NCLEX Review

Prefix/suffix for -pril

ACE inhibitor (Lisinopril)

Prefix/suffix for -dine

histamine blocker (famotidine)

Anti-protozol

*Used for:* Giardia C-diff PUD Vaginosis (form of an STI) *Types of meds:* ventrominazol take with food. don't drink alcohol. causes a metallic taste in mouth.

Prefix/suffix for -done

opioid (hydrocodone)

Normal Lithium Level

0.6-1.2 mEq/L

Penicillin

*Types of meds:* amoxycillin ampicillin *Used for:* pneumonia Upper resp infection sepsis *Adverse reaction:* anaphylaxis

A client brings her 6-month-old infant in for a well-baby visit. During the exam, the nurse is unable to elicit the Moro reflex. Which of the following is the appropriate action by the nurse? a. Explaining to the client that this reflex disappears around 3-4 months b. Contacting the physician with the finding c. Waiting 5 minutes then attempting to elicit the reflex again d. Explaining that this reflex disappears around 6-8 weeks

Answer = a Rationale: The Moro reflex disappears around 3-4 months of age; therefore, it is considered a normal finding for it not to be elicited in a 6-month-old infant. The nurse should explain to the mother that the reflex disappears around 3-4 months. There is no need to attempt to elicit the reflex again or to contact the physician with the finding.

A client has received burns to the anterior and posterior lower extremities. In order to calculate the expected amount of fluid resuscitation, the nurse calculates the client's percentage of body area burned as what percent? Record your answer using a whole number. a. 50 b. 36

Answer = b Rationale: Using the Rule of Nines, the clients surface area that has been burned is calculated as 9% for the anterior surface of the left leg, 9% for the posterior surface of the left leg, 9% for the anterior surface of the right leg, and 9% for the posterior surface of the right leg = 9% X 4 or 36%.

A client with a urinary tract infection is ordered co-trimoxazole. The nurse should provide which medication instruction? a. " "Take the medication with food." b. "Drink at least eight 8-oz (240 mL) glasses of fluid daily." c. "Avoid taking antacids during co-trimoxazole therapy." d. "Don't be afraid to go out in the sun."

Answer = b You answered: c Rationale: The nurse should instruct a client receiving a sulfonamide such as co-trimoxazole to drink at least eight 8-oz (240 mL) glasses of fluid daily to maintain a urine output of at least 1,500 ml/day. Otherwise, inadequate urine output may lead to crystalluria or tubular deposits. For maximum absorption, the client should take this drug at least 1 hour before or 2 hours after meals. No evidence indicates that antacids interfere with the effects of sulfonamides. To prevent a photosensitivity reaction, the client should avoid direct sunlight during co-trimoxazole therapy

A client is prescribed lisinopril for the treatment of hypertension. What are the potential adverse effects of this medication? Select all that apply. a. Constipation b. Dizziness c. Headache d. Hyperglycemia e. Hypotension f. Impotence

You Selected: Hypotension Dizziness Headache Correct response: Dizziness Headache Hypotension Impotence Rationale: Dizziness, headache, and hypotension are all common adverse effects of lisinopril and other ACE inhibitors. Lisinopril may cause diarrhea, not constipation. Adverse effects are possible with lisinopril. Sexual side effects, while rare, include a decreased sex drive and erectile dysfunction or impotence. Lisinopril isn't known to cause hyperglycemia.

A primigravid client is admitted to the labor and delivery area, where the nurse evaluates her. Which assessment finding may indicate the need for cesarean birth? a. Insufficient perineal stretching b. Rapid, progressive labor c. Umbilical cord prolapse d. Fetal prematurity

You Selected: Insufficient perineal stretching Correct response: Umbilical cord prolapse Explanation: Indications for cesarean birth include umbilical cord prolapse, breech presentation, fetal distress, dystocia, previous cesarean birth, herpes simplex infection, condyloma acuminatum, placenta previa, abruptio placentae, and unsuccessful labor induction. Insufficient perineal stretching; rapid, progressive labor; and fetal prematurity aren't indications for cesarean birth

The nurse should teach the diabetic client that which is most indicative of hypoglycemia? a. nervousness b. anorexia c. Kussmaul's respirations d. bradycardia

You Selected: Kussmaul's respirations Correct response: nervousness Explanation: The four most commonly reported signs and symptoms of hypoglycemia are nervousness, weakness, perspiration, and confusion. Other signs and symptoms include hunger, incoherent speech, tachycardia, and blurred vision. Anorexia and Kussmaul's respirations are clinical manifestations of hyperglycemia or ketoacidosis. Bradycardia is not associated with hypoglycemia; tachycardia is.

A client ingested a large amount of acetaminophen at 1:00 am. Two hours later, the client comes to the emergency department, and is diagnosed with acetaminophen poisoning. What is the priority intervention for this client? a. Perform gastric lavage b. Obtain blood work c. Administer IV fluid d. Administer acetylcysteine

You Selected: Perform gastric lavage Correct response: Administer acetylcysteine Explanation: If the client is seen within one hour of ingestion, activated charcoal can be given to prevent absorption, or gastric lavage can be used. Blood work would be obtained but wouldn't be the first priority. Intravenous fluids would also be administered, but administering ?-acetylcysteine, the specific antidote for acetaminophen poisoning, is the priority.

A nurse overhears a fellow staff member talking about the mother of a child for whom the staff nurse is caring. The nurse is telling others private information that the mother had shared. What is the best response by the nurse overhearing the conversation? a. Report this incident to the nurse-manager. b. Report the incident to the organization's privacy officer. c. Talk to the staff member privately about this. d. Talk to the staff in general about confidentiality.

You Selected: Report this incident to the nurse-manager. Correct response: Talk to the staff member privately about this. Explanation: The best approach is to talk to the staff member privately about the information that the mother shared. This information is confidential and should not be disclosed. Reporting the incident to the nurse-manager is appropriate once the nurse has spoken to the staff member privately. The decision to contact a privacy officer is dependent on the seriousness of the breech and should be determined after discussion with the nurse manager. Talking to the staff in general about confidentiality may be beneficial. However, the nurse needs to speak with the staff member in private first.

A nurse is planning care for a client in acute addisonian crisis. Which nursing diagnosis should receive the highest priority? a. Risk for infection b. Decreased cardiac output c. Impaired physical mobility d. Imbalanced nutrition: Less than body requirements

You Selected: Risk for infection Correct response: Decreased cardiac output Explanation: An acute addisonian crisis is a life-threatening event, caused by deficiencies of cortisol and aldosterone. Glucocorticoid insufficiency causes a decrease in cardiac output and vascular tone, leading to hypovolemia. The client becomes tachycardic and hypotensive and may develop shock and circulatory collapse. The client with Addison's disease is at risk for infection; however, reducing infection isn't a priority during an addisonian crisis. Impaired physical mobility and Imbalanced nutrition: Less than body requirements are appropriate nursing diagnoses for the client with Addison's disease, but they aren't priorities in a crisis.

A child with a poor nutritional status and weight loss is at risk for a negative nitrogen balance. To help diagnose this problem, the nurse anticipates that the physician will order which laboratory test? a. Total iron-binding capacity b. Hemoglobin (Hb) c. Total protein d. Sweat test

You Selected: Sweat test Correct response: Total protein Explanation: The nurse anticipates the physician will order a total protein test because negative nitrogen balance may result from inadequate protein intake. Measuring total iron-binding capacity and Hb levels would help detect iron deficiency anemia, not a negative nitrogen balance. The sweat test helps diagnose cystic fibrosis, not a negative nitrogen balance.

Which of the following arterial blood gas (ABG) results would the nurse anticipate for a client with a 3-day history of vomiting? a. pH: 7.55, PaCO2: 60 mm Hg, HCO3-: 28 b. pH: 7.45, PaCO2: 32 mm Hg, HCO3-: 21 c. pH: 7.28, PaCO2: 25 mm Hg, HCO3: 15 d. pH: 7.34, PaCO2: 60 mm Hg, HCO3: 34

You Selected: pH: 7.45, PaCO2: 32 mm Hg, HCO3-: 21 Correct response: pH: 7.55, PaCO2: 60 mm Hg, HCO3-: 28 Explanation: The client's ABG would likely demonstrate metabolic alkalosis. Metabolic alkalosis is a clinical disturbance characterized by a high pH (decreased H+ concentration) and a high plasma bicarbonate concentration. It can be produced by a gain of bicarbonate or a loss of H+. A common cause of metabolic alkalosis is vomiting or gastric suction with loss of hydrogen and chloride ions. The disorder also occurs in pyloric stenosis where only gastric fluid is lost. The other results do not represent metabolic alkalosis.

Which practice should a nurse recommend to a client who has had a cesarean birth? a. frequent douching after she's discharged b. coughing and deep/breathing exercises c. doing sit ups 2 weeks after birth d. side rolling exercises

You selected: d Correct response: b As for any post operative client this client needs to be taught coughing and deep-breathing exercises to keep the alveoli open and prevent infection. Frequent douching isn't recommended for any group of women and is contraindicated in women who have just given birth. doing sit ups at 2 weeks post part could damage the healing of the incision. Side rolling exercises aren't an accepted medical practice.

Findings with systemic lupus erythematosus

decreased urine output butterfly rash joint inflammation NOT renal calculi NOT subcutaneous nodules

Contact Precautions

infections that are spread via skin to skin or skin from other surfaces C-Diff MRSA VRE (vancomycin resistance)

Prefix/suffix for -zide

thiazide diuretic (Hydrochlorothiazide)

Prefix/suffix for -kinase

thrombolytic (streptokinase)

Cephalosporins

SALAD drugs, all start with "CEF" *Used for:* upper resp infection skin infection UTI *Side effects:* cross sensitivity to penicillin can cause supra infection can cause C-diff

Prefix/suffix for -ase

Thrombolytic (Alteplase)

Prefix/suffix for -sartan

angio II blocker (losartan)

Prefix/suffix for -pam

anti-anxiety (Lorazepam)

Prefix/suffix for -gliptin

oral hypoglycemic (DPP-4 inhibitor) (sitagliptin)

Droplet precautions

spread of larger droplets people can spread this by coughing, sneezing or even talking influenza bacterial meningitis

A nurse is teaching a client who is receiving chemotherapy. The client's lab results indicate bone marrow suppression. Which instructions should the nurse include in the teaching? a. take aspirin for minor aches and pains b. clean your toothbrush with warm water weekly c. bathe with an antimicrobial soap twice per day d. wear clothing that will minimize sun exposure

Answer = c bathing with an antimicrobial soap will limit the exposure to micro-organisms. the toothbrush should be washed weekly with liquid bleach or run the toothbrush through the dishwasher to destroy micro-organisms.

During assessment, a client verbally rates the pain as 9 out of 10 on a 0 to 10 pain scale. There is no indication of pain relief, even though the previous nurse signed for an opioid for this client one hour prior. The client denies receiving anything for pain since the previous night. Which action should the nurse take next? a. Notify the provider that an opioid is missing b. Notify the supervisor that the client didn't receive the prescribed pain medication c. Notify the pharmacist that the client didn't receive the prescribed pain medication d. Approach the nurse who signed for the opioid to seek clarification about the missing drug

Answer = d No rationale

Short acting insulin types and protocol

Regular insulin - administered 30-60 minutes before meals

Prefix/suffix for nitr-

Vasodilator (nitroglycerin)

Prefix/suffix for -lam

anti-anxiety (alprazolam)

Prefix/suffix for -parin

anti-coagulation (heparin)

Amino-glycosides (use, types of meds, side effects)

*Used for:* sepsis meningitis pneumonia pre surgery as prophylactic *Types of meds:* Anacacyn gentamicin streptamycin neomycin *Side effects:* ototoxicity (ringing ears, can't hear as well, dizziness) nephrotoxicity (BUN, creatinine) Check peak and troff since these medications are very toxic.

Prefix/suffix for -ide

Oral hypoglycemic & loop diuretic (repaglinide)

Prefix/suffix for -sone

steroid (prednisone)

Anti-malerials

*Used for:* malaria RA SLE Increases risk for psoriasis. Can cause a drug induced retinopathy, patient's should wear sunglasses and protect their eyes.

Anti-retrovirals

*Used for:* Genital herpes shingles HIV *Types of meds:* Acyclovir Valcyclovir Zyvudine Most anti-retrovirals end in "vir". So if the questions has a medication ending in "vir" the patient most likely has a viral infection. give with food. increase fluids. give at onset of symptoms.

HIV Stages

*Stage 1* = acute infection and retroviral syndrome. Patient will tell you it's the worse flue ever. CD4 will drop to 500 and then will increase to normal as the body recovers. *Stage 2* = often called chronic infection or asymptomatic infection. During this stage CD4 will be anywhere from 200-499. Lasts 8-10 years. *Stage 3* = patient has AIDS. CD4 less than 200. Body now has opportunistic infections. Survival is maybe 1-3 years. WHO recommendation for therapy: give patient efavirenz, give azidothymidine, iamivudine (3 drugs from 2 different classes). In a pregnant woman with HIV, they will recommend PEP with zidovudine, PrEP will use tenofvir and emtricitabine (two drugs combined is called Truvada).

The nurse is teaching a client with stomatitis about mouth care. Which instruction is most appropriate? a. Drink hot tea at frequent intervals. b. Gargle with antiseptic mouthwash. c. Use an electric toothbrush. d. Eat a soft, bland diet.

Answer = d Rationale: Clients with stomatitis (inflammation of the mouth) have significant discomfort, which impacts their ability to eat and drink. They will be most comfortable eating soft, bland foods, and avoiding temperature extremes in their food and liquids. Gargling with an antiseptic mouthwash will be irritating to the mucosa. Mouth care should include gentle brushing with a soft toothbrush and flossing.

Prefix/suffix for -caine

Local anesthetic (Lidocaine)

Prefix/suffix for -oxin

cardiac glycoside (digoxin)

Prefix/suffix for -vir

Antiviral (acyclovir)

A client who tested positive for HIV 3 years ago is admitted to the hospital with Pneumocystis jiroveci pneumonia (PCP). Based on diagnostic criteria established by the CDC, the client is diagnosed as having a. Early chronic infection. b. HIV infection. c. AIDS. d. Intermediate chronic infection.

Answer = C Rationale: Development of PCP pneumonia meets the diagnostic criteria for AIDS.

Standard Precautions

Wear gloves If possibility for "splashing" when doing a dressing change, wear face shield as well

With acute leukemia, what can you expect to see with the following lab values. (WBC, Hgb, Hct, Platelets)

elevated WBC decreased Hgb decreased Hct decreased platelets

A seven year old has just been admitted to the unit for excessive vomiting. Based on the available chart data, what is the nurse's most appropriate action? 10/15/16 0730 Vital Signs Record T: 104.9° F (40.5° C) P: 98 RR: 30 Lab Values Serum Potassium: 3.1 mmol/L Serum Sodium: 128 mmol/L Nurse's Note Skin flushed and warm to touch; good turgor; petechiae noted over entire trunk a. Cover the petechiae with dry sterile dressings b. Initiate extremity restraints as seizure precautions c. Suspect that the child has been abused d. Assess the child's neurological status

You Selected: Assess the child's neurological status Correct response: Assess the child's neurological status Rationale: Since fever, seizures, vomiting, and petechiae are signs of meningitis, the nurse should promptly assess the child's neurological status and report the findings to the provider. Petechiae does not require dry sterile dressings, nor are they signs of abuse. Restraints are not used as a seizure precautions, the finding of petechiae wouldn't be a reason to initiate seizure precautions. The lab values are just below normal, and would expected if the child has been vomiting.

