NCLEX Remediation

The 25-year-old client comes to the emergency department reporting cramping pelvic pain and having saturated 5 peri pads in the past 2 hours. Which priority questions does the nurse ask? *Select all that apply.* 1. "Are you feeling dizzy?" 2. "When was the first day of your last period?" 3. "Are you taking ibuprofen for your pain?" 4. "When did the bleeding start?" 5. "When did you last have intercourse?" 6. 'What did you eat at your last meal?"

1. "Are you feeling dizzy?" 2. "When was the first day of your last period?" 4. "When did the bleeding start?" Explanation Strategy: Consider the ABCs when thinking about the answers. Determine why the nurse would ask each question. Is it important to this situation? 1) CORRECT — the problem is bleeding; assesses the "here and now" and worst-case scenario; helps determine true amount of blood loss 2) CORRECT — it is important to assess the last period to determine pregnancy potential and the possible loss of pregnancy 3) may be helpful to determine if the pain medication had any effect on the pain, but not priority at this time 4) CORRECT —- it is important to gather history of this event, as it will help determine amount of bleeding 5) may be a follow-up question after determining if pregnancy is a possibility, but not priority at this time 6) may be a follow-up question if pregnancy is not a possibility, but not priority at this time

The nurse assesses the client diagnosed with seizures, migraines and type 1 diabetes. Which client statements require a follow-up by the nurse? Select all that apply. 1. "I see fireflies around my head." 2. "I can't seem to wake up today." 3. "My hands won't stop shaking." 4. "I usually give myself the insulin." 5. "I usually sleep after a seizure."

1. "I see fireflies around my head." 2. "I can't seem to wake up today." 3. "My hands won't stop shaking." Explanation Strategy: "Requires a follow-up" indicates something is wrong. Answers are client quotes. Think about what the words indicate and how the client statements relate to the diagnoses in the stem of the question. 1) CORRECT — flashing lights may indicate aura before the seizure or a migraine 2) CORRECT — may indicate hyperglycemia 3) CORRECT — tremors may be associated with hypoglycemia 4) promotion of independence with self-care appropriate 5) postictal confusion and sleepiness common

The nurse instructs a client about how to collect a 24-hour urine specimen. The nurse determines that teaching is effective if the client makes which of the following statements? 1. 'I should discard my first morning specimen, collect all urine for 24 hours, and place the urine in one container." 2. 'I should begin the collection at 8 am, collect all urine voided between 8 am and 8 pm, and place the urine in one container." 3. "I should not mix the urine I collect within the 24 hours." 4. "I will call the nurse to notify the lab about when to begin the test."

1. 'I should discard my first morning specimen, collect all urine for 24 hours, and place the urine in one container." Explanation Strategy: "Teaching is effective" indicates correct information. 1) CORRECT - discarding first morning specimen removes residual urine from the bladder 2) collect urine for 24 hours 3) all urine should be placed in one container 4) should discard urine, note time, and collect all urine specimens during next 24 hours

The nurse cares for clients in the skilled nursing facility. Which client requires the nurse's immediate attention? 1. A client admitted for a cerebral vascular accident (CVA) whose prescription for warfarin expired 2 days ago. 2. A client in pain who was receiving morphine in an acute care institution and was transferred with a prescription for acetaminophen with codeine. 3. A client who has dysuria and foul-smelling, cloudy, dark amber urine. 4. An immunosuppressed client who has not received an influenza immunization.

1. A client admitted for a cerebral vascular accident (CVA) whose prescription for warfarin expired 2 days ago. Explanation Strategy: Determine the least stable client (1) CORRECT - duration of warfarin is 2 to 5 days, client at risk for a repeat CVA (2) anticoagulant takes priority, client still receiving pain medication (3) painful urination, may indicate infection (4) anticoagulant takes priority

The nurse plans staff assignments. Which clients are appropriate to assign to the LPN/LVN? Select all that apply. 1. A client who is 48 hours post surgery and requires heparin 5,000 units SQ every 8 hours. 2. A client who fell in the long-term care facility and sustained an orbital fracture yesterday. 3. A client who sustained a gunshot injury and has a chest tube to water-seal drainage. 4. A client who was admitted with a bowel obstruction and is now passing soft-formed stools. 5. A client who is 1 day post Iaminectomy and is receiving morphine sulfate via PCA pump.

1. A client who is 48 hours post surgery and requires heparin 5,000 units SQ every 8 hours. 4. A client who was admitted with a bowel obstruction and is now passing soft-formed stools. Explanation Strategy: Assign the LPN/LVN to stable clients with expected outcomes. 1) CORRECT — post-surgical thrombosis prophylaxis, stable client, unchanging orders 2) inappropriate because of possible increased intracranial pressure, requires RN assessment 3) inappropriate because of a need for RN assessment for complications 4) CORRECT— stable client with unchanging orders, no assessment needed 5) requires frequent RN assessment, potentially changing condition

An adult comes to the emergency room in acute respiratory distress. The client has a 20-year history of asthma. The nurse considers which of the following as an ominous sign in this patient? 1. Absence of wheezing on auscultation. 2. Crackles are heard on auscultation. 3. Bilateral rales are absent on auscultation. 4. Coarse rhonchi are present on auscultation.

1. Absence of wheezing on auscultation. Explanation Strategy: Think about the causes of each sign. 1) CORRECT - indicates acute respiratory distress; small airways completely constricted; patient requires immediate intervention 2) crackles: rales; abnormal breath sounds caused by air through fluid; not usually seen with asthma 3) not expected with asthma; symptoms of asthma include dyspnea, wheezing, nonproductlve cough, tachycardia, tachypnea 4) continuous grating sounds; indicates disease of bronchi; not expected with asthma

The child is in the early stages of nephrotic syndrome. The nurse discusses which dietary change with the parents? 1. Adequate protein, low sodium intake. 2. Low protein, low potassium intake. 3. Low potassium, low calorie intake. 4. Limited protein, high carbohydrate intake.

1. Adequate protein, low sodium intake. Explanation Strategy: Think about each answer. 1) CORRECT - if child can tolerate the protein intake, then this diet is encouraged to speed healing; sodium is usually restricted 2) low protein contraindicated in clients with kidney disease 3) does not address protein need at all 4) may be appropriate only if the child cannot tolerate protein intake

The nurse supervises nursing assistive personnel (NAP). Which tasks does the nurse delegate to the MAP? Select all that apply. 1. Apply an abdominal binder. 2. Prepare an antibiotic injection for the nurse. 3. lrrigate a client's fresh wound using sterile technique. 4. Determine the staging of a client's pressure ulcer. 5. Apply an elastic bandage. 6. Assist a client with use of a urinal.

1. Apply an abdominal binder. 6. Assist a client with use of a urinal. Explanation Strategy: Nursing assistive personnel are assigned to clients requiring standard, unchanging procedures. 1) CORRECT — applying abdominal binder can be delegated to NAP; however, nurse is responsible for assessment of area where binder will be applied and client's comfort level after application 2) preparing injections cannot be delegated to NAP 3) wound irrigation cannot be delegated to NAP; however, in some settings, cleansing of chronic wounds using clean technique can be delegated to NAP 4) assessment and staging of pressure ulcer cannot be delegated to NAP; requires RN assessment 5) application of elastic bandage cannot be delegated to NAP; nurse's responsibility to assess circulation immediately after application 6) CORRECT — NAP can assist with toileting and basic care measures

The nursing assistive person on an acute urology unit gives the nurse the intake and output sheet for a client diagnosed with chronic kidney disease. The client's output was measured on the day shift but not recorded on the evening shift. Which action should the charge nurse take first? 1. Call the nurse assigned to the evening shift and request the information. 2. Complete an agency incident report. 3. Ask the client to give the output for last

1. Call the nurse assigned to the evening shift and request the information. Explanation Strategy 'FIRST indicates priority. 1) CORRECT - the goal is to make every effort to retrieve the data; knowledge of output used to support decision making about most appropriate interventions; nurses often carry notes home with them or store their work sheets in their lockers; this method seeks a possible resource 2) last step; information may be available; quality client care is first priority; don't have problem yet 3) some clients notice the volume and some do not; is a possible resource, but is not the best resource; is nurse's job to record output 4) focus is not maintaining system at this point; focus is on collection of prime data for management of client health needs

The nurse cares for the client diagnosed with paranoid schizophrenia. The nurse knows that questioning the client about the client's false ideas will elicit which response? 1. Cause the client to defend the idea. 2. Help the client clarify thoughts. 3. Facilitate better communication. 4. Lead to a breakdown of the defense.

1. Cause the client to defend the idea. Explanation Strategy: Think about each answer. 1) CORRECT - contraindicated; encourages client to engage in further distortion of reality 2) needs reality testing from nurse, not questioning 3) questioning is nontherapeutic; may cause client to avoid nurse physically 4) needs defense; questioning will further distort reality or elaborate on delusion

The client diagnosed with Addison's disease comes to the health clinic. When assessing the client's skin, the nurse expects to make which observation? 1. Darker skin that is more pigmented. 2. Skin that is ruddy and oily. 3. Skin that is puffy and scaly. 4. Skin that is pale and dry.

1. Darker skin that is more pigmented. Explanation Strategy: Determine how each answer relates to Addison's disease. (1) CORRECT - increase in melanocyte-stimulating hormone results in "eternal tan" (2) not seen with Addison's disease (3) not seen with Addison's disease (4) not seen with Addison's disease

A client diagnosed with an adjustment disorder with depressed mood has the greatest chance of success in activities that require psychic and physical energy if the nurse schedules activities at which time? 1. During the morning hours. 2. During the middle of the day. 3. During the afternoon hours. 4. During the evening hours.

1. During the morning hours. Explanation Strategy: Think about each answer. (1) CORRECT - client with reactive depression has the highest level of physical and psychic energy in the morning (2) as the day progresses, energy level declines (3) as the day progresses, energy level declines (4) as the day progresses, energy level declines

The nurse recognizes which symptoms are early signs of lithium toxicity? Select all that apply. 1. Fine motor tremors. 2. Involuntary muscle movements. 3. Seizures. 4. Nausea and vomiting. 5. Orthostatic hypotension. 6. Diarrhea.

