some spots but causes pressure in others by its design.

The nurse is gathering data from a pregnant client about physiological risk factors. The nurse should be sure to obtain which priority data?

Weight and height rationale Height and weight are important factors to assess when determining physiological risk factors.

which client is most likely at risk to become a victim of elder abuse?

a 90-year-old woman with advanced Parkinson's disease 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 typical abuse victim is a woman of advanced age with few social contacts and at least one physical or mental impairment that limits her ability to perform activities of daily living. in addition, the client usually lives alone or with the abuser and depends on the abuser for care.

the nurse assisting with monitoring a client in labor is told that the client's cervix is 3cm dilated with contractions occurring every 2 to 3 minutes. when monitoring the client's psychological status, the nurse anticipates the client will reflect which attitude?

excitement rationale in early labor, contractions are usually mild. the woman feels able to cope with the discomfort and may be relieved that labor has begun. excitement is high about the impending birth. irritability, seriousness and helplessness represent psychological states often noted late in labor when discomfort and fatigue are greater and coping ability may be reduced.

an adolescent with diabetes mellitus becomes flushed and complains of hunger and dizziness. a blood glucose level is drawn and the results indicate a glucose level of 60 mg/dL. which is the appropriate intervention?

give the child a glass of fruit juice rationale a blood glucose less than 70 mg/dL indicates hypoglycemia. when signs of hypoglycemia occur, the child needs an immediate source of glucose.

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?

pulmonary function studies rationale bleomycin is an antineoplastic medication that can cause interstitial pneumonitis, which can progress to pulmonary fibrosis. pulmonary function studies 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.

the nurse is caring for an older adult client who has recently lost her husband. the client says, no one cares about me anymore. all the people i loved are dead. which response by the nurse is therapeutic?

you must be feeling all alone at this point rationale the client is experiencing loss and is feeling hopeless. the therapeutic response by the nurse is the one that attempts to translate words into feelings.

the nurse is caring for a client who has a history of opioid abuse and is monitoring the client for signs of withdrawal. which observation is indicative of the signs/symptoms associated with withdrawal from opioids?

fever, yawning, irritability, diaphoresis and diarrhea rationale opioids are CNS depressants. increased appetite, irritability, anxiety and restlessness describe withdrawal from nicotine. depressed feelings, high drug cravings, fatigue, agitation and disorientation describe withdrawal from cocaine. tachycardia, mild hypertension, fever, sweating, nausea, vomiting and marked tremors describe withdrawal from alcohol.

The nurse should plan to reinforce instructions to which client's about the risk for transmission of disease through blood and sexual contact? Select all that apply.

a client diagnosed with hepatitis B virus // a client diagnosed with hepatitis C virus // a client diagnosed with HIV rationale Clients, who are diagnosed with hepatitis B, hepatitis C, and HIV, and their close household members need to be taught that the viruses are spread through blood and sexual contact. Hepatitis A is spread through the feces via a fecal-oral route. Rocky Mountain spotted fever is spread through the bite of an infected wood tick. The reservoirs for Staphylococcus aureus include wound drainage, skin, hair, anterior nares, and mouth.

ketoconazole is prescribed for an assigned client. the nurse prepares to administer the medication in which manner?

with food rationale ketoconazole is an antifungal medication. it should be administered with food to minimize gastrointestinal irritation. the medication requires acidity and should be administered at least 2 hours apart from an antacid.

a pediatric nurse arrives at work and is told to report to the ED for the day because the ED is expecting numerous victims arriving following a train crash. the nurse has never worked in the ED and is anxious about floating in this area. which is the appropriate nursing action

discuss her anxieties and concerns with the nursing supervisor about floating? rationale floating is an acceptable legal practice used by hospitals to solve their understaffing problems. legally, the nurse cannot refuse to flat unless a union contract guarantees that nurses can only work in a specified area or the nurse can prove the lack of knowledge for the performance of assigned tasks. when encountered with this situation, the nurse should discuss any anxieties and concerns with the supervisor about floating

A child is diagnosed with Reye's syndrome. The nurse assists to develop a nursing care plan for the child and should include which intervention in the plan?

Providing a quiet atmosphere with dimmed lighting rationale Reye's syndrome is an acute encephalopathy that follows a viral illness and is characterized pathologically by cerebral edema and fatty changes in the liver. A definitive diagnosis is made by liver biopsy. In Reye's syndrome, supportive care is directed toward monitoring and managing cerebral edema. 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.

The nurse is reading the health care provider's (HCP) documentation regarding a pregnant client and notes that the HCP has documented that the client has an android pelvic shape. The nurse understands that this pelvic shape is which?

