NCLEX Questions

The steps the nurse should use to resolve an ethical dilemma.

1 Determine if an ethical dilemma exists. 2 Gather necessary information. 3 Clarify values. 4 Verbalize the problem. 5 Identify possible courses of action. 6 Negotiate a plan. 7 Evaluate the plan. Rationale:Milk and milk products contain the essential amino acid tryptophan, which enhances sleep by promoting the production of the neurotransmitter serotonin in the brain. Drinking a glass of warm milk or eating a cube of Swiss cheese may be helpful to sleep. Caffeine-free tea may be soothing and will not keep the client awake. The client should avoid spicy foods such as a taco before bedtime. The client should also avoid alcohol such as wine at bedtime. The client may become sleepy but often wakes up in a few hours. Caffeine products including chocolate and coffee should not be taken at bedtime.

A licensed practical nurse (LPN) is assisting in the care of a client who is having central venous pressure (CVP) measurements taken by the registered nurse (RN). The LPN should assist the RN by placing the bed in which position for the reading? 1.Flat 2.Semi-Fowler's 3.Trendelenburg's 4.Reverse Trendelenburg's

1. Flat Rationale: To obtain a CVP measurement, the head of the bed should be flat in order for the readings to be accurate. The use of the other positions listed would result in false low or false high readings.

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

1.Aim at the base of the fire. Rationale:A fire can be extinguished by using a fire extinguisher. To use the extinguisher, the pin is pulled first. The extinguisher should then be aimed at the base of the fire. The handle of the extinguisher is squeezed, and the fire is extinguished by sweeping from side to side to coat the area evenly. Remember that the safety of anyone present is more important than extinguishing the fire. Remember the mnemonic RACE: R (Rescue) A (Alarm) C (Confine) E (Extinguish)

The nurse is planning measures to decrease the incidence of chest pain for a client with angina pectoris. The nurse should do which intervention to effectively accomplish this goal? 1.Provide a quiet and low-stimulus environment. 2.Encourage the family to come visit very frequently. 3.Encourage the client to call friends and relatives each day. 4.Recommend that the client watch TV as a constant diversion.

1.Provide a quiet and low-stimulus environment. Rationale:Chest pain can be minimized by a quiet, low-stimulus environment, which reduces factors that trigger chest pain such as emotional excitement. Each of the incorrect options increases the amount of client stimulation, which increases the risk of an anginal episode.

The nurse is explaining The Joint Commission's (TJC's) universal protocol for preventing wrong-site, wrong-procedure, and wrong-person surgery to a group of nursing students. The nurse explains that site marking involves which action? 1.The surgeon marking the area of the operative procedure 2.The circulating nurse marking the area of the operative procedure 3.Marking the site of the operative procedure during the "time-out" period 4.Marking the site of the operative procedure at the completion of the procedure to measure any increase in swelling

1.The surgeon marking the area of the operative procedure Rationale:The surgeon is responsible for verifying the operative site, and he or she must mark the operative site before the client is brought into the operating suite. The client will be asked to verify the site that requires surgery. The client may refuse to have the site marked and is asked about marking the site. Although the nurse may also verify the site, this procedure is a primary responsibility of the primary health care provider. Verification of the site should be done both before and during the time-out period. The verification of the surgical site is not done at the completion of the procedure.

A primary health care provider is about to perform a paracentesis on a client diagnosed with abdominal ascites. The nurse should assist the client to assume which position? 1.Upright 2.Supine 3.Left side-lying 4.Right side-lying

1.Upright Rationale:An upright position allows the intestine to float posteriorly and helps prevent intestinal laceration during catheter insertion. Ideally, the client sits upright in a chair, with feet flat on the floor, and with the bladder emptied before the procedure. Therefore, options 2, 3, and 4 are incorrect.

A client has just completed an information session about measures to minimize the progression of coronary artery disease (CAD). Which statement indicates an initial understanding of lifestyle alterations? 1. Decrease opportunities for multidisciplinary rounds. 2. Share the frustrations at unit multidisciplinary meetings. 3. Tell stories about the experiences with other professionals. 4. Participate in continuing education that is restricted to nurses. 5. Engage in ethics discussions with both nurses and other health care practitioners.

2. Share the frustrations at unit multidisciplinary meetings. 3. Tell stories about the experiences with other professionals. 5. Engage in ethics discussions with both nurses and other health care practitioners. Rationale: Moral distress is a shared experience with both nurses and health care practitioners and efforts to alleviate this distress are most successful when the efforts are also shared.

The nurse asks a nursing student to describe case management. Which student response indicates a lack of understanding about this concept? 1."It is managing client care by managing the client care environment." 2."It represents a primary health prevention focus managed by a single case manager." 3."It maximizes hospital revenues while providing for optimal outcome of client care." 4."It is designed to promote appropriate use of hospital personnel and material resources."

2."It represents a primary health prevention focus managed by a single case manager." Rationale:Case management represents an interdisciplinary health care delivery system to promote appropriate use of hospital personnel and material resources to maximize hospital revenues while providing for optimal outcome of care. Options 1, 3, and 4 identify the components of managed care.

A client who is breastfeeding her newborn infant is experiencing nipple soreness. To relieve the soreness, which action should the nurse suggest to the client? 1.Stop nursing until the nipples heal. 2.Begin feeding on the less sore nipple. 3.Avoid rotating breastfeeding positions. 4.Substitute a bottle-feeding until the nipples heal.

2.Begin feeding on the less sore nipple. Rationale: The nurse should instruct the mother to begin feeding on the less sore nipple. The infant sucks with greater force at the beginning of feeding. Rotating breastfeeding positions, breaking suction with the little finger, nursing frequently, not allowing the newborn to chew on the nipple or to sleep holding the nipple in the mouth, and applying tea bags soaked in warm water to the nipple are also measures to alleviate nipple soreness. The mother should be encouraged to continue breastfeeding to maintain adequate milk supply while nipples toughen and adapt to feedings.

The nurse is preparing to initiate a tube feeding for a client and the primary health care provider has prescribed that the feeding be infused at 50 mL per hour. The nurse brings an electronic feeding pump to the bedside and discovers that there is no available outlet in the wall socket to plug the pump into. Which action should the nurse implement? 1.Initiate the feeding without the use of a pump. 2.Contact the electrical maintenance department for assistance. 3.Use an extension cord from the nurse's lounge for the pump plug. 4.Plug the pump cord into the available outlet above the room sink.

2.Contact the electrical maintenance department for assistance. Rationale:The nurse needs to use hospital resources for assistance. A regular extension cord should not be used because it poses the risk of fire. The use of electrical appliances near a sink also presents a hazard. If the use of a pump is required to administer the feeding as prescribed, the nurse must provide safe means for its use.

A client who has open draining lesions from Kaposi's sarcoma needs to be bathed and have bed linens changed. Which should the nurse wear to perform these tasks? 1.Gloves 2.Gown and gloves 3.Gloves and mask 4.Gown, gloves, and a mask:

2.Gown and gloves Rationale:Gowns and gloves are required if the nurse anticipates contact with body fluids, such as wound drainage, diarrhea, or ileostomy or colostomy drainage. Masks are not required unless droplet or airborne precautions are necessary.

A pregnant client in the prenatal clinic states that her last menstrual period (LMP) began April 5 and ended April 12. According to Nägele's rule, which is the estimated date of delivery (EDD)? 1.January 21 2.January 12 3.January 19 4.December 19

2.January 12 Rationale: Nägele's's rule is a noninvasive method of calculating the EDD as follows: subtract 3 months, add 7 days to the first day of the LMP, and add 1 year as appropriate. This is based on the assumption that the cycle is 28 days. April 5 plus 7 days minus 3 months is January 12.

The maternity nurse prepares the client for which techniques commonly used to relieve shoulder dystocia? 1.Leopold's maneuver 2.McRoberts' maneuver 3.Placing the client in the lithotomy position 4.Positioning the client laterally on her left side

2.McRoberts' maneuver Rationale: The McRoberts' maneuver is used to relieve shoulder dystocia. It is described as the woman flexing her thighs sharply against her abdomen to straighten the pelvic curve. This procedure will assist the fetus to move past the pelvic curve of the woman. Leopold's maneuver is used to locate the position and presentation of the fetus. Options 3 and 4 are positions, not techniques, and will not assist in relieving shoulder dystocia.

A client has a new prescription to take guaifenesin every 4 hours as needed. Which medication instructions should the nurse reinforce? 1.Be aware of irritability as a side effect. 2.Take the tablet with a full glass of water. 3.Take an extra dose if the cough is accompanied by fever. 4.Crush the sustained-release tablet if immediate relief is needed.

