NCLEX QUESTIONS PART TWO

A client is being encouraged to attend music therapy as part of the individual plan of care. The client refuses to attend and states that he "cannot sing." Which response by the nurse is therapeutic?

"Perhaps you could just enjoy the music without singing." Rationale: The correct response encourages the client to socialize and deflects the client's attention away from the subject of singing.

The client is taking phenytoin (Dilantin) for seizure control, and a blood sample for a serum drug level is drawn. Which laboratory finding indicates a therapeutic serum drug result?

15 mcg/mL Rationale: The therapeutic serum drug level range for phenytoin (Dilantin) is 10 to 20 mcg/mL.

The nurse arrives at the scene of a code and begins to assist in performing cardiopulmonary resuscitation (CPR) on an adult client. After determining proper hand placement, the nurse begins delivering compressions by pushing down on the chest at which depth?

2 inches Rationale: When performing CPR on an adult client, the sternum should be depressed 2 inches.

An older client is a victim of elder abuse, and the client's family has been attending weekly counseling sessions. Which statement by the abusive family member indicates the client has learned positive coping skills?

"I feel better able to care for my father now that I know where to obtain assistance." Rationale: Elder abuse sometimes occurs with family members who are being expected to care for their aging parents. This can cause family members to become overextended, frustrated, or financially depleted. Knowing where in the community to turn for assistance in caring for aging family members can bring much-needed relief. Taking advantage of these alternatives is a positive alternative coping strategy, which many families use.

The nurse is collecting data from a client and is attempting to obtain subjective data regarding the client's sexual reproductive status. The client states, "I don't want to discuss this-it's private and personal." Which statement by the nurse indicates a therapeutic response?

"I know that some of these questions are difficult for you, but as the nurse, I must legally respect your confidentiality." Rationale: Acknowledging the client's discomfort with the questions and assuring confidentiality is the only option that identifies a therapeutic response. The nurse acknowledging that she also hates being asked these sorts of questions makes the nurse's feelings the focus. This response clearly ignores that the issue is about the client and his or her discomfort, not about the nurse. Eliminate the option where the nurse becomes pompous, angry, and supercilious, which is not therapeutic. In the remaining option, the nurse begins correctly with an empathetic stance and then becomes demanding, so this can also be eliminated.

A mother of a child with cystic fibrosis asks the nurse when the postural drainage should be performed. The mother states that the child eats meals at 8:00 am, 12 noon, and at 6:00 pm. What times should the nurse tell the mother to perform postural drainage?

10:00 am, 2:00 pm, and 8:00 pm Rationale: Respiratory treatments should be performed at least 1 hour before meals or 2 hours after meals to prevent vomiting. In some children with cystic fibrosis, treatments are prescribed every 2 hours, particularly if infection is present. It is also important to perform these treatments before bedtime to clear airways and facilitate rest.

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

6.25 mL Rationale: Use the medication calculation formula. Formula: Desired --------- × Volume Available 25 mg ----- × 5 mL = 6.25 mL/dose 20 mg

The nurse is assisting in developing a plan of care for the client in a crisis state. When developing the plan, the nurse should consider which?

A client's response to a crisis is individualized, and what constitutes a crisis for one person may not constitute a crisis for another person. Rationale: Although each crisis response can be described in similar terms as far as presenting symptoms are concerned, what constitutes a crisis for one person may not constitute a crisis for another person because each is a unique individual. Being in a crisis state does not mean that the client is suffering from an emotional or mental illness.

The nurse is caring for a client with respiratory insufficiency. The arterial blood gas results indicate a pH of 7.50 and a PCo2 of 30 mm Hg, and the nurse is told that the client is experiencing respiratory alkalosis. Which additional laboratory value should the nurse expect to note?

A potassium level of 3.2 mEq/L Rationale: Signs/symptoms of respiratory alkalosis include tachypnea, mental status changes, dizziness, pallor around the mouth, spasms of the muscles of the hands, and hypokalemia. The remaining options identify normal laboratory results.

An assessment of a woman at 32 weeks of gestation indicates moderate fetal distress. Which intervention is the nurse's priority?

Administer oxygen with a face mask at 7 to 10 L/min. Rationale: Administering oxygen will increase the amount of oxygen for transport to the fetus. This action is essential regardless of the cause of the distress. Although the remaining options may be needed at some point during the care of the client, they are not priorities.

Theophylline is being administered to a client with acute bronchitis. The nurse planning care for the client demonstrates understanding of the primary action of this medication when which outcome is identified?