Macrolides

*Used for:* whooping cough (purtussis) upper resp infection STI's *Types of meds:* Azythromyacin Chlorithromycin Erythromycin (vibromycin) drug of choice for patient's and children allergic to penicillin. *Side effects:* GI effects. N/V. Make sure to eat with it.

Normal test result for PKU

< 2 mg/dl

Prefix/suffix for -olol

Beta Blockers (propanolol)

Prefix/suffix for -phylline

Bronchodilator (Theophylline)

Which statement by the client with rheumatoid arthritis would indicate the need for additional teaching to safely receive the maximum benefit of aspirin therapy? a. "I always take aspirin with food to protect my stomach." b. "Once I learned to take my aspirin with meals, I was able to start using the inexpensive generic brand." c. "I always watch for bleeding gums or blood in my stool." d. "I try to take aspirin only on days when the pain seems particularly bad."

Correct response: "I try to take aspirin only on days when the pain seems particularly bad." Explanation: Aspirin therapy in rheumatoid arthritis involves continuous ongoing administration to establish and maintain therapeutic blood levels. Aspirin should not be used on an as-needed basis. Aspirin should always be buffered with food. Generic aspirin is acceptable. Clients should be instructed to observe for symptoms of bleeding.

Erikson's Stages of Psychosocial Development

Infant - 18 montrhs: Tust vs Mistrust 18 months - 3 years: Autonomy vs Shame & Doubt 3-5 years: Initiative vs Guilt 5-13 years: Industry vs Inferiority 13-21 years: Identify vs Role Confusion

a 15 year old client gives birth to a healthy neonate. The neonates adolescent father arrives on the unit demanding to see his baby. Both sets of grandparents are also present and asking to see their grandchild. The newly hired nurse assigned to the nursery should take which action? a. notify security because the neonates father is demanding to see his baby b. teach the grandparents how to scrub and gown before entering the nursery c. discuss the unit's policy with the charge nurse d. invite everyone into the large conference room to see the neonate

You answered: a Correct response: c Because the nurse is new to the hospital, she should check with the charge nurse about the unit's visiting policy. The scenario doesn't provide information about whether the neonates parents are married or if the mother is an emancipated minor.

Air borne precautions

chicken pox/varicella TB measles

Benztropine is used to treat the extrapyramidal effects induced by antipsychotics. This drug exerts its effect by: a. decreasing the anxiety causing muscle rigidity. b. blocking cholinergic activity in the central nervous system (CNS). c. increasing the level of acetylcholine in the CNS. d. increasing norepinephrine in the CNS.

Correct response: blocking cholinergic activity in the central nervous system (CNS). Explanation: Benztropine blocks cholinergic activity in the CNS. Anxiety doesn't cause extrapyramidal effects. Overactivity of acetylcholine and lower levels of dopamine are the causes of extrapyramidal effects. Benztropine doesn't increase norepinephrine in the CNS.

A nurse is providing teaching to a client who has an allergy to peanuts. Which of the following instructions is the priority to include in the teaching? a. inform other health care professionals of the allergy b. wear a medical id tag c. carry and emergency anaphylaxis kit d. keep a food diary

Answer = C The greatest risk to the client is injury or death from an anaphylactic reaction. Therefore, the priority instruction for the client is to be prepared for emergency treatment by carrying an emergency anaphylaxis kit. The nurse should instruct the client to wear a medical ID tag. However, this is not the priority instruction to include in the teaching.

The nurse is preparing to teach a group of caregivers about medication management for family members with Alzheimer's disease. What is the most important information for the nurse to include? Select all that apply. a. Determine if the client is able to safely self-medicate b. Visually inspect the mouth after giving a pill c. Use one pharmacy for all of the client's prescriptions Be certain that this client can swallow a pill d. Consult with the pharmacy about altering the dosage e. Know what to do if the client refuses to take the medication.

You Selected: - Use one pharmacy for all of the client's prescriptions - Be certain that this client can swallow a pill - Visually inspect the mouth after giving a pill - Know what to do if the client refuses to take the medication. - Consult with the pharmacy about altering the dosage - Determine if the client is able to safely self-medicate Correct response: - Determine if the client is able to safely self-medicate - Visually inspect the mouth after giving a pill - Use one pharmacy for all of the client's prescriptions - Be certain that this client can swallow a pill - Know what to do if the client refuses to take the medication Rationale: A teaching plan would include evaluating whether the client is able to safely self-medicate, performing a visual mouth inspection after giving a pill, using only one pharmacy for all of the client's prescriptions, checking that the client can swallow a pill, and knowing what to do if the client refuses to take the medication. The caregiver should consult with the pharmacist about obtaining an alternative form of the drug if the client can no longer swallow a pill or capsule. The health care provider would be consulted to change the medication dose.

A nurse inadvertently gives a client a double dose of an ordered medication. After discovering the error, whom should the nurse notify first? a. The client b. The prescriber c. The pharmacist d. The risk manager

Answer = b You answered: d Rationale: After discovering a medication error, the safety of the patient is top priority. The nurse should immediately check the client and observe for any adverse effects which may develop. The first person the nurse needs to notify is the prescriber, followed by the nursing manager (or the nursing supervisor). Then pharmacist and risk manager should also be notified.

When evaluating teaching a client how to administer insulin, which action indicates that additional teaching is necessary? a. Client draws up the regular insulin first and then the NPH. b. Client rotates sites from legs to arms. c. Client identifies that the syringe is U-100 d. Client waits 30 minutes to eat breakfast after injecting rapid-acting insulin

Answer = d You selected: b Rationale: The nurse instructs the client to not wait any longer than 5 to 15 minutes to eat after injecting rapid-acting insulin, which has an onset action of 5 minutes and duration of 1 hour. The client is using proper technique for mixing the insulins, rotating sites, and using the U-100 syringe.

A nurse is performing an assessment on an adult with hypertension who falls into the middle-old elderly population. Which of the following findings should be reported to the primary care provider? a. Nails are thickened, brittle, and yellow b. Urine output of 600mL/24 hours c. Lower peripheral pulses +1 bilaterally d. Increased sensitivity to glare

Answer = b You answered: c Rationale: Normal urinary output ranges from 30-80mL/hour. An output of 600mL/24 hours indicates a problem with urinary elimination because it is less than 30mL/hour. Normal physiologic changes associated with aging include thickened, brittle, yellow nails, diminished peripheral pulses, and increased sensitivity to glare.

A young female client is receiving chemotherapy and mentions to the nurse that she and her husband are using a diaphragm for birth control. Which information is most important for the nurse to discuss? a. inconvenience of the diaphragm b. transmission of sexually transmitted diseases c. body changes related to hormones d. infection control

Answer = d You answered: b Rationale: The risk of becoming neutropenic during chemotherapy is very high. Therefore, an inserted foreign object such as a diaphragm may be a nidus for infection. Although the nurse may wish to inform the client about the ease with which various contraceptive modalities may be used, the focus of this discussion should be on preventing an infection, which can be fatal for the neutropenic client. There are no data to suggest the client is at risk for acquiring a sexually transmitted disease. The client will not be experiencing body changes directly related to hormonal changes.

The nurse is teaching a client about the risk factors for developing osteoporosis. What is the most important information for the nurse to include? Select all that apply. a. Inadequate dietary intake of calcium b. Blood pressure medications c. Family history d. Smoking e. Oral hypoglycemics

You Selected: Family history Smoking Oral hypoglycemics Inadequate dietary intake of calcium Correct response: Inadequate dietary intake of calcium Family history Smoking Rationale: Inadequate dietary intake of calcium, family history, and smoking are risk factors of osteoporosis. There is no evidence that blood pressure medications or oral hypoglycemics are risk factors.

A child with suspected infective endocarditis arrives at the emergency department. Which assessment findings would the nurse anticipate in this child? Select all that apply. a. Weight gain b. Murmur c. Low-grade fever d. Malaise e. Headache

You Selected: Malaise Low-grade fever Correct response: Murmur Low-grade fever Malaise Headache Rationale: Symptoms may include a low-grade intermittent fever, decrease in hemoglobin level, tachycardia, anorexia, weight loss, malaise, headache, joint and muscle pain, and decreased activity level. Bacteremia leads to these signs of an infection. The murmur is due to damage to the cardiac valves or myocardium.

Normal blood level for Valproic Acid

50 to 100 mcg/mL

Shift to the Left in WBCs

A shift to the left means that more immature than mature WBCs are at the site of inflammation or infection. Immature WBCs are less effective at phagocytosis and do not produce classic signs of inflammation, such as pus, redness, swelling, or heat. Fever is the only sign; therefore, it is a significant sign of infection in a client with immature or depressed WBCs.

Cholinergic vs. Adrenergic

Adrenergic is called the sympathetic line (SNS) while cholinergic is called the parasympathetic line (PNS). Nicotinic and muscarinic receptors are part of the cholinergic line while alpha and beta receptors are involved in the adrenergic line

A client is taking fluphenazine. The nurse understands that teaching and discharge instructions are understood when the client states: a. "I need to stay out of the sun." b. "I need to double my fluids." c. "I can't eat cheese or eggs." d. "I need to plan frequent naps."

Answer = a Rationale: Fluphenazine is an antipsychotic drug that can cause photosensitivity and sunburn. Clients taking this drug don't need to increase fluid intake, avoid cheese or eggs, or plan rest periods.

One of the advantages of the antipsychotic medication APO-risperidone is: a. the absence of anticholinergic effects. b. a lower incidence of extrapyramidal effects. c. photosensitivity and sedation. d. no incidence of neuroleptic malignant syndrome.

Answer = b Rationale: Risperidone has a lower incidence of extrapyramidal effects than the typical antipsychotics. Risperidone does produce anticholinergic effects, and neuroleptic malignant syndrome can occur. Photosensitivity is not an advantage.

A client is recovering from an acute myocardial infarction (MI). During the first week of the client's recovery, the nurse should stay alert for which abnormal heart sound? a. Opening snap b. Graham Steell's murmur c. Ejection click d. Pericardial friction rub

Answer = d Rationale: A pericardial friction rub, which sounds like squeaky leather, may occur during the first week following an MI. Resulting from inflammation of the pericardial sac, this abnormal heart sound arises as the roughened parietal and visceral layers of the pericardium rub against each other. Certain stenosed valves may cause a brief, high-pitched opening snap heard early in diastole. Graham Steell's murmur is a high-pitched, blowing murmur with a decrescendo pattern; heard during diastole, it indicates pulmonary insufficiency, such as from pulmonary hypertension or a congenital pulmonary valve defect. An ejection click, associated with mitral valve prolapse or a rigid, calcified aortic valve, causes a high-pitched sound during systole.

Prefix/suffix for cef-

Antibiotic (cefazolin)

Prefix/suffix for -mycin

Antibiotic (clindamycin)

Prefix/suffix for -cycline

Antibiotic (doxycycline)

Prefix/suffix for sulf-

Antibiotic (sulfadiazine)

Prefix/suffix for -coxib

COX 2 inhibitor (celecoxib)

A client with chronic schizophrenia has received 10 mg of fluphenazine hydrochloride p.o qid. Now the client has a temperature of 102° F (38.9° C), a heart rate of 120 beats/minute, a respiratory rate of 20 breaths/minute, and a blood pressure of 210/140 mm Hg. Because the client is also confused and incontinent, the nurse suspects neuroleptic malignant syndrome. What steps should the nurse take? a. Give the client his next dose of fluphenazine, call the physician, and monitor the client's vital signs. b. Withhold the client's next dose of fluphenazine, call the physician, and monitor the client's vital signs. c. Give the client his next dose of fluphenazine and restrict him to his room to decrease stimulation. d. Withhold the client's next dose of fluphenazine, administer an antipyretic agent, and increase the client's fluid intake.

Correct response: Withhold the client's next dose of fluphenazine, call the physician, and monitor the client's vital signs. Explanation: Neuroleptic malignant syndrome is a dangerous adverse effect of neuroleptic drugs such as fluphenazine. The nurse should withhold the next dose, notify the physician, and continue to monitor the client's vital signs. Although an antipyretic agent may be used to reduce fever, increased fluid intake is contraindicated because additional fluid may further increase the client's fluid volume, elevating his blood pressure even more.

Prefix/suffix for -mide

Diuretic (furosemide)

Long acting insulin types and protocols

Glargine & Detemir - administered at the same time each day - subQ only

Rapid acting insulin types and protocols

Lispro, Aspart, & Glulisine - should be administered before meals - administer in conjunction with intermediate or long acting insulines

Trimethoprim and Sulfamthoxazole (baxtrum)

Not used as often anymore. May be used for UTI's, bronchitis, otitis media. MUST increase fluids! Can lead to renal fluid so must be flushed out. Stay out of sun, causes photosensitivity. Use a back up contraceptive.

When preparing to admit an infant diagnosed with diarrhea to the pediatric unit, the nurse should assign the infant to which room? a. a single negative pressure room b. a two-bed room with an infant with respiratory disease c. a private room d. a room with other infants younger than age 1 year

When preparing to admit an infant diagnosed with diarrhea to the pediatric unit, the nurse should assign the infant to which room? You Selected: a single negative pressure room Correct response: a private room Explanation: To reduce the risk of infection transmission, an infant with diarrhea of undetermined origin should be placed in a private room until a causative organism can be identified. However a negative pressure room is not needed because airborne precautions are not required with diarrheal disease.

The nurse is checking the blood sugar level of a client who is at 33-weeks' gestation. This client has had type 1 diabetes since she was 12 years old. Which value would indicate to the nurse that this client's disease is controlled? a. 45 mg/dl (2.5 mmol/L) b. 85 mg/dl (4.7 mmol/L) c. 120 mg/dl (6.7 mmol/L) d. 136 mg/dl (7.6 mmol/L)

You Selected: 120 mg/dl (6.7 mmol/L) Correct response: 85 mg/dl (4.7 mmol/L) Explanation: The recommended fasting blood sugar level in a pregnant client with diabetes is 60 to 90 mg/dl (3.3 to 5.0 mmol/L). A fasting blood sugar level of 45 mg/dl (2.5 mmol/L) is low, and may result in symptoms of hypoglycemia. A blood sugar level below 120 mg/dl (6.7 mmol/L) is a recommended one-hour postprandial value. A blood sugar level above 136 mg/dl (7.6 mmol/L) in a pregnant client indicates hyperglycemia.

The nurse is performing an assessment on a client after her third electroconvulsive therapy (ECT). Which finding should she anticipate most frequently? a. A cardiac arrhythmia b. A prolonged seizure c. A headache d. Short-term memory loss

You Selected: A headache Correct response: Short-term memory loss Explanation: Short-term memory loss is the most common adverse effect of ECT. In many cases, the memory does not return. ECT does not affect the heart. A seizure is not an adverse effect; rather, it is intentionally induced. Brain damage caused by ECT has not been substantiated. A headache is common but not the most frequent effect.