2.Take the tablet with a full glass of water. Rationale: Guaifenesin is an expectorant. It should be taken with a full glass of water to decrease viscosity of secretions. Sustained-release preparations should not be broken open, crushed, or chewed. The medication occasionally may cause dizziness, headache, or drowsiness as side effects. The client should contact the primary health care provider if the cough lasts longer than 1 week or is accompanied by fever, rash, sore throat, or persistent headache.

The nurse is reinforcing teaching with a client who is having difficulty sleeping. Which bedtime snacks will help the client achieve a restful night's sleep? Select all that apply. 1.A beef taco 2.A small glass of wine 3.A glass of warm milk 4.A cube of Swiss cheese 5.A chocolate chip cookie 6.A cup of caffeine-free tea

3.A glass of warm milk 4.A cube of Swiss cheese 6.A cup of caffeine-free tea Rationale:Milk and milk products contain the essential amino acid tryptophan, which enhances sleep by promoting the production of the neurotransmitter serotonin in the brain. Drinking a glass of warm milk or eating a cube of Swiss cheese may be helpful to sleep. Caffeine-free tea may be soothing and will not keep the client awake. The client should avoid spicy foods such as a taco before bedtime. The client should also avoid alcohol such as wine at bedtime. The client may become sleepy but often wakes up in a few hours. Caffeine products including chocolate and coffee should not be taken at bedtime.

A client with a history of gastrointestinal upset has been diagnosed with acute diverticulitis. To aid the client in symptom management, the nurse should most appropriately suggest which diet during the acute phase? 1.A low-fat diet 2.A high-fat diet 3.A low-fiber diet 4.A high-carbohydrate diet

3.A low-fiber diet Rationale:A low-fiber diet places less strain on the intestines because this type of diet is easier to digest. This diet is usually prescribed during the acute phase for acute diverticulitis, ulcerative colitis, and irritable bowel syndrome. Once the acute phase has subsided the health care provider usually prescribes a high fiber diet. The diets identified in options 1, 2, and 4 will not aid in symptom management in acute diverticulitis.

An adolescent with type 1 diabetes mellitus will become a member of the school's football cheerleader team. The adolescent excitedly reports to the school nurse to obtain information regarding adjustments needed in the treatment plan for the diabetes. The school nurse should instruct the adolescent to take which action? 1.Eat half the amount of food normally eaten at lunchtime. 2.Take two times the amount of prescribed insulin on practice and game days. 3.Eat six graham crackers or drink a cup of orange juice before practice or game time. 4.Take the prescribed insulin one half hour before practice or game time rather than in the morning.

3.Eat six graham crackers or drink a cup of orange juice before practice or game time. Rationale:An extra snack of 15 to 30 g of carbohydrate eaten before activities such as cheerleader practice will prevent hypoglycemia. Six graham crackers or a cup of orange juice will provide 15 to 30 g of carbohydrate. The adolescent should not be instructed to adjust the amount or time of insulin administration. Meal amounts should not be decreased.

A client who is postoperative with incisional pain complains to the nurse about completing respiratory exercises. The client is willing to do the deep breathing exercises but states that it hurts to cough. The nurse provides gentle encouragement and appropriate pain management to the client, knowing that coughing is needed for which reason? 1. To expel mucus from the airways 2. To dilate the terminal bronchioles 3. To exercise the muscles of respiration 4. To provide for increased oxygen tension in the alveoli

1. To expel mucus from the airways Rationale: Coughing is one of the protective reflexes. Its purpose is to move mucus that is in the airways upward toward the mouth and nose. Coughing is needed in the postoperative client to mobilize secretions and expel them from the airways. The other options do not accurately address the purpose of coughing in the postoperative client.

The nurse provides home care instructions to a postpartum client following a vaginal birth with episiotomy. Which statement by the client indicates the need for further teaching? 1."I can resume sexual activity at any time." 2."I can expect red drainage for a few days." 3."Walking is an excellent form of exercise for me now." 4."I should drink an adequate amount of fluids every day."

1."I can resume sexual activity at any time." Rationale: It is recommended that the woman refrain from sexual intercourse until the episiotomy has healed and the lochia has stopped. This process usually takes about 3 weeks. Lochia is bright red for about 3 days postpartum and then changes to brownish pink discharge (from days 4 to 10), then white (from days 11 to 14). Walking is an excellent form of exercise in the immediate postpartum period because it is not strenuous and maintains circulation. An adequate intake of fluid (2000 mL daily) is important to prevent dehydration and constipation.

The nurse has given medication instructions to the client receiving phenytoin. The nurse determines that the client understands the instructions if the client makes which comments? Select all that apply. 1."I should not suddenly stop taking this medication." 2."Alcohol is not contraindicated while taking this medication." 3."Good oral hygiene is needed, including brushing and flossing." 4."The medication dose may be self-adjusted, depending on side effects." 5."The morning dose of the medication should be taken before a sample for a serum drug level is drawn."

1."I should not suddenly stop taking this medication." 3."Good oral hygiene is needed, including brushing and flossing." Rationale:Typical anticonvulsant medication instructions include taking the prescribed dose daily to keep the blood level of the drug constant, having a serum drug level drawn before taking the morning dose, avoiding abruptly stopping the medication, avoiding alcohol, checking with the primary health care provider before taking over-the-counter medications, avoiding activities in which alertness and coordination are required until medication effects are known, providing good oral hygiene and getting regular dental care, and wearing a Medic-Alert bracelet or tag.

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

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

The nurse determines that a client with coronary artery disease (CAD) understands disease management if the client makes which statement? 1."I will walk for one-half hour daily." 2."As long as I exercise I can eat anything I wish." 3."My weight has nothing to do with this disease." 4."It doesn't matter if my father had high cholesterol."

1."I will walk for one-half hour daily." Rationale:Lack of physical exercise contributes to the development of CAD, and engaging in a regular program of exercise helps retard progression of atherosclerosis by lowering cholesterol levels and developing collateral circulation to heart tissue. Options 2 and 4 are incorrect because obesity and a diet high in fat can contribute to CAD. Option 4 is incorrect because genetic factors also contribute to CAD.

A client with a headache arrives in the emergency department and is staggering, confused, smells of alcohol, and is verbally abusive. The nurse explains to the client that the primary health care provider will need to perform an assessment before the administration of medication. When the client becomes verbally abusive, the nurse threatens to place the client in restraints. With what can the client legally charge the nurse as a result of this nursing action? 1.Assault 2.Battery 3.Negligence 4.Invasion of privacy

1.Assault Rationale:An assault occurs when a person puts another person in fear of a harmful or offensive contact. For this intentional tort to be actionable, the victim must be aware of the threat of harmful or offensive contact. Battery is the actual contact with one's body. Negligence involves actions below the standards of care. When the individual's private affairs are unreasonably intruded upon, invasion of privacy occurs.

The nurse is caring for a client who has refused to take an oral medication. The nurse tells the client that the nurse will hold the client down and give the medication by injection if the client doesn't take the oral medication. The nurse then takes the client's bathrobe so the client will have to remain in his room. Which intentional torts has this nurse committed? Select all that apply. 1.Assault 2.Battery 3.False imprisonment 4.Invasion of privacy 5.Defamation of character

1.Assault 3.False imprisonment Rationale: The nurse has assaulted or threatened the client with an injection. The nurse did not touch the client without consent, so there was no battery. The nurse forced the client to stay in the room, which is false imprisonment, but the nurse did not invade the client's privacy nor did the nurse defame (publish false statements about) the client's character.

The nurse reinforces instructions regarding diet for a client at risk for hypokalemia. The nurse determines there is a need for further teaching when the client selects which foods as sources high in potassium? Select all that apply. 1.Bread and butter 2.Carrots and peas 3.Peppers and onions 4.Beef and potato salad 5.Avocados and mushrooms

1.Bread and butter 2.Carrots and peas 3.Peppers and onions Rationale: Clients taking thiazide or loop diuretics need to have adequate potassium intake and benefit from dietary teaching about the potassium values of foods. Bread and butter, carrots and peas, and peppers and onions are relatively low sources of potassium. Meats and certain fruits and vegetables are high in potassium and include beef and potato salad and avocados and mushrooms.

A client with a history of ear problems telephones the ambulatory care nurse to cancel an appointment because he will be away on business. The client mentions that he will be flying during this trip. The nurse advises the client to engage in which activities to prevent barotrauma during takeoff and landing? Select all that apply. 1.Chewing gum 2.Yawning occasionally 3.Swallowing a few times 4.Keeping the mouth motionless 5.Sucking on a piece of hard candy

1.Chewing gum 2.Yawning occasionally 3.Swallowing a few times 5.Sucking on a piece of hard candy Rationale:Clients who are susceptible to barotrauma should do any of a variety of mouth movements to equalize pressure in the ear, particularly during takeoff and landing of an aircraft. These include yawning, swallowing, drinking, chewing, and sucking on hard candy. Valsalva maneuver also may be helpful. The client should avoid sitting with the mouth motionless during this time because it enhances pressure buildup behind the tympanic membrane.