Airway muscles are relaxed. Rationale: Theophylline is a bronchodilator that directly relaxes the smooth muscles of the bronchial airway.

The nurse is preparing a client who is scheduled to have cerebral angiography performed. Which should the nurse check before the procedure?

Allergy to iodine or shellfish Rationale: The client undergoing cerebral angiography is assessed for possible allergy to the contrast dye, which can be determined by questioning the client about allergies to iodine or shellfish. Allergy to salmon is not associated with this procedure. Claustrophobia and excessive weight are areas of concern with magnetic resonance imaging.

A client with narcolepsy has been prescribed a central nervous system (CNS) stimulant. The client complains to the nurse that he cannot sleep well anymore at night and does not want to take the medication any longer. Before making any specific comment, the nurse plans to investigate whether the client takes the medication at which time schedule?

At least 6 hours before bedtime Rationale: A central nervous system (CNS) stimulant acts by releasing norepinephrine from nerve endings. The client should take the medication at least 6 hours before going to bed at night to prevent disturbances with sleep.

The nurse in the labor room is caring for a client in the first stage of labor. When monitoring the fetal patterns, the nurse notes an early deceleration of the fetal heart rate (FHR) on the monitor strip. Which is the appropriate nursing action?

Document the findings and continue to monitor the fetal patterns. Rationale: Early deceleration of the FHR is a gradual decrease in and return to baseline FHR in response to compression of the fetal head. It is a normal and benign finding. Because early decelerations are considered benign, interventions are not necessary. The remaining options are unnecessary.

A client arrives at the health care clinic and tells the nurse that he was just bitten by a tick and would like to be tested for Lyme disease. Which nursing action is appropriate?

Inform the client that he will need to return in 4 to 6 weeks to be tested because testing before this time is not reliable. rationale There is a blood test available to detect Lyme disease; however, it is not reliable if performed before 4 to 6 weeks following the tick bite.

Mafenide acetate (Sulfamylon) is prescribed for the client with a burn injury. When applying the medication, the client complains of local discomfort and burning. Which is the most appropriate nursing action?

Informing the client that this is normal Rationale: Mafenide acetate is bacteriostatic for gram-negative and gram-positive organisms and is used to treat burns to reduce bacteria present in avascular tissues. The client should be informed that the medication will cause local discomfort and burning and that this is a normal reaction.

A tricyclic antidepressant is administered to a client daily. The nurse plans to alleviate the common side effects of the medication and includes which in the plan of care?

Offer hard candy or gum periodically. Rationale: Dry mouth is a common side effect of tricyclic antidepressants. Frequent mouth rinsing with water, sucking on hard candy, and chewing gum will alleviate this common side effect. It is not necessary to monitor the blood pressure every 2 hours. In addition, it is not necessary to check the WBC count daily. Weight gain is a common side effect and frequent snacks will aggravate this problem.

An infant returns to the nursing unit after the surgical repair of a cleft lip located on the right side of the lip. The best position to place this infant at this time is which?

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

The nursing instructor asks a nursing student to describe the procedure for relieving an airway obstruction on an unconscious pregnant woman at 8 months' gestation. How should the student describe the procedure correctly?

Place a rolled blanket under the right abdominal flank and hip area. Rationale: To relieve an airway obstruction on an unconscious woman in an advanced stage of pregnancy, the woman is placed on her back. A wedge, such as a pillow or rolled blanket, is placed under the right abdominal flank and hip to displace the uterus to the left side of the abdomen

The nurse reinforces dietary instructions to a client who will be taking warfarin sodium (Coumadin). The nurse tells the client to avoid which food item?

Spinach Rationale: Warfarin sodium is an anticoagulant. Anticoagulant medications act by antagonizing the action of vitamin K, which is needed for clotting. When a client is taking an anticoagulant, foods high in vitamin K often are omitted from the diet. Vitamin K-rich foods include green, leafy vegetables; fish; liver; coffee; and tea.

An emergency department nurse is caring for a client who sustained a burn injury to the anterior arms and anterior chest area. The client sustained the burn from a home fire that occurred in the basement. Which data would indicate that the client sustained a respiratory injury as a result of the burn?

Use of accessory muscles for breathing Rationale: Clinical indicators in a burn client that would indicate respiratory injury include the presence of facial burns, the presence of soot around the mouth or nose, and singed nasal hairs. Signs of respiratory difficulty include changes in respiratory rate and the use of accessory muscles for breathing. Although anxiety may be a sign of hypoxemia, anxiety along with bradycardia, dysrhythmias, and lethargy would most likely indicate a concern related to a respiratory injury. Abnormal breath sounds and abnormal arterial blood gas values would also be noted. Pain is not specifically related to a respiratory injury.