1. Fine motor tremors. 4. Nausea and vomiting 6. Diarrhea. Explanation Strategy: Think of lithium toxicity. 1) CORRECT - A symptom of toxicity. 2) Associated with antipsychotics. 3) Associated with severe lithium toxicity. 4) CORRECT - An early symptom. 5) Associated with antipsychotics. 6) CORRECT — An early symptom. 2. Involuntary movements. 3. Seizures. 4. Nausea and 5. Orthostatic hypotension. 6. Diarrhea.

The client receives a blood transfusion and experiences a hemotytic reaction. The nurse anticipates which assessment findings? Select all that apply. 1. Hypotension. 2. Low back pain. 3. Wet breath sounds. 4. Fever. 5. Urticaria. 6. Severe shortness of breath.

1. Hypotension. 2. Low back pain. 4. Fever. Explanation Type: select all that apply. Did you identify the topic correctly? Signs and symptoms of hemolytic blood reaction. Note: The topic is not what you are worried about if you see it; it is very specific to hemolytic reaction. Use the words. is (the answer) a finding for hemolytic reaction? This will help keep you focused. 1) CORRECT — blood pressure drops 2) CORRECT — classic symptom related to hemolytic reaction 3) related to circulatory overload 4) CORRECT — fever is an expected symptom 5) related to an allergic reaction 6) related to circulatory overload Step 5: Do you have more than one answer? Yes. Does your answer make sense for hemolytic reactions? Yes.

The nurse cares for the client diagnosed with a recurrent urinary tract infection. The health care provider prescribes ciprofloxacin. The nurse instructs the client to limit intake of which fluid? 1. Milk. 2. Cranberry juice. 3. Water. 4. Tea.

1. Milk. Explanation Strategy: Think about each answer. 1) CORRECT — should limit intake of alkaline foods and fluids 2) can be increased to acidify urine 3) does not need to be restricted 4) does not need to be restricted

The toddler diagnosed with lead poisoning is admitted to the pediatric unit- The health care provider writes an order to encourage fluids. Which fluid is best for the nurse to offer to the toddler? 1. Milk. 2. Water. 3. Orange juice 4. Fruit punch.

1. Milk. Explanation Strategy: Determine how each answer relates to lead poisoning. (1) CORRECT - milk contains calcium; calcium binds to lead and inhibits its absorption (2) good for fluid replacement; does not relate to the lead poisoning (3) good for fluid replacement; does not relate to the lead poisoning (4) good for fluid replacement; does not relate to the lead poisoning

During a sudden rise in a nearby river, the nurse at a day camp evacuates the children to an area away from the river. Which action should the nurse take NEXT? 1. Place an identification bracelet on each child. 2. Go back for an adequate supply of water. 3. Notify the parents of the children's location. 4. Comfort children who are anxious.

1. Place an identification bracelet on each child. Explanation Strategy: Determine the outcome of each answer. 1) CORRECT - aids in communication after rescue or recovery 2) nurse should not leave the children alone 3) identification takes priority over notification 4) priority is assuring that each child can be identified

A client comes to the outpatient psychiatric clinic for treatment of a fear of heights. The nurse knows that phobias involve which behaviors? 1. Projection and displacement. 2. Sublimation and internalization. 3. Rationalization and intellectualization- 4. Reaction formation and symbolization.

1. Projection and displacement. Explanation Strategy: Think about each answer. Both parts of the answer must be correct 1) CORRECT - projection (attributing one's thoughts or impulses to another) and displacement (shifting of emotion concerning person or object to another neutral or less dangerous person or object) 2) sublimation (diversion of unacceptable drives into socially acceptable channels) and internalization (incorporation of someone else's opinion as one's own) 3) rationalization (attempt to make behavior appear to be the result of logical thinking) and intellectualization (excessive reasoning or logic used to avoid experiencing disturbing feelings) 4) reaction formation (development of conscious attitudes and behavior patterns into opposite of what one really wants to do) and symbolization (something represents something else); symbolization is involved in phobias; reaction formation not a defense mechanism used in phobias

The home care nurse visits a new parent and a 2-week-old infant. The client asks the nurse which solid foods to give the child first. Which response does the nurse give? 1. Rice cereal is usually the first solid food and is started around 4 to 5 months. 2. Strained fruits are well tolerated as the first solid food, and infants like them. 3. Introduction of solid foods is not important at this time. 4. Solid foods are usually not started until the infant is around 6 months old.

1. Rice cereal is usually the first solid food and is started around 4 to 5 months. Explanation Strategy: All answers are implementation. Determine the outcome of each answer. Is it desired? 1) CORRECT - infants are less likely to be allergic to rice cereal than to any other solid food; usually started between 4 and 5 months of age; breast- fed infants may be started on solids even later 2) inaccurate 3) does not answer the parent's question 4) usually started between 4 and 5 months of age

The health care provider prescribes lithium carbonate 300 mg PO QID for an adult client. The nurse in the outpatient clinic instructs the client about the medication. The nurse should encourage the client to maintain an adequate intake of which substance? 1. Sodium. 2. Protein. 3. Potassium. 4. Iron.

1. Sodium. Explanation Strategy: Think about each answer. (1) CORRECT - alkali metal salt acts like sodium ions in the body; excretion of lithium depends on normal sodium levels; sodium reduction causes marked lithium retention, leading to toxicity (2) doesn't interact with lithium (3) doesn't interact with lithium (4) doesn't interact with lithium

If the nurse cares for a client with ataxia, which action is most important? 1. Supervise ambulation. 2. Measure the intake and output accurately. 3. Consult the speech therapist 4. Elevate the foot of the bed.

1. Supervise ambulation. Explanation Strategy: Think about each answer. (1) CORRECT — client's coordination is poor, the only relevant nursing action is to supervise ambulation (2) unnecessary (3) not relevant ( 4) not relevant

The nurse cares for an older client scheduled for a colon resection this morning. The nurse notes the client had polyethylene glycol-electrolyte solution and a soapsuds enema the previous evening. This morning the client passes a medium amount of soft brown stool. Which conclusion by the nurse is most accurate? 1. The bowel preparation is incomplete. 2. The client ate something after midnight 3. This is an expected finding before this type of surgery. 4. The client passed the last stool left in the colon.

1. The bowel preparation is incomplete. Explanation Strategy: Think about each answer. (1) CORRECT - colon should not have remaining soft stool (2) anything eaten after midnight would not appear as stool by the next moming (3) not expected; need to clean gastrointestinal tract for surgery ( 4) assumption; not substantiated

The nurse supervisor observes the staff member entering the client's room wearing gown and gloves. The nurse knows the staff member is caring for which client? 1. The child with respiratory syncytial virus. 2. The child with Kawasaki disease. 3. The child with Lyme disease. 4. The child with infectious mononucleosis.

1. The child with respiratory syncytial virus. Explanation Strategy: Think about each answer. 1) CORRECT - acute viral infection; requires contact precautions; assign to private room or with other RSV-infected children 2) acute systemic vasculitis in children under 5; standard precautions 3) connective tissue disease; standard precautions 4) standard precautions

In preparing a teaching plan regarding colostomy irrigations, the nurse should include which information? 1. The colostomy needs to be irrigated at the same time every day. 2. irrigate the colostomy alter meals to increase peristalsis. 3. Insert the catheter about 10 inches into the stoma. 4. The solution should be very warm to increase dilation and flow.

1. The colostomy needs to be irrigated at the same time every day. Explanation Strategy: All answers are implementation. Determine the outcome of each answer. Is it desired? (1) CORRECT - colostomy irrigation should be done at same time each day to assist in establishing a normal pattern of elimination (2) colostomy should be irrigated only once a day (3) catheter should never be inserted more than 4 inches. (4) solution should be at body temperature; increasing the temperature does not make irrigation more efficient

The outpatient clinic nurse cares for an elderly client diagnosed with type 1 diabetes. Because the client is unwilling to perform blood glucose monitoring, the client tests urine for sugar and acetone. The nurse knows that blood glucose monitoring is preferred over urine testing for glucose because of which reason? 1. The renal threshold for glucose is elevated in the elderly. 2. Blood glucose monitoring is easier and less costly for clients to perform. 3. Urine testing for glucose provides false-positive readings. 4. Determination of the color on a reagent strip varies from person to person.

1. The renal threshold for glucose is elevated in the elderly. Explanation Strategy: Think about each answer. 1) CORRECT - the level at which glucose starts to appear in the urine increases, leading to false-negative readings; results in elevated glucose levels 2) more expensive procedure 3) provides false-negative readings; may be negative from 0 to 180 (0-10 mmollL) mgldL 4) results are expressed as a percentage according to color change

A client develops a postoperative infection and receives ceftriaxone sodium IV every day. It is most important for the nurse to monitor for which changes? 1. The surface of the tongue. 2. Hemoglobin and hematocrit. 3. Skin surfaces in skin folds. 4. Changes in urine characteristics.

1. The surface of the tongue. Explanation Strategy: Answer choices indicates a complication. (1) CORRECT - cephalosporin, long-tenn use of ceftriaxone sodium can cause overgrowth of organisms; monitoring of tongue and oral cavity is recommended (2) does not reflect a problem with this medication (3) does not reflect a problem with this medication (4) does not reflect a problem with this medication

Which symptoms alert the nurse to consider an alcohol problem in a client hospitalized for a physical illness? Select all that apply. 1. Tremors. 2. Elevated temperature. 3. Depression. 4. Noctumal leg cramps. 5. Night sweats. 6. Decreased concentration.

1. Tremors. 2. Elevated temperature. 4. Noctunal leg cramps. Explanation Strategy: Think about symptoms of withdrawal from alcohol. 1) CORRECT - symptom of withdrawal 2) CORRECT - symptom of withdrawal 3) seen in a depressed client 4) CORRECT - symptom of withdrawal 5) seen in clients with tuberculosis, leukemia, or other infections 8) seen in a depressed client

The health care provider suggests play therapy for the 7-year-old child having some difficulty adjusting to the parents' impending divorce. The nurse identifies which reason this type of therapy is effective for this age group? 1. Young children have difficulty verbalizing emotions. 2. Children hesitate to confide in anyone but their parents. 3. Play is an enjoyable form of therapy for children. 4. Play therapy is helpful in preventing regression.