A client receives midazolam, 2 mg IV, as sedation before bronchoscopy. Five minutes after he receives the drug, his respiratory rate drops to 4 breaths/min. What is the nurse's most appropriate action? a. Administer naloxone b. Administer protamine sulfate (Heparin antagonist) c. Administer phentolamine d. Administer flumazenil

You Selected: Administer naloxone Correct response: Administer flumazenil Explanation: Flumazenil reverses the effects of benzodiazepines such as midazolam. Naloxone is used to reverse opioids, such as morphine. Protamine sulfate reverses the effects of heparin. Phentolamine is injected into the tissues to reverse the damaging effects of a dopamine infiltration.

A client presents to the emergency room with abdominal pain and upper gastrointestinal bleeding. The client is sweating and appears to be in moderate distress. Which nursing action would be a priority at this time? a. Obtain vital signs. b. Document history of the symptoms. c. Assess bowel sounds and abdominal tenderness. d. Insert an NG tube and connect to suction

You Selected: Assess bowel sounds and abdominal tenderness. Correct response: Obtain vital signs. Explanation: The priority nursing action is vital signs. Vital signs provide valuable information on the internal body system. Symptoms of shock, such as low blood pressure, a rapid weak pulse, cold clammy skin, and restlessness, can be monitored. Assessing bowel sounds and abdominal tenderness can provide useful data but is not a priority. Documentation is a lower priority and a health care provider's order is needed for a nasogastric tube placement

An elderly female client has been complaining of sleeping more, increased urination, anorexia, weakness, irritability, depression, and bone pain that interferes with her going outdoors. Based on these assessment findings, the nurse should suspect which disorder? a. Diabetes mellitus b. Diabetes insipidus c. Hypoparathyroidism d. Hyperparathyroidism

You Selected: Diabetes insipidus Correct response: Hyperparathyroidism Explanation: Hyperparathyroidism is most common in older women and is characterized by bone pain and weakness from excess parathyroid hormone. Clients also exhibit hypercalciuria-causing polyuria. Although clients with diabetes mellitus and diabetes insipidus have polyuria, they don't have bone pain and increased sleeping. Hypoparathyroidism is characterized by urinary frequency rather than by polyuria.

The nurse is working in a community mental health clinic. A client who is diagnosed with schizophrenia is taking clozapine and reports of a sore throat. What is the most appropriate action for the nurse to take? a. Suggest that the client drink warm beverages and rest. b. Have the client decrease the daily amount of clozapine by half. c. Obtain an order for the client to have a white blood cell count drawn. d. Encourage the use of saline mouth rinses until the sore throat is gone.

You Selected: Encourage the use of saline mouth rinses until the sore throat is gone. Correct response: Obtain an order for the client to have a white blood cell count drawn. Explanation: The report of a sore throat may indicate an infection caused by agranulocytosis, a depletion in white blood cells. The way to determine this is by obtaining a white blood cell count. The other options do not get to the cause of the client's concern

A pregnant client calls the nurse at 22 weeks gestation to report that she is experiencing some edema of her face and hands, with puffiness in her eyelids in the morning. What is the priority action by the nurse? a. Explain that this is a normal finding for pregnancy. b. Suggest that the client recline in a lateral recumbent position. c. Tell the client to monitor her symptoms for 24 hours. d. Refer the client to her physician.

You Selected: Explain that this is a normal finding for pregnancy. Correct response: Refer the client to her physician. Explanation: With preeclampsia, edema begins to accumulate in the upper part of the body, rather than just the typical ankle edema of pregnancy. With severe preeclampsia, the edema will be present in the woman's hands and face as puffiness and is not responsive to 12 hours of bed rest. A physician needs to be seen to determine appropriate treatment, and other actions are not appropriate at this time.

The nurse is providing dietary teaching for a client with diabetes. Which of the following statements about the diet would be accurate? a. It is based on nutritional requirements that are the same for all clients. b. It is planned around a wide variety of commonly available foods. c. It is rigidly controlled to avoid similar diabetic emergencies. d. It does not include processed foods because they have too many variables.

You Selected: It is rigidly controlled to avoid similar diabetic emergencies. Correct response: It is planned around a wide variety of commonly available foods. Explanation: Each client should be given an individually devised diet selecting commonly used foods from the Diabetic Association exchange diet. Family members should be included in the diet teaching. Nutritional requirements are not the same for all clients. Flexibility is needed based on activity, not rigid control. Seasoning and processed food should be managed.

A community health nurse is administering pneumococcal polysaccharide vaccinations and flu vaccinations to clients with asthma, chronic bronchitis, and emphysema. A client asks the nurse why these vaccines are recommended. What is the nurse's best response? a. These vaccines are recommended for all clients. b. These vaccines produce bronchodilation and improve oxygenation. c. These vaccines help reduce the tachypnea these clients experience. d. Respiratory infections can cause severe hypoxia and possibly death in these clients.

You Selected: These vaccines are recommended for all clients. Correct response: Respiratory infections can cause severe hypoxia and possibly death in these clients. Rational: It's highly recommended that clients with respiratory disorders receive vaccines to protect against respiratory infections. These clients may require intubation and mechanical ventilation if they become infected. The vaccines have no effect on bronchodilation or respiratory rate.

The nurse is receiving over the telephone a laboratory results report of a neonate's blood glucose level. The nurse should: a. write down the results, read back the results to the caller from the laboratory, and receive confirmation from the caller that the nurse understands the results. b. repeat the results to the caller from the laboratory, write the results on scrap paper first, and then transfer the results to the medical record. c. indicate to the caller that the nurse cannot receive verbal results from laboratory tests for neonates, and ask the laboratory to bring the written results to the nursery. d. request that the laboratory send the results by e-mail to transfer to the client's medical record.

Answer = a Rationale: To ensure client safety, the nurse should first write the results on the medical record, then read them back to the caller and wait for the caller to confirm that the nurse has understood the results. Using scrap paper increases the risk of losing the results as well as transcription errors. The nurse may receive results by telephone, and while electronic transfer to the client's medical record is appropriate, the nurse can also accept the telephone results if the laboratory has called the results to the nursery. Sending client information via e-mail is unacceptable due to potential security and privacy issues.

Four clients are assigned to a nurse. The nurse understands that the client with which condition would most benefit from ordered hyperbaric oxygen therapy? a. a compromised skin graft. b. a malignant tumor. c. pneumonia. d. hyperthermia

Answer = a You answered: c Rationale: A client with a compromised skin graft could benefit from hyperbaric oxygen therapy because increasing oxygenation at the wound site promotes wound healing. Hyperbaric oxygen therapy isn't indicated for malignant tumors, pneumonia, or hyperthermia. Hyperbaric oxygen therapy: Medical treatment that delivers 100% oxygen while the patient is in a special pressurized chamber.

A client needs to be transferred to the oncology unit for further care. Which of the following information is necessary to include in the transfer report? a. Current client assessment. b. Client's admission number. c. Nursing treatment initiated. d. Results of laboratory tests

Answer = a You answered: d Rationale: The nurse should include the current assessment of the client in the transfer report because it enables the receiving nurse to prepare for the client before arrival and to clarify any information from written transfer summaries they may have obtained. It is not important to mention the client's admission number during the transfer report. Information regarding the nursing treatment initiated and information about laboratory tests is important when reporting to the primary care provider and not in the transfer report.

A triple-lumen indwelling urinary catheter is inserted for continuous bladder irrigation following a transurethral resection of the prostate. In addition to balloon inflation, the functions of the three lumens include: a. continuous inflow and outflow of irrigation solution. b. intermittent inflow and continuous outflow of irrigation solution. c. continuous inflow and intermittent outflow of irrigation solution. d. intermittent flow of irrigation solution and prevention of hemorrhage.

Answer = a You answered: d Rationale: When preparing for continuous bladder irrigation, a triple-lumen indwelling urinary catheter is inserted. The three lumens provide for balloon inflation and continuous inflow and outflow of irrigation solution.

A nurse-manager works for a nonprofit health care corporation whose revenues have significantly exceeded annual expenses. The nurse-manager has been told to anticipate which action? a. Receiving a portion of the revenue to improve client services on the unit b. Identifying revenue as profit c. Dividing revenue among stockholders as dividends d. Reducing operating expenses to help the organization pay taxes on the revenue

Answer = a You selected: b Rationale: In a nonprofit organization, revenue exceeding expenses is tax-exempt and is usually reinvested in the organization and used to improve services. A for-profit organization calls revenue in excess of expenses a profit and divides it as a dividend among stockholders or reinvests it in the organization.

In developing a security plan for a pediatric unit, a nurse must consider which factors? Select all that apply. a. Methods for educating all staff regarding the security plan b. Available resources to obtain and maintain the security plan c. The facility's physical layout d. The climate in which the hospital is located e. Identification of neonates, infants, toddlers, children, and adolescents at all times

Answer = a, b, c, e Rationale: When developing a security plan for a pediatric unit, the nurse should consider the identification of neonates, infants, toddlers, children, and adolescents; the facility's physical layout; available resources; and methods for educating staff. She needn't consider the climate in which the hospital is located.

Which goal is most important when developing a long-term care plan for a child with hemophilia? a. Increase the parent's and child's knowledge about hemophilia. b. Prevent injury during each stage of development. c. Improve the child's self-esteem during bleeding episodes. d. Manage acute pain when there is bleeding into joints.

Answer = b Rationale = The priority for ongoing care for this child is to prevent injury while maintaining normal growth and interests. As with all chronic illnesses, there is a potential for self-esteem problems, but no data are presented to support this as a priority for care planning. The parents should have a good understanding of the disease process and realize the importance of obtaining regular health care for their child. The client may have episodes of acute pain, for the child who has bleeding into a joint, but this is a transient situation.

The nurse is providing care for a client who is a Muslim. The client has recently received a diagnosis of type 1 diabetes and is receiving health education. What statement by the nurse best addresses this client's religious beliefs? a. "You will be able to manage your diabetes while maintaining a vegetarian diet, but it requires careful management." b. "Insulin used to be derived from pigs, but now it is produced synthetically."

Answer = b Rationale: A client who adheres to Islam may be concerned that insulin is porcine derived, since pork products are proscribed. Fasting produces special challenges that must be carefully addressed. There is no need to discard dietary restrictions to maintain glucose levels. Islam does not dictate a vegetarian diet.

A nurse is monitoring a client recovering from moderate sedation that was administered during a colonoscopy. Which finding requires the nurse's immediate attention? a. Heart rate of 94 beats/minute b. Oxygen saturation (SaO2) of 89% c. Decreased cough and gag reflexes d. Blood-tinged stools

Answer = b Rationale: Normal SaO2 is 95% to 100%. Oxygen saturation below 94% indicates inadequate oxygenation, which may be a consequence of the moderate sedation. Appropriate nursing actions include rousing the client, if necessary, assisting the client with coughing and deep breathing, and evaluating the need for additional oxygen. A heart rate of 84 beats/minute is within normal limits. Colonoscopy doesn't affect cough and gag reflexes, although these reflexes may be slightly decreased from the administration of sedation. These findings don't require immediate intervention. Blood-tinged stools are a normal finding after colonoscopy, especially if the client had a biopsy.

A client of Mexican descent has bacterial pneumonia and has a temperature of 102° F (39° C). The client tells the nurse that client has treated the infection by drinking milk, and the nurse interprets the client's remark as: a. confusion from fever. b. use of the hot disease concept. c. use of milk as a laxative. d. the need for a dietitian to assist her with meal planning

Answer = b The nurse interprets the client's statement as use of the hot disease concept in the Mexican culture, where the belief of a hot and cold balance of the body exists. A hot disease such as an infection is treated with the opposite, a cold food such as milk. The nurse should focus on the cultural differences and be sensitive to the cultural diversity.

A nurse is caring for a client who has viral pneumonia. Which of the following findings should the nurse report to the provider immediately? a. negative blood culture b. left shift in WBC differential c. oxygen saturation 93% d. crackles heard on auscultation

Answer = b When using the urgent vs non urgent approach to client care, the nurse should determine that the priority finding is a left shift in the client's WBC differential, which indicates that the pneumonia is of bacterial origin, rather than viral. The left shift can be manifestation of sepsis, and the nurse should report this finding to the provider. left shift also means an acute infection. Crackles heard is non urgent because it is an expected finding.

A nurse is performing a breast examination on a female client who is pregnant. Which of the following findings should the nurse report? a. slight asymmetrical breast size b. breast tissue with an orange-peel appearance c. nipple inversion of one breast since puberty d. elevated Montgomery's glands

Answer = b an orange peel appearance of the client's skin can indicate a blockage of lymph channels, which is a manifestation of advanced breast cancer. Elevated Montgomery's glands is an expected findings for a client who is pregnant.

A nurse has custody of a client's daily Kardex and care plan so she can give a change-of-shift report. After reporting to the next shift, what steps should the nurse implement to maintain client confidentiality? a. Throw the documents in the trash can. b. Shred the documents or place them in a container to protect confidentiality. c. Place the documents in the client's chart. d. Leave the documents at the nurses' station.

Answer = b You answered: c Rationale: Kardexes, care plans, and other client documents contain confidential client information. The nurse should shred them or place them in a special confidential container for proper disposal. Regular garbage isn't secure and isn't an appropriate place to dispose of documents containing a client's name and information. Leaving the documents at the nurses' station may allow others to view them. It isn't necessary to place the nursing Kardex and care plan in the client's chart when the nurse has finished using them.

What should be charted by the nurse when the client has an involuntary commitment or formal admission status? a. Nothing should be charted. The forms are in the chart; there is no need to duplicate. b. The client's receipt of information about status and rights should be charted. c. The client's willingness to cooperate with seclusion should be charted. d. The name of the physician officially signing the certificates should be charted

Answer = b You answered: c Rationale: Nurses are required to document that clients have been given information about their status and rights. Seclusion is not related to people becoming involuntary or certified clients. Including details contained within the certificates, such as a health care provider (HCP) signing the certificates, is not required.

A client is 37 weeks gestation and is experiencing preeclampsia. The physician has ordered magnesium sulfate, increased fetal surveillance, and increased nursing interventions. The nightshift charge nurse is preparing the patient-nurse assignment before the morning shift begins. Which of the following factors should be the primary factor in the decision surrounding who should care for this client? a. Client preference b. Complexity of care requirements c. Continuity: the nurse who cared for the client yesterday d. The most senior nurse on that morning shift

Answer = b You answered: c Rationale: Registered nurses are responsible for exhibiting critical thinking skills and caring for clients with fluctuating changes in their condition. This client requires extensive nursing care because she has experienced a change in health status and requires enhanced surveillance. It is critical that the nurse caring for her recognizes if her condition further deteriorates. While it is appropriate to consider senior nursing staff, client wishes and continuity of care, it is the responsibility of nurses to provide safe and ethical care. Therefore, in this context, client safety is the priority and requires that the charge nurse considers the complexity of her care requirements when assigning the appropriate care provider.