For a client diagnosed with pulmonary edema, the nurse establishes a goal to have the client participate in activities that reduce cardiac workload. Which client activities will contribute to achieving this goal?

Using a bedside commode for stools Rationale: Using a bedside commode decreases the work of getting to the bathroom or struggling to use the bedpan. Elevating the client's legs would increase venous return to the heart and result in an increase in cardiac workload. The supine position can increase respiratory effort and decrease oxygenation, which increases cardiac workload. Meat tenderizers are high in sodium. Sodium contributes to hypertension, which increases cardiac workload.

The nurse is caring for a client with pneumonia with a history of bleeding esophageal varices. Based on this information, the nurse plans care, knowing that which could result in a potential complication?

Vigorous coughing Rationale: Increased intrathoracic pressure contributes to rupturing of varices. Straining at stool, coughing, and vomiting all increase intrathoracic pressure. The nurse needs to implement measures that will prevent increased intrathoracic pressure. pain; diarrhea and frequent swallowing will not increase intrathoracic pressure

A client who received a kidney transplant is taking azathioprine (Imuran), and the nurse reinforces instructions about the medication. Which statement by the client indicates a need for further teaching?

"I need to discontinue the medication after 14 days of use." Rationale: Azathioprine is an immunosuppressant medication that is taken for life. Because of the effects of the medication, the client must watch for signs of infection, which are reported immediately to the HCP. The client should also call the HCP if more than one dose is missed. The medication may be taken with meals to minimize nausea.

The nurse reinforces home care instructions to the postcraniotomy client. Which statement by the client indicates the need for further teaching?

"I will not hear sounds clearly unless they are loud." Rationale: Seizures are a complication that can occur for up to 1 year after surgery. For this reason, the client must diligently take anticonvulsant medications. The client and family are encouraged to keep track of doses administered. The family should learn seizure precautions and accompany the client while ambulating if dizziness or seizures tend to occur. The suture line is kept dry until sutures are removed to prevent infection. The postcraniotomy client can hear sounds, is typically sensitive to loud noises, and can find them irritating (e.g., loud television). Awareness control of environmental noise by others is helpful to this client.

A health care provider prescribes tetracycline hydrochloride (Sumycin) 0.5 g orally 4 times daily. The medication label on the bottle of medication reads tetracycline hydrochloride 250 mg tablets. The nurse prepares how many tablet(s) to administer one dose?

2 tablets rationale Convert 0.5 grams (g) to milligrams (mg). In the metric system, to convert larger to smaller, multiply by 1000 or move the decimal 3 places to the right. Therefore, 0.5 g = 500 mg. Next use the medication calculation formula to determine the correct dose. Formula: Desired --------- × Quantity = tablet(s) per dose Available 500 mg ------ × 1 tablet = 2 tablets 250 mg

The nurse is preparing to assist a client of Orthodox Jewish faith with eating lunch. A kosher meal is delivered to the client. Which nursing action is appropriate when assisting the client with the meal?

Allowing the client to unwrap the utensils and prepare his own meal for eating rationale Kosher meals arrive on paper plates and with plastic utensils sealed. Health care providers should not unwrap the utensils or transfer the food to another serving dish. Although the nurse may want to be helpful by assisting the client with the meal, the only appropriate option for this client is this option.

Permethrin (Elimite) is prescribed for a 4-year-old child with a diagnosis of scabies. The nurse reinforces instructions to the mother regarding the use of this treatment. Which instruction is appropriate?

Apply the lotion to cool, dry skin at least half an hour after bathing. Rationale: Permethrin is applied from the neck downward, with care taken to ensure that the soles of the feet, the areas behind the ears, and the areas under the toenails and fingernails are covered. The lotion should be kept on for 8 to 14 hours, and then the child should be given a bath. The lotion should be applied at least 30 minutes after bathing, and it should be applied only to cool, dry skin. The child should be clothed during treatment.

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

Atropine sulfate (Isopto Atropine) Mydriatic medications dilate the pupil and can cause an increase in intraocular pressure in the eye. Betaxolol (Betoptic) and Pilocarpine hydrochloride (Isopto Carpine) are miotic agents used to treat glaucoma. Pilocarpine (Ocusert Pilo -20) is a mydriatic and cycloplegic medication, and its use is contraindicated in clients with glaucoma.

A client is diagnosed with cancer and is told that surgery followed by chemotherapy will be necessary. The client states to the nurse, "I have read a lot about complementary therapies. Do you think I should try any?" The nurse should respond by making which appropriate statement?