1. Young children have difficulty verbalizing emotions. Explanation Strategy: Think about each answer. (1) CORRECT - children have difficulty putting feelings into words; play is how they express themselves (2) somewhat true, but not best reason for play therapy (3) not reason play therapy is used; is used because it is the best way for children to express themselves (4) may encourage child to act out earlier developmental stage to reveal underlying conflicts

The nurse in the critical care unit reviews postoperative care for a patient after a supratentorial craniotomy. It is MOST important for the nurse to instruct the aide to do which of the following? 1."Put an icepack on the patient's eye and a cool compress on his forehead" 2."Determine how much pain the patient is experiencing on a scale of 1 to 10 and report back to me." 3."Keep the head of the bed flat, with the patient lying on his back." 4."If the patient starts to have a seizure, place a padded tongue blade in his mouth right away and call for help."

1."Put an icepack on the patient's eye and a cool compress on his forehead" Explanation: appropriate to delegate to unlicensed assistive personal (UAP) application of heat or cold to a closed inflated or painful area patient may have periorbital edema and burning after the surgery; ice will help with vasoconstriction and decrease of edema; cool compress is a comfort measure.

A client newly diagnosed with Meniére's disease is counseled by the office nurse about important dietary modifications. Which comment, if made by the client to the nurse, BEST indicates teaching is successful? 1. "l have seen a lot of dietetic foods in the store. I will focus on buying them." 2. "I will avoid Chinese restaurants and fast-food places when I go out to eat." 3. "I will buy one of those commercial salt substitutes to use when l have a craving for salt." 4. "I understand that I can have corned beef and smoked fish, but not pickles or creamed sauces."

2. "I will avoid Chinese restaurants and fast-food places when I go out to eat." Explanation Strategy: "Teaching is successful' indicates correct information. (1.) not best; not all dietetic foods are low in sodium; labels need to be read (2.) CORRECT - clients with Meniére's disease require a low-sodium diet to decrease fluid retention (endolymphatic fluid, which is clear, intracellular fluid located in the labyrinth of the inner ear); many Chinese restaurants use MSG and soy sauce, both of which are high in sodium; fast-food places and products also have a tendency to be high in sodium (3.) spices and herbs would be better substances for flavor enhancement (4.) meat and fish products that are canned, smoked, pickled, or cured should be avoided because they are high in sodium, as are pickles and, often, creamed sauces

The school nurse conducts a workshop on eating disorders for parents and teens. Which participant statements indicate correct understanding of the teaching? Select all that apply. 1. "I do not need to worry as long as my child's BMI stays between 20 and 25." 2. "I will set healthy goals for my food and fluid intake." 3. "it is important to weigh or measure all of the food my child eats." 4. "I will keep a food journal in which I will write down what I'm eating and how I'm feeling." 5. "Our family needs to eat every meal together each day." 6. "Medical treatment of anorexia will not be effective unless my child participates willingly."

2. "I will set healthy goals for my food and fluid intake." 4. "I will keep a food journal in which I will write down what I'm eating and how I'm feeling." Explanation Strategy: "Correct understanding of the teaching" indicates correct information. Determine the outcome of each answer. Is it desired? 1) clients with bulimia may maintain a normal BMI, but they still need intervention 2) CORRECT —- when clients with eating disorders participate in goal setting, their chances of successful treatment increase 3) this level of involvement by family members is often counterproductive 4) CORRECT —- recognizing feelings of anxiety or powerlessness often leads to insight into maladaptive eating behaviors 5) although family involvement is a necessary part of treatment, it is not reasonable to expect families to eat all meals together 6) in cases of extreme malnutrition or dehydration emergency, medical care is required; the client may not desire this

The home care nurse teaches the daughter of an elderly client about her father's hydration status. The nurse is MOST concerned if the daughter states which of the following? 1. 'I should check my father's mouth for dryness: 2. 'I should pinch a fold of skin on the back of my father's hand." 3. 'I should check my father's eyes for dryness." 4. 'I should make sure that my father stands up slowly.'

2. 'I should pinch a fold of skin on the back of my father's hand." Explanation Strategy 'MOST concerned 'indicates something is wrong. 1) decreased fluid volume causes mucous membranes to dry out; tongue will reflect hydration status since it is not affected by the aging process 2) CORRECT - elasticity of skin in this area is affected by aging; gives an inaccurate assessment of hydration status 3) will be dry due to dehydration 4) decreased fluid volume causes postural hypotension; instruct to change position slowly

Four children come to the office of the school nurse at the same time. After performing an assessment, the nurse determines that the parents of which of the following children should be contacted FIRST to come pick up their child? 1. A child with a red rash on the cheeks that makes the child's face look like it has been slapped. 2. A child with a fever who complains of headache, malaise, anorexia, and an earache when chewing. 3. A child with an apparent upper respiratory infection (URI) and an inflamed conjunctiva with swollen eyelids and watery drainage. 4. A child with clusters of small, erythematous, intensely pruritic papules in the antecubital space.

2. A child with a fever who complains of headache, malaise, anorexia, and an earache when chewing. Explanation Strategy: Determine the child who is most infectious. (1.) indicates fifth disease; most contagious before rash appears, isolation not required once rash appears; child can attend school (2.) CORRECT - indicates probable mumps; communicability greatest immediately before and after the swelling begins (3.) symptoms are of viral conjunctivitis; not priority (4.) describes eczema; not priority

The nursing team consists of an RN, an LPN, and two nursing assistants. The RN should care for which of the following clients? 1. A child recovering from surgical repair of a hypospadias. 2. A client recovering from excision of a malignant melanoma. 3. A client diagnosed with a myocardial infarction requiring assistance to the bathroom. 4. A client diagnosed with urolithiasis recovering from lithotripsy.

2. A client recovering from excision of a malignant melanoma. Explanation Strategy: RN cares for clients requiring assessment, teaching, and nursing judgment. 1) ensure patency of urinary diversion after surgery; assign to the LPN/LVN 2) CORRECT - may require a wide excision that requires nurse to anticipate the need for analgesic medications; psychological support is also necessary because of diagnosis of cancer; requires assessment, teaching, and nursing judgment 3) standard, unchanging procedure; assign to the nursing assistant 4) observe for obstruction and infection, strain urine; assign to LPN/LVN

The nurse supervises the staff caring for four clients receiving blood transfusions. Which client should the nurse see first? 1. A client complaining of a headache. 2. A client vomiting. 3. A client complaining of itching. 4. A client with neck vein distention.

2. A client vomiting. Explanation Strategy: Determine the least stable client. (1) febrile reaction; symptoms include fever, chills, nausea, headache; treatment is to stop blood and administer aspirin (2) CORRECT - hemolytic reaction; most dangerous type of transfusion reaction; symptoms include nausea, vomiting, pain in lower back, hematuria; treatment is to stop blood, obtain urine specimen, and maintain blood volume and kidney perfusion (3) allergic reaction; symptoms include urticaria, pruritus, fever; treatment is to stop blood, give diphenhydramine, and administer oxygen (4) circulatory overload; treatment is to stop blood, position in an upright position, and administer oxygen

The nurse plans discharge teaching for the client after a lumbar laminectomy. Which muscle or muscles does the nurse instruct the client to exercise regularly? 1. Anal sphincter. 2. Abdominal. 3. Trapezius. 4. Rectus femoris.

2. Abdominal. Explanation Strategy: Think about each answer. 1) does not contribute to support of the lumbar spine 2) CORRECT —- strengthening the abdominal muscles adds support for the muscles supporting the lumbar spine 3) does not contribute to support of the lumbar spine 4) does not contribute to support of the lumbar spine

The nurse in the emergency department (ED) cares for a client who states that her partner became angry with her and began hitting her. Which of the following actions should the nurse take FIRST? 1. Encourage the client to verbalize her feelings. 2. Assess for physical trauma. 3. Provide privacy for the client during the interview. 4. Assist the client to identify a support system.

2. Assess for physical trauma. Explanation Strategy: Assess before implementing. 1) it is very important for the nurse to encourage the client to verbalize about the incident and relationship; assess first 2) CORRECT - assess for trauma to determine physical needs 3) appropriate action; assess before implementing 4) important assessment; take care of the physical before psychosocial needs

The nurse recognizes which nursing intervention is most important when caring for a client just placed in physical restraints? 1. Prepare PRN dose of psychotropic medication. 2. Check that the restraints have been applied correctly. 3. Review hospital policy regarding duration of restraints. 4. Monitor the client's needs for hydration and nutrition while restrained.

2. Check that the restraints have been applied correctly. Explanation Strategy: Answers are a mix of assessment and implementation. Is this a situation that requires assessment? Yes. Is there an appropriate assessment? Yes. (1) implementation; inappropriate for the client in restraints (2) CORRECT - assessment; while a client is restrained, physiological integrity is important; monitoring positioning, tightness, and peripheral circulation is essential; nurse documents the client's response and clinical status after being restrained (3) implementation; all staff members involved in a restraint event must be aware of hospital policy before using restraints (4) assessment; important to attend to client's nutrition and hydration after the client is safely restrained

The nurse cares for a client admitted 2 days ago with a diagnosis of closed head injury. If the client develops diabetes insipidus, the nurse will observe which symptoms? Select all that apply. 1. Glucosuria. 2. Cracked lips. 3. Weight gain of 5 lb. 4. BP160/100, pulse 56. 5. Urinary output of 4 L/24 hours. 6. Urine specific gravity of 1.004.

2. Cracked lips. 5. Urinary output of 4 L/24 hours. 6. Urine specific gravity of 1.004. Explanation Strategy: Think of water loss with diabetes insipidus. 1) occurs with diabetes mellitus. 2) CORRECT - due to dehydration caused by excessive water loss. 3) weight loss occurs; symptom of SlADH (syndrome of inappropriate antidiuretic hormone) opposite of diabetes insipidus. 4) late signs of increased intracranial pressure or brain damage. 5) CORRECT - excessive fluid loss is major occurance of diabetes insipidus. 6) CORRECT - specific gravity very low as urine is not concentrated in the kidney.