The nurse is preparing to discontinue an indwelling urinary catheter. Which pieces of equipment should the nurse obtain to perform this procedure? Select all that apply. 1.Clean towel 2.Sterile gloves 3.Water-soluble lubricant 4.Sterile 5- or 6-mL syringe 5.Sterile 10- or 12-mL syringe

1.Clean towel 2.Sterile gloves 5.Sterile 10- or 12-mL syringe Rationale:The nurse, while preparing to discontinue an indwelling urinary catheter, should obtain nonsterile gloves, a clean towel, and a sterile syringe to remove the saline from the catheter balloon. The client is positioned similarly to the position used with insertion. The nurse dons the gloves and places the towel between the legs to protect the client and bed from any drainage. The balloon of a urinary catheter is filled with 10 mL of sterile saline during the insertion process. The nurse needs to use a 10- or 12-mL syringe to aspirate and remove all the saline through the self-sealing port of the urinary catheter. The nurse then asks the client to take a deep breath and slowly and smoothly withdraws the catheter. The nurse assists the client with perineal care after discontinuing the catheter.

The nurse knows that litigation involving nurses is common because of which reasons? Select all that apply. 1.Clients are better educated about health care. 2.Clients are better informed about their rights. 3.Clients do not trust nurses and primary health care providers. 4.Clients have a higher expectation about the care they receive. 5.Clients are aware that lawsuits result in payment of large sums of money.

1.Clients are better educated about health care. 2.Clients are better informed about their rights. 4.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.

An outbreak of illness has occurred in a community and is suspected to be related to food ingestion. A community health nurse places priority on which intervention? 1.Determining what common food item was ingested by those affected 2.Reviewing the signs and symptoms related to the Salmonella bacteria 3.Notifying the U.S. Centers for Disease Control and Prevention (CDC) 4.Teaching the basic methods for preventing food contamination to those affected

1.Determining what common food item was ingested by those affected Rationale:The initial step is to determine what food has been ingested by all the clients experiencing symptoms. Reviewing signs and symptoms associated with a particular food-borne illness, notifying the CDC, and teaching methods of food contamination prevention, while appropriate in this situation, do not have the priority that identifying the common contaminated agent has.

The nurse has been asked to serve on the health care facility ethics committee and knows that this committee serves which purposes? Select all that apply. 1.Education 2.Case consultation 3.Caring for aging clients 4.Process ethical dilemmas 5.Approve emergency mental health commitment

1.Education 2.Case consultation 4.Process ethical dilemmas Rationale:The purposes of an ethics committee include processing ethical dilemmas, providing education, and providing policy recommendations and case consultations. An ethics committee would not provide care for aging clients or approve emergency mental health commitment.

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

1.Explain the procedure to the client. 2.Irrigate the NG tube with saline. 4.Elevate the head of the bed to 45 degrees. Rationale: When a tube feeding is initiated, the most important intervention is to make sure the NG tube is properly placed in the stomach to prevent aspiration of the formula. After explaining the procedure to the client and assessing placement of the tube, the nurse should irrigate the tube with saline to ensure the formula flows well through the tube. When a tube feeding is administered, the client is placed in a high-Fowler's position for a bolus feeding and in a semi-Fowler's position (30-45 degrees) for a continuous feeding to allow gravity to help the flow of formula and to prevent reflux and aspiration. There is no need to aspirate contents because the formula has not been given and the contents are gastric secretions. Scissors are not kept at the bedside with an NG tube but with the Sengstaken-Blakemore tube used to treat bleeding esophageal varices. The correct placement for the end of the NG tube is in the stomach, not the esophagus.

The motor function of this nerve is tested by asking the client to smile, frown, close the eyes tightly, lift the eyebrows, and puff the cheeks. 1.Facial 2.Acoustic 3.Trigeminal 4.Glossopharyngeal

1.Facial Rationale:The motor function of the facial nerve is tested by asking the client to smile, frown, close the eyes tightly, lift the eyebrows, and puff the cheeks. The acoustic nerve assesses hearing and is sensory. To determine if motor function of the trigeminal nerve is intact, the nurse should have the client clench the teeth tightly and attempt to separate the client's jaw while the teeth are tightly clenched. To test the motor function of the glossopharyngeal nerve, the nurse should depress the client's tongue with a tongue blade, have the client say "ahhh," and watch for the uvula and soft palate to rise in the midline.

The nurse is preparing to administer an acetaminophen suppository to a child. The nurse plans which action? 1.Insert the suppository 1 to 2 cm into the rectum. 2.Position the child on the right side with the left leg flexed. 3.Ask the child to expel the suppository after it has been inserted. 4.Ask the child to hold the breath during insertion of the suppository.

1.Insert the suppository 1 to 2 cm into the rectum. Rationale:When administering a suppository to a child, the child should be positioned on the left side with the right leg flexed. The child should be asked to take a deep breath (not hold the breath) to further relax the sphincter. The suppository is gently inserted past the internal sphincter; the distance required to place the medication is approximately 1 to 2 cm. After insertion, the buttocks should be held together until the urge to expel the suppository has passed.

The nurse is reinforcing discharge instructions to a client with a hiatal hernia. Which considerations should the nurse include in the teaching session? Select all that apply. 1.It is advisable to stop smoking cigarettes. 2.Lie flat for at least 30 minutes after meals. 3.Wait at least 1 hour after meals to perform chores. 4.Be sure to elevate the head of the bed during sleep. 5.Foods with moderate fat should be a part of your diet.

1.It is advisable to stop smoking cigarettes. 3.Wait at least 1 hour after meals to perform chores. 4.Be sure to elevate the head of the bed during sleep. Rationale:The client should elevate the head of the bed during sleep and wait at least 1 hour after meals to perform chores. Smoking cigarettes increases acid secretion, so the client should be advised to stop smoking. The consumption of low-fat or nonfat foods is recommended, not moderate fat. The client should remain upright for an hour after eating.

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

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

The licensed practical nurse knows that which items are examples of common law? Select all that apply. 1.Malpractice 2.Informed consent 3.Nurse practice act 4.Americans with Disabilities Act 5.Client's right to refuse treatment

1.Malpractice 2.Informed consent 5.Client's right to refuse treatment Rationale: Common law results from judicial decisions made in courts when individual legal cases are decided. Malpractice, informed consent, and a client's right to refuse treatment all came from legal decisions. Statutory laws are created by elected legislative bodies. The nurse practice act arises from each state's statutory law and the Americans with Disabilities Act arises from Federal statutory law.

The nurse shares with a client that violation of a civil law usually results in which types of penalty? Select all that apply. 1.Monetary fine 2.Public service 3.Replacement of property 4.Imprisonment for more than 1 year 5.Monetary fine and imprisonment for less than 1 year

1.Monetary fine 2.Public service 3.Replacement of property Rationale: Civil laws protect the rights of individuals within our society, and the consequences of civil law violations are damages in the forms of fines or specific performance of good works such as public service. A monetary fine, public service, and replacement of damaged property would be examples of this. Criminal law protects society as a whole and provides punishment of crimes. A felony (serious crime) is punishable by imprisonment for more than 1 year. A misdemeanor (less serious crime) is punishable by payment of a fine and imprisonment for less than 1 year.

The nurse is planning to get a client out of bed for the first time after having a total hip arthroplasty (THA). What specific actions would the nurse take? Select all that apply. 1.Place a gait belt on the client. 2.If stretch bands are used, reinforce the correct use. 3.Stand on the same side of the bed as the unaffected leg. 4.Observe for any signs/symptoms of dizziness the first time the client gets out of bed. 5.Lift the client into the bedside chair if the client complains of pain when standing. 6.After the client sits on the side of the bed, remind the client to stand on the unaffected leg.

1.Place a gait belt on the client. 2.If stretch bands are used, reinforce the correct use. 4.Observe for any signs/symptoms of dizziness the first time the client gets out of bed. 6.After the client sits on the side of the bed, remind the client to stand on the unaffected leg. Rationale:The first time the postoperative THA client gets out of bed, the nurse must be prepared to prevent falls and observe for dizziness. When getting the client out of bed, put a gait belt on the client and then stand on the same side of the bed as the affected, not unaffected, leg. If the client has been instructed by PT to use stretch bands, reinforce the correct use of this device to support and assist in proper positioning of the operative leg. After the client sits on the side of the bed, remind him or her to stand on the unaffected leg and pivot to the chair with guidance. To avoid injury, do not lift the client!