A client asks a nurse a question about the tuberculin skin test for tuberculosis. The nurse should base her response on the fact that the: a. area of redness is measured in 3 days and determines whether tuberculosis is present. b. skin test doesn't differentiate between active and dormant tuberculosis infection. c. presence of a wheal at the injection site in 2 days indicates active tuberculosis. d. test stimulates a reddened response in some clients and requires a second test in 3 months.

Answer = b You selected: c Rationale: The tuberculin skin test doesn't differentiate between active and dormant infections. If a positive reaction occurs, a sputum smear and culture as well as a chest X-ray are necessary to provide more information. Although the area of redness is measured in 3 days, a second test may be needed; neither test indicates that tuberculosis is active. In the tuberculin skin test, an induration 5 to 9 mm in diameter indicates a borderline reaction; a larger induration indicates a positive reaction. The presence of a wheal within 2 days doesn't indicate active tuberculosis.

A client at an outpatient psychiatric clinic has been experiencing anxiety. The nurse would like to suggest activities for the client to do in his/her spare time. What would be an appropriate activity for the nurse to suggest to the client? Select all that apply. a. Board games b. daily walks c. taking up a hobby d. stretching exercises e. bingo

Answer = b, c, d Rationale = Taking daily walks and stretching exercises allow the client to expend energy and establish a trusting, neutral relationship with the nurse. Taking up a hobby will help the client change their attention and focus from negative anxiety to more positive and relaxed thoughts. The other suggestions are higher stimulation activities that insert competition and added anxiety to the situation.

A nurse should expect to administer which medication to a client with gout? a. Aspirin b. Furosemide c. Colchicine d. Calcium gluconate

Answer = c Rationale: A disease characterized by joint inflammation (especially in the great toe), gout is caused by urate crystal deposits in the joints. The physician orders colchicine to reduce these deposits and thus ease joint inflammation. Although aspirin reduces joint inflammation and pain in clients with osteoarthritis and rheumatoid arthritis, it isn't indicated for gout because it has no effect on urate crystal formation. Furosemide, a diuretic, doesn't relieve gout. Calcium gluconate reverses a negative calcium balance and relieves muscle cramps; it doesn't treat gout. Action of Colchicine: Exact mechanism of action is not fully known; thought to involve a reduction in lactic acid produced by leukocytes, reducing uric acid deposits and phagocytosis, thereby decreasing the inflammatory process. USED FOR GOUT

When a client has an acute attack of diverticulitis, the nurse should first: a. prepare the client for a colonoscopy. b. encourage the client to eat a high-fiber diet. c. assess the client for signs of peritonitis. d. encourage the client to drink a glass of water every 2 hr

Answer = c Rationale: The nurse should first assess the client for signs of peritonitis. Complications of diverticulitis include perforation with peritonitis, abscess, and fistula formation, bowel obstruction, ureteral obstruction, and bleeding. A computed tomography (CT) scan with oral contrast is the test of choice for diverticulitis. A client with acute diverticulitis does not receive a barium enema or colonoscopy because of the possibility of peritonitis and perforation. With acute diverticulitis, the goal of treatment is to allow the colon to rest and inflammation to subside. The client is kept on NPO status; parenteral fluid therapy is provided.

A nurse is planning an education program about testicular cancer for a group of male adolescents. Which of the following information should the nurse include? a. testicular cancer is more common in men older than 65 b. with early tx, the survival rate is 50% c. examine the testicles immediately after showering d. schedule an annual u.s. to screen for testicular cancer

Answer = c self exams should be done on a monthly basis by examining the testicles after a bath or a shower to allow for easier palpation. men who are between the ages of 15 to 39 have an increased risk for testicular cancer.

A mother is visiting her neonate in the neonatal intensive care unit. Her baby is fussy and the mother wants to know what to do. In order to quiet a sick neonate, what can the nurse teach the mother to do? a. Bring in toys for distraction. b. Place a musical mobile over the crib. c. Stroke the neonate's back. d. Use constant, gentle touch

Answer = d Rationale: Neonates that are sick do not have the physical resources or energy to respond to all elements of the environment. The use of a constant touch provides comfort and only requires one response to a stimulus. To comfort a sick neonate, the care provider applies gentle, constant physical support or touch. Toys for distraction are not developmentally appropriate for a neonate. Sick neonates react to any stimulus; in responding, the sick neonate may have increased energy demands and increased oxygen requirements. A musical mobile may be too much audio stimulation and thus increases energy and oxygen demands. Repetitive touching with a hand going off and on the neonate, as with stroking or patting, requires the neonate to respond to every touch, thus increasing energy and oxygen demands.

A boy, age 3, develops a fever and rash and is diagnosed with rubella. His mother has just given birth to a baby girl. Which statement by the mother best indicates that she understands the implications of rubella? a. "I told my husband to give my son aspirin for his fever." b. "I'll ask the physician about giving the baby an immunization shot." c. "I don't have to worry because I've had the measles." d. "I'll call my neighbor who's 2 months pregnant and tell her not to have contact with my son."

Answer = d You answered: b Rationale: By saying she'll call her pregnant neighbor, the mother demonstrates that she understands the implications of rubella. Fetal defects can occur during the first trimester of pregnancy if the pregnant woman contracts rubella. Aspirin shouldn't be given to young children because aspirin has been implicated in the development of Reye's syndrome. Acetaminophen should be used instead of aspirin. Rubella immunization isn't recommended for children until ages 12 to 15 months. Having the measles (rubeola) won't provide immunity for rubella.

The nurse teaches the client to report signs and symptoms of which potential complication after hypophysectomy? a. acromegaly b. Cushing's disease c. diabetes mellitus d. hypopituitarism

Answer = d You answered: b Rationale: Most clients who undergo adenoma removal experience a gradual return of normal pituitary secretion and do not experience complications. However, hypopituitarism can cause growth hormone, gonadotropin, thyroid-stimulating hormone, and adrenocorticotropic hormone deficits. The client should be taught to monitor for change in mental status, energy level, muscle strength, and cognitive function. In adults, changes in sexual function, impotence, or decreased libido should be reported. Acromegaly and Cushing's disease are conditions of hypersecretion. Diabetes mellitus is related to the function of the pancreas and is not directly related to the function of the pituitary. Hypophysectomy: Surgical excision of all or part of the pituitary gland

A child's most recent diagnostic testing reveals elevated levels of T3 and T4. When assessing this child for exophthalmos, the nurse should inspect what region?

They eyes/forehead. Rationale: Exophthalmos is the abnormal protrusion of the eye globes that occurs when there is an overproduction of thyroid hormone, or hyperthyroidism.

The nurse is reviewing the chart of a client with type 2 diabetes prior to a scheduled appointment. The chart states: Progress notes 10/15/16 0245 Client states that he has not been following his prescribed diabetes management program for the past 2 to 3 months. Client is aware of his blood glucose monitoring regimen and diet but has difficulty integrating each into his routines. Client denies recent changes in urinary function, sensation or vision. a. Arrange assessment of the client's fasting glucose level b. Ask the client to complete a 24-hour food recall c. Review the results of the client's HbA1c d. Ask the client to describe his recommended diet and glucose monitoring routine

You Selected: Ask the client to complete a 24-hour food recall Correct response: Review the results of the client's HbA1c Remediation: An HbA1c provides an overview of a person's blood glucose level over the previous 2 to 3 months. Glycosylated hemoglobin values are reported as a percentage of the total hemoglobin within an erythrocyte. The time frame is based on the fact that the usual life span of an erythrocyte is 2 to 3 months. The client's description of health maintenance will not determine adherence to the prescribed schedule. Fasting glucose gives a point-in-time result. A 24-hour food recall is subjective, and does not help the nurse gauge the client's overall adherence. HbA1c test: A normal result is an HbA1c level of 6% or less (SI, 42 mmol/mol or less). Blood test that measures the percentage of glycated hemoglobin (hemoglobin coated with glucose) in the blood. Results determine the average blood glucose level for the previous 2 to 3 months. Purpose is to determine whether the patient has diabetes and if it is being managed successfully.

The nurse is assessing breath sounds of a child admitted to the unit. Based on the following progress notes, which respiratory illness would the nurse suspect? Progress notes 10/15/16 2030 Seven-year-old child admitted from ER. Oxygen via mask at 4 L/min. Frequent, tight cough. A/Ox3. Shortness of breath noted while talking to mom. HEENT normal. Lungs with wheezing in bases. Heart RRR, no murmur. Abdomen soft, flat. Active bowel sounds. Moving all extremities well. a. Pneumonia b. Croup c. Pulmonary edema d. Asthma

You Selected: Croup Correct response: Asthma Rationale: Asthma frequently presents with wheezing and coughing. Airway inflammation and edema increase mucous production. Other signs include dyspnea, tachycardia, and tachypnea. Stridor is heard in croup. Rhonchi and rales are heard with pneumonia and pulmonary edema.

A female client with bulimia nervosa reports that her major problem is eating too much food in a short period of time and then vomiting. Which short-term goal is the most important? a. Help the client understand every person has a satiety level b. Encourage the client to verbalize fears and concerns about food c. Determine the amount of food the client will eat without purging d. Obtain a therapy appointment to look at the emotional causes of bulimia nervosa

You Selected: Encourage the client to verbalize fears and concerns about food Correct response: Determine the amount of food the client will eat without purging Rationale: This client must meet her nutritional needs to prevent further complications. She must identify the amount of food she can eat without purging as her first short-term goal. Binge eaters cannot recognize their satiety level or their feelings of fullness. Obtaining knowledge, or verbalizing her fears and feelings about food are not priority goals for this client. After meeting immediate physiologic needs, therapy is an important of treatment for this disorder.

A nurse is admitting a child to the unit. Based on the history, what illness would the nurse suspect? History and physical 10/15/16 1030 Nine-year-old child admitted with frequent cough and fever of > 100.5°F (38.1° C) for the past month. Child lives with parents and with grandparents who recently emigrated from SE Asia. Weight = 20 kg. Mom reports significant weight loss in child. Child reporting fatigue and poor appetite. Denies vomiting/diarrhea. Does have some nausea. No problems with voiding or stooling. Child does well in school. a. Pneumonia b. Tuberculosis c. Asthma d. HIV

You Selected: HIV Correct response: Tuberculosis Explanation: Tuberculosis often presents with a chronic, unremitting cough and fever lasting more than three weeks. Weight loss and fatigue are common symptoms. Risk factors include visiting or living with persons from endemic areas. Pneumonia typically does not produce significant weight loss. Asthma is not usually accompanied by fever. HIV symptoms are varied, non-specific, and seen with specific risk factors such as a mother with HIV at delivery.

A client, diagnosed with cardiomyopathy, is demonstrating signs of left-sided heart failure with an ejection fracture is 50%. While providing this client with education regarding management of his condition, which interventions should the nurse include? Select all that apply. a. Implantable cardioverter defibrillator b. Low sodium diet c. Graduated exercise program d. Diuretic medication therapy e. Anticoagulant medication therapy f. ACE inhibitor medication therapy

You Selected: Low sodium diet Graduated exercise program ACE inhibitor medication therapy Correct response: Low sodium diet Graduated exercise program Diuretic medication therapy ACE inhibitor medication therapy Rationale: The multi-faceted treatment will include a low sodium diet, gradual increase in activity and diuretic medication therapy to decrease fluid overload and cardiac workload. The use of ACE inhibitors, in conjunction with beta-adrenergic blockers will affect myocardial tissue remodeling. Anticoagulant therapy is not indicated in the management of these conditions at this time. An implantable cardioverter defibrillator becomes an option when the ejection fracture is below 35%.

A nurse is caring for an anorexic client with a nursing diagnosis of imbalanced nutrition: less than body requirements related to dysfunctional eating patterns. Which interventions would be supportive for this client? Select all that apply. a. Provide small, frequent meals. b. Monitor weight gain. c. Allow the client to skip meals until the antidepressant levels are therapeutic. d. Encourage the client to keep a journal. e. Monitor the client during meals and for 1 hour after meals. f. Encourage the client to eat three substantial meals per day.

You Selected: Monitor weight gain. Encourage the client to keep a journal. Provide small, frequent meals. Correct response: Provide small, frequent meals. Monitor weight gain. Encourage the client to keep a journal. Monitor the client during meals and for 1 hour after meals. Rationale: Anorexia nervosa is an eating disorder characterized by excessive food restriction and irrational fear of gaining weight. Because the clients are engaged in self-starvation, clients with anorexia rarely can tolerate large meals three times per day. Small, frequent meals may be tolerated better and they provide a way to gradually increase daily caloric intake. The nurse would monitor the client's weight carefully because a client with anorexia may try to hide the weight loss. The nurse would also monitor the client during meals and for 1 hour afterward to ensure that the client consumes all of the food and does not attempt to purge. The client may be afraid to express feelings; keeping a journal can serve as an outlet for these feelings, which can assist recovery. A client with anorexia is already underweight and should not be permitted to skip meals.

A four-year-old child has recently been diagnosed with acute lymphocytic leukemia (ALL). What information about ALL should the nurse provide when educating the child's parents? Select all that apply. a. Leukemia is a rare form of childhood cancer. b. ALL affects all blood-forming organs and systems throughout the body. c. The child shouldn't brush his teeth because of the increased risk of bleeding. d. Adverse effects of treatment include sleepiness, alopecia, and stomatitis. e. There's a 95 percent chance of remission with treatment. f. The child shouldn't be disciplined during this difficult time

You Selected: - Leukemia is a rare form of childhood cancer. - Adverse effects of treatment include sleepiness, alopecia, and stomatitis. - The child shouldn't brush his teeth because of the increased risk of bleeding. - ALL affects all blood-forming organs and systems throughout the body. Correct response: - ALL affects all blood-forming organs and systems throughout the body. - Adverse effects of treatment include sleepiness, alopecia, and stomatitis. - There's a 95 percent chance of remission with treatment Rationale: In ALL, abnormal white blood cells proliferate, but they don't mature past the blast stage. These blast cells crowd out the healthy white blood cells, red blood cells, and platelets in the bone marrow, leading to bone marrow depression. The blast cells also infiltrate the liver, spleen, kidneys, and lymph tissue. Common adverse effects of chemotherapy and radiation include nausea, vomiting, diarrhea, sleepiness, alopecia, anemia, stomatitis, mucositis, pain, reddened skin, and increased susceptibility to infection. There's a 95 percent chance of obtaining remission with treatment. Leukemia is the most common form of childhood cancer. The child still needs appropriate discipline and limits. A lack of consistent parenting may lead to negative behaviors and fear.

A nurse is developing a teaching plan for sleep hygiene. Which interventions should the nurse include? Select all that apply. a. Keep the room very warm b. Eat a large meal and drink fluids before bedtime c. Schedule bedtime when you feel tired d. Avoid caffeine, alcohol, and nicotine before bedtime e. Prepare the room for sleep and turn off distracting noise f. Participate in a bedtime routine

You Selected: - Prepare the room for sleep and turn off distracting noise - Participate in a bedtime routine - Schedule bedtime when you feel tired Correct response: - Avoid caffeine, alcohol, and nicotine before bedtime - Prepare the room for sleep and turn off distracting noise - Participate in a bedtime routine Rationale: Caffeine, alcohol, and substances such as nicotine act as stimulants, avoiding them should help promote sleep. Maintaining a cool temperature in the room will facilitate optimal sleep. Excessive fullness or hunger can disrupt or interfere with sleep. A regular sleep-wake time facilitates physiologic patterns, rather than waiting until an individual begins to feel tired. The room should be conducive to sleep. Eliminate distractions such as a television or radio. Participation in a relaxation, prayer, or meditation routine can help prepare an individual for a restful night.