A client receives morphine sulfate after admission to the emergency department in acute respiratory distress. The client is very anxious, edematous, and cyanotic. Which finding should the nurse recognize as the desired response to the medication? 1. Increase in pulse pressure. 2. Decrease in anxiety. 3. Depression of the sympathetic nervous system. 4. Enhanced ventilation and decreased cyanosis.

2. Decrease in anxiety. Explanation Strategy: Think about each answer. (1) is not affected by morphine sulfate (2) CORRECT - morphine sulfate is administered to minimize anxiety associated with respiratory distress from pulmonary edema (3) is not the action of the medication (4) medication does not improve ventilation

An adolescent is scheduled for a below-knee (BK) amputation following a motorcycle accident. The nurse knows preoperative teaching for this client should include which information? 1. Explain that the client will walk with a prosthesis soon after surgery. 2. Encourage the client to share feelings and fears about the surgery. 3. Take the informed consent form to the client and ask the client to sign it. 4. Evaluate how the client plans to complete schoolwork during hospitalization.

2. Encourage the client to share feelings and fears about the surgery. Explanation Strategy: Remember therapeutic communication. (1) fails to recognize client's immediate concerns (2) CORRECT - discussing client's feelings and fears is important in dealing with anxiety due to a change in body image and functioning (3) client is underage; parents will need to sign the permit (4) is more appropriate for the postoperative period of time than for the preoperative period

The nurse plans care for a neonate with tetralogy of Fallot. It is most important for the nurse to take which action? 1. Offer the infant water every four hours. 2. Enlarge the hole in the nipple of the formula bottle. 3. Position the infant on his stomach after bottle feeding. 4. Gradually increase the time between bottle feedings.

2. Enlarge the hole in the nipple of the formula bottle. Explanation 1) should offer formula to meet nutritional needs; has increased calorie needs due to increased metabolic rate 2) CORRECT— allows the child to obtain nourishment easily; feed on a 3-hour schedule and feed soon after awakening so infant doesn't cry 3) support infant and feed in a semi-upright position 4) should offer feeding every 3 hours; stroke infant's jaw and cheek to encourage sucking; complete feeding in half an hour

The nurse cares for the client during an acute manic episode. The nurse identifies which client behaviors as most characteristic of mania? Select all that apply. 1. Paranoia. 2. Grandiose delusions. 3. Somatic difficulties. 4. Difficulty concentrating. 5. Agitation. 6. Distorted perceptions.

2. Grandiose delusions. 4. Difficulty concentrating. 5. Agitation. Explanation Strategy: Think about mania and how it is manifested. 1) related to schizophrenia 2) CORRECT - delusions of grandeur are common during mania 3) related to personality disorders 4) CORRECT - due to excessive activity 5) CORRECT - clients are constantly in motion 6) related to depression

The health care provider inserts a temporary pacemaker in a client following a myocardial infarction. The nurse knows that which outcome is the primary purpose of the pacemaker? 1. Increases the force of myocardial contraction. 2. Increases the cardiac output. 3. Prevents premature ventricular contractions (PVCs). 4. Prevents systemic overload.

2. Increases the cardiac output. Explanation Strategy: Think about each answer. (1) action of cardiac glycosides such as digoxin (2) CORRECT - acts to regulate cardiac rhythm (3) action of antiarrhy'thmics such as quinidine (4) action of diuretics such as furosemide

The nurse cares for a 3-month old infant scheduled for a barium swallow in the morning. Prior to the procedure, it is most appropriate for the nurse to take which action? 1. Offer the infant only clear liquids. 2. Make the infant NPO for 3 hours. 3. Feed the infant regular formula. 4. Maintain the infant NPO for 6 hours.

2. Make the infant NPO for 3 hours. Explanation Strategy: All answers are implementation. Determine the outcome of each answer. Is it desired? 1) inappropriate 2) CORRECT - infant should be NPO 3 hours prior to the procedure 3) inappropriate 4) unnecessary for an infant to be NPO for 6 hours

The nurse cares for a client receiving lithium 300 mg PO TID. The nurse identifies which symptoms as early signs of toxicity? Select all that apply. 1. Mild thirst. 2. Nausea and vomiting. 3. Coarse hand tremor. 4. Ataxia. 5. Slurred speech. 6. Muscle weakness.

2. Nausea and vomiting 5. Slurred speech. 6. Muscle weakness. Explanation Strategy: Think about each answer. 1) lithium is an antimanic used to treat bipolar disorder; mild thirst is expected side effect; other side effects include fine hand tremor, polyuria 2) CORRECT—early sign of toxicity; withhold medication, obtain blood lithium level, dose will be re-evaluated 3) indicates advanced sign of toxicity; other indications include persistent GI upset, mental confusion, incoordination 4) indicates severe toxicity 5) CORRECT - also will see diarrhea, thirst, and polyuria 6) CORRECT - withhold medication and obtain blood lithium level

The nurse discusses changes due to aging with a group at the senior citizen center. The nurse knows which change in the urinary elimination pattern occurs normally with aging? 1. Decreased frequency. 2. Nocturia. 3. Incontinence. 4. Hematuria.

2. Nocturia. Explanation Strategy: Think about each answer. 1) frequency increases because bladder capacity decreases 2) CORRECT - decreased ability to concentrate urine increases urine formation and increased nocturnal urine production leads to need to awaken to void 3) ureters, bladder, and urethra lose muscle tone; results in stress and urge incontinence 4) blood in the urine may be a sign of cancer, infection, or trauma of urinary tract, glomerular disease, urinary tract calculi, bleeding disorders

The nurse recognizes which client symptoms as characteristic of a panic attack? Select all that apply. 1. Decreased blood pressure. 2. Palpitations. 3. Decreased perceptual field. 4. Bradycardia. 5. Diaphoresis. 6. Fear of going crazy.

2. Palpitations. 3. Decreased perceptual field. 5. Diaphoresis. 6. Fear of going crazy. Explanation Strategy: Think about a panic attack and the neurological changes that occur. 1) blood pressure increases= 2) CORRECT - the heart rate increases and palpitations occur 3) CORRECT - the visual field narrows; part of the fight or fight reaction 4) tachycardia occurs 5) CORRECT - neurological changes cause diaphoresis 6) CORRECT clients fear they are going crazy; part of the neurological changes

Which observation suggests to the nurse that the client has developed an Addisonian crisis? 1. Muscular weakness and fatigue. 2. Restlessness and rapid weak pulse. 3. Dark pigmentation of the skin. 4. Gastrointestinal disturbances and anorexia

2. Restlessness and rapid. weak pulse. Explanation Strategy: Determine how each answer relates to Addisonian crisis (1) signs and symptoms of Addison's disease, but do not indicate a crisis (2) CORRECT - may be signs of shock related to an Addisonian crisis (3) signs and symptoms of Addison's disease, but do not indicate a crisis (4) signs and symptoms of Addison's disease, but do not indicate a crisis

The nurse assesses the client diagnosed with a spinal cord injury. Which findings suggest the complication of autonomic dysreflexia? Select all that apply. 1. Urinary bladder spasm pain. 2. Severe pounding headache. 3. Profuse sweating. 4. Tachycardia. 5. Severe hypotension. 6. Nasal congestion.

2. Severe pounding headache. 3. Profuse sweating. 6. Nasal congestion. Explanation Strategy: Think about each answer. 1) may be the cause of autonomic dysreflexia due to overfilling of the bladder, but pain is not perceived 2) CORRECT - severe headache results from rapid onset of hypertension 3) CORRECT - especially of forehead 4) pulse will slow 5) BP will increase 6) CORRECT - also causes piloerection (goose bumps)

A client diagnosed with arterial insufficiency calls the nurse in the outpatient clinic to say that she is awakened at night by pain in her lower extremities. Which of the following suggestions by the nurse is BEST? 1. Elevate both legs on two pillows. 2. Sit on the side of the bed. 3. Place a bed cradle over her legs. 4. Wear cotton pants to keep her legs warm.

2. Sit on the side of the bed. Explanation Strategy: Determine the outcome of each answer. 1) promotes venous return; does not increase circulation 2) CORRECT - enhances arterial blood supply 3) prevents pressure; does not promote arterial circulation to lower extremities 4) pain is not caused by cold, pain is caused by decreased circulation

The 6-month-old is brought to the clinic for a well-baby checkup. During the exam, the nurse expects to observe which assessment findings? Select all that apply. 1. A pincer grasp. 2. Sitting with support. 3. Tripling of the birth weight. 4. Presence of the posterior fontanelle. 5. Playing peek-a-boo. 6. Rolling from back to abdomen.

2. Sitting with support. 5. Playing peek-a-boo. 6. Rolling from back to abdomen. Explanation Strategy: Think of behaviors of a 6-month-old child. 1) Present at 9 months of age. 2) CORRECT - Should occur at this age. 3) Should happen at 1 year. 4) Posterior fontanelle closes at 2-3 months of age. 5) CORRECT - Should be present at this time. 6) CORRECT - Should be able to do this.

The nurse cares for the client diagnosed with rheumatoid arthritis (RA). The nurse expects to assess which findings? Select all that apply. 1. Kyphosis of the spine. 2. Symmetrical joint swelling. 3. Crepitus with range of motion. 4. Pathological fractures. 5. Joint stiffness in the morning. 6. Joint pain relieved by resting.

2. Symmetrical joint swelling. 5. Joint stiffness in the morning. Explanation Strategy: Think about each answer. Does it indicate rheumatoid arthritis? 1) kyphosis of the spine is seen with osteoporosis 2) CORRECT — symmetrical or mirror joint swelling occurs with RA 3) crepitus with range of motion occurs with osteoarthritis 4) pathological fractures occur with osteoporosis 5) CORRECT — RA is characterized by joint stiffness in the morning 6) osteoarthritis is characterized by joint pain that is relieved by resting

The nurse is supervising care provided by a nursing assistive personnel (NAP). Which action by the NAP requires intervention by the nurse? Select all that apply. 1. The NAP applies nonsterile gloves to empty a client's urostomy bag. 2. The NAP applies elastic compression stockings to the client after the client returns to bed after breakfast. 3. The NAP assists a 190 kg client diagnosed with lower extremity weakness to the bathroom. 4. The NAP wears a gown and gloves when assisting a client just admitted with meningitis to change into a hospital gown. 5. The NAP documents morning vital signs and blood glucose levels obtained from a group of clients.