The nurse is caring for a client with pneumonia who is to receive oxygen via nasal cannula at 2L. To provide a safe delivery of the oxygen the nurse should avoid which actions? Select all that apply. 1.Securing the oxygen tubing to the client's bottom sheet 2.Observing the client's nares frequently for skin breakdown 3.Examining the top of the client's ears for redness and irritation 4.Checking the oxygen flow rate and primary health care provider's prescriptions every shift 5.Positioning the nasal prongs in the nares and adjusting the plastic slide on the cannula so that the cannula fits as tight as possible

1.Securing the oxygen tubing to the client's bottom sheet 5.Positioning the nasal prongs in the nares and adjusting the plastic slide on the cannula so that the cannula fits as tight as possible Rationale:Oxygen is most commonly administered with a nasal cannula to clients in the hospital or at home. If the tubing is attached to the client's bed linen, it will become dislodged from the nares whenever the client moves. The cannula should be applied by placing the nasal prongs in the nose and then adjusting the plastic slide on the cannula so that it is snug and comfortable but not tight. The tubing should have sufficient slack and be secured to the client's clothes. The tops of the ears should be examined for signs of redness and irritation. The nares should be checked frequently because oxygen will dry the nasal mucosa. Oxygen is a medication and its prescription should be verified every shift to ensure the correct rate.

The nurse is caring for a client who becomes agitated and begins to pull on a surgically placed abdominal drainage tube. The primary health care provider visits and prescribes restraints if needed. Which actions are appropriate to delegate to the unlicensed assistive personnel (UAP), who has completed the facility's education about care of the restrained client? Select all that apply. 1.Socialize with the restrained client. 2.Determine the type of restraint to be used. 3.Document the client's orientation and degree of confusion. 4.Remove the restraint and perform range of motion activity. 5.Reapply the restraint after assisting the client to the bathroom. 6.Plan the frequency that the position of the client should be changed.

1.Socialize with the restrained client. 3.Document the client's orientation and degree of confusion. 4.Remove the restraint and perform range of motion activity. 5.Reapply the restraint after assisting the client to the bathroom. Rationale:The skill of applying restraints can be delegated to the UAP whom the nurse knows is competent in caring for a client with restraints. The nurse is responsible to document the mental status of the client necessitating the restraints. The nurse must determine the appropriate type of restraint and frequency of position change. The UAP may perform care including meeting mobility, hydration, nutrition, elimination, and socialization needs and removing and reapplying restraints under the direction of the nurse.

The nurse admits a client who has seizure precautions prescribed. The client has a seizure just after the nurse has implemented the precautions. Which actions should the nurse take? Select all that apply. 1.Time the start and stop of the seizure. 2.Apply oxygen at 2L with nasal cannula. 3.Turn the client to the side and do not restrain. 4.Note the distinguishing characteristics of the seizure. 5.Use a padded tongue blade to avoid tongue injury. 6.Turn on the suction machine with oral catheter.

1.Time the start and stop of the seizure. 2.Apply oxygen at 2L with nasal cannula. 3.Turn the client to the side and do not restrain. 4.Note the distinguishing characteristics of the seizure. 6.Turn on the suction machine with oral catheter. Rationale:Seizure precautions are interventions prescribed for clients at high risk of having a seizure. This involves keeping equipment at the client's bedside to protect and attend quickly to the needs of the client during a seizure. Clean gloves, oxygen with a nasal cannula setup, and a suction machine with oral catheter should be at the client's bedside. The nurse should turn the client to the side to avoid aspiration of secretion and maintain a patent airway. The suction machine with oral catheter should be turned on and ready in case the client needs suctioned. Nasal oxygen per cannula should be instituted to avoid hypoxemia. The client is not restrained but the padded side rails are up to avoid a fall or injury. The nurse should time and observe the signs that occur with the seizure to assist the primary health care provider with diagnosis. Nothing including a padded tongue blade should be inserted in the mouth of a client having a seizure since the teeth are clenched. An oral airway or biteblock could be inserted if the nurse recognizes in advance that a client will have a tonic-clonic seizure.

The nurse is caring for a non-English-speaking client. Best practices for client safety and quality of care incorporates which actions by the nurse? Select all that apply. 1.Use interpreters who are familiar with health care. 2.Avoid eye contact with the client while communicating. 3.Avoid the use of relatives as interpreters to prevent misinterpretation. 4.Use dialect-specific interpreters who are the same gender if possible. 5.Become familiar with common health care words used in the client's language. 6.Remember most non-English-speaking clients cannot understand English phrases.

1.Use interpreters who are familiar with health care. 3.Avoid the use of relatives as interpreters to prevent misinterpretation. 4.Use dialect-specific interpreters who are the same gender if possible. 5.Become familiar with common health care words used in the client's language. Rationale:Guidelines for communicating with non-English-speaking clients include the use of dialect-specific interpreters who are the same gender and age, the use of interpreters who are familiar with health and health care, avoiding the use of relatives as interpreters to decrease the occurrence of bias and misinterpretation, using common health care terms in the client's language, maintaining eye contact with the client when communicating unless it is not culturally accepted, and realizing that clients can often understand English better than they can speak English.

The nurse is collecting physical assessment data for a patient with possible splenomegaly. The nurse should palpate which abdominal quadrant? 1. 1 Right upper quadrant 2. 2 Left upper quadrant 3. 3 Right lower quadrant 4. 4 Left lower quadrant

2. 2 Left upper quadrant Rationale:The spleen is located in the left upper quadrant of the abdomen and can be palpated in the area. Therefore, the other options are incorrect.

A client is seen in the health care clinic, and a diagnosis of conjunctivitis is made. The nurse reinforces discharge instructions to the client regarding care of the disorder while at home. Which statement by the client indicates a need for further teaching? 1."I can use an ophthalmic analgesic ointment at night if I have eye discomfort." 2."I do not need to be concerned about spreading this infection to others in my family." 3."I should apply a warm compress before instilling antibiotic drops if purulent discharge is present in my eye." 4."I should perform a saline eye irrigation before instilling the antibiotic drops into my eye if purulent discharge is present."

2."I do not need to be concerned about spreading this infection to others in my family." Rationale: Conjunctivitis is inflammation or infection of the lining of the eyelids. Conjunctivitis is highly contagious and clients must follow strict hand washing and avoid touching their eyes and others. Antibiotic drops usually are administered four times a day. When purulent discharge is present, saline eye irrigations or eye applications of warm compresses may be necessary before instilling the medication. Ophthalmic analgesic ointment or drops may be instilled, especially at bedtime, because discomfort becomes more noticeable when the eyelids are closed.

The nurse has reinforced instructions to the client with Raynaud's disease about self-management of the disease process. The nurse determines that the client needs further teaching if the client makes which statement? 1."Smoking cessation is very important." 2."Moving to a warmer climate should help." 3."Sources of caffeine should be eliminated from the diet." 4."Taking nifedipine as prescribed will decrease vessel spasm."

2."Moving to a warmer climate should help." Rationale:Raynaud's disease responds favorably to the elimination of nicotine and caffeine. Medications such as calcium channel blockers may inhibit vessel spasm and prevent symptoms. Avoiding exposure to cold through a variety of means is very important. However, moving to a warmer climate may not necessarily be beneficial because the symptoms could still occur with the use of air conditioning and during periods of cooler weather.

A client received a dose of regular insulin this morning at 7:00 am. At which time should the nurse likely anticipate the potential for a hypoglycemic reaction to occur? 1.8:00 am 2.10:00 am 3.12:00 noon 4.2:00 pm

2.10:00 am Rationale: Regular insulin is a rapid-acting insulin with a peak action of 2 to 4 hours after injection. During the peak action of insulin is when hypoglycemic reactions are most likely to occur. This makes option 2 correct.

A client with a history of seizure disorder is having a routine serum phenytoin level drawn. The nurse who receives a telephone report of the results notes that the client's blood level of the medication is within the normal range if which value is reported? 1.6 mcg/mL 2.15 mcg/mL 3.28 mcg/mL 4.35 mcg/mL

2.15 mcg/mL Rationale:The therapeutic range for serum phenytoin level is 10 to 20 mcg/mL. If the level is below the therapeutic range, the client could experience seizure activity. If the level is too high, the client is at risk for phenytoin toxicity.

The nurse is told in intershift report that a client has been appointed a legal guardian. The nurse looks for what evidence that supports this information? 1.Testimony of three neighbors 2.A judicial decision in a court of law 3.A primary health care provider's prescription 4.A licensed nurse's observation of bizarre behavior

2.A judicial decision in a court of law Rationale:Appointment of a guardian must be done through due legal process. It cannot be done by a primary health care provider's prescription. Options 1 and 4 could support the decision that a legal guardian is necessary if the client is incompetent to make his or her own decisions, but they are not sufficient by themselves.