Glycopeptide

*Types of meds:* Vancomycin (not all "mycin" are macrolides) *Used for:* MRSA Bacterial infections C-diff if allergic to corn you can't take vancomycin. watch renal and hearing function. *Side effects:* Causes red mans syndrome (due to being given too fast, so give over one hour and give in the proper amount of dilutent) Monitor peak and trough.

Anti-tubercule drugs

*Used for:* HIV (because of their suppressed immune system) TB patient's *Types of meds:* isoniazide (first drug of choice) rifampin ethambutol pirzinomide streptomycin take up to 6-9 months. *Side effects:* hepatotoxicity and neuropathy. discolors urine. Avoid tyramine containing food, like cheeses and wine. Avoid alcohol. increase vitamin B6.

Fluoroquinalones

*Used for:* bronchitis STI's PID (pelvic inflammatory disease) UTI's anthrax *Side effects:* Achilles tendons rupture Don't give to people that have any kind of seizure disorder because it lowers the seizure threshold. Careful with renal and hepatic fx. Monitor LFT's and creatinine.

If the answer is "watch it or observe it, then come back"... THAT IS ALWAYS THE WRONG ANSWER

N/A

A 14-year old client is admitted to an eating disorder clinic after the sudden death of her best friend. The client states that she and her friend had shared in bulimic behaviors since junior high school, and that she is now struggling to understand her friend's death. Which points should the nurse teach this client about the short-term and long-term effects of bulimic behaviors? Select all that apply. a. Risk for malnutrition b. Risk for dehydration c. Risk for internal bleeding d. Risk for severe tooth infection e. Risk for stress fractures f. Risk for fainting

You Selected: Risk for severe tooth infection Risk for dehydration Risk for malnutrition Correct response: Risk for malnutrition Risk for dehydration Risk for stress fractures Risk for fainting Rationale: Electrolyte imbalances caused by malnutrition and dehydration contribute to depletions severe enough to cause acute symptoms as well as more prolonged organ impairment. This can include fainting episodes and stress fractures associated with resulting osteoporosis. Chronic vomiting can lead to esophageal bleeding that results in severe blood loss and death. Dental infections can result from long-term vomiting, but may not present until an advanced stage of the illness.

Anti-fungals

*Used for:* Candidiasis (yeast infection) *Types of meds:* Fluconizole Watch liver (LFTs) and renal function. This will increase bleeding times.

Phases of Labor:

Active labor is characterized by cervical dilation of 4-7 cm. Second refers to the second stage of labor; begins when the cervix is 10 cm dilated. Latent phase is characterized by the onset of regular contractions and cervical dilation of 0-4 cm. Third phase refers to the third stage of labor, which is the time between birth and the completed birth of the placenta.

A nurse is assessing a client who has HIV. Which of the following findings should cause the nurse to suspect that the client's diagnosis has progressed to AIDS? a. small, purple-colored skin leasions b. fever and diarrhea lasting longer than 1 month c. persistent, generalized lymphadenopathy d. CD4-T cells decreased to 750 cells/mm

Answer = a purple-colored skin lesions is an indication that the client has acquired Kaposi's sarcoma, which is an AIDS-defining illness. CD4-T cell count of 750 is an indication of HIV. Below 200 is an indication of AIDS.

A nurse explains to a client with thyroid disease that the thyroid gland normally produces: a. iodine and thyroid-stimulating hormone (TSH). b. thyrotropin-releasing hormone (TRH) and TSH. c. TSH, triiodothyronine (T3), and calcitonin. d. T3, thyroxine (T4), and calcitonin.

Correct response: T3, thyroxine (T4), and calcitonin. Explanation: The thyroid gland normally produces thyroid hormone (T3 and T4) and calcitonin. The pituitary gland produces TSH to regulate the thyroid gland. The hypothalamus gland produces TRH to regulate the pituitary gland.

When caring for a 2-year-old child, the nurse should offer choices, when appropriate, about some aspects of care. According to Erikson, offering choices helps the child achieve: a. trust. b. autonomy. c. industry. d. initiative.

Correct response: autonomy. Explanation: According to Erikson's theory of development, a 2-year-old child is at the stage of autonomy versus shame and doubt. Offering the child choices about some aspects of care encourages autonomy. An infant is at the stage of trust versus mistrust; a school-age child, industry versus inferiority; and a preschooler, initiative versus guilt.

Prefix/suffix for -zole

Anti-fungal (fluconazole)

Prefix/suffix for -floxacin

Antibiotic (Ofloxacin)

Prefix/suffix for -azine

Antiemetic (promethazine)

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Which statement would lead the nurse to determine that a client lacks understanding of her acute cardiac illness and the ability to make changes in her lifestyle? a. "I already have my airline ticket, so I will not miss my meeting tomorrow." b. "These relaxation tapes sound okay; I will see if they help me." c. "No more working 10 hours a day for me unless it is an emergency." d. "I talked with my husband yesterday about working on a new budget together."

Correct response: "I already have my airline ticket, so I will not miss my meeting tomorrow." Explanation: Leaving the hospital and immediately flying to a meeting indicate poor judgment by the client and little understanding of what she needs to change regarding her lifestyle. The other statements show that the client understands some of the changes she needs to make to decrease her stress and lead a healthier lifestyle.

Which instruction about levothyroxine administration should a nurse teach a client? a. "Take the drug on an empty stomach." b. "Take the drug with meals." c. "Take the drug in the evening." d. "Take the drug whenever convenient."

Correct response: "Take the drug on an empty stomach." Explanation: The nurse should instruct the client to take levothyroxine on an empty stomach (to promote regular absorption) in the morning (to help prevent insomnia and to mimic normal hormone release).

The nurse caring for a client with diabetes realizes that the client has a higher risk of developing cataracts and should also assess the client for indications of: a. background retinopathy. b. proliferative retinopathy. c. neuropathy. d. diabetic retinopathy.

Correct response: diabetic retinopathy. Explanation: Diabetic retinopathy involves background and proliferative retinopathy. Both forms are associated with vascular changes in the basement membrane of the arterioles and capillaries of the choroid and retina. Neuropathy is usually associated with the lower extremities.

Which finding in a client who is receiving albuterol would require a nurse to take immediate action? a. Stridor b. Crackles c. Wheezes d. Pleural rub

You Selected: Pleural rub Correct response: Stridor Explanation: Stridor indicates partial airway obstruction, and requires immediate intervention. A pleural rub, crackles, and wheezes should be further assessed.

While caring for a poster multigravida who is being induced with IV oxytocin solution, what finding should the nurse interpret as indicative of a possible complication? a. convulsions b. generalized edema c. depressed DTR d. hypotension

Correct response: a Severe water intoxication with convulsions and coma can occur when clients are induced with oxytocin. Other serious adverse effects include HTN, uterine rupture, titanic contractions, neonatal jaundice, and postpartum hemorrhage. generalized edema is not a complication of administering oxytocin. depression of DTR is a possible complication of mag sulfate therapy. HTN, rather than hypotension, may be a complication of oxytocin.

Intermediate/long acting insulin types and protocol

NPH - administered between meals & at night NOT before meals - administered subQ ony

Hodgkin Lymphoma

Neoplastic disorder characterized by painless, progressive enlargement of lymph nodes, spleen, and other lymphoid tissue

Prefix/suffix for -nium

Neuromuscular blocking agent (pancuronium)

Parkland/Baxter burn formula Client weights 165 pounds. Brought to ER with second degree burns covering both legs anterior and posterior. Client received 1 L of fluid first hour from EMS. How much more fluid do they need?

Step 1: 4mL x wt (kg) x TBSA Step 2: what is the patients weight? 165 pounds divided by 2.2 = 75 kg Step 3: find patients TBSA % = 36% Step 4: Calculate fluids (4mL x 75 x 36 = 10800) Step 5: Give half the dose (5400) during the first 8 hours; patient already had 1L; so over the first 8 hours the patient needs 4400 mL of fluid (8 hours starts when you first start treating patient); then over the last 16 hours patient needs the other 5400 which equals out to 10800

The nurse has received change-of-shift report on the following clients. Who should the nurse plan to assess first? a. A client who had a temporary pacemaker inserted 2 hours ago, who is now pacing 1:1 with a heart rate of 70. b. A client with atrial fibrillation who is scheduled to go the cardiac catheterization lab at 10 am for an ablation. c. A client with first-degree heart block and a heart rate of 62 who is dizzy when ambulating. d. A client newly admitted after their implantable cardioverter-defibrillator (ICD) fired twice who has a dose of amiodarone due.

You Selected: A client with first-degree heart block and a heart rate of 62 who is dizzy when ambulating. Correct response: A client newly admitted after their implantable cardioverter-defibrillator (ICD) fired twice who has a dose of amiodarone due. Explanation: The firing of the ICD suggests that the client's ventricles are irritable. The nurse's priority is to assess the client and administer the amiodarone to prevent further dysrhythmias. The client with reports of dizziness should be kept in bed until the nurse is available to perform further assessment. Other clients can be seen after the medication is administered.

A client with diabetes mellitus has had declining renal function over the past several years. Which diet regimen should the nurse recommend to the client on days between dialysis? a. A high-protein diet with a prescribed amount of water b. A low-protein diet with a prescribed amount of water c. A low-protein diet with an unlimited amount of water d. No protein in the diet and use of salt sparingly

You Selected: A low-protein diet with an unlimited amount of water Correct response: A low-protein diet with a prescribed amount of water Explanation: Although dialysis removes water, creatinine, and urea from the blood, the client's diet must still be monitored. A high-protein diet is not recommended for renal clients. Eating too much protein may cause urea to build up more quickly. Water intake must be monitored, so unlimited water is not a correct choice. The client would be on a no-salt-added diet.

A nurse asks a pregnant client about her alcohol use. The client admits she sometimes has several glasses of wine with dinner. Her alcohol consumption puts her fetus at risk for which condition? a. Alcohol addiction b. Anencephaly c. Down syndrome d. Learning disability

You Selected: Anencephaly Correct response: Learning disability Explanation: Maternal alcohol use during pregnancy may cause fetal and neonatal central nervous system deficits such as learning disabilities. It also may lead to characteristic physical anomalies and growth restriction. Maternal alcohol use doesn't cause alcohol addiction in the fetus or neonate. Anencephaly occurs when the cranial end of the neural tube fails to fuse before the 26th day of gestation; this condition isn't related to maternal alcohol use. Down syndrome results from a chromosomal disorder.

A client is scheduled for surgery at 8 a.m.(0800). While completing the preoperative checklist, the nurse sees that the surgical consent form isn't signed. It's time to administer the preoperative analgesic. Which nursing action takes the highest priority in this situation? a. Giving the client the preoperative analgesic at the scheduled time b. Asking the client to sign the consent form c. Notifying the surgeon that the client hasn't signed the consent form d. Canceling the surgery

You Selected: Asking the client to sign the consent form Correct response: Notifying the surgeon that the client hasn't signed the consent form Explanation: Notifying the surgeon takes priority because the physician must obtain informed consent before the client receives drugs that can alter cognition. Giving the preoperative analgesic at the scheduled time would alter the client's ability to give informed consent. Obtaining consent to surgery isn't within the scope of nursing practice, although the nurse may confirm or witness consent. Canceling surgery isn't within the scope of nursing practice

A client prescribed enalapril reports symptoms of a persistent dry cough. What is the nurse's best action? a. Notify the healthcare provider b. Administer dextromethorphan c. Review medication administration with the client d. Assess the client's oxygenation status

You Selected: Assess the client's oxygenation status Correct response: Notify the healthcare provider Explanation: ACE inhibitors can cause a characteristic dry, nonproductive cough that reverses when therapy is stopped. By notifying the healthcare provider the nurse can discuss a change of medication. The other answer choices do not correctly address the cause of the dry cough.

When assessing the chest of a 4-month-old infant, the nurse identifies the ratio of the anteroposterior-to-lateral diameter as 1:1. What action should the nurse take next? a. No action is needed; this is a normal finding. b. Inform the physician of the finding and obtain an order for a chest X-ray. c. Instruct the parents to bring the infant back in 1 month for reevaluation. d. Check the infant for signs of respiratory distress.

You Selected: Check the infant for signs of respiratory distress. Correct response: No action is needed; this is a normal finding. Explanation: No action is needed by the nurse because in an infant, the anteroposterior diameter is normally equal that of the lateral diameter (a ratio of 1:1). As the infant reaches toddlerhood, the anteroposterior diameter becomes less than the lateral diameter.

A client who is receiving acetaminophen for osteoarthritis reports continuing pain. The health care provider prescribes celecoxib. What important information regarding this medication, should the nurse share with this client? a. Report black and tarry stools to the health care provider b. Use a stool softener or fiber laxative daily to prevent constipation c. If you miss a dose, take a double dose the next day d. Don't take the medication with dairy products

You Selected: Don't take the medication with dairy products Correct response: Report black and tarry stools to the health care provider Explanation: Black and tarry stools are a sign of gastrointestinal (GI) bleeding, and may necessitate a medication change. Dairy products can help reduce GI irritation. The celecoxib dose should never be doubled. Constipation isn't an adverse effect of this medication.

A client who is bound to a wheelchair comes to the clinic for a follow-up evaluation of pressure ulcers on his buttocks. The client reports that his family has been changing his hydrocolloid dressings every 3 to 5 days. During the past few weeks, he has been spending less time in his wheelchair, and when he does use the wheelchair, he uses a cushion. During his appointment the nurse notes that he is not using a cushion, and that the wound is covered with a dry sterile dressing. How should the nurse initially approach the client about his treatment regimen? a. Ask the client to explain his treatment regimen. b. Call the family contact to ask about how the treatments have been done. c. Explain pressure ulcer development in terms that the client understands. d. Provide a brief anatomy and physiology lesson on how pressure ulcers develop.

You Selected: Explain pressure ulcer development in terms that the client understands. Correct response: Ask the client to explain his treatment regimen. Explanation: It is important to first assess what the client knows about his treatment regimen. The nurse should then provide further teaching to the client in terms that he understands; this should be done second to an assessment of what he knows. The client should be using a cushion to sit on to reduce pressure, and the wound should be kept moist to promote healing. The client can make his own care decisions; however, the nurse must ensure that he has available knowledge to make an informed decision. Calling the family may be an option, but the client should be the first one to explore what he knows about the treatment. Providing an indepth explanation about the anatomy and physiology of pressure ulcer development is not necessary.

A 14-year-old client diagnosed with acne vulgaris asks the nurse about the cause. Which factors should the nurse identify for this client? Select all that apply.