Wedge-shaped and narrow and unfavorable for a vaginal birth Home History Help Calculator Review ModeQuestion 64 of 75 Previous 64 ▲ ▼ Go Next Stop Bookmark Rationale Strategy Reference Submit The nurse is reading the health care provider's (HCP) documentation regarding a pregnant client and notes that the HCP has documented that the client has an android pelvic shape. The nurse understands that this pelvic shape is which?Rationale: The android pelvic shape is wedge-shaped and narrow and is an unfavorable shape for a vaginal birth. A gynecoid pelvic shape is rounded with a wide pubic arch and is the most favorable pelvic shape for a vaginal birth. An anthropoid pelvic shape is long, narrow, and oval. It is not as favorable for a vaginal birth as the gynecoid pelvic shape; however, it is a more favorable pelvic shape than the platypelloid or android. The platypelloid pelvic shape is flattened with a wide, short oval shape and is an unfavorable shape for a vaginal birth.

the nurse employed in a psychiatric unit receives a client assignment for the day. which client assigned to the nurse is at the highest risk for committing suicide?

a client with severe depression and cancer rationale the individual at highest risk for suicide is the individual with a terminal illness. other high-risk groups include adolescents; drug abusers; and those individuals with social problems, recent losses, few or no social supports, and a history of suicide attempts and a suicide plan

a mother brings her child to the health care clinic because the child has developed lesions located around the mouth and nose, and mild impetigo is diagnosed. the nurse reinforces instructions to the mother regarding care of the child. which statement by the mother indicates the need for further teaching?

my child will need to be treated with oral antibiotics rationale impetigo is extremely contagious and may spread to other parts of the child's skin or to others who touch the child, use the same towel, or drink from the same glass. lesions should be washed gently three times a day with a warm, soapy face cloth and crusts soaked and carefully removed. mild cases are treated with topical antibiotic ointment. the topical antibiotic ointment is applied to the lesions after they are wasted. severe cases are treated with oral antibiotics.

A postpartum nurse is monitoring the amount of lochial flow in a client following delivery. Which activity is a part of the method to accurately determine the amount of flow for documentation purposes?

Weighing the perineal pad before and after use rationale The most accurate method for determining the amount of lochial flow is to weigh the perineal pads before and after use. Once these two weights are noted, the amount of lochial flow can be accurately determined. Each gram increase in the weight is roughly equivalent to 1 mL of blood loss. To obtain an accurate estimate of lochial flow, the time between pad changes is a factor that must also be incorporated into the analysis.

A client has been on total parenteral nutrition for 8 weeks. The health care provider prescribes that the total parenteral nutrition be weaned down by 50 mL/hr/day until discontinued. The client asks the nurse, "Why doesn't the doctor just stop the parenteral nutrition instead of dragging it on for 3 days?" The nursing response should be to explain that the health care provider is concerned about which phenomenon?

Rebound hypoglycemia rationale Clients receiving total parenteral nutrition are receiving high concentrations of glucose. To give the pancreas time to adjust to decreasing glucose loads, the infusion rates are tapered down. Before discontinuing the parenteral nutrition, the body must adjust to the lowered glucose levels. If the total parenteral nutrition were suddenly withdrawn, the client would probably have rebound hypoglycemia.

the nurse is reinforcing discharge instructions to a client who had a unilateral adrenalectomy. which information should be a component of the instructions?

instructions about early signs of a wound infection rationale a client who is undergoing a unilateral adrenalectomy will be placed on corticosteriods temporarily to avoid a cortisol deficiency. these medications will be gradually weaned in the postoperative period until they are discontinued. because of the anti-inflammatory properties of corticosteriods, clients who undergo an adrenalectomy are at increased risk for developing wound infections. because of the increased risk for infection, it is important for the client to know measures to prevent infection, early signs of infection and what to do if an infection is present.

Etidronate (Didronel), an antihypercalcemic medication, is prescribed for a client. Which information should the nurse reinforce when instructing the client about taking this medication?

Take 2 hours before meals. rationale Etidronate should be taken on an empty stomach 2 hours before meals. It should not be taken within 2 hours of vitamins, mineral supplements, antacids, or medications high in calcium, magnesium, iron, or albumin.

the nurse is caring for a client with a fractured tibia and fibula. eight hours after a long leg cast was applied, the client began to report an increase in pain level even after administration of the prescribed dose of opioid analgesic. which is the initial nursing action?

check the neurovascular status of the toes on the casted leg rationale an increase in pain level in an extremity at risk for neurovascular compromise (compartment syndrome) is often the first sign of increasing pressure in a compartment, in this case, the casted extremity. the nurse needs to obtain additional data in order to determine whether the HCP needs to be notified immediately or whether other interventions are appropriate.

the nurse knows that litigation involving nurses is common because of which reasons? select all that apply.

clients are better educated about health care // clients are better informed about their rights // clients have a higher expectation about the care they receive rationale the reasons that health-care related litigation involving nurses is common is because clients are more educated, more aware of their rights, and have a higher expectation regarding the care they receive. lawsuits involving nurses are not common because of an expectation of monetary gain or because nurses are not trusted.