"Let's talk more about the different forms of complementary therapies." Rationale: Complementary (alternative) therapies include a wide variety of treatment modalities that are used in addition to conventional treatment to treat a disease or illness. These therapies complement conventional treatment, but they should be approved by the person's health care provider (HCP) to ensure that the treatment does not interact with prescribed therapy. Although the HCP should approve the use of a complementary therapy, it is important for the nurse to explore the complementary therapies first with the client.

A client with depression who has attempted suicide says to the nurse, "I should have died. I've always been a failure. Nothing ever goes right for me." The nurse should make which therapeutic response to the client?

"You've been feeling like a failure for a while?" Rationale: Responding to the feelings expressed by a client is an effective therapeutic communication technique. The correct option is an example of the use of restating. The incorrect options block communication because they minimize the client's feelings and do not facilitate exploration of his or her expressed feelings.

The nurse is assisting in caring for a client who has a placenta previa. The nurse understands that a cervical examination should not be performed on the client primarily because it could do which?

Cause hemorrhage. Rationale: Because the placenta is implanted low in the uterus, cervical examination could cause the disruption of the placenta and initiate profound hemorrhage. The other options are also correct, but the profound hemorrhage is of the greatest concern in this case.

The nurse witnesses an accident in which the victim was hit by a car. The nurse stops at the scene of the accident and administers safe care to a victim who sustained a compound fracture of the femur. The victim is hospitalized and later develops sepsis as a result of the fractured femur. The victim files suit against the nurse who provided care at the scene of the accident. Which accurately describes the nurse's immunity from this suit?

The Good Samaritan laws will protect the nurse if the care given at the scene was not negligent. Rationale: A Good Samaritan law is passed by a state legislator to encourage nurses and other health care providers to provide care to a person when an accident, emergency, or injury occurs, without fear of being sued for the care provided. Called "immunity from suit," this protection usually applies only if all of the conditions of the law are met, such as the health care provider receives no compensation for the care provided, and the care given is not willfully and wantonly negligent.

The nurse is performing an environmental assessment in the home of an older client. Which requires immediate attention?

Unsecured scatter rugs Rationale: Trauma to the older client in the home may be caused by a variety of factors. Some of these factors include an unsteady gait, the presence of unsecured scatter rugs, cluttered passageways, inoperable smoke detectors, or a history of previous falls.

A licensed practical nurse has decided to purchase disciplinary defense insurance and is aware that this type of insurance would provide which type of benefits? Select all that apply.

representation by a qualified attorney // reimbursement for travel to the state board of nursing // payment of all legal fees for defense of a nursing license rationale Disciplinary defense insurance provides benefits if the individual has had action brought against a nursing license by a state board of nursing. The benefits of this insurance are to provide a qualified nurse attorney or attorney to represent the nurse and to pay for or reimburse the nurse for this attorney. It will reimburse for loss of wages and also for travel, food, and lodging to a hearing at the state board of nursing. It does not pay legal fees or any monetary benefit to an individual if the nurse is involved in a lawsuit related to negligent care.

According to Sigmund Freud's theory of personality development, which statement best describes the phallic stage?

Children recognize differences between males and females. Rationale: Freud's phallic stage of development includes the recognition of differences between the sexes. children gain control of the anal sphincter muscles describes Freud's anal stage; maturation of the genital reproductive system occurs describes the genital stage and physical energy is channeled into acquisition of knowledge describes the latency stage

The nurse is trying to communicate with a stroke (brain attack) client with aphasia. Which action by the nurse would be least helpful to the client?

Completing the sentences that the client cannot finish Rationale: Clients with aphasia after stroke often fatigue easily and have a short attention span. General guidelines when trying to communicate with the aphasic client include speaking more slowly and allowing adequate response time, listening to and watching attempts to communicate, and trying to put the client at ease with a caring and understanding manner. The nurse should avoid shouting (because the client is not deaf), appearing impatient for a response, and completing responses for the client.

The nurse is collecting data on a client with a diagnosis of right-sided heart failure. The nurse should expect to note which specific characteristic of this condition?

Dependent edema Rationale: Right-sided heart failure is characterized by signs of systemic congestion that occur as a result of right ventricular failure, fluid retention, and pressure buildup in the venous system. Edema develops in the lower legs and ascends to the thighs and abdominal wall. Other characteristics include jugular (neck vein) congestion, enlarged liver and spleen, anorexia and nausea, distended abdomen, swollen hands and fingers, polyuria at night, and weight gain. Left-sided heart failure produces pulmonary signs. These include dyspnea, crackles on lung auscultation, and a hacking cough.