2. The NAP applies elastic compression stockings to the client after the client returns to bed after breakfast. 3. The NAP assists a 190 kg client diagnosed with lower extremity weakness to the bathroom. 4. The NAP wears a gown and gloves when assisting a client just admitted with meningitis to change into a hospital gown. Explanation Strategy: "Requires intervention by the nurse" indicates an incorrect action by the NAP. Determine the outcome of each nursing action. Does it require the nurse to intervene? 1) appropriate action; within scope of NAP, nonsterile procedure 2) CORRECT— compression stockings should be placed after elevation of the limbs or when there is minimal dependent edema; client who has been up for breakfast will have increased dependent edema 3) CORRECT — additional assistance in transfers is necessary for large clients; safety risk to both NAP and client 4) CORRECT— clients with meningitis require use of droplet precautions; mask should be applied 5) appropriate action; within scope of NAP

The nurse cares for the client diagnosed with Méniere's syndrome. The nurse stands directly in front ofthe client when speaking. Which best describes the rationale for the nurse's position? 1. This enables the client to read the nurse's lips. 2. The client does not have to turn the head to see the nurse. 3. The nurse will have the client's undivided attention. 4. There is a decrease in client"s peripheral visual field.

2. The client does not have to turn the head to see the nurse. Explanation Strategy: Think about each answer. 1) client is not hard of hearing 2) CORRECT - by decreasing movement of client's head, vertigo attacks may be decreased 3) not the reason 4) there is no problem with visual fields

The nurse cares for the client diagnosed with anorexia nervosa. Which client statement best indicates to the nurse improvement in the client's condition? 1. "I realize hit too thin and that it's not good for me, but I don't know how to eat more without getting fat." 2. The client requests a sanitary pad or tampon, saying, "I didn't think to bring anything with me; l haven't had a period for months." 3. "Either the food here is getting better or my appetite is coming back, but lately I find myself looking forward to meals." 4. The client asks for a discharge date to be delayed, saying, "I don't feel ready yet to deal with the tension in my family and their demands for perfection."

2. The client requests a sanitary pad or tampon, saying, "I didn't think to bring anything with me; l haven't had a period for months." Explanation Strategy: "BEST" indicates that discrimination is required to answer the question. 1) not best indicator, although does at least verbally manifest insight and openness to and readiness for client teaching 2) CORRECT - amenorrhea, a definite physiologic symptom, is resolved; menstruation is usually absent in anorexic women; its return is a measure ofsuccessful treatment; DSlil-IV-TR describes amenorrhea as a criteria measure forthe diagnosis of anorexia, and defines it as the absence of at least three consecutive menstrual cycles in a postmenarchal female 3) not best indicator, although does at least verbally convey interest and willingness to eat more, which will result in weigh gain; however, may be said to please nurse, to appear cooperative and motivated, when in fact that is not the case; also, anorexia nervosa has little to do with appetite and more to do with fear of obesity and of losing control over food intake 4) not best indicator, although does convey recognition of the family component to her condition and some insight

The nurse assists forensic investigators in the emergency department with evidence preservation and collection after a client's death. Which actions by the nurse are considered professionally negligent? Select all that apply. 1. The nurse documents time of events. 2. The nurse cuts through holes in fabric to remove client's shirt. 3. The nurse places paper bags over the client's hands. 4. The nurse gives the client's clothing to the family. 5. The nurse places evidence in a plastic bag. 6. The nurse removes intravenous lines before the medical examiner arrives.

2. The nurse cuts through holes in fabric to remove client's shirt. 4. The nurse gives the client's clothing to the family. .5. The nurse places evidence in a plastic bag. 6. The nurse removes intravenous lines before the medical examiner arrives. Explanation Strategy: Determine the outcome of each answer choice. Is the answer choice considered negligent behavior by the nurse? 1) appropriate and necessary; nurse should document description of all wounds, mechanism of injury, time of events, and collection of evidence 2) CORRECT — nurse should not cut through or disrupt any tears, holes, blood stains, or dirt present on clothing 3) appropriate and necessary; only paper bags should be used; preserves evidence on hands and under fingernails 4) CORRECT — clothing should not be given to families; clothing may contain evidence 5) CORRECT — negligent action; plastic bags are not used because they retain moisture; moisture may promote mold and mildew formation, which can destroy evidence 6) CORRECT — all tubes and lines must remain in place for medical examiner

When assessing orientation to person, place, and time for an elderly hospitalized client, which principle should be understood by the nurse? 1. Short-term memory is more efficient than long-term memory. 2. The stress of an unfamiliar environment may cause confusion. 3. A decline in mental status is a normal part of aging. 4. Learning ability is reduced during hospitalization of the elderly client.

2. The stress of an unfamiliar environment may cause confusion. Explanation Strategy: Think about each answer. (1 ) just the opposite is true; long.term memory is more efficient than short-term memory (2) CORRECT - stress of an unfamiliar situation or environment may lead to confusion in elderly clients (3) mental status and learning ability are not affected by aging, although elderly client may be slower at doing things (4) mental status and learning ability are not affected by aging, although elderly client may be slower at doing things

Which assessment findings should the nurse recognize as pertinent to a diagnosis of Cushing's syndrome? 1. Low blood pressure and weight loss. 2. Thin extremities with easy bruising. 3. Decreased urinary output and increased serum potassium. 4. Tachycardia with reports of night sweats.

2. Thin extremities with easy bruising. Explanation Strategy: Think about each answer. (1) BP increases and client gains weight (2) CORRECT - clients with Cushing's syndrome tend to lose weight in their legs and have petechiae and bruising (3) no correlation with urinary output; potassium decreases (4) no correlation with Cushing's syndrome

The health care provider orders mannitol for a client with a closed head injury. Which should the nurse recognize as the desired response to this medication? 1. The blood pressure increases to 150/90. 2. Urinary output increases to 175 mL/hour. 3. There is a decrease in the level of activity. 4. There is an absence of fine tremors of the fingers.

2. Urinary output increases to 175 mL/hour. Explanation Strategy: Think about each answer. (1) increase in blood pressure is not desired (2) CORRECT - mannitol is an osmotic diuretic; increases urinary output and decreases intracranial pressure (3) does not indicate desired effect of medication (4) does not indicate desired effect of medication

The home care nurse visits an elderly client diagnosed with depression. The client's daughter states that it is difficult for her mother to complete activities of daily living. It is MOST appropriate for the nurse to suggest which of the following? 1. Medicate the client before beginning activities. 2. Write a schedule of activities and allow extra time for the client to complete the activities. 3. Assist the client with all grooming activities. 4. Provide frequent forceful directions to keep the client focused on the activities.

2. Write a schedule of activities and allow extra time for the client to complete the activities. Explanation Strategyz'MOST appropriateiindicates discrimination is required to answer the question. 1) will not increase client's independence 2) CORRECT - communicates to client what is expected and then gives herthe time to accomplish her tasks; depression causes decreased attention span and concentration 3) maintain client's independence by allowing her time to complete activities 4) communicating clear expectations and giving client time to complete activities are more useful

A young adult is admitted to the hospital with a diagnosis of catatonic schizophrenia. When the nurse places the patient's hand over his head, it remains in that position. The nurse identifies that this is 1. conversion hysteria. 2. waxy flexibility. 3. dystonic reaction. 4. neurasthenia.

2. waxy flexibility. Explanation Strategy: Think about each answer. 1) motor or sensory neurological symptoms with no identifiable physiological cause 2) CORRECT—abnormal posturing; catatonic schizophrenia causes sudden loss of animation and a tendency to remain motionless in a stereotyped position 3) muscle spasms of any muscles ofthe body 4) unexplained chronic fatigue with nervousness, anxiety, and irritability

The nurse prepares a patient diagnosed with cervical cancer for the insertion of an internal radiation implant. The nurse knows that it is MOST important to respond to which client statement? 1. "Unless I have a bowel movement every day, I just do not feel right." 2. "I am glad this whole process is only going to last 3 days." 3. "I will get up only when I have to urinate, and then I will go right back to bed." 4. "lf it were not for my children, I would not be going through all of this."

3. "I will get up only when I have to urinate, and then I will go right back to bed." Explanation Strategy: Topic of question is unstated. (1.) of concern, but not priority; priorto patient receiving implant, an enema is given so rectum is empty in order to facilitate placing the implant through the vagina and into uterus; bowel movement during the implantation period (1—3 days) is avoided in order to prevent the implant from dislodging (2.) internal radiation treatment for this condition is 1—3 days (3.) CORRECT - patient will be on strict bedrest on her back with head of bed elevated no more than 20 degrees; movement is restricted; a Foley catheter is inserted into bladder in order to prevent the implant from being dislodged by a full bladder or by voiding attempts; severe radiation burns can result from a distended bladder (4.) indicates probable depression; requires further exploration but is not priority

The nurse on the neurology unit prepares a client for discharge. The client has been treated for an exacerbation of multiple sclerosis. Which statement, if made by the client to the nurse, indicates that teaching is successful? 1. "When lam exercising, I will push a little beyond when I start to feel tired and then stop." 2. "When my muscles seem especially spastic, I will take hot baths to relieve them." 3. "I will sleep on my stomach as much as I can." 4. "I will be firm and steady when I pull a spastic leg open."

3. "I will sleep on my stomach as much as I can." Explanation Strategy: "Teaching is successful" indicates correct information. (1.) overexertion must be avoided because it will cause fatigue and exacerbate symptoms; exercises for muscle strengthening done to the point of fatigue can actually cause further paresis or weakness, numbness, incoordination (2.) heat and humidity, whether environmental or a hot bath or shower, can aggravate the fatigue which is so much a part of multiple sclerosis; fatigue can precipitate and/or intensify multiple sclerosis symptoms (3.) CORRECT - may minimize spasm ofthe flexor muscles ofthe hips and knees of a person with multiple sclerosis; if these spasms are not relieved, joint contractions will occur as well as pressure ulcers on the sacrum and hips from difficulty positioning the patient correctly (4.) spastic extremity should not be forced open; instead it should be gently rotated in the direction it is being pulled and then gradually rotated in the opposite direction, which is usually outward since spasticity usually is into an adducted position; these rotations are repeated, going a little farther each time

The nurse cares for a client the first day postoperative after a transurethral prostatectomy (TURP). The client has a continuous bladder irrigation (CBI). The client's spouse asks why the client has the CBI. Which response by the nurse is best? 1. "The CBI prevents urinary stasis and infection." 2. "The CBI dilutes the urine to prevent infection." 3. "The CBI enables urine to keep flowing." 4. "The CBI delivers medication to the bladder."