You Selected: Growth of anaerobic bacteria Chocolates and sweets Increased hormone levels Heredity Caffeine Fatty foods Correct response: Increased hormone levels Growth of anaerobic bacteria Heredity

The parents of an eight-month-old child with iron deficiency anemia have not been compliant with the administration of oral iron supplements. The child must now receive an iron dextran injection. How should the nurse administer this injection? a. Intradermally b. Subcutaneously c. Intravenous d. Intramuscularly using the z-track method

You Selected: Intravenous Correct response: Intramuscularly using the z-track method Rationale: If iron dextran is ordered, it must be injected deep into a large muscle mass, using the z-track method to minimize skin staining and irritation. Neither a subcutaneous nor an intradermal injection would inject the dextran into muscle. The z-track method is preferred over a normal intramuscular injection. Intravenous is not appropriate for this scenario.

The nurse enters the room to do an initial assessment on a client with a fracture of the femoral head. What would be the expected findings on the affected limb? a. Lengthening of the affected extremity with internal rotation b. Shortening of the affected extremity with external rotation c. Abduction with external rotation of the right leg d. Abduction with internal rotation of the left leg

You Selected: Lengthening of the affected extremity with internal rotation Correct response: Shortening of the affected extremity with external rotation Explanation: As a result of the muscles contracting and pulling on the two portions of bone, there is a characteristic shortening of the femur with external rotation of the extremity. The other answers are incorrect based on pathology of a hip fracture.

During a physical examination, a client who is 32 weeks pregnant becomes pale, dizzy, and light-headed while supine. Which action should the nurse immediately take? a. Turn the client on her left side. b. Ask the client to breathe deeply. c. Listen to fetal heart tones. d. Measure the client's blood pressure.

You Selected: Listen to fetal heart tones. Correct response: Turn the client on her left side. Explanation: As the uterus enlarges, pressure on the inferior vena cava increases, compromising venous return and causing blood pressure to drop. This may lead to syncope and accompanying symptoms when the client is supine. Turning the client on her left side relieves pressure on the vena cava, restoring normal venous return and blood pressure. Deep breathing wouldn't relieve this client's symptoms. Listening to fetal heart tones and measuring the client's blood pressure wouldn't provide relevant information nor would they treat the client's symptoms.

A primiparous client at 4 hours after a vaginal birth and manual removal of the placenta voids for the first time. The nurse palpates the fundus, noting it to be 1 cm above the umbilicus, slightly firm, and deviated to the left side, and notes a moderate amount of lochia rubra. The nurse notifies the primary care provider based on the interpretation that the assessment indicates which problem? a. perineal lacerations b. retained placental fragments c. cervical lacerations d. urine retention

You Selected: urine retention Correct response: retained placental fragments Explanation: At 4 hours postpartum, the fundus should be midline and at the level of the umbilicus. Whenever there is manual removal of the placenta, there is a possibility that all of the placenta has not been removed. Sometimes small pieces of the placenta are retained, a common cause of late postpartum hemorrhage. The client is exhibiting signs associated with retained placental fragments. The client will continue to bleed until the fragments are expelled. Perineal and cervical lacerations are characterized by bright red bleeding and a firmly contracted fundus at the level that is expected. Urinary retention is characterized by a full bladder, which can be observed by a bulge or fullness just above the symphysis pubis. Also, the client's fundus would be deviated to one side and boggy to the touch.

During a home visit on the fourth postpartum day, a primiparous client tells the nurse that she has been experiencing breast engorgement. To receive engorgement, the nurse teaches the client to use which intervention before nursing her baby? a. apply an ice cube to the nipples b. rub her nipples gently with lanolin cream c. express a small amount of breast milk d. offer the neonate a small amount of formula

You answered: a Correct response: c Expressing a little milk before nursing, massaging the breasts gently, or taking a warm shower before feeding also may help to improve milk flow. Although various measures such as ice, heat, and massage may be tried to relieve breast engorgement, prevention of breast engorgement by frequent feedings is the method of choice. Applying ice to the nipples does not relieve breast engorgement. However frequent breastfeeding sessions, rather than offering the neonate a small amount of formula, is the method of choice for preventing and relieving breast engorgement. In addition, offering the neonate small amounts of formula may result in nipple confusion.

A gravida 3 para 1 laboring client is 9 cm dilated and is changing position frequently to cope with the intensity of the contractions. The client's husband has gone to the cafeteria to take a break. The client tells the nurse that she is tired but is afraid of being left alone and that her husband will miss the birth. Which of the following is the nurse's most appropriate action? a. tell the client that he/she will have someone try to find her husband b. return to the nurse's station to phone the physician because birth is imminent c. tell the client not to worry because the birth likely won't happen for another 4-5 hours d. use the call bell to ask another nurse if he/she can help locate the client's husband

You selected: a Correct response: d During the transition phase of labor, the client may fear being left alone, but the support person may need a break. During this time it is critical that the nurse remain with the client, provide relief for the support person, and keep the client aware of where her support people are. Given that the client is multiparous and 9 cm dilated, her transition phase should approximately an hour and her second stage (which begins with cervical dilation at 10 cm and ends with the birth) usually lasts less than 30 minutes. Because birth will be approximately 1-2 hours from this point, the answer of 4-5 hours is incorrect. It is not appropriate to call the physician at this stage, and the nurse should not leave the client alone to do so. The best action is to use the call bell and to request another nurse to assist in locating the client's husband, as this allows the nurse to remain with the client and keep the client informed.

The nurse evaluates the mothering skills of an adolescent primigravida changing her baby's diaper for the first time. When caring for this client, the nurse should focus on the client's need for which support? a. praise and encouragement b. detailed written instructions c. family availability for assistance d. acceptance by the client's peers

You selected: d Correct response: a The adolescent client may have special needs during the post part period. Praise and encouragement of her mother skills are important for building the client's confidence and self-esteem. Peer acceptance is a major component of adolescence, but lack of knowledge or experience about infant care is unrelated to peer acceptance. The reality of caring for a neonate may be a crisis for the adolsecent.

A client is to receive 100 mg of cefazolin following an open reduction and internal fixation (ORIF) for repair of a fractured femur. The pharmacy has sent 100 mg of cefazolin in 50 ml of dextrose. The medication is to be administered over 30 minutes. Calculate the gtt/min using a 20 gtt/ml set. Record your answer using a whole number.

Your Response: 17 Correct response: 33 Explanation: Formula for IV calculations: (Amount/Rate) = (Volume/Rate) x Set A medication volume of 50 mL is to be administered in 30 min using a 20 gtt/ml set. X = (50 ml / 30 min) x (20 gtt/min) X = 33.33. Rounded to: 33 gtt/min.

Prefix/suffix for -statin

antihyperlipidemic (Lovestatin)

A client who seeks health care for vague symptoms of fatigue and headaches has HIV testing and is found to have a positive enzyme immunoassay (EIA) for HIV antibodies. In discussing the test results with the client, the nurse informs the client that a. The enzyme immunoassay test will need to be repeated to verify the results. b. A viral culture will be done to determine the progress of the disease. c. It will probably be 10 or more years before the client develops AIDS. d. The Western Blot test will need to be done to determine whether AIDS has developed.

Answer = A Rationale: After the initial positive EIA test, the EIA is repeated before specific testing such as the Western blot is done.

A client reports abdominal pain. Which action allows the nurse to investigate this complaint? a. assessing the painful area last b. assessing the painful area first c. using deep palpation d. checking for warmth in the painful area

Answer = a You answered: b Rationale: Assessing the painful area last allows the nurse to obtain the maximal amount of information with minimal client discomfort. The nurse should always let the client know when she will be assessing the painful area. Pressure resulting from deep palpation may cause an underlying mass to rupture. Checking for warmth in the painful area offers no real information about the client's pain.

A nurse is teaching a client with bipolar disorder about the drug carbamazepine. The nurse determines teaching was effective when the client states: a. "My hair will fall out after I take this drug for a few months." b. "I will drink plenty of water so I don't develop kidney problems." c. I need to have my blood counts checked periodically." d. "I can't take any other drugs while I am taking this one."

Answer = c You checked: b Rationale: The most dangerous adverse effect of carbamazepine is bone marrow depression. Other medications may be taken with carbamazepine. Hair loss doesn't occur in clients taking carbamazepine. Clients who take lithium, not carbamazepine, must be closely monitored for nephrogenic diabetes insipidus. The interactions of all drugs must be monitored because some can either increase or decrease the blood level of carbamazepine.

A nurse must assess a client's judgment to determine his mental status. To best accomplish this, the nurse should have the client: a. interpret proverbs. b. spell words backward. c. count by serial sevens. d. discuss hypothetical ethical situations

Answer = d You answered: c Rationale: The best way to assess a client's judgment is to discuss hypothetical ethical situations, such as "What would you do if you found a wallet that contained several credit cards and identification?" Interpreting proverbs tests thinking. Spelling words backward and counting by serial sevens test concentration.

Nitrofurantoins

Mainly used for UTI's. Or as a honeymoon prophylactic. *Types of meds:* Macrodenton *Side effects:* renal dysfunction brown discoloration to urine increase fluid intake!

Tetracyclines

*Types of meds:* Doxycycline Tetracycline (yellows teeth) Don't want to give to kids because will damage bone development and yellow teeth, stay out of sun, increase fluids, use a back up contraceptive, don't consume dairy because dairy will inactivate it.

A nurse is caring for a client who has non-Hodgkin's lymphoma and is receiving chemotherapy. Which of the following is the priority assessment finding? a. loss of body hair b. report of anorexia c. mucositis of the oral cavity d. erythema at the IV insertion site

Answer = d The greatest risk to the client is injury to the tissue due to extravasation of chemotherapy. Erythema a the IV insertion site can indicate extravasation is occurring, which can lead to infection and tissue loss. This is the priority assessment finding. sores in the mouth is an expected adverse effect of chemotherapy. Therefore, another assessment finding is the priority.

When administering total parenteral nutrition (TPN) through a peripheral I.V. line to a school-age child, what is the lowest amount of glucose that is considered safe and not caustic to small veins that will also provide adequate TPN? a. 5% glucose b. 0% glucose c. 15% glucose d. 17% glucose

Correct response: 10% glucose Explanation: The amount of glucose that is considered safe for peripheral veins while still providing adequate parenteral nutrition is 10%. A glucose amount of 5% isn't sufficient nutritional replacement, although it's safe for peripheral veins. Any amount above 10% glucose, such as 15% and 17%, must be administered via central venous access.

A student with type 1 diabetes tells the nurse she is feeling light-headed. The student's blood sugar is 60 mg/dL (3.3 mmol/L). Using the 15-15 rule, the nurse should give: a. 15 mL of juice and give another 15 mL in 15 minutes. b. 15 g of carbohydrate and retest the blood sugar in 15 minutes. c. 15 g of carbohydrate and 15 g of protein. d. 15 oz of juice and retest in 15 minutes

Correct response: 15 g of carbohydrate and retest the blood sugar in 15 minutes. Explanation: The 15-15 rule is a general guideline for treating hypoglycemia where the client consumes 15 g of carbohydrate and repeats testing the blood sugar in 15 minutes. Fifteen grams of carbohydrate equals 60 calories and is roughly equal to ½ cup (120 mL) of juice or soda, six to eight lifesavers, or a tablespoon of honey or sugar. The general recommendation is if the blood sugar is still low, the client may repeat the sequence. Fifteen milliliters of juice would only provide 8 calories. This would not be sufficient carbohydrates to treat the hypoglycemia. Protein does not treat insulin-related hypoglycemia; however, a protein-starch snack may be offered after the blood glucose improves. Fifteen ounces of juice would be approximately 440 mL—almost four times the recommended 4 oz (120 mL) of juice.

The nurse is checking the blood sugar level of a client who is at 33-weeks' gestation. This client has had type 1 diabetes since she was 12 years old. Which value would indicate to the nurse that this client's disease is controlled? a. 45 mg/dl (2.5 mmol/L) b. 85 mg/dl (4.7 mmol/L) c. 120 mg/dl (6.7 mmol/L) d. 136 mg/dl (7.6 mmol/L)

Correct response: 85 mg/dl (4.7 mmol/L) Explanation: The recommended fasting blood sugar level in a pregnant client with diabetes is 60 to 90 mg/dl (3.3 to 5.0 mmol/L). A fasting blood sugar level of 45 mg/dl (2.5 mmol/L) is low, and may result in symptoms of hypoglycemia. A blood sugar level below 120 mg/dl (6.7 mmol/L) is a recommended one-hour postprandial value. A blood sugar level above 136 mg/dl (7.6 mmol/L) in a pregnant client indicates hyperglycemia.

Which client should the nurse assess first? a. A client newly diagnosed with hypertension, with a blood pressure of 164/92 mm Hg who is having chest pain. b. A client with peripheral vascular disease with a blood pressure of 190/102 mm Hg who is due to receive a scheduled beta blocker. c. A client with a history of cerebral vascular attack, right sided weakness, blood pressure of 180/96 mm Hg who has a headache. d. A client with type 1 diabetes with a fasting blood glucose of 102 mg/dL, blood pressure of 172/90 mm Hg and whose urine shows microalbuminuria.

Correct response: A client newly diagnosed with hypertension, with a blood pressure of 164/92 mm Hg who is having chest pain. Explanation: The client with chest pain may be experiencing acute myocardial infarction and is unpredictable. A rapid assessment and intervention are needed. The remaining clients are all stable and have expected symptoms associated with their diagnosis.

A nurse is working on the pediatric unit. Which assignment best demonstrates primary care nursing? a. Caring for the same child from admission to discharge b. Caring for different children each shift to gain nursing experience c. Taking vital signs for every child hospitalized on the unit d. Assuming the charge nurse role instead of participating in direct child care

Correct response: Caring for the same child from admission to discharge Explanation: Primary care nursing requires that the primary nurse care for the same child (to whom she's assigned) during her scheduled shift. The associate nurse is assigned to the child care assignment when the primary nurse has a day off or during the evening and night shifts. Caring for different children each shift doesn't promote continuity of care. Taking vital signs for every child on the floor is an example of team nursing, in which each member of the team is assigned one specific task for each child. The charge nurse may be directly involved in child care.

A client with acute osteomyelitis is to receive parenteral penicillin for 4 to 6 weeks. Before administering the first dose, the nurse asks the client about known drug allergies. An allergy to which antibiotic or antibiotic class necessitates cautious use of penicillin? a. Tetracyclines b. Aminoglycosides c. Erythromycin d. Cephalosporins

Correct response: Cephalosporins Explanation: A client who is allergic to cephalosporins may also be allergic to penicillin. For the same reason, penicillin must be used cautiously in clients who are allergic to cephamycins, griseofulvin, or penicillamine. Cross-sensitivity between penicillin and tetracyclines, aminoglycosides, and erthyromycins hasn't been observed

A nurse is assessing a client with hyperparathyroidism. Which finding should the nurse report immediately to the physician? a. Urinary output of 30 mL/hour b. Blood pressure of 138/80 mm Hg c. Client reports loss of appetite d. Client reports flank pain

Correct response: Client reports flank pain Explanation: The client with hyperparathyroidism has elevated calcium levels, which promotes the formation of kidney stones. Flank pain may be indicative of kidney stones. Anorexia is common with this condition and is not cause for immediate intervention. Urinary output and blood pressure are normal.