A client has just delivered a viable newborn. The first nursing action to initiate attachment is which?

Determine the parents' desires for contact with the newborn. Rationale: Although immediate contact may be important for attachment or breast-feeding, the parents' wishes concerning contact with their newborn must be supported and determined first. The remaining options would follow the initial intervention.

A client with multiple sclerosis is receiving diazepam (Valium), a centrally acting skeletal muscle relaxant. Which data would indicate that the client is experiencing a side effect related to this medication?

Drowsiness rationale Incoordination and drowsiness are common side effects resulting from this medication.

The nurse prepares to explain the purpose of effleurage to a client in early labor. Which explanation by the nurse describes effleurage?

Effleurage is light stroking of the abdomen to facilitate relaxation during labor. Rationale: Effleurage is a specific type of cutaneous stimulation involving light stroking of the abdomen and is used before transition to promote relaxation and relieve mild to moderate pain.

A client is being treated for depression with amitriptyline hydrochloride. During the initial phases of treatment, which is the most important nursing intervention?

Getting baseline postural blood pressures before administering the medication and each time the medication is administered rationale Amitriptyline hydrochloride is a tricyclic antidepressant often used to treat depression. It causes orthostatic changes and can produce hypotension and tachycardia. This can be frightening to the client and dangerous because it can result in dizziness and client falls. The client must be instructed to move slowly from a lying to a sitting to a standing position to avoid injury if these effects are experienced. The client may also experience sedation, dry mouth, constipation, blurred vision, and other anticholinergic effects, but these are transient and will diminish with time.

A woman is admitted to an inpatient psychiatric unit with the diagnosis of anorexia nervosa. A behavior therapy approach is used as part of her treatment plan. Which is the purpose of the behavior therapy approach?

Help the client identify and examine dysfunctional thoughts and beliefs. Rationale: Behavior therapy is used to help clients identify and examine dysfunctional thoughts and the values and beliefs that maintain these thoughts.

The nurse is preparing to care for a child who received an allogenic bone marrow transplant (BMT). The nurse understands that which is the priority concern?

Infection Rationale: Once the marrow is infused, nursing care focuses on preventing immunocompromised children from developing a life-threatening infection until they engraft and produce their own white blood cells to fight infections.

To ensure a safe environment for a child admitted to the hospital for a craniotomy to remove a brain tumor, the nurse should include which in the plan of care?

Initiating seizure precautions Rationale: Safety of the child is the nursing priority. Seizure precautions should be implemented for any child with a brain tumor, both preoperatively and postoperatively. A thorough neurological assessment should be performed on the child, and the child's safety should be assessed before allowing the child to get out of bed without help. Assessment of the child's gait should be assessed daily

A client arrives at the emergency department with a foreign body in the left ear that has been determined to be an insect. Which initial intervention should the nurse anticipate to be prescribed?

Instillation of mineral oil or diluted alcohol Rationale: Insects are killed before removal unless they can be coaxed out by a flashlight or a humming noise. Mineral oil or diluted alcohol is instilled into the ear to suffocate the insect, which is then removed by using ear forceps. When the foreign object is vegetable matter, irrigation is not used because this material expands with hydration and the impaction becomes worse.

A client with a spinal cord injury has been experiencing discomfort because of spasticity, and dantrolene (Dantrium) is prescribed for the client. Before initiating therapy, the nurse anticipates that which testing will be prescribed?

Liver function studies Rationale: Dantrolene can cause liver damage, and the nurse should monitor the liver function studies. Baseline liver function studies are done before therapy starts, and regular liver function studies are performed throughout therapy. Dantrolene is discontinued if no relief of spasticity is achieved in 6 weeks.

The nurse administers an injection to a client with a diagnosis of acquired immunodeficiency syndrome (AIDS). After administering the medication, the nurse should dispose of the used needle by which method?

Placing the needle and syringe in a puncture-resistant container Rationale: The correct procedure for needle disposal is to discard uncapped needles and sharps in a hard-walled, puncture-resistant, leak-proof container immediately after use. Discarding the uncapped needle and attached syringe in a designated sharps container prevents injury to the client and health care personnel. Recapping needles increases the risk of needle-stick injury.

The nurse collecting data on a child suspects physical abuse. The nurse understands that which is a primary and legal nursing responsibility?

Report the case in which the abuse is suspected. Rationale: The primary legal nursing responsibility when child abuse is suspected is to report the case. All 50 states require health care professionals to report all cases of suspected abuse. Although documentation of findings, assisting the family, and referring the family to appropriate resources and support groups are important, the primary legal responsibility is to report the case.