3. "The CBI enables urine to keep flowing." Explanation Strategy: Think about each answer. 1) refers to a possible preoperative complication of infection due to the enlarged prostate 2) not the reason for the CB! 3) CORRECT - continuous bladder irrigation prevents formation of clots that can lead to obstruction and spasm in the postoperative TURP client 4) medication is not routinely administered via a CBl in a first-day postop TURP

Which statement should be documented by the nurse to reflect a client's emotional adjustment to being hospitalized in the intensive care unit? 1. 'The client is unable to complete activities of daily living without assistance." 2. 'The client appears to be depressed and anxious regarding impending surgery. 3. 'The client constantly calls for nurses and cries uncontrollably." 4. 'The family is unable to visit more often than once a week because they live far away."

3. 'The client constantly calls for nurses and cries uncontrollably." Explanation Strategy: Good documenting is the objective. (1) does not describe emotional adjustment (2) draws conclusions without supporting data (3) CORRECT - gives an objective description of the client's behavior and affect ( 4) describes the client's family, not the client

The psychiatric home care nurse plans visits for the day. The weather report states that temperatures will be around 95 degrees. Which client should the psychiatric home health nurse see first upon leaving the office? 1. A client diagnosed with chronic schizophrenia who is frequently noncompliant with medications. The client lives with parents in a house without air-conditioning and is a 10-minute drive from the office. 2. A client diagnosed with obsessive-compulsive disorder who is taking clomipramine. The client lives with a sibling, has a psychiatrist who is on vacation, and is a 30-minute drive from the office. 3. A client diagnosed with bipolar disorder who lives with the spouse. The client was discharged from the inpatient unit 1 week ago after being started on lithium carbonate, and is a 45-minute drive from the office. 4. A client diagnosed with depression who lives alone. The client likes to garden, is taking amitriptyline for depression, and is a 20-minute drive from the office.

3. A client diagnosed with bipolar disorder who lives with the spouse. The client was discharged from the inpatient unit 1 week ago after being started on lithium carbonate, and is a 45-minute drive from the office. Explanation Strategy: Determine the MOST unstable patient. (1.) may need reminders about photosensitivity side effect of antipsychotics and about appropriate precautions to take (2.) may need reminders about photosensitivity side effect of clomipramine and about appropriate precautions to take; absence of psychiatrist can be especially stressful for this tightly controlled client; the nurse should strive for congruence between expected and actual arrival time (3.) CORRECT - potentially the least stable client due to recent hospitalization and taking Lithium; response to the lithium needs to be monitored, including side effects; a particular concern at this time, because of the weather, is to be certain client is maintaining adequate sodium levels as well as drinking appropriate amounts of water in orderto prevent lithiumtoxicity (4.) may need reminders about photosensitivity side effect of amitriptyline and about appropriate precautions to take

The nurse cares for clients on the medical/surgical floor. Which of the following clients should the nurse assign to the LPN/LVN? 1. A client who returns after an appendectomy complicated by a pneumothorax during surgery. 2. A client with increased intracranial pressure who responds to painful stimuli. 3. A client diagnosed with cellulitis receiving antibiotics. 4. A client with a mandibular fracture immobilized by wiring the jaw who is preparing for discharge.

3. A client diagnosed with cellulitis receiving antibiotics. Explanation Strategy: Assign stable clients with expected outcomes. 1) requires assessment and nursing judgment; assign to RM 2) requires assessment and nursing judgment; assign to RN 3) CORRECT - stable client with expected outcome 4) requires discharge teaching regarding importance of oral hygiene and nutrition

The nurse receives report on the following patients upon arrival at the medicine unit. Which of the following patients should the nurse see FIRST? 1. A patient drinking contrast for an abdominal CT scan who complains of nausea. 2. A patient with a respiratory rate of 24 and an oxygen saturation of 94% on room air. 3. A patient complaining of frequent small amounts of watery diarrhea with abdominal pain and nausea. 4. A patient whose family member is threatening to sue the hospital and the nurse if the nurse doesn't talk with the family immediately.

3. A patient complaining of frequent small amounts of watery diarrhea with abdominal pain and nausea. Explanation Strategy: Determine the MOST unstable client. (1.) symptom management is important to patient comfort and to insure the patient is able to complete the contrast for the test, but a potentially life-threatening condition takes precedence (2.) respiratory status is stable (3.) CORRECT - may indicate a possible bowel obstruction that can be life-threatening if the bowel perforates (4.) important to address the family member's concerns, but this person does not pose an immediate physical threat to the patient, staff, or other visitors, and the potentially life-threatening condition takes precedence

The nurse on a psychiatric unit of the hospital declines the client's request to organize a party on the unit for the client's friends. The client becomes angry and uses abusive language toward the nurse. Which statement indicates the nurse has an understanding of the client's behavior? 1. Allowing the client to use abusive language will undermine the authority of the nurse. ' 2. Responding in kind to a client who uses abusive language will perpetuate the behavior. 3. Abusive language is one of the behaviors symptomatic of the client's illness. 4. The nurse should model acceptable behavior and language for all clients.

3. Abusive language is one of the behaviors symptomatic of the client's illness. Explanation Strategy: Think about each answer. 1) inaccurate; doesn't undermine authority of staff 2) shows lack of understanding of cause for client's behavior 3) CORRECT - symptoms will respond to treatment 4) suggests that using acceptable language will change client's behavior; shows lack of understanding of client's behavior

The client is brought to the emergency department by friends who state, "Our friend has been hanging with the wrong crowd. We are worried about drug use."The nurse notes that the client stares blankly and has an unsteady gait, stiff muscles, and eyes that are moving rapidly side to side and up and down. The nurse plans care. Which is most important for the nurse to anticipate? 1. Increased adventitious breath sounds. 2. Decreased blood pressure, temperature, and pulse. 3. Aggressive behaviors. 4. Nausea, vomiting, abdominal cramping.

3. Aggressive behaviors. Explanation Strategy: The topic of the question is unstated. 1) client's symptoms indicate phencyclidine piperidine (PCP) intoxication; breath sounds important to assess with any new client but not priority; respiratory arrest can occur with PCP overdose 2) with PCP, blood pressure, temperature, and pulse are expected to increase, not decrease; overdose could even lead to a hypertensive crisis; hyperthermia can also occur 3) CORRECT - symptoms of blank stare, rigid muscles, ataxia, and nystagmus that is both vertical and horizontal indicate probable phencyclidine piperidine (PCP) intoxication; another name for PCP is angel dust; aggression in all forms is another symptom that manifests with PCP; can take the form of assault, belligerence, impulsiveness, and/or suicidality, and is very often bizarre in nature; often occurs in unpredictable outbursts; interventions should be planned to monitor for aggressive symptoms, to prevent them, and to manage them should they occur; decreasing stimuli, securing potential injurious objects in the environment, having chemical and physical restraints (along with sufficient staff) available are all measures that can be planned in advance and utilized; PCP is used by itself, but is also frequently used as an adulterant with other drugs 4) no particular association with PCP; these are symptoms that occur with opiate withdrawal

The nurse is discussing growth and development with the parents of a 4-year-old child. The nurse identifies which type of play as characteristic of this age group? 1. Solitary play. 2. Parallel play. 3. Associative play. 4. Aggressive play.

3. Associative play. Explanation Strategy: Picture a 4-year-old. 1) describes play for an infant 2) describes play for a toddler 3) CORRECT - this is the play that characterizes 4-year-olds 4) is not play but a behavior

The nurse cares for the postoperative client diagnosed with type 2 diabetes controlled with oral antihyperglycemic agents. The client asks why the health care provider ordered subcutaneous insulin injections after surgery. The nurse's response is based on knowing which physiological process? 1. Tissue injury after surgery decreases blood glucose. 2. Anesthesia acts to increase glycogen stores. 3. Being NPO inhibits normal blood glucose control. 4. Surgery often leads to insulin dependency.

3. Being NPO inhibits normal blood glucose control. Explanation Strategy: Think about each answer. 1) inaccurate 2) inaccurate 3) CORRECT - temporary control by insulin is needed due to inability to control diabetes mellitus by diet and oral agents, surgically induced metabolic changes, being NPO both before and after surgery, and the infusion of intravenous fluids 4) inaccurate

The 7-year-old child is seen in the clinic with a diagnosis of pituitary dwarfism. Which clinical manifestation is the nurse most likely to observe? 1. Abnormal body proportions. 2. Early sexual maturation. 3. Delicate features. 4. Coarse, dry skin.

3. Delicate features. Explanation Strategy: Determine how each answer relates to dwarfism. 1) see small size but normal body proportions 2) usually have delayed sexual maturity 3) CORRECT - appear younger than chronological age 4) usually see fine, smooth skin

The nurse cares for a client during a radium implant. During the removal of the implant, it is most important for the nurse to take which action? 1. Clean the radium implant carefully with a disinfectant (alcohol or bleach) using long forceps. 2. Handle the radium carefully using forceps and rubber latex gloves. 3. Document the date and time of removal together with the total time of implant treatment. 4. Double-bag the radium implant before the person from radiology removes it from the room.

3. Document the date and time of removal together with the total time of implant treatment. Explanation Strategy: Answers are all implementation. Determine the outcome of each answer. is it desired? (1) at no time should the nurse or client handle the radium; radiology department is responsible for handling implant (2) at no time should the nurse or client handle the radium; radiology department is responsible for handling implant (3) CORRECT - important that accurate documentation be maintained on the internal radium implant (4) at no time should the nurse or client handle the radium; radiology department is responsible for handling implant

The client, gravida 2 para 1, is admitted with hypertension. The client reports her wedding band is tight. The nurse assesses for which indications of mild pre-eclampsia? 1. Blurred vision and proteinuria. 2. Epigastric pain and headache. 3. Facial swelling and proteinuria. 4. Oliguria and hypertonic reflexes.