The nurse palpates the anterior fontanel of a newborn and notes that it feels soft. What does this datum indicate to the nurse? 1.Dehydration 2.A normal finding 3.Increased intracranial pressure 4.Decreased intracranial pressure

2.A normal finding Rationale:The anterior fontanel is normally 2.5 to 5 cm in width and diamond shaped. It can be described as soft, which is normal, or full and bulging, which could indicate increased intracranial pressure. Conversely, a depressed fontanel could mean that the neonate is dehydrated.

The nurse is assigned to care for a client 1 hour after delivery. The nurse palpates a firm, uterine fundus 2 cm above the umbilicus and displaced to the right. The nurse recognizes that this finding indicates which condition? 1.Uterine atony 2.Bladder distention 3.Endometrial infection 4.Retained placental fragments

2.Bladder distention Rationale:Immediately following expulsion of the placenta, the fundus is firmly contracted, midline, and located one half to two thirds of the way between the symphysis pubis and the umbilicus. Because the uterine ligaments are still stretched, a full bladder can move the uterus upward and to the side. Options 1, 3, and 4 are complications not usually indicated by a firm and displaced uterus.

The nurse in charge of a nursing unit in a long-term care facility is concerned because staff members openly verbalize racial comments about clients on the unit. What should the nurse do to appropriately manage this concern? 1.Ignore the racial comments. 2.Discourage the racial comments. 3.Leave articles about racial prejudice in the nurse's lounge. 4.Report the racial comments to the grievance committee.

2.Discourage the racial comments. Rationale: Prejudice reduction is a method of managing or discouraging racial comments made by others. When racial comments are discouraged, fewer comments will be made. Ignoring the racial comments is an inappropriate option because the concern will not be addressed. Leaving articles about racial prejudice in the nurse's lounge indirectly addresses the issue. In addition, the nurse cannot ensure that the staff will read the articles. Likewise, reporting the racial comments to the grievance committee does not directly address the issue. The best approach that the nurse could take would be to directly discuss the concern with the staff members. This action is not identified in the options. Therefore, from the options presented, option 2 would most appropriately manage this concern.

A vascular surgeon repeatedly asks the nurse to obtain signed consent forms on his surgical clients. The nurse is uncomfortable with obtaining the informed consents and explains this to the surgeon, but the surgeon tells the nurse that she will be reported if the consents are not obtained. The nurse should appropriately manage this situation by taking which action? 1.Obtain the informed consents. 2.Discuss the situation with the nurse manager. 3.Contact the national medical association and report the surgeon. 4.Tell the surgeon, "I don't really care if you report me. I am not obtaining the consents."

2.Discuss the situation with the nurse manager. Rationale:If a conflict arises, it is most appropriate to try to resolve the conflict directly. In this situation, the nurse has attempted to explain the reasons for being uncomfortable with the surgeon but was unable to resolve the conflict. The nurse would then appropriately use the organizational channels of communication and discuss the issue with the nurse manager, who would then proceed to resolve the conflict. The nurse manager may attempt to discuss the situation with the surgeon or seek assistance from the nursing supervisor. Options 1, 3, and 4 are inappropriate actions. Option 1 ignores the issue. Option 3 is inappropriate because the nurse needs to use the appropriate organizational channels of communication to resolve the conflict. Option 4 is an inappropriate statement and will initiate further conflict between the nurse and surgeon.

The nurse is caring for a client admitted with fat embolism syndrome (FES). Which are some of the early manifestations of this syndrome? Select all that apply. 1.Fever 2.Dyspnea 3.Petechiae 4.Hypoxemia 5.Tachypnea 6.Decreased level of consciousness

2.Dyspnea 4.Hypoxemia 5.Tachypnea Rationale:The earliest manifestations of FES are a low arterial oxygen level (hypoxemia), dyspnea, and tachypnea (increased respirations). FES is a serious complication that usually results from fractures or fracture repair. In this syndrome, fat globules are released from the yellow bone marrow into the bloodstream within 12 to 48 hours after an injury or other illness (mechanical theory). Headache, lethargy, agitation, confusion, decreased level of consciousness, seizures, and vision changes may follow. Petechiae may appear over the neck, upper arms, and/or chest. Although this rash is a classic manifestation, it is usually the last sign to develop.

A client has just completed an information session about measures to minimize the progression of coronary artery disease (CAD). Which statement indicates an initial understanding of lifestyle alterations? 1. I should take daily medication for life. 2. I should eat a diet that is low in fat and cholesterol. 3. I should continue to smoke to keep the metabolic rate high. 4. I should begin to exercise if diet is not sufficient to achieve weight loss.

2.I should eat a diet that is low in fat and cholesterol. Rationale:A diet that is low in fat and cholesterol helps slow the progression of CAD. This must be accompanied by regular exercise and cessation of smoking. If these measures are effective, the client may not need daily medication.

The nurse is assigned to the care of a client who is being admitted to a facility. The nurse notes which observations as indications the client likely has a hearing deficit? Select all that apply. 1.The client speaks in a quiet tone. 2.The client answers questions incorrectly. 3.The client states she quit attending social events. 4.The client holds on to the furniture when walking in the room. 5.The client asks appropriate questions to clarify information given. 6.The client does not respond to a person unless facing the speaker.

2.The client answers questions incorrectly. 3.The client states she quit attending social events. 6.The client does not respond to a person unless facing the speaker. Rationale:The client with a hearing deficit frequently displays noticeable difficulties with communication. The client may respond incorrectly because of misinterpreting questions. Clients may isolate themselves because of embarrassment or difficulty coping in social situations. The client may quit attending clubs or meetings. The client only responds to a person when they see that a person is talking to them. The client needs visual stimulation in order to respond to vocal stimuli. Often the client with a hearing deficit speaks loudly and not in a normal quiet tone. Holding on to the furniture is not associated with a hearing problem but may be associated with a balance problem. A client with normal hearing ability will participate in a conversation and ask for clarification appropriately.

A hospitalized client who recently experienced the loss of a spouse is grieving. The client progresses well and is approaching discharge. Which is an appropriate outcome for this client? 1.The client reports three additional coping strategies. 2.The client verbalizes stages of grief and plans to attend a community grief group. 3.The client verbalizes connections between the significant loss and low self-esteem. 4.The client verbalizes decreased desire for self-harm and discusses two alternatives to suicide.

2.The client verbalizes stages of grief and plans to attend a community grief group. Rationale:The appropriate outcome is for the client to verbalize stages of grief and plans to attend a community grief group. The question is focused on grieving. The only client outcome that deals with grief is option 2. The other outcomes are unrelated to grieving. Additionally there are no data in the question about self-harm.

The client has a prescription for metoclopramide four times a day. The nurse determines that which is the most appropriate time to schedule this medication? 1.With each meal and at bedtime 2.Thirty minutes before meals and at bedtime 3.One hour after each meal and at bedtime 4.Every 6 hours spaced evenly around the clock

2.Thirty minutes before meals and at bedtime Rationale: Metoclopramide is a gastrointestinal stimulant. The client should be taught to take this medication 30 minutes before meals and at bedtime. Therefore, the other options are incorrect.

A mental health nurse caring for a client diagnosed with mania selects which activity for this client? 1. Painting in art therapy 2. Letter writing to family 3. Going for a walk with staff 4. Listening to favorite music

3. Going for a walk with staff Rationale:The activity the mental health nurse selects for the client diagnosed with mania is going for a walk with staff. A person who is experiencing mania is overactive and full of energy, lacks concentration, and has poor impulse control. The client needs an activity that will facilitate the use of excess energy, yet not endanger others during the process. The remaining activities are relatively sedate activities. Writing and painting require concentration, a quality that is lacking in the manic state. Such activities may lead to increased frustration and anxiety for the client. Walking is an exercise that uses the large muscle groups of the body and is a great way to expend the increased energy that this client is experiencing.

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? 1."I should encourage fluid intake." 2."I should avoid toilet training right now." 3."I should carry my child by straddling the child on my hip." 4."I should use double diapers to hold the surgery site in place."

3."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.

While the nurse is involved in preparing a client for a cardiac catheterization, the client says, "I don't want to talk with you. You're only the nurse. I want my doctor." Which response by the nurse should be therapeutic? 1."Your doctor expects me to prepare you for this procedure." 2."That's fine, if that's what you want. I'll call your health care provider." 3."So you're saying that you want to talk to your health care provider?" 4."I'm concerned with the way you've dismissed me. I know what I am doing."

3."So you're saying that you want to talk to your health care provider?" Rationale: In option 3, the nurse uses the therapeutic communication technique of reflection to redirect the client's feelings back for validation. Option 1 is nontherapeutic and addresses the legal issue of performing a procedure when in fact the client is refusing. Although option 2 may seem appropriate, it does not reflect the client's feelings and doesn't provide an opportunity for the client to express feelings. Option 4 is clearly nontherapeutic because it focuses on the nurse's feelings rather than the client's feelings.