The nurse is teaching the paraplegic client measures to promote skin integrity. Which instructions would be helpful to the client? Select all that apply.

eat a nutritious diet // use a pressure relief pad in a wheelchair // check the bottom sheet for wetness and wrinkles rationale To prevent pressure ulcers from developing, the paraplegic client should shift weight in the wheelchair at least every 2 hours and use a pressure relief pad. While in bed, the bottom sheet should be free of wrinkles and wetness. The client should use a mirror to inspect the skin twice a day (morning and evening) to assess for redness, edema, and breakdown. Additional general measures include a nutritious diet and meticulous skin care.

the nurse is reinforcing instructions to a mother of a child with atopic dermatitis (eczema) regarding the application of topical cortisone cream to the affected skin sites. which statement made by the mother indicates an understanding of the use of this medication?

i need to wash sites gently before i apply the medication rationale topical corticosteroids should be applied sparingly and rubbed into the area thoroughly. the affected area should be cleansed gently before application. the cream should not be applied over extensive areas. systemic absorption is more likely to occur with extensive application.

The nurse is planning to reinforce instructions to a client with peripheral arterial disease about measures to limit disease progression. The nurse should include which items on a list of suggestions to be given to the client? Select all that apply.

be careful not to injure the legs or feet // walk each day to increase circulation to the legs // cut down on the amount of fats consumed in the diet Rationale: Long-term management of peripheral arterial disease consists of measures that increase peripheral circulation (exercise), relieve pain, and maintain tissue integrity (foot care and nutrition). Elastic stockings will not increase circulation. They are worn with peripheral vascular disease, but not peripheral arterial disease. Application of heat directly to the extremity is contraindicated. The affected extremity may have decreased sensitivity and is at risk for burns. Direct application of heat raises oxygen and nutritional requirements of the tissue even further.

The nurse is caring for a client with heart failure. The client suddenly becomes anxious and restless, has a sudden onset of breathlessness, and becomes cyanotic. The nurse suspects pulmonary edema and immediately places the client in which best position?

High-Fowler's rationale Positioning the client upright (high-Fowler's position), with the legs dangling over the side of the bed, has an immediate effect of decreasing venous return and decreasing lung congestion. Low-Fowler's position will not achieve this effect. The supine position is a flat position, and when in Trendelenburg's position, the client is flat with the head lower than the rest of the body. These positions would worsen the client's condition.

the nurse is discharging a client from the hospital who was given a prescription for atorvastatin (Lipitor). the nurse should tell the client to report which adverse effect to the HCP immediately?

muscle pain and weakness rationale atorvastatin can injure muscle tissue. the muscle injury can progress to myositis, which is muscle inflammation associated with moderate elevation of creatine kinase (CK) an enzyme released from injured muscle. myositis, in turn, may progress to potentially fatal rhabdomyolysis, associated with a marked elevation of CK and possibly with renal failure.

The nurse is caring for a client who has just died. Which end-of-life information needs to be documented in the client's medical record? Select all that apply

Time and date of death // Time of body transfer and destination // Name of health care provider certifying death //Medical tubes, devices, or lines left in the body rationale Proper documentation of postmortem care, or care of the body after death, is required. Agency policies and procedures are always followed to provide an accurate and reliable medical record of all activities and assessments surrounding a death. Time and date of death and all actions taken to respond to the impending death, time of body transfer and destination, the name of the certifying health care provider, persons notified of the death, and any medical tubes, devices, or lines left in the body are some of the essential aspects that should be documented. Documentation of present family members is not required.

The nurse is reviewing the health history of a pregnant client. Which data noted in the client's health history would indicate a risk for spontaneous abortion?

Syphilis Rationale: Maternal infections such as syphilis, toxoplasmosis, and rubella are causes of spontaneous abortion. There is inconclusive evidence that genital herpes is a causative agent in abortion. Maternal age older than 40 years and diabetes mellitus are considered high risk factors in a pregnancy, increasing the risk for congenital malformations.

the nurse is caring for a client with glaucoma. which medication prescribed for the client should the nurse question?

atropine sulfate (Isopto Atropine) rationale mydriatic medications dilate the pupil and can cause an increase in intraocular pressure in the eye

The nurse is collecting data from a client receiving pioglitazone (Actos) 30 mg orally daily. Which finding indicates that the client is experiencing the expected result of the action of this medication?

Decreased fasting blood glucose and reduced hemoglobin A1C (HbA1c) Rationale: Pioglitazone is similar to other thiazolidinediones, also known as glitazones. Like rosiglitazone, pioglitazone activates peroxisome proliferator-activated receptor PPAR-gamma, and thereby reduces insulin resistance. In clients with type 2 diabetes, monotherapy with pioglitazone can decrease fasting blood glucose by 30 to 56 mg/dL, and can lower HbA1c by about 0.9%.