When providing discharge teaching for a client with uric acid calculi, the nurse would include an instruction to avoid which type of diet? a. Low calcium b. Low oxalate c. High oxalate d. High purine

Correct response: High purine Explanation: To control uric acid calculi, the client would follow a low-purine diet, which excludes high-purine foods such as organ meats. The other diets do not control uric acid calculi.

Which nursing intervention is most important postoperatively for an infant who has received a ventriculoperitoneal shunt? a. Monitor intake and output. b. Initiate oral feedings. c. Allow the infant to rest undisturbed. d. Provide age-appropriate diversionary activities.

Correct response: Monitor intake and output. Explanation: In the postoperative period, intake and output are carefully monitored to prevent fluid overload that could lead to increased intracranial pressure. Feedings should start when the infant is fully awake. The infant will need to be disturbed to check vital signs and be repositioned. Age-appropriate activities are important but not until the infant is awake and less fussy.

A client is voluntarily admitted to a substance abuse unit. He admits to drinking at least 1 qt of vodka each day and occasionally using cocaine. Several hours after admission, a nurse suspects that the client is likely experiencing early alcohol withdrawal. What assessment findings support the nurse's suspicions? a. Vomiting, diarrhea, and pulse below 80 beats/minute b. Dehydration, temperature above 101° F (38.3° C ), and pruritus c. Blood pressure of 120/80 mm Hg, increased appetite, and somnolence d. Pulse rate of 135 beats/minute, tremors, and nervousness

Correct response: Pulse rate of 135 beats/minute, tremors, and nervousness Explanation: Signs of alcohol withdrawal include diaphoresis, tremors, nervousness, nausea, vomiting, malaise, increased blood pressure and pulse rate, sleep disturbance, and irritability. Dehydration and an elevated temperature may occur, but a temperature above 38.3° C (101° F) indicates an infection rather than alcohol withdrawal. Pruritus rarely occurs in alcohol withdrawal.

A physician orders a tricyclic antidepressant for a client who has suffered an acute myocardial infarction (MI) within the previous 6 months. Which action should the nurse take? a. Administer the medication as ordered. b. Discontinue the medication. c. Question the physician about the order. d. Inform the client that he should discuss his MI with the physician.

Correct response: Question the physician about the order. Explanation: Cardiovascular toxicity is a problem with tricyclic antidepressants, and the nurse should question the use of these drugs in a client with cardiac disease. Administering the medication would be an act of negligence. A nurse can't discontinue a medication without a physician's order. It's the nurse's responsibility, not the client's, to discuss questions of care with the physician.

The client with Cushing's disease needs to modify dietary intake to control symptoms. In addition to increasing protein, which strategy would be most appropriate? a. Increase calories. b. Restrict sodium. c. Restrict potassium. d. Reduce fat to 10%.

Correct response: Restrict sodium. Explanation: A primary dietary intervention is to restrict sodium, thereby reducing fluid retention. Increased protein catabolism results in loss of muscle mass and necessitates supplemental protein intake. The client may be asked to restrict total calories to reduce weight. The client should be encouraged to eat potassium-rich foods because serum levels are typically depleted. Although reducing fat intake as part of an overall plan to restrict calories is appropriate, fat intake of less than 20% of total calories is not recommended.

Which meal would be appropriate for the child with osteomyelitis to choose? a. beef and bean burrito with cheese, carrot and celery sticks, and a glass of milk b. beef hot dog, and an apple c. potato soup; jelly sandwich; and a peach d. tomato soup made with water, grilled cheese sandwich, and a banana

Correct response: beef and bean burrito with cheese, carrot and celery sticks, and a glass of milk Explanation: Children with osteomyelitis need a diet that is high in protein and calories. Milk, eggs, cheese, meat, fish, and beans are the best sources of these nutrients

The nurse is caring for a client with possible Cushing's syndrome undergoing diagnostic testing. The health care provider orders lab work and a dexamethasone suppression test. Which parameter would the nurse assess on the dexamethasone suppression test? a. The amount of dexamethasone in the system b. Cortisol levels after the system is challenged c. Changes in certain body chemicals, which are altered in depression d. Cortisol levels before and after the system is challenged with a synthetic steroid

The nurse is caring for a client with possible Cushing's syndrome undergoing diagnostic testing. The health care provider orders lab work and a dexamethasone suppression test. Which parameter would the nurse assess on the dexamethasone suppression test? You Selected: The amount of dexamethasone in the system Correct response: Cortisol levels before and after the system is challenged with a synthetic steroid Explanation: The dexamethasone suppression test measures cortisol levels before and after the system is challenged with a synthetic steroid. The dexamethasone suppression test does not measure dexamethasone or body chemicals altered in depression. Dexamethasone is used to challenge the cortisol level.

Which client statement indicates the need for further teaching about percutaneous umbilical blood sampling (PUBS) to assess fetal hemoglobin and hematocrit? a. "I will lie on my back in a cylinder-type machine." b. "My baby's heart rate might drop temporarily after this test." c. "A blood transfusion can be given to my baby this way if the tests shows he needs it." d. "A needle will be inserted into my belly for this test."

You Selected: "A blood transfusion can be given to my baby this way if the tests shows he needs it." Correct response: "I will lie on my back in a cylinder-type machine." Explanation: With PUBS, the client is scanned with an ultrasound, and a spinal needle is inserted into the client's abdomen and into the fetal vein. Fetal blood is aspirated into a syringe containing an anticoagulant. The client will not be placed in a cylindrical unit; this type of unit is used for magnetic resonance imaging. Transient fetal bradycardia is possible following this procedure. PUBS may be used for a fetal blood transfusion. With PUBS, the client is scanned with a linear-array ultrasound placed in a sterile glove, and a 25-gauge spinal needle is inserted into the client's abdomen and into the fetal vein. Fetal blood is aspirated into a syringe containing an anticoagulant

After teaching the client about bottle-feeding, which client statement indicates the need for additional teaching? a. "Bottle-fed babies up to 6 months of age may gain as much as 1 ounce (30 g)/day." b. "Iron-fortified formulas are usually recommended for newborns." c. "Bottle-fed babies will usually regain their birth weight by 10 to 14 days of age." d. "Whole milk is an acceptable alternative to formula once the baby is 4 months old."

You Selected: "Bottle-fed babies will usually regain their birth weight by 10 to 14 days of age." Correct response: "Whole milk is an acceptable alternative to formula once the baby is 4 months old." Explanation: Neither unmodified cow's milk nor whole milk is an acceptable alternative for newborn nutrition. The American Academy of Pediatrics and Canadian Pediatric Society recommend that infants be given breast milk or formula until 1 year of age. However, the American Academy of Pediatrics Committee on Nutrition has decreed that cow's milk could be substituted in the second 6 months of life, but only if the amount of milk calories does not exceed 65% of total calories and iron is replaced through solid foods. The protein content in cow's milk is too high, is poorly digested, and may cause gastrointestinal tract bleeding. Bottle-fed infants may gain as much as 1 oz (30 g)/day up to age 6 months. Iron-fortified formulas are recommended. Bottle-fed neonates may regain their birth weight by 10 to 14 days of age.

The nurse assigns an unlicensed assistive personnel (UAP) to care for a client who has a newly applied long-leg plaster cast. What should the nurse tell the UAP about proper care of the cast while it is drying? a. "Keep the cast covered with a sheet to protect it while drying." b. "Turn the client every 2 hours to promote even drying of the cast." c. "Use a blow dryer on the cast for 15 minutes every 2 hours until the cast is dry." d. "Carefully use your fingers to lift the cast and reposition the legs."

You Selected: "Carefully use your fingers to lift the cast and reposition the legs." Correct response: "Turn the client every 2 hours to promote even drying of the cast." Explanation: The client should be repositioned every 2 hours to promote even drying of the cast. The cast should be kept uncovered while drying to allow air to circulate around the cast and prevent heat from building up within it. It takes 24 to 72 hours for a plaster cast to dry; using a blow dryer may cause a heat burn and does not reduce the time for the cast to dry. The palms of the hands, not the fingers, should be used to move a drying cast in order to prevent indentations that can cause pressure points to develop

A nurse is obtaining a prenatal history from a client who's 8 weeks pregnant. To help determine whether the client is at risk for a TORCH infection, the nurse should ask: a. "Have you ever had osteomyelitis?" b. "Do you have any cats at home?" c. "Do you have any birds at home?" d. "Have you recently had a rubeola vaccination?"

You Selected: "Have you recently had a rubeola vaccination?" Correct response: "Do you have any cats at home?" Explanation: TORCH refers to Toxoplasmosis, Other Rubella virus, Cytomegalovirus, and Herpes simplex virus — agents that may infect the fetus or neonate, causing numerous ill effects. Toxoplasmosis is transmitted to humans through contact with the feces of infected cats (which may occur when emptying a litter box), through ingesting raw meat, or through contact with raw meat followed by improper hand washing. Osteomyelitis, a serious bone infection; histoplasmosis, which can be transmitted by birds; and rubeola aren't TORCH infections.

A client has identified to the community mental health nurse that an inability to be assertive with the client's boss has contributed to long work hours and increased stress and anxiety. To assist the client, which of the following questions would be most appropriate for the nurse to ask? a. "When is the best time of day to approach your boss?" b. "How is it best for you to approach your boss?" c. "What have you done so far to try to solve this problem?" d. "What are your alternative plans at this time?"

You Selected: "How is it best for you to approach your boss?" Correct response: "What have you done so far to try to solve this problem?" Explanation: To help the client resolve this situation, the nurse assists the client in determining what has worked or not worked in the past. This general understanding helps the client see the bigger picture and begin the problem-solving process. Immediately seeking alternatives is not advised. It is important to focus on helping the client identify strengths to manage the work situation, rather than providing quick solutions at this early stage of assessment.

A primigravida client in labor is now fully dilated and effaced after 8 hours in labor. The client asks the nurse, "When is this going to be over? It hurts so bad!" What is the best response by the nurse? a. "Since it is your first baby, your second stages of labor can last up to 4 hours." b. "You are progressing well and the second stage of labor should be complete within an hour." c. "If nothing is wrong with the baby, you should complete the second stage within 15 minutes." d. "I really can't tell you since it is different with everyone."

You Selected: "I really can't tell you since it is different with everyone." Correct response: "You are progressing well and the second stage of labor should be complete within an hour." Explanation: The average length of time for the second stage of labor for a primigravada is 1 hour. Longer than 1 hour might mean the client is experiencing an arrest in descent. Encouraging the client that she is progressing will assist her to focus on breathing and pushing. Indicating that there may be something wrong with the baby can create anxiety. Fifteen minutes for completion of the second stage of labor for a primigravada is not generally realistic. Informing the client that the nurse "can't really tell her" is not educating the client.

A client has a cerclage placed at 16 weeks' gestation. She has had no contractions and her cervix is dilated 2 cm. The nurse is preparing the client for discharge. Which statement by the client should indicate to the nurse that the client needs further instruction? a. "I will need more frequent prenatal visits." b. "I should call if I am leaking fluid or have bleeding or contractions." c. "I can have sex again in about 2 weeks." d. "I can have nothing in my vagina until I am at term."

You Selected: "I should call if I am leaking fluid or have bleeding or contractions." Correct response: "I can have sex again in about 2 weeks." Explanation: Intercourse commonly stimulates uterine contractions. The prostaglandins found in semen can also initiate contractions. After placement of a cerclage for advanced dilation and contractions, the client is considered at high risk for preterm birth and should be seen by her health care provider (HCP) more frequently. The client should call the HCP immediately if she sees signs of complications, such as leaking fluid (rupture of membranes), vaginal bleeding, and contractions (particularly with a cerclage in place). Anything in the vagina may initiate contractions and the labor process.

A client diagnosed with hyperosmolar hyperglycemic nonketotic syndrome (HHNS) is stabilized and prepared for discharge. When preparing the client for discharge and home management, which statement indicates that the client understands the condition and how to control it? a. "I can avoid getting sick by not becoming dehydrated and by paying attention to my need to urinate, drink, or eat more than usual." b. "If I experience trembling, weakness, and headache, I should drink a glass of soda that contains sugar." c. "I should be sure to limit my food and fluid intake when I'm not feeling well so my blood sugar doesn't go up." d. "If I begin to feel especially hungry and thirsty, I'll eat a snack high in carbohydrates."

You Selected: "If I experience trembling, weakness, and headache, I should drink a glass of soda that contains sugar." Correct response: "I can avoid getting sick by not becoming dehydrated and by paying attention to my need to urinate, drink, or eat more than usual." Explanation: Stating the need to remain hydrated and pay attention to eating, drinking, and voiding needs indicates that the client understands HHNS. Inadequate fluid intake during hyperglycemic episodes commonly leads to HHNS. By recognizing the signs of hyperglycemia (polyuria, polydipsia, and polyphagia) and increasing fluid intake, the client may prevent HHNS. Drinking a glass of nondiet soda would be appropriate for hypoglycemia. Limiting fluids will exacerbate the development of HHNS; limiting food might be acceptable, but it may lead to ketosis. A high-carbohydrate diet would exacerbate the client's condition, particularly if fluid intake is low.

The triage nurse in the pediatrician's office returns a call to a mother who is breastfeeding her 4-day-old infant. The mother is concerned about the yellow seedy stool that has developed since discharge home. What is the best reply by the nurse? a. "This type of stool indicates the infant may have diarrhea and should be seen in the office today." b. "The stool will transition into a soft, brown, formed stool within a few days and is appropriate for breastfeeding." c. "The stool results from the gassy food eaten by the mother. Refrain from eating these foods while breastfeeding." d. "Soft and seedy unformed stools with each feeding are normal for this age and will continue through breastfeeding."

You Selected: "The stool will transition into a soft, brown, formed stool within a few days and is appropriate for breastfeeding." Correct response: "Soft and seedy unformed stools with each feeding are normal for this age and will continue through breastfeeding." Explanation: A soft seedy unformed stool is the norm for a 4-day-old infant. It may surprise the mother as it is a change from the meconium the infant had since birth. This stool is not diarrhea even though it has no form. There is no need for the infant to be seen for this. As long as the infant is breastfeeding, the stools will remain of this color and consistency. Brown and formed stool is common for an infant who is bottle-fed or after the breastfeeding infant has begun eating food

The parent of an 18-year-old with chronic renal disease states, "My son has so many problems. I'm really worried that he will not get the right care if he gets sick at college." The nurse should tell the parent: a. "I can have his records sent to the school's health center." b. "Make sure your son always carries his nephrologist's phone number." c. "Your son can make an e-health history to facilitate his care if he gets sick away from home." d. "Your son is going to need to learn to manage his own disease."

You Selected: "Your son is going to need to learn to manage his own disease." Correct response: "Your son can make an e-health history to facilitate his care if he gets sick away from home." Explanation: Access to a well-constructed e-history will facilitate care if the adolescent becomes ill while at college. Because the client is 18, legally the nurse cannot transfer the records to the school without permission. Also, the adolescent may need to seek treatment in facilities other than the health center. Instructing the adolescent to always carry the nephrologist's phone number is not bad advice, but compliance may vary and there is no guarantee the provider will be available in all instances. Telling the parent that the son must learn to manage his own disease does not address the parent's concern.