3. Facial swelling and proteinuria. Explanation Strategy: Determine how each answer relates to pre—eclampsia. 1) only partially correct; blurred vision appears later, with severe preeclampsia 2) contains signs of eclampsia before a seizure 3) CORRECT - represents two of the three symptoms seen with pre-eclampsia; also includes hypertension 4) oliguria is seen later with severe preeclampsia

The home care nurse visits a client diagnosed with Parkinson's disease. The client's husband states that even though his wife eats, she is losing weight. Which of the following suggestions by the nurse is MOST appropriate? 1. Instruct the husband to offer the client thick milkshakes. 2. inform the husband that this is to be expected. 3. Observe the client feed herself. 4. Refer the client to the dietician.

3. Observe the client feed herself. Explanation Strategy 'MOST appropriate'indicates discrimination is required to answer the question. 1) appropriate action; soft diet may be more easily tolerated; assess before implementing 2) may have difficulty maintaining weight, but nurse should try to increase client's caloric intake 3) CORRECT—because of feeding difficulties, client may drop more food in her lap than she eats; nurse should observe the client eat and record actual intake 4) do not pass the buck

The nurse cares for a child diagnosed with pediculosis capitis (head lice) and is being treated with permethrin 1% cream rinse. The nurse should include which information when instructing the child's parents? 1. Apply the cream rinse every other day for 1 week. 2. Wash the child's clothing and personal belongings in soap and cool water. 3. Repeat the application of the cream rinse in 7 days if nits still present- 4. Comb the child's hair weekly with a nit comb.

3. Repeat the application of the cream rinse in 7 days if nits still present- Explanation Strategy: Answers are implementation. Determine the outcome of each answer. ls it desired? (1) too frequent an application of the rinse (2) very hot water and dry for 20 minutes in the dryer (3) CORRECT - may be repeated 7 days after first application (4) hair should be combed daily with a nit comb

The adult client is admitted to the hospital unit diagnosed with hepatitis A. Which precautions does the nurse include in the client's overall care during hospitalization? 1. Contact precautions. 2. Airborne precautions. 3. Standard precautions. 4. Droplet precautions.

3. Standard precautions. Explanation Strategy: Think about each answer. 1) required with patient care activities that require physical skin-to-skin contact, or occurs by contact with contaminated inanimate objects in the patient's environment 2) unnecessary; used with pathogens transmitted by airborne route 3) CORRECT— standard precautions should be used on everyone; sources for this virus are saliva, feces, and blood; use contact isolation if fecal incontinence 4) unnecessary; used when pathogens transmitted by infectious droplets

The older client with a history of hypertension and angle-closure glaucoma visits the clinic for a routine check-up. Which medication, if ordered by the health care provider, should the nurse question? 1. Propranolol, 80 mg orally fourtimes daily. 2. Verapamil, 40 mg PO three times daily. 3. Tetrahydrozoline, 2 drops in both eyes three times daily. 4. Timolol, 1 drop in both eyes onetime daily.

3. Tetrahydrozoline, 2 drops in both eyes three times daily. Explanation Strategy: "Medication should the nurse question" indicates a contraindication. (1) antihypertensive, beta-blocker used as an antianginal, reduces cardiac oxygen demand, no effect on glaucoma (2) calcium channel blocker used as antianginal; not contraindicated (3) CORRECT - contraindicated; ophthalmic vasoconstrictor, contraindicated with angle-closure glaucoma; use cautiously with hypertension (4) reduces aqueous formation and increases outflow, used for glaucoma

The nurse prepares an older client for an intravenous pyelogram (IVP). The client asks the nurse to explain the reason why the procedure is performed. The nurse's response should be based on which explanation? 1. The health care provider is able to directly observe the renal pelvis. 2. An IVP assesses glomerular filtration rate. 3. The health care provider is able to examine the urinary tract by x—ray. 4. Medication is injected into the urinary system.

3. The health care provider is able to examine the urinary tract by x—ray. Explanation Strategy: Think about each answer. (1) would involve invasive procedure, such as cystoscopy (2) not primary purpose (3) CORRECT - x—rays of entire urinary tract taken, evaluates kidney function (4) not primary purpose

The nurse provides care for the client diagnosed with early stage chronic kidney disease. The client states, "I do not understand why my health care provider thinks I am having trouble with my kidneys. I urinate frequently day and night." Which response by the nurse is best? 1. 'Did you tell the health care provider you are putting out lots of urine?" 2. 'If you manage your diabetes well, there should be no further damage." 3."You seem to be very upset about this diagnosis." 4. "A high volume of urine indicates your kidneys are releasing too much fluid."

4. "A high volume of urine indicates your kidneys are releasing too much fluid." Explanation Strategy: "Best" indicates discrimination is required to answer the question. 1) this is a "yes/no" question, which is nontherapeutic 2) there is no information in the question that indicates the client has diabetes mellitus; in addition, the statement does not address the client's misunderstanding about the symptoms 3) the statement can be an appropriate leading statement when the nurse is exploring a subject; however, the client has enough information to a have structured discussion 4) CORRECT — in the early stage of chronic kidney disease hypertrophy of kidney tissue results in increased surface available for urinary excretion; increased or near normal urinary output may not seem abnormal to the client

The nurse provides teaching for a client diagnosed with liver cirrhosis. Which statements by the client cause the nurse to determine that teaching is effective? Select all that apply. 1. "I will use a medium- or hard-bristle toothbrush." 2. "I will limit myself to 1 serving of alcohol per day." 3. "I will eat no more than 1,200 calories per day." 4. "I will apply calamine lotion to my dry, itchy skin." 5. "I will immediately report melena to my health care provider." 6. "I will change positions in bed every 4 hours."

4. "I will apply calamine lotion to my dry, itchy skin." 5. "I will immediately report melena to my health care provider." Explanation Strategy: "Teaching is effective" indicates correct information. Determine the outcome of each answer. Is it correct information? 1) thrombocytopenia expected with cirrhosis; client should only use soft bristle toothbrush to minimize risk of bleeding 2) client should completely abstain from alcohol use 3) malnutrition is serious clinical problem associated with cirrhosis; diet for cirrhosis client without complications should be high in calories (3,000 calories/day) 4) CORRECT - appropriate action; client may have pruritus accompanied by jaundice 5) CORRECT - melena (black, tarry stools) should be reported to health care provider immediately; can indicate bleeding esophageal varices 6) nurse will intervene; client should change positions at least every 2 hours; edema is characteristic of cirrhosis, and edematous tissues are subject to breakdown

During a regional outbreak of the flu, a nursing assistant reports to work on the oncology unit. The nurse notes that the nursing assistant is coughing and has a runny nose, and the nurse assistant admits to having an elevated temperature. The nursing assistant tells the nurse that the nursing assistant has no sick leave and is the breadwinner of the family. Which of the response by the nurse is MOST appropriate? 1.'Did you take a flu shot? 2. 'You may work at the desk and help the unit secretary with the charts.= 3. 'I will call one of the other units where clients are less vulnerable" 4. 'l'm sorry, but you will have to go home."

4. 'l'm sorry, but you will have to go home." Explanation Strategyz'lilOST appropriateiindicates discrimination is required to answer the question. 1) should take an annual flu shot; not relevant to this conversation 2) influenza is spread by droplets; even though nursing assistant will not be caring for clients, will still come in contact with other staff members; clients in oncology are immunocompromised 3) hospital is full of immunocompromised clients 4) CORRECT—during community outbreaks of the flu, should exclude staff with febrile infections from caring for high risk clients

The nurse cares for a 4-year-old child diagnosed with epiglottitis. It is MOST important for the nurse to take which action? 1. Instruct a nursing assistive personnel to take the child to the x-ray department. 2. Use a padded tongue blade to assess the child's gag reflex. 3. Obtain a blood culture and arterial blood gases (ABGs) as ordered. 4. Apply a pulse oximeter and start an IV.

4. Apply a pulse oximeter and start an IV. Explanation Strategy "MOST important" indicates priority. 1) epiglottitis is inflammation of the epiglottis and can be life-threatening; a professional should be with the child at all times 2) never insert a tongue blade into the mouth of a child diagnosed with epiglottitis; gag reflex can cause complete obstruction of the airway 3) crying can cause obstruction of airway 4) CORRECT - treatment includes moist air and IV antibiotics to decrease epiglottal swelling; pulse oximeter measures oxygen saturation to determine the need for supplemental oxygen

Which is the best method for the nurse to use when evaluating the effectiveness of tracheal suctioning? 1. Notes subjective data, such as "My breathing is much improved now." 2. Notes objective findings, such as decreased respiratory rate and pulse. 3. Consults with the respiratory therapist to determine effectiveness. 4. Auscultates the chest for change or clearing of adventitious breath sounds.

4. Auscultates the chest for change or clearing of adventitious breath sounds Explanation Strategy: Determine how each answer relates to suctioning. (1) subjective data and not as conclusive (2) correct but not as effective (3) not appropriate (4) CORRECT - to assess the effectiveness of suctioning. auscultate the client's chest to determine if adventitious sounds are cleared and to ensure that the airway is clear of secretions

The home care nurse visits a client diagnosed with ulcerative colitis. The nurse instructs the client about an appropriate diet. The nurse determines that teaching is effective if the client selects which menu? 1. White chili, crackers, applesauce, and tea. 2. Grilled cheese sandwich on white bread, bouillon, an orange, and coffee. 3. Raisin Bran cereal, milk, white toast, and coffee. 4. Baked fish, cream of potato soup, cooked baby carrots, and tea.

4. Baked fish, cream of potato soup, cooked baby carrots, and tea. Explanation Strategy: Recall the diet required for ulcerative colitis. 1) ulcerative colitis is inflammation and ulceration of the colon and rectum; requires high-calorie, high-protein, *low-residue diet; chili contains beans, which are not allowed;* crackers made with white flour and applesauce are allowed 2) raw fruit is not allowed; grilled cheese sandwich and bouillon are allowed 3) Raisin Bran not allowed 4) *CORRECT*—all of these foods are allowed on diet

The nurse observes that a health care provider has ordered 100 mL 05W with KCI 80 mEq to infuse in 30 minutes. Which action should the nurse take first? 1. Assess the client's urinary output. 2. Ensure the patency of the client's IV. 3. Request an order for IV lidocaine. 4. Contact the health care provider.