The nurse is reinforcing home care instructions to the mother of a child with hemophilia. Which activity should the nurse suggest that the child can safely participate in with peers?

Swimming Rationale: Children with hemophilia need to avoid contact sports and need to take precautions, such as wearing elbow and knee pads and helmets, when participating in other sports. The safest activity that will prevent injury is swimming.

The nurse notes documentation in a client's record that the client is experiencing delusions of persecution. The nurse understands that these types of delusions are characteristic of which?

The false belief that one is being singled out for harm by others Rationale: A delusion is a false belief held to be true even when there is evidence to the contrary. A delusion of persecution is the thought that one is being singled out for harm by others. A delusion of grandeur is the false belief that he or she is a very powerful and important person. A delusion of jealousy is the false belief that one's partner is being unfaithful.

The nurse is monitoring a newborn with a suspected diagnosis of imperforate anus. The nurse understands that which is unassociated with this disorder?

The passage of currant jelly-like stools Rationale: During the newborn assessment, imperforate anus should be easily identified visually. However, a rectal thermometer or tube may be necessary to determine patency if meconium is not passed in the first 24 hours after birth. The presence of stool in the urine or vagina should be reported immediately as an indication of abnormal anorectal development. Currant jelly-like stool is not a symptom of this disorder.

The nurse reinforces medication instructions to a client who is taking levothyroxine (Synthroid). The nurse instructs the client to notify the health care provider (HCP) if which sign/symptom occurs?

Tremors Rationale: Excessive doses of levothyroxine (Synthroid) can produce signs and symptoms of hyperthyroidism. These include tachycardia, chest pain, tremors, nervousness, insomnia, hyperthermia, heat intolerance, and sweating. The client should be instructed to notify the HCP if these occur. The remaining options are signs of hypothyroidism

The nurse has obtained a personal and family history from a client with a neurological disorder. Which finding in the client's history is least likely associated with a risk for neurological problems?

Allergy to pollen Rationale: Previous neurological problems such as headaches or back injuries place the client more at risk for development of a neurological disorder. Chronic diseases such as hypertension and diabetes mellitus also place the client at greater risk. Assessment of allergies is a routine part of the health history, regardless of the nature of the client's problem. In addition, an allergy to pollen would not place the client at risk for a neurological problem.

The nurse is reinforcing instructions to a client about complete/high quality protein foods. Which food choice should indicate the client understood the teaching?

Eggs Rationale: Complete/high-quality proteins are found in a variety of meats and dairy products, specifically eggs. Beans are incomplete/low-quality proteins as are some cereals. Oranges contain vitamins and minerals.

The nurse is caring for a new immigrant from the Philippines who is in labor. The client is 4 cm dilated and 30% effaced. This is her first child. The mother is grimacing. Her pulse, respiratory rate, and blood pressure are elevated. The nurse offers to check on a prescription for an epidural. The mother declines. The nurse hypothesizes the client declines the epidural for which reasons? Select all that apply.

Filipino mothers fear drug addiction // Filipino mothers believe pain is a form of spiritual atonement for one's past deeds Rationale: Childbirth experiences differ among different cultures. Filipino mothers fear drug addiction. They also believe that pain is a form of spiritual atonement. Hispanic and Arab-American mothers are more vocal during childbirth. Mexican mothers have parteras (specially trained persons) attend them during the childbirth process. Vietnamese mothers are quiet during childbirth and view it as a normal part of life.

A client who has been newly diagnosed with diabetes mellitus has been stabilized with daily insulin injections. Which teaching information should the nurse reinforce upon discharge?

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

The nurse is working in the emergency department and is caring for a child who has been diagnosed with epiglottitis. Which is an indication that the child may be experiencing airway obstruction?

The child thrusts the chin forward and opens the mouth Rationale: Clinical manifestations that are suggestive of airway obstruction include tripod positioning (leaning forward supported by the hands and arms with the chin thrust out and the mouth open), nasal flaring, tachycardia, a high fever, and a sore throat.

A client with a diagnosis of major depression becomes more anxious, reports sleeping poorly, and seems to display increased anger. The nurse should make which interpretation about the client's behavior?

The client is at increased risk for suicide. Rationale: The behaviors identified in the question may be manifested by the client who is contemplating suicide. In clients who are depressed, anger may be self-directed in the form of suicide. Many of these symptoms are those of the depressed client; however, with this client, these behaviors have increased. Hospitalization may actually lessen these symptoms in the depressed client because a feeling of hope or relief may occur once treatment begins. Dealing with pertinent issues may be traumatic, but this is not the best interpretation of the behavior. Time off the unit for this client could put the client at risk for injury.