The mother of a child who had a myringotomy with insertion of tympanostomy tubes calls the nurse and tells the nurse that the "tubes" fell out. The nurse should make which response to the mother? 1."Replace the tubes immediately so that the created opening does not close." 2."Soak the tubes in alcohol for 1 hour before replacing them in the child's ears." 3."This is not an emergency. I will speak to the primary health care provider and call you right back." 4."This is an emergency and requires immediate intervention. Bring the child to the emergency department."

3."This is not an emergency. I will speak to the primary health care provider and call you right back." Rationale: The size and appearance of the tympanostomy tubes should be described to the parents following surgery. They should be reassured that if the tubes fall out, it is not an emergency but that the primary health care provider should be notified. The tubes cannot be replaced without surgical intervention.

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? 1.Pillow 2.Air ring 3.Alternating air pad 4.Plastic-lined absorbent pad

3.Alternating air pad Rationale:The client who cannot independently shift weight, which includes a client with tetraplegia, 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 caring for a child with a diagnosis of roseola. The nurse provides instructions to the mother regarding preventing the transmission of the infection to the other children in the family and the other household members. Which instructions should the nurse reinforce to the mother? 1.Isolate the child from others because the virus is transmitted by breathing and coughing. 2.Wash sheets and towels used by the child separately in bleach to prevent the spread of the infection to the others. 3.Avoid allowing the children to share drinking glasses or eating utensils because the disease is transmitted through the saliva. 4.Have the child use a separate bathroom for urination and bowel movements to prevent the spread of infection through the urine and feces.

3.Avoid allowing the children to share drinking glasses or eating utensils because the disease is transmitted through the saliva. Rationale: Roseola, a viral disease affecting infants from 6 months to 2 years, involves an upper respiratory infection, and a pink to red rash that occurs after several days of high fever stops. It is transmitted via saliva; therefore, others should not share drinking glasses or eating utensils. Isolating the child, washing linens in bleach separately, and having the child use a separate bathroom are not accurate instructions regarding the prevention of the transmission of roseola.

A mother of a child who underwent a myringotomy with insertion of tympanostomy tubes calls the nurse and reports that the child is complaining of discomfort. Which should the nurse instruct the mother to do? 1.Give the child children's aspirin for the discomfort. 2.Be sure that the child is resuming normal activities. 3.Give the child acetaminophen for the discomfort as per discharge instructions. 4.Speak to the primary health care provider because the child should not be having any discomfort.

3.Give the child acetaminophen for the discomfort as per discharge instructions. Rationale: Following myringotomy with insertion of tympanostomy tubes, the child may experience some discomfort. Acetaminophen or ibuprofen can be given to relieve the discomfort. Aspirin should not be administered to the child. The child should rest if discomfort is present.

The nurse assists a primary health care provider (PHCP) with the insertion of a nasogastric tube. Which positions should the nurse place the client in to prepare for the procedure? Select all that apply. 1.Supine prone 2.Low-Fowler's position 3.High-Fowler's position 4.Slight flexion of the neck 5.Slight extension of the neck

3.High-Fowler's position 5.Slight extension of the neck Rationale:The nurse, while assisting the PHCP with the insertion of the nasogastric tube insertion, should place the client in a high-Fowler's position (sitting at a 90-degree angle) with neck slightly extended. This position will assist the use of gravity and straighten the pathway for the tube. Supine and low-Fowler's positions and slight neck flexion will not facilitate the procedure.

A newly pregnant client is asking how to prevent neural-tube birth defects. The nurse reinforces which food choices to include in the diet? Select all that apply. 1.Milk 2.Peanuts 3.Oranges 4.Broccoli 5.Egg yolks 6.Grapefruit

3.Oranges 4.Broccoli 6.Grapefruit Rationale:Folic acid (folate) helps prevent neural tube birth defects; it is found in green, leafy vegetables; liver, beef, and fish; legumes; and grapefruit and oranges. Peanuts are high in protein and niacin. Milk is high in calcium and vitamin D. Egg yolks are high in vitamin A, iron, and cholesterol.

The nurse on the mental health unit is caring for a client with a history of alcoholism. Aversion conditioning has been chosen as the treatment for this client because other less drastic measures have failed to produce the desired effects. Which are some paradigms or clear examples of aversion conditioning? Select all that apply. 1.Emphasis on group and social interaction and that rules and expectations are mediated by peer pressure. 2.Increased exposure to an object or situation that causes anxiety increases until the anxiety about the object ceases. 3.Punishment (e.g., punishment applied after the client has had an alcoholic drink) 4.Cognitions (verbal or pictorial events) based on attitudes or assumptions developed from previous experiences. These cognitions may be fairly accurate, or they may be distorted. 5.Avoidance training (e.g., client avoids punishment by pushing a glass of alcohol away within a certain time limit) 6.Pairing of a maladaptive behavior with a noxious stimulus (e.g., pairing the sight and smell of alcohol with electric shock), so that anxiety or fear becomes associated with the once-pleasurable stimulus

3.Punishment (e.g., punishment applied after the client has had an alcoholic drink) 5.Avoidance training (e.g., client avoids punishment by pushing a glass of alcohol away within a certain time limit) 6.Pairing of a maladaptive behavior with a noxious stimulus (e.g., pairing the sight and smell of alcohol with electric shock), so that anxiety or fear becomes associated with the once-pleasurable stimulus Rationale:When working with a client diagnosed with anorexia nervosa, the nurse must limit the amount of rigorous exercise that the client performs while providing for appropriate types and amount of exercise. Clients with anorexia nervosa frequently are preoccupied with rigorous exercise and push themselves beyond normal limits to work off caloric intake, which causes further deterioration of the physical state. The other nursing actions are inappropriate.

The nurse prepares to care for a client with inflamed joints and plans to use which item to maintain proper positioning for the inflamed joints? 1.Footboards 2.Large pillows 3.Small pillows 4.Soft mattress

3.Small pillows Rationale:Small pillows, trochanter rolls, and splints will properly and safely maintain proper positions for rest of inflamed joints. Large pillows may cause positions of more flexion than indicated. A soft mattress and footboards will not be helpful to inflamed joints and should be avoided.

The nurse is reinforcing home care instructions to a client following a gastric resection. The nurse should include which instruction to the client? 1.Avoid iron supplementation. 2.Eat a diet high in vitamin B12. 3.Take actions to prevent dumping syndrome. 4.Self-monitor for signs and symptoms of lower gastrointestinal hemorrhage.

3.Take actions to prevent dumping syndrome. Rationale:Dumping syndrome can occur in clients after gastric surgery and may occur as an early or late complication. Upper rather than lower gastrointestinal hemorrhage may also occur. A diet high in vitamin B12 will not prevent pernicious anemia because the client lacks intrinsic factor needed for absorption of the vitamin. Instead the client requires injections to supplement this vitamin. Iron supplements are necessary to help the absorption of parenteral vitamin B12.

The nurse is assigned to care for a client who has a nasogastric (NG) tube and is receiving tube feedings. When implementing nursing care for the client, the nurse remembers which information? Select all that apply. 1.To maintain the client in a supine position 2.To change the NG tube with every other feeding 3.That aspiration as a complication is a primary concern 4.To increase the rate of the feeding if the infusion rate falls behind schedule 5.To determine correct placement by aspirating contents from the tube to observe characteristics and check pH

3.That aspiration as a complication is a primary concern 5.To determine correct placement by aspirating contents from the tube to observe characteristics and check pH Rationale:Nasogastric tube feedings are beneficial but present several significant possible complications such as diarrhea, lactose intolerance, dumping syndrome, or excess fluid volume. The most common complication is aspiration pneumonia, which is caused by the regurgitation of formula contents from the stomach into the respiratory tract. Before administering a tube feeding, correct placement (stomach, not lungs) should be checked by observing the aspirated fluid and checking pH. The aspirated fluid from the stomach will appear green or yellowish. The pH is 1 to 4 if the client has fasted for 4 hours; the pH is 5 or higher on fluid aspirated from a continuous feeding. The client should not be supine, but rather the head of the bed is elevated to at least 30 degrees during the feeding. An NG tube can remain in place from weeks to months, depending on the type of tube that is inserted, and is not changed with every other feeding. Problems with diarrhea may be caused by infusing a formula that is cold or contaminated or of the wrong consistency. A rate of the formula that is too rapid may also cause diarrhea. The rate of the infusion is not increased to "catch up" if the schedule is behind.

The nurse is assisting a client to ambulate when the client states he is feeling faint and cannot stand. Which action should the nurse take to assist the client now? 1.The nurse should bend at the waist to assist the client to the floor. 2.The nurse should stand with legs close together for added support. 3.The nurse should extend one leg to use to slide the client's body down to the floor. 4.The nurse should hold the client under the arms and hold the upper body off the floor.