4. Contact the health care provider. Explanation Strategy: "FIRST" indicates priority. 1) decreased kidney function can cause hyperkalemia 2) severe pain and tissue necrosis may occur because of extravasation 3) Lidocaine used for treatment of ventricular dysrhythmia 4) CORRECT — rate of IV administration should be no faster than 10 mEq/h; contact health care provider to clarify order

The nurse cares for a client admitted with a diagnosis of a stroke and facial paralysis. Nursing care should be planned to prevent which complication? 1. Inability to talk. 2. Loss of the gag reflex. 3. Inability to open the affected eye. 4. Corneal abrasion.

4. Corneal abrasion. Explanation Strategy: Think about each answer. (1) may occur, but nursing care cannot prevent it (2) may occur, but nursing care cannot prevent it (3) may occur, but nursing care cannot prevent it (4) CORRECT - client will be unable to close eye voluntarily; when facial nerve (cranial nerve Vll) is affected, the lacrimal gland will no longer supply secretions that protect eye

The client is brought to the emergency department after being raped in the home. The client asks the nurse to call the spouse to come to the emergency department. The nurse knows the most common reaction of the significant other to a rape victim is reflected in which behavior? 1. Supportive and helpful to the victim. 2. Disconnected from and apathetic toward the victim. 3. Frustrated and feeling vulnerable, but denying the need for help. 4. Emotionally distressed and needing assistance.

4. Emotionally distressed and needing assistance. Explanation Strategy: Think about each answer. 1) significant others may want to be helpful; however, they generally do not have the immediate coping strategies to do so 2) rarely feel disconnected 3) usually family members will need and respond well to psychological intervention 4) CORRECT - sexual assault by rape is a crisis situation for victim and family members and friends

The nurse on the surgical unit receives a call from the operating room to administer preoperative medication to a client scheduled for surgery. After administering the preoperative medication, the nurse discovers that the client has not signed the informed consent for the surgery. Which action should the nurse take next? 1. Notify the health care provider. 2. Ask the client to sign the consent form. 3. Transfer the client to the operating room. 4. Inform the nurse's immediate supervisor.

4. Inform the nurse's immediate supervisor. Explanation Strategy: "next" indicates priority. 1) nurse should stay within the chain of command 2) consent not valid if client has been drinking or has been premedicated 3) surgery performed without consent considered battery 4) CORRECT— nurse should follow chain of command; risks and benefits of the procedure must be explained by the person performing the procedure

A client with an endotracheal tube requires suctioning. Which statement is an accurate description of how the nurse should perform the procedure? 1. Insert the suction catheter 4 in into the tube. Apply suction for 30 seconds, using a twirling motion as the catheter is withdrawn. 2. Hyperoxygenate the client- Insert the suction catheter into the tube, and suction while removing the catheter in a back and forth motion. 3. Explain the procedure to the client. Insert the catheter gently while applying suction, and withdraw using a twisting motion. 4. Insert the suction catheter until resistance is met, and then withdraw it slightly. Apply suction intermittently as the catheter is withdrawn.

4. Insert the suction catheter until resistance is met, and then withdraw it slightly. Apply suction intermittently as the catheter is withdrawn. Explanation Strategy: All answers are implementations. Determine the outcome of each answer. Is it desired? (1) catheter is inserted until resistance is met; never suction longer than 10—15 seconds (2) use twirling motion when withdrawing catheter (3) suction is never applied when catheter is inserted ( 4) CORRECT - insert suction catheter until resistance is met without applying suction, withdraw 0.4 to 0.8 inches (1 to 2 cm), and apply intermittent suction with twirling motion

The nurse performs range-of-motion (ROM) exercises for an elderly client recently immobilized. The nurse identifies which statement as correct about range-of-motion? 1. Passive ROM exercises increase muscle strength. 2. A full ROM must be completed for the elderly client. 3. Exercises should be completed to the point of discomfort 4. ROM assists the elderly to cany out activities of daily living (ADLs).

4. ROM assists the elderly to carry out activities of daily living (ADLs). Explanation Strategy: Think about each answer. 1) inaccurate statement 2) full ROM may not be needed or accomplished without discomfort for an elderly client; ROM may be limited 3) should not be done to point of discomfort 4) CORRECT — emphasis should be on ROMS that support ADLs

A Miller-Abbott tube is ordered for a client. The nurse knows that the main reason this tube is inserted is for which reason? 1. Provides an avenue for nutrients to flow past an obstructed area. 2. Prevents fluid and gas accumulation in the stomach. 3. Administers medications that can be absorbed directly from the intestinal mucosa. 4. Removes fluid and gas from the small intestine.

4. Removes fluid and gas from the small intestine. Explanation Strategy: Think about each answer. (1) tube would be placed in an area of reduced peristalsis and would slowly work past an obstruction (2) describes a tube such as a Levin or Salem Sump, which decompresses the stomach (3) tube provides for decompression instead of instillation of medications (4) CORRECT - Miller-Abbott tube provides for intestinal decompression; intestinal tube is often used for treatment of paralytic ileus

The nurse knows which action is an important consideration in the care of a newborn with fetal alcohol syndrome? 1. Prevent iron deficiency anemia. 2. Decrease touch to prevent overstimulation. 3. Provide feedings via gavage to decrease energy expenditure. 4. Replace vitamins depleted as a result of poor maternal diet.

4. Replace vitamins depleted as a result of poor maternal diet. Explanation Strategy: All answers are implementation. Determine the outcome of each answer. Is it desired? (1) not highest priority (2) infant needs to be held and cuddled due to a poorly developed CNS (3) usually unnecessary (4) CORRECT - frequently, maternal diet is poor and infant is malnourished; adequate intake of B complex vitamins is necessary for normal CNS function

The charge nurse of a psychogeriatric unit makes rounds on the unit. Which situation requires an immediate intervention by the nurse? 1. The dietary aide removes a full breakfast tray untouched by a client with major depression who is still in bed wearing night clothing. 2. The psychiatric aide makes the bed while a client with schizophrenia is sitting in the bedside chair shaving with a disposable razor and mirror. 3. The LPN/LVN assigned to medication administration argues loudly with a bipolar client who is refusing to take prescribed medication. 4. The client care technician places personal care items in reach of a client with stage 2 dementia of the Alzheimer type and then leaves to fill the wash basin with water.

4. The client care technician places personal care items in reach of a client with stage 2 dementia of the Alzheimer type and then leaves to fill the wash basin with water. Explanation Strategy: Determine the most unstable client. 1) these are expected signs of depression that need to be addressed but are not the priority 2) self-care with sharp items is allowed under staff supervision; this client is supervised 3) LPN's behavior needs addressing; client may have the right to refuse medication 4) CORRECT - client at risk for choking on inedible items such as soap, lotions, caps of sample bottles, etc.

The nursing team consists of one RN, two LPNs/LVNs, and three nursing assistive personnel (NAP). The RN should care for which client? 1. The client with a chest tube who is ambulating in the hall. 2. The client with a colostomy requiring assistance with an irrigation. 3. The client with a right-sided stroke requiring assistance with bathing. 4. The client declining medication to treat cancer of the colon.

4. The client declining medication to treat cancer of the colon. Explanation Strategy: Determine the skill level involved with each client's care. The RN cares for clients who require assessment, teaching, and nursing judgment. (1) stable client with an expected outcome; assign to the LPN/LVN (2) stable client with an expected outcome; assign to the LPN/LVN (3) standard, unchanging procedure; assign to the NAP (4) CORRECT - requires assessment skills of the RN

During the client's fourth stage of labor, the nurse should palpate the client's fundus in which location?

Explanation: uterus is normally contracted and palpable at the umbilicus

The nurse cares for clients in the outpatient clinic. In which order does the nurse return messages about these situations? Place the answers in order of priority. All options must be used. The umbilical cord of the 5-day-old is soft and draining exudate. The circumcision site of the 3-day-old is slightly swollen. The "soft spot" on the head of the 4-day-old feels slightly elevated when asleep. When bed is bumped, a 2-day-old rapidly extends the extremities.

The "soft spot" on the head of the 4-day-old feels slightly elevated when asleep. The circumcision site of the 3-day-old is slightly swollen. The umbilical cord of the 5-day-old is soft and draining exudate. When bed is bumped, a 2-day-old rapidly extends the extremities. Explanation Strategy: Identify any normal behaviors. Identify the least stable infant to see first. 1) first: bulging fontanelle may indicate increased intracranial pressure and is most serious 2) second: circumcision should have yellowish exudate at this time, but swelling is not normal and may interfere with urination 3) third: umbilical cord should be dry and hard; draining indicates a possible infection and needs to be assessed 4) last describes the Moro Reflex and is normal

The home care nurse plans activities for the day. In which order does the nurse see the clients? Place the answers in order of priority beginning with the first Client to see. All options must be used. The elderly client diagnosed with pneumonia and discharged from the hospital 3 days ago. The client discharged yesterday after IV heparin therapy for a deep vein thrombosis. The client who is breastfeeding a 2-day-old infant born 5 days before the due date. The elderly client who used all the diuretic medication and is expectorating pink-tinged mucus

The elderly client who used all the diuretic medication and is expectorating pink-tinged mucus The client discharged yesterday after IV heparin therapy for a deep vein thrombosis. The elderly client diagnosed with pneumonia and discharged from the hospital 3 days ago. The client who is breastfeeding a 2-day-old infant born 5 days before the due date. Explanation Strategy: identify the most unstable clients to see first. 1) first: the client with pink tinged mucus; symptoms of pulmonary edema; requires immediate attention 2) second: the client on heparin; still potential for problems related to heparin; assess for bleeding gums, hematuria 3) third: the client with pneumonia; potential for relapse; assess breath sounds, encourage fluids, cough and deep breathe 4) fourth: breastfeeding client; stable client, least critical/priority