The health care provider is performing a vaginal examination on a pregnant woman. Which assessments are considered to be normal physiological changes in the vagina? Select all that apply.

vaginal secretions increase // bluish discoloration of the vagina // higher levels of glycogen in vaginal secretions rationale Vaginal secretions increase and have a higher level of glycogen. Chadwick's sign is a bluish discoloration of the vagina caused by increased vascular congestion. The vaginal mucosa thickens. The vaginal secretions become acidic to prevent infections.

The nurse is caring for a client diagnosed with scabies who has just been prescribed crotamiton (Eurax). The nurse provides which instruction for application of this medication?

Massage the medication into the skin from the chin downward, and apply a second application in 24 hours, followed up with a cleansing bath 48 hours after the second application. Rationale: The medication is massaged into the skin of the entire body, starting with the chin and working downward. The head and face are treated only if needed. Special attention should be given to skinfolds and creases. A second application is made 24 hours after the first. A cleansing bath should be taken 48 hours after the second application, and treatment can be repeated in 7 days if needed.

An infant returns to the nursing unit following surgery for an esophageal atresia with tracheoesophageal fistula (TEF). The infant is receiving intravenous (IV) fluids, and a gastrostomy tube is in place. The nurse assisting in caring for the infant should ensure that which action is done to the gastrostomy tube?

Elevated Rationale: In the immediate postoperative period, the gastrostomy tube is elevated, allowing gastric contents to pass to the small intestine and air to escape. This promotes comfort and decreases the risk of leakage at the anastomosis.

A mother of a 9-year-old child calls the emergency department and tells the nurse that her child received a minor burn on the hand after accidentally touching a grill during a family cookout. The mother asks the nurse for advice on how to treat the burn. Which action should the nurse tell the mother to immediately perform?

Place the child's hand under cool running water. Rationale: Most minor burns can be handled at home by the parents. For minor burns, exposure to cool running water is the best treatment. This stops the burning process and helps alleviate pain. Ice is contraindicated because it may add more damage to already injured skin. Option 4 is an incorrect measure. In addition, the mother may not have a sterile dressing available.

The nurse is assisting in preparing a client for a cardiac catheterization. The nurse understands that it is important to check the client's record for which history?

Allergy to shellfish Rationale: Allergy to seafood, iodine, or iodine contrast media in the preprocedure period may necessitate a skin test for allergy severity and the use of prophylactic antihistamines to prevent an allergic response to the contrast medium. The other options are important parts of the client's history but are not specific to a cardiac catheterization procedure.

A client in the third trimester of pregnancy visits the clinic for a scheduled prenatal appointment. The client tells the nurse that she frequently has leg cramps, primarily when she is reclining. On the basis of the client's complaint which should the nurse do first?

Check for signs of thrombophlebitis. Rationale: Leg cramps may be a result of compression of the nerves supplying the legs because of the enlarging uterus, a reduced level of diffusible serum calcium, an increase in serum phosphorus, or the presence of thrombophlebitis. In the pregnant client who complains of leg cramps, the nurse should first check for signs of thrombophlebitis and notify the registered nurse. If thrombophlebitis is not present, the nurse may be instructed to massage and place heat on the affected area, dorsiflex the foot until the spasm relaxes, or have the client stand on a cold surface. The health care provider may prescribe oral supplementation with calcium carbonate tablets or calcium hydroxide gel with each meal to increase the calcium level and lower the phosphorus level. Although the nurse may check for edema and check the pedal pulses, these would not be the first actions.

A client tells the nurse her contractions are getting stronger and that she is getting tired. She appears restless, asks the nurse not to leave her alone, and states, "I can't take it anymore." Based on the client's behavior the nurse should suspect the client is how far dilated?

8 to 10 cm rationale During the transition phase of the first stage of labor, cervical dilation progresses from 8 to 10 cm. As contractions intensify, women often doubt their ability to cope with labor and fear abandonment.

A 39-year-old man learned today that his 36-year-old wife has an incurable cancer and is expected to live not more than a few weeks. The nurse identifies which response by the husband as indicative of effective individual coping?

He expresses his anger at God and the health care providers for allowing this to happen. rationale the expression of anger is known to be a normal response to impending loss, and the anger may be directed toward the self, the dying person, God or other spiritual being, or the caregivers.

The nurse is assigned to care for a client with a diagnosis of Ménière's disease. Which part of the ear is affected with Ménière's disease?