3.The nurse should extend one leg to use to slide the client's body down to the floor. Rationale:When a client feels faint, the nurse should act to protect the client from injury. The nurse should call for help and stop the client from falling and potential injury. The nurse assumes a wide stance to provide a broad base of support, extends one leg to the side, and slides the client's body down the leg while bending the knees. When the client is near the floor, the nurse protects the client from hitting the head. The nurse should not stand with legs together, bend at the waist, or hold the client up under the arms.

The nurse prepares to take a blood pressure (BP) on a school-age child. Where should the nurse place the blood pressure cuff to obtain an accurate measurement? 1.One half the distance between the antecubital fossa and the shoulder 2.One third the distance between the antecubital fossa and the shoulder 3.Two thirds the distance between the antecubital fossa and the shoulder 4.One quarter the distance between the antecubital fossa and the shoulder

3.Two thirds the distance between the antecubital fossa and the shoulder Rationale:The size of the BP cuff is important. Cuffs that are too small will cause falsely elevated values and those that are too large will cause inaccurate low values. The cuff should cover two thirds the distance between the antecubital fossa and the shoulder.

A young adult college student begins to throw objects, shout insults, and stamp his feet after an instructor returned his work, noting it was substandard. Using Erikson's theory of personality development, which developmental stage has this individual unsuccessfully mastered? 1. Initiative vs. guilt 2. Industry vs. inferiority 3. Identity vs. role confusion 4. Autonomy vs. shame and doubt

4. Autonomy vs. shame and doubt Rationale: Negative feelings of doubt and shame arise when individuals are made to feel self-conscious and shame. The positive outcomes of mastering this developmental stage are self-control and willpower. The lasting outcomes of initiative vs. guilt are direction and purpose. Not mastering this stage leads to guilt and lack of purpose. The ego quality developed from a sense of industry is competence. Feelings of inadequacy and inferiority may result from not mastering this task. The outcome of successful mastery of identity vs. role confusion is a sense of personal identity. Inability to solve this conflict results in role confusion.

A client in a long-term care facility who has a history of angina pectoris wants to go for a short walk outside with a family member. It is a sunny but chilly December day. The nurse should perform which intervention to care for this client in a holistic manner? 1. Tell the client that this is not allowed. 2. Tell the family member not to take the client outdoors. 3. Give the client a cup of hot coffee before going outside. 4. Instruct the family member to dress the client warmly before going outside.

4. Instruct the family member to dress the client warmly before going outside. Rationale: The nurse should meet both the physiological and psychosocial needs of the client in a holistic manner by asking the family member to be sure that the client is dressed warmly before going outside. Option 4 is correct because dressing the client warmly will decrease the chance of vasoconstriction, which may lead to an angina attack. Options 1 and 2 ignore the psychosocial needs. Option 3 is detrimental to physiological needs because, in addition to the cold weather, caffeine places an additional burden on the heart.

The nurse in the delivery room is assisting with the delivery of a newborn. The nurse prepares to prevent heat loss in the newborn due to conduction by initiating which action? 1. Wrapping the newborn in a blanket 2. Closing the doors to the delivery room 3. Drying the newborn with a warm blanket 4. Warming the crib pad before placing the newborn in the crib

4. Warming the crib pad before placing the newborn in the crib Rationale: Hypothermia caused by conduction occurs when the newborn is on a cold surface such as a pad or mattress and heat from the newborn's body is transferred to the colder object. Warming the crib pad will assist in preventing hypothermia by conduction. Evaporation of moisture from a wet body dissipates heat along with the moisture. Drying the wet newborn at birth will prevent hypothermia via evaporation. Convection occurs as air moves across the newborn's skin from an open door and heat is transferred to the air. Radiation occurs when heat from the newborn radiates to a colder surface.

The nurse is caring for a client with a diagnosis of end-stage renal disease. The client tells the nurse that a lawyer has prepared a living will and will be visiting the client today so that the will can be reviewed. The client also tells the nurse that the lawyer has asked for a witness to sign the will and requests that the nurse act as a witness. Which is the most appropriate nursing response to the client? 1."I would be pleased to do that for you." 2."You need to talk to the nursing supervisor." 3."I never sign anything, and I need to refuse to do this too." 4."A nurse caring for a client cannot serve as a witness to a living will."

4."A nurse caring for a client cannot serve as a witness to a living will." Rationale:Living wills address the withdrawal or withholding of life-sustaining interventions that unnaturally prolong life. It identifies the person who will make care decisions if the client is unable to take action. It is witnessed and signed by two people who are unrelated to the client. Nurses or employees of a facility in which the client is receiving care and beneficiaries of the client must not serve as witnesses.

A nursing instructor asks a nursing student about the use of bacillus Calmette-Guerin vaccine (BCG). Which response made by the nursing student is correct? 1."BCG is administered to children with a positive Mantoux test." 2."BCG is administered to all children to prevent tuberculosis (TB)." 3."BCG is administered to children with both a positive Mantoux test and positive chest x-ray." 4."BCG is administered to asymptomatic human immunodeficiency virus (HIV)-infected children who are at increased risk for developing TB."

4."BCG is administered to asymptomatic human immunodeficiency virus (HIV)-infected children who are at increased risk for developing TB." Rationale:The BCG vaccine is used mainly for children with a negative chest x-ray and skin test results who have had repeated exposures to TB and for asymptomatic HIV-infected children who are at increased risk for developing TB.

During a routine prenatal visit, a client complains of gingivitis and gums that bleed easily with brushing. When assisting to plan the care for the client, the nurse includes a goal that addresses proper nutrition to minimize this problem. The nurse determines that the goal has been achieved when the client makes which statement? 1."I am drinking 8 ounces of water with each meal." 2."I eat two saltine crackers before I get up each morning." 3."I am eating three servings of cracked-wheat bread each day." 4."I am eating fresh fruits and vegetables for snacks and for dessert each day."

4."I am eating fresh fruits and vegetables for snacks and for dessert each day." Rationale:Fresh fruits and vegetables will provide vitamins and minerals needed for healthy gums. Drinking water with meals has no direct effect on gums; saltine crackers before arising helps decrease nausea. Cracked-wheat bread may abrade the tender gums.

The nurse manager asks a licensed practical nurse to work on her day off because of a short-staffing problem. The licensed practical nurse has already made plans and does not want to work on the day scheduled to be off. Which response by the licensed practical nurse to the nurse manager is assertive? 1."I can't work that day." 2."You know how I hate to work extra shifts." 3."I will if you need me but I might be a few minutes late." 4."I have planned to take the day off and will not be able to work on that day."

4."I have planned to take the day off and will not be able to work on that day." Rationale:The most assertive response is the one that is direct and conveys a clear message in a positive manner. Option 1 is a passive response. Option 2 is an aggressive response. Option 3 is a passive-aggressive response.

A hospitalized client tells the nurse that a living will is being prepared and that the lawyer will be bringing the will to the hospital today for witness signatures. The client asks the nurse for assistance in obtaining a witness to the will. Which response to the client is appropriate? 1."I will sign as a witness to your signature." 2."You will need to find a witness on your own." 3."Whoever is available at the time will sign as a witness for you." 4."I will call the nursing supervisor to seek assistance regarding your request."

4."I will call the nursing supervisor to seek assistance regarding your request." Rationale:Living wills are required to be in writing and signed by the client. The client's signature must be either witnessed by specified individuals or notarized. Many states prohibit any employee, including the nurse of a facility where the declaring is receiving care, from being a witness. Option 2 is not therapeutic and not a helpful response. The nurse should seek the assistance of the nursing supervisor.

A client is being evaluated as a potential kidney donor for a family member. The donor asks the nurse why a different team of people other than the team working with the potential recipient is doing the evaluation. Which response should the nurse give to the client? 1.It helps reduce the cost of the preoperative workup. 2.It saves the client and recipient valuable preoperative time. 3.A sufficient number of people have to review the case so that no information is overlooked. 4.A conflict of interest by the team evaluating the recipient and the team evaluating the donor is avoided.

4.A conflict of interest by the team evaluating the recipient and the team evaluating the donor is avoided. Rationale:Both the kidney donor and recipient need thorough medical and psychological evaluation before transplant surgery. To avoid conflict of interest, evaluation of the donor is done by a team different from that caring for the recipient. The psychosocial issues in living-related organ donation may be very complex, and conversations with the donor are held in strict confidence to preserve family relations.

An adolescent is seen in the emergency department following an athletic injury, and it is suspected that the child sprained an ankle. X-rays are taken, and a fracture has been ruled out. The nurse reinforces instructions to the adolescent regarding home care for treatment of the sprain and provides the adolescent with which information? 1.Elevate the extremity and maintain strict bed rest for a period of 7 days. 2.Immobilize the extremity and maintain the extremity in a dependent position. 3.Apply heat to the injured area every 4 hours for the first 48 hours, and then begin to apply ice. 4.Apply ice to the injured area for a period of 30 minutes every 4 to 6 hours for the first 24 hours.