At what gestational age should a primigravida expect to start feeling quickening? a. 12 weeks b. 18 to 20 weeks c. 21 to 23 weeks d. 26 weeks

You Selected: 12 weeks Correct response: 18 to 20 weeks Explanation: For the client who's pregnant for the first time, quickening occurs around 18 to 20 weeks. Women who have had children will feel quickening earlier, usually around week 16, because they recognize the sensations.

The nurse has received change-of-shift report on the following clients. Who should the nurse plan to assess first? a. A client who had a temporary pacemaker inserted 2 hours ago, who is now pacing 1:1 with a heart rate of 70. b. A client with atrial fibrillation who is scheduled to go the cardiac catheterization lab at 10 am for an ablation. c. A client with first-degree heart block and a heart rate of 62 who is dizzy when ambulating. d. A client newly admitted after their implantable cardioverter-defibrillator (ICD) fired twice who has a dose of amiodarone due.

You Selected: A client with atrial fibrillation who is scheduled to go the cardiac catheterization lab at 10 am for an ablation. Correct response: A client newly admitted after their implantable cardioverter-defibrillator (ICD) fired twice who has a dose of amiodarone due. Explanation: The firing of the ICD suggests that the client's ventricles are irritable. The nurse's priority is to assess the client and administer the amiodarone to prevent further dysrhythmias. The client with reports of dizziness should be kept in bed until the nurse is available to perform further assessment. Other clients can be seen after the medication is administered

A physician orders triamcinolone and salmeterol for a client with a history of asthma. What action should the nurse take when administering these drugs? a. Administer the triamcinolone and then administer the salmeterol. b. Administer the salmeterol and then administer the triamcinolone. c. Allow the client to choose the order in which the drugs are administered. d. Monitor the client's theophylline level before administering the medications.

You Selected: Administer the triamcinolone and then administer the salmeterol. Correct response: Administer the salmeterol and then administer the triamcinolone. Explanation: A client with asthma typically takes bronchodilators and uses corticosteroid inhalers to prevent acute episodes. Triamcinolone is a corticosteroid; Salmeterol is an adrenergic stimulant (bronchodilator). If the client is ordered a bronchodilator and another inhaled medication, the bronchodilator should be administered first to dilate the airways and to enhance the effectiveness of the second medication. The client may not choose the order in which these drugs are administered because they must be administered in a particular order. Monitoring the client's theophylline level isn't necessary before administering these drugs because neither drug contains theophylline.

A client reports abdominal pain. Which action allows the nurse to investigate this complaint? a. Using deep palpation b. Assessing the painful area last c. Assessing the painful area first d. Checking for warmth in the painful area

You Selected: Assessing the painful area first Correct response: Assessing the painful area last Explanation: Assessing the painful area last allows the nurse to obtain the maximal amount of information with minimal client discomfort. The nurse should always let the client know when she will be assessing the painful area. Pressure resulting from deep palpation may cause an underlying mass to rupture. Checking for warmth in the painful area offers no real information about the client's pain.

Which of the following information should the nurse include when providing discharge instructions to a client with psoriasis? a. Avoid applying creams after bathing. b. Trim fingernails regularly. c. Scrub vigorously when bathing to remove scales on skin. d. Use a washcloth when bathing.

You Selected: Avoid applying creams after bathing. Correct response: Trim fingernails regularly. Explanation: Clients with psoriasis are likely to experience itching. Trimming nails will help to prevent damage to the client's skin caused by scratching. Applying creams after bathing may help to reduce itching. Scrubbing vigorously when bathing should be avoided, as it can cause bleeding. Using a washcloth on skin is considered to be too harsh and should be avoided.

A client is diagnosed with human immunodeficiency virus (HIV). After recovering from the initial shock of the diagnosis, the client expresses a desire to learn as much as possible about HIV and acquired immunodeficiency syndrome (AIDS). When teaching the client about the immune system, the nurse states that humoral immunity is provided by which type of white blood cell? a. Neutrophil b. Basophil c. Monocyte d. Lymphocyte

You Selected: Basophil Correct response: Lymphocyte Explanation: The lymphocyte provides humoral immunity — recognition of a foreign antigen and formation of memory cells against the antigen. Humoral immunity is mediated by B and T lymphocytes and can be acquired actively or passively. The neutrophil is crucial to phagocytosis. The basophil plays an important role in the release of inflammatory mediators. The monocyte functions in phagocytosis and monokine production.

A nurse is obtaining assessment data on a client diagnosed with acute renal failure. Which finding warrants calling the healthcare provider? a. Respiratory rate of 16 breaths per minute b. Sodium level 145 mEq/L c. Blood urea nitrogen (BUN) 25 mg/dl d. Peaked T waves on electrocardiogram

You Selected: Blood urea nitrogen (BUN) 25 mg/dl Correct response: Peaked T waves on electrocardiogram Explanation: Hyperkalemia, a life threatening complication of acute renal failure, is characterized by tall peaked T waves on electrocardiogram. Elevated BUN is expected. The other findings are normal.

A nurse is following the progress of a client being treated for hypothyroidism. Which findings indicate that thyroid replacement therapy has been inadequate? Select all that apply. a. ECG changes. b. Tachycardia. c. Low body temperature. d. Nervousness. e. Bradycardia. f. Dry mouth.

You Selected: Bradycardia. Low body temperature. Correct response: ECG changes. Low body temperature. Bradycardia. Explanation: In hypothyroidism, the body is in a hypometabolic state. Therefore, ECG changes with bradycardia and subnormal body temperature would indicate that replacement therapy was inadequate. Tachycardia, nervousness, and dry mouth are symptoms of an excessive level of thyroid hormone; these findings would indicate that the client has received an excessive dose of thyroid hormone.

The nurse understands that certain medications protect the ischemic myocardium by blocking catecholamines and sympathetic nerve stimulation. Which class of medications serve this function? a. Beta-adrenergic blockers b. Calcium channel blockers c. Opioids d. Nitrates

You Selected: Calcium channel blockers Correct response: Beta-adrenergic blockers Explanation: Beta-adrenergic blockers work by blocking beta receptors in the myocardium, reducing the response to catecholamines and sympathetic nerve stimulation. They protect the myocardium, and help reduce the risk of another infarction by decreasing the workload of the heart and decreasing myocardial oxygen demand. Calcium channel blockers reduce the workload of the heart by reducing contractility and vasodilatation; thus, lowering afterload. Opioids reduce myocardial oxygen demand, promote vasodilation, and decrease anxiety. Nitrates reduce myocardial oxygen consumption by decreasing left ventricular end-diastolic pressure and systemic vascular resistance.

A newborn is diagnosed with meconium ileus. Which diagnostic test should be performed on the client? a. Rectal biopsy b. Heel stick for glucose c. Sweat chloride test d. Chest X-ray

You Selected: Chest X-ray Correct response: Sweat chloride test Explanation: A meconium ileus should trigger the screening for cystic fibrosis, which would be diagnosed with a sweat chloride test. A rectal biopsy is used to diagnose Hirschsprung's disease, which is not related to cystic fibrosis. A heel stick would be appropriate to diagnose low blood sugar not related to cystic fibrosis in the infant. A chest X-ray would be used for pleural effusion not specific to cystic fibrosis.

The most important responsibility of the nurse is to prioritize and ensure that routine nursing measures on non-critical clients are assigned. The nurse is performing which of the following functions? a. Delegation b. Networking c. Clinical coordination d. Advocacy

You Selected: Clinical coordination Correct response: Delegation Explanation: The professional nurse is responsible for delegating routine nursing measures to non-licensed personnel. The nurse needs to make the decision as to which aspects can be delegated and which clients need to be assessed and cared for by professional nurses. The definitions of the other terms do not pertain to this situation.

The nurse is teaching an adolescent with celiac disease about dietary changes that will help maintain a healthy lifestyle. Which of the following foods can the nurse safely recommend as part of the adolescent's diet? Select all that apply. a. Potatoes b. Apples c. Bagels d. Corn e. Pizza

You Selected: Corn Apples Correct response: Potatoes Apples Corn Explanation: Celiac disease is an intolerance to the gluten factor of protein found in grains. Specific grains to be removed from the diet include wheat, rye, oats, and barley. Clients with a diagnosis of celiac disease can tolerate corn, fruits, and vegetables.

A 20-year-old nulligravid client expresses a desire to learn more about the symptothermal method of family planning. Which information would the nurse include in the teaching plan? a. This method has a 50% failure rate during the first year of use. b. Couples must abstain from coitus for 5 days after the menses. c. Cervical mucus is carefully monitored for changes. d. The male partner uses condoms for significant effectiveness.

You Selected: Couples must abstain from coitus for 5 days after the menses. Correct response: Cervical mucus is carefully monitored for changes. Explanation: The symptothermal method is a natural method of fertility management that depends on knowing when ovulation has occurred. Because regular menstrual cycles can vary by 1 to 2 days in either direction, the symptothermal method requires daily basal body temperature assessments plus close monitoring of cervical mucus changes. The method relies on abstinence during the period of ovulation, which occurs approximately 14 days before the beginning of the next cycle. Abstinence from coitus for 5 days after menses is unnecessary because it is unlikely that ovulation will occur during this time period (days 1 through 10). Typically, the failure rate for this method is between 10% and 20%. Although a condom may increase the effectiveness of this method, most clients who choose natural methods are not interested in chemical or barrier types of family planning.

A patient from Pakistan informs the nurse of his cultural dietary requests. The nurse responds to the special dietary needs by stating, "You are now living in the United States, and you should try to start eating those foods common to an American diet." This inappropriate response is an example of: a. Cultural imposition. b. Cultural blindness. c. Cultural diversity. d. Cultural assimilation.

You Selected: Cultural assimilation. Correct response: Cultural imposition. Explanation: The nurse's response is an example of cultural imposition, which is defined as the belief that everyone should conform to the majority belief system. Cultural blindness is the result of ignoring differences and proceeding as though they do not exist. In this situation, the nurse did not ignore the request but inappropriately responded to it. Cultural diversity is defined as a diverse group in society, with varying racial classifications and national origins, religious affiliations, languages, physical sizes, genders, sexual orientations, ages, disabilities, socioeconomic statuses, occupational statuses, and geographic locations. Cultural assimilation occurs when members of a minority group live within a dominant group and lose the cultural characteristics that make them different.

A woman with a progressively enlarging neck comes into the clinic. She mentions that she has been in a foreign country for the previous 3 months and that she didn't eat much while she was there because she didn't like the food. She also mentions that she becomes dizzy when lifting her arms to do normal household chores or when dressing. What endocrine disorder should the nurse expect the physician to diagnose? a. Diabetes mellitus b. Goiter c. Diabetes insipidus d. Cushing's syndrome

You Selected: Diabetes insipidus Correct response: Goiter Explanation: A goiter can result from inadequate dietary intake of iodine associated with changes in foods or malnutrition. It's caused by insufficient thyroid gland production and depletion of glandular iodine. Signs and symptoms of this malfunction include an enlarged thyroid gland, dizziness when raising the arms above the head, dysphagia, and respiratory distress. Signs and symptoms of diabetes mellitus include polydipsia, polyuria, and polyphagia. Signs and symptoms of diabetes insipidus include extreme polyuria (4 to 16 L/day) and symptoms of dehydration (poor tissue turgor, dry mucous membranes, constipation, dizziness, and hypotension). Cushing's syndrome causes buffalo hump, moon face, irritability, emotional lability, and pathologic fractures.

A 45-year-old female client is admitted to the hospital with Cushing's syndrome. Which nursing interventions are appropriate for this client? Select all that apply. a. Assess for peripheral edema. b. Stress the need for a high-calorie, high-carbohydrate diet. c. Measure intake and output. d. Encourage oral fluid intake. Weigh the client daily. Instruct the client to avoid foods high in potassium.

You Selected: Encourage oral fluid intake. Weigh the client daily. Instruct the client to avoid foods high in potassium. Measure intake and output. Assess for peripheral edema. Correct response: Assess for peripheral edema. Measure intake and output. Weigh the client daily. Explanation: Because weight gain and edema are common symptoms of Cushing's syndrome, appropriate interventions include assessing for peripheral edema, measuring intake and output, and weighing the client daily. A low-calorie, low-carbohydrate, high-protein diet is ordered for a client with this disorder. Fluid restriction is often prescribed as well. Treatment of Cushing's syndrome includes the administration of potassium replacements; therefore, restricting foods high in potassium would not be appropriate.

A client is admitted to the psychiatric clinic for treatment of anorexia nervosa. Which actions are most important for the nurse to perform at this time? Select all that apply. a. Restrict the client's physical activities b. Weigh the client daily after the evening meal c. Monitor the client's vital signs d. Encourage the client to keep an accurate recording of her food and fluid intake e. Assess the client's serum albumin and electrolyte levels

You Selected: Encourage the client to keep an accurate recording of her food and fluid intake Assess the client's serum albumin and electrolyte levels Monitor the client's vital signs Weigh the client daily after the evening meal Correct response: Monitor the client's vital signs Assess the client's serum albumin and electrolyte levels Explanation: An anorexic client who requires hospitalization is in poor physical condition as a result of starvation and may die as a result of arrhythmias, hypothermia, malnutrition, infection, or cardiac abnormalities secondary to electrolyte imbalances. Therefore, monitoring the client's vital signs, serum electrolyte level, and albumin levels is crucial. Other laboratory values to assess are complete blood count and transferrin. Restricting the client's physical activities may worsen anxiety. A weight obtained after breakfast is more accurate than one obtained after the evening meal, although weights should be done weekly. Encouraging the client to keep a record of food and fluid intake would be more accurate than recalling from memory

Nursing care for a client in Addisonian crisis should include which intervention? a. Encouraging independence with activities of daily living (ADLs) b. Allowing ambulation as tolerated c. Offering extra blankets and raising the heat in the room to keep the client warm d. Placing the client in a private room

You Selected: Encouraging independence with activities of daily living (ADLs) Correct response: Placing the client in a private room Explanation: The client in Addisonian crisis has a reduced ability to cope with stress as a result of an inability to produce corticosteroids. A private room is easy to keep quiet, dimly lit, and temperature controlled. Also, visitors can be limited to reduce noise, promote rest, and decrease the risk of infection. The client should be kept on bed rest, receiving total assistance with ADLs to avoid stress as much as possible. Because extremes of temperature should be avoided, measures to raise the body temperature, such as extra blankets and turning up the heat, should be avoided.

When checking a client's medication profile, a nurse notes that the client is receiving a drug contraindicated for clients with glaucoma. The nurse knows that this client, who has a history of glaucoma, has been taking the medication for the past 3 days. What should the nurse do first? a. Continue to give the medication because the client has been taking it for 3 days. b. Hold the medication and report the information to the physician to ensure client safety. c. File an incident report because several other staff members have given the medication to the client. d. Find out whether there are extenuating reasons for giving the drug to this client.

You Selected: Find out whether there are extenuating reasons for giving the drug to this client. Correct response: Hold the medication and report the information to the physician to ensure client safety. Explanation: The nurse should report the information to the physician because the client's safety may be endangered. She shouldn't give the drug until clarifying the order with the physician. The fact that the client has taken the drug for several days doesn't guarantee that giving him another dose is safe. Filing an incident report and finding out whether there are extenuating reasons for giving the drug wouldn't address