Inner ear Rationale: Ménière's disease is a disorder of the labyrinth of the inner ear. This disorder does not affect the external ear, tympanic membrane, or the middle ear.

A pregnant client is receiving magnesium sulfate for the management of preeclampsia. The nurse determines that the client is experiencing toxicity from the medication if which is noted on data collection?

Respirations of 10 breaths per minute Rationale: Magnesium toxicity can occur as a result of magnesium sulfate therapy. Signs of magnesium sulfate toxicity relate to the central nervous system depressant effects of the medication and include respiratory depression (respiratory rate less than 12 breaths per minute), a loss of deep tendon reflexes, and a sudden drop in the fetal heart rate, maternal heart rate, and blood pressure. Therapeutic serum levels of magnesium are 4 to 7.5 mEq/L or 5 to 8 mg/dL. Proteinuria of 3+ is likely to be noted in a client with preeclampsia.

The nurse reviews the record of a 3-week-old infant and notes that the health care provider has documented a diagnosis of suspected Hirschsprung's disease. The nurse understands that which manifestation led the mother to seek health care for the infant?

Foul-smelling, ribbon-like stools Rationale: Chronic constipation that begins during the first month of life and that results in foul-smelling, ribbon-like or pellet-like stools is a clinical manifestation of Hirschsprung's disease. The delayed passage or absence of meconium stool during the neonatal period is a characteristic sign. Bowel obstruction (especially during the neonatal period), abdominal pain and distention, and failure to thrive are also signs and symptoms. This disorder results in a decrease in passage of stool, so diarrhea would not be a presenting manifestation. Hirschsprung's disease affects the colon, so regurgitation and vomiting most often associated with esophageal and stomach pathology would not be presenting manifestations.

The nurse is assisting in developing a plan of care for a newborn with spina bifida (myelomeningocele type). The nurse includes measures in the plan to monitor for increased intracranial pressure (ICP). Which action will detect the presence of an increase in ICP?

Monitoring the anterior fontanel for bulging Rationale: A bulging or taut anterior fontanel would indicate the presence of increased ICP. Blood pressure is difficult to assess during the newborn period and is not the best indicator of increased ICP. Urine concentration is also not well developed in the newborn stage of development. Monitoring for signs of dehydration will not provide data related to increased ICP.

To use an external cardiac defibrillator on a client, which action should be performed to check the cardiac rhythm?

Applying the adhesive patch electrodes to the skin and moving away from the client Rationale: The nurse or rescuer puts two large adhesive patch electrodes on the client's chest in the usual defibrillator position. The nurse stops cardiopulmonary resuscitation and orders anyone near the client to move away and not touch the client. The defibrillator then analyzes the rhythm, which may take up to 30 seconds. The machine then indicates if it is necessary to defibrillate. Although automatic external defibrillation can be done transtelephonically, it is done through the use of patch electrodes (not standard electrocardiographic electrodes) that interact via telephone lines to a base station that controls any actual defibrillation. It is not necessary to hold defibrillator paddles against the client's chest with this device.

The nurse is assisting in caring for a client with a diagnosis of bladder cancer who recently received chemotherapy. The nurse receives a telephone call from the laboratory who reports that the client's platelet count is 20,000/mm3. Based on this laboratory value, the nurse revises the plan of care and suggests including which intervention?

Monitor skin for the presence of petechiae. Rationale: When the platelet count is decreased, the client is at risk for bleeding. A high risk of hemorrhage exists when the platelet count is less than 20,000/mm3. Fatal central nervous system hemorrhage or massive gastrointestinal hemorrhage can occur when the platelet count is less than 10,000/mm3. the client should be assessed for signs of bleeding.

The nurse is preparing to reinforce a teaching plan for a client who is undergoing cataract extraction with intraocular implant. Which home care measures should the nurse include in the plan? Select all that apply.

to avoid activities that require bending over // to place an eye shield on the surgical eye at bedtime // to contact the surgeon if a decrease in visual acuity occurs // to take acetaminophen (tylenol) for minor eye discomfort rationale After eye surgery, some scratchiness and mild eye discomfort may occur in the operative eye and is usually relieved by mild analgesics. If the eye pain becomes severe, the client should notify the surgeon because this may indicate hemorrhage, infection, or increased intraocular pressure. The nurse would also instruct the client to notify the surgeon of purulent drainage, increased redness, or any decrease in visual acuity. The client is instructed to place an eye shield over the operative eye at bedtime to protect the eye from injury during sleep and to avoid activities that increase intraocular pressure such as bending over.