4.Apply ice to the injured area for a period of 30 minutes every 4 to 6 hours for the first 24 hours. Rationale:To treat a sprain, the injured area should be wrapped immediately to support the joint and control the swelling. Ice is applied to reduce the swelling and should be applied for no longer than 30 minutes every 4 to 6 hours for the first 24 to 48 hours. The joint should be immobilized and elevated, but strict bed rest for a period of 7 days is not required. A dependent position will cause swelling in the affected area.

A client has been taking benzonatate as prescribed. The nurse determines that the medication is having the intended effect if the client experiences which response? 1.Decreased anxiety level 2.Increased comfort level 3.Reduction in nausea and vomiting 4.Decreased frequency and intensity of cough

4.Decreased frequency and intensity of cough Rationale: Benzonatate is a locally acting antitussive. Its effectiveness is measured by the degree to which it decreases the intensity and frequency of cough, without eliminating the cough reflex. Options 1, 2, and 3 are not associated with the effects of this medication.

The nurse is reviewing the record of a client admitted to the hospital for treatment of bladder cancer. Which risk factor related to this type of cancer should the nurse likely note in the client's record? 1.Female African-American 2.Recorded age of 35 years 3.Occupation of computer analyzer 4.Drinks coffee and smokes cigarettes

4.Drinks coffee and smokes cigarettes Rationale:The incidence of bladder cancer is greater in men than in women and affects the white population twice as often as African-Americans. It most often occurs after the age of 40 years. Environmental health hazards have been attributed as causes. Cigarette smoking and drinking coffee are some factors associated with bladder cancer.

The nursing student is preparing to administer a medication to a newborn as a preventive measure against ophthalmia neonatorum. The nursing instructor asks the student to identify the medication and placement for the prophylaxis of ophthalmia neonatorum caused by gonococcal or chlamydia infection. The student correctly identifies which medication and location? 1.Penicillin, ears 2.Neomycin, eyes 3.Silver nitrate, ears 4.Erythromycin, eyes

4.Erythromycin, eyes Rationale:Ophthalmic erythromycin 0.5% ointment is a broad-spectrum antibiotic and is used prophylactically to prevent ophthalmia neonatorum, an eye infection acquired from the baby's passage through the birth canal. Ophthalmia neonatorum is caused mostly by the presence of gonococci and/or chlamydia. Infection from these organisms can cause blindness or serious eye damage. Erythromycin is effective against both chlamydia and gonococci. None of the other medications are effective against both bacteria, and the ears is not the correct location.

To assess for the presence of the posterior tibialis pulse, the nurse should palpate which areas? 1.In the groove just below the inguinal ligament 2.Behind the knee and lateral to the medial tendon 3.Lateral to and parallel with the extensor tendon of the big toe 4.In the groove behind the medial malleolus and the Achilles tendon

4.In the groove behind the medial malleolus and the Achilles tendon Rationale:The posterior tibialis pulse can be located in the groove behind the medial malleolus or the inside of the ankle behind the bone. The femoral pulse is palpated just below the inguinal ligament halfway between the pubis and anterior superior iliac spine. Popliteal pulses, although difficult to palpate, may be felt behind the knee in the popliteal fossa. The dorsalis pedis pulse is located on the top of the foot.

The nurse is participating in a health screening clinic and is preparing materials about colorectal cancer. The nurse should include which risk factor for colorectal cancer in the material? 1.Age of 20 years 2.High-fiber, low-fat diet 3.Distant relative with colorectal cancer 4.Personal history of ulcerative colitis or gastrointestinal (GI) polyps

4.Personal history of ulcerative colitis or gastrointestinal (GI) polyps Rationale:Common risk factors for colorectal cancer include age over 40 years; first-degree relative with colorectal cancer; high-fat, low-fiber diet; and history of bowel problems such as ulcerative colitis or familial polyposis.

The nurse is preparing to feed a client who is at risk for aspiration. The nurse assesses the client and uses a penlight and tongue blade to check the mouth and cheeks for pockets of food. Which action does the nurse take next? 1.Performs mouth care 2.Starts feeding the client 3.Adds thickener to the food 4.Places the client in an upright position

4.Places the client in an upright position Rationale: When preparing a client who is at risk for aspiration for feeding, the nurse first performs an assessment of the client. The nurse next checks the client's mouth and cheeks for pockets of food or other substances. The nurse next elevates the head of the client's bed (hips should be bent at a 90-degree angle with the head slightly forward) because this position will assist in swallowing and preventing aspiration. The nurse then performs mouth care, adds thickening to the food, and starts feeding the client.

The nurse is changing the neck ties on a tracheostomy tube. Which method is appropriate for the nurse to take? 1.Apply the new neck ties securely before removing the old neck ties. 2.Insert the obturator in the tracheostomy tube while the neck ties are changed. 3.Ask the client to hold the tracheostomy tube in place while the nurse changes the neck ties. 4.Remove the old ties, clean the site, and then apply the new ties while a second health care team member holds the tracheostomy tube.

4.Remove the old ties, clean the site, and then apply the new ties while a second health care team member holds the tracheostomy tube. Rationale:When changing neck ties that hold the tracheostomy tube in place, the nurse must use a technique that guarantees the tracheostomy tube will not be coughed out while the ties are changed. This is done by having a second caregiver assist by holding the tracheostomy tube in place while the other nurse removes the neck ties, cleanses the area, and applies the new ties. Applying the new neck ties before removing the old neck ties would not allow for cleansing the neck area. The obturator is the handle device with a blind smooth end that is placed inside the outer cannula of a tracheostomy tube and used during the insertion process. It occludes the cannula and would block breathing. Safety does not allow the client to assist with holding the tracheostomy tube during the change of neck ties.

A client is newly diagnosed with hypothyroidism. Levothyroxine is prescribed. The nurse should reinforce to the client which instructions about the medication? 1.Take with milk. 2.Take with food. 3.Take with fruit juice. 4.Take on an empty stomach.

4.Take on an empty stomach. Rationale: Levothyroxine should be taken on an empty stomach to enhance absorption. The client also is instructed to take the medication in the morning before breakfast. Therefore, options 1, 2, and 3 are incorrect.

The nurse is employed in a long-term care facility as a charge nurse of the night shift. The nurse determines that as a charge nurse, authority appropriately refers to which explanation? 1.Being responsible for what the staff members do 2.Accepting the responsibility for the actions of others 3.Carrying the legal responsibility for the task performance of others 4.The official power to approve an action, command an action, or to see that a decision is enforced

4.The official power to approve an action, command an action, or to see that a decision is enforced Rationale: Authority refers to the official power an individual has to approve an action, to command an action, or to see that a decision is enforced. Options 1, 2, and 3 are not related to the description of a position of authority.

The nurse assists in conducting a home safety assessment with a client preparing for discharge. The client tells the nurse that a space heater is used to heat part of the apartment. Which instruction should the nurse provide to the client regarding the use of the space heater? 1.A space heater should not be used in an apartment. 2.The space heater should always be kept at a low setting. 3.The space heater should be placed in the hallway at nighttime. 4.The space heater needs to be placed at least 3 feet from anything that can burn.

4.The space heater needs to be placed at least 3 feet from anything that can burn. Rationale:Space heaters need to be used appropriately because they present a great risk of fire. A space heater needs to be placed at least 3 feet from anything that can burn. Placing a heater in a hallway does not guarantee that it will be 3 feet from anything that can burn. A low setting does not reduce the risk of fire. A space heater can be used in an apartment if there is ample space and safety precautions are followed.

The nurse is assisting in teaching a series of classes on maintaining a healthy pregnancy. The goal for the class is "The pregnant woman will verbalize measures that may prevent physical traumatic conditions distressing to the fetus." Based on this goal, which topic should be a part of the teaching plan for this class? 1.Use of over-the-counter medications 2.Fetotoxic substances in the workplace 3.Effects of secondary cigarette smoke on the fetus 4.Travel precautions and use of shoulder seat belts

4.Travel precautions and use of shoulder seat belts Rationale: Placental separation as a result of uterine distortion can occur from trauma, such as in car accidents, and decreases or shuts off uteroplacental circulation. Partial placental separation will also result in fetal distress, with the amount of distress depending on the degree of separation. Complete separation leads to sudden severe fetal distress followed by fetal death. Use of the shoulder seat belt decreases the risk of placental separation by preventing the traumatic flexion of the woman's body from sharp braking or impact, if an accident occurs. Although consuming over-the-counter medications, exposure to fetotoxic substances in the workplace and secondary effects of smoking are important teaching points, they are not related to physical trauma conditions affecting the fetus.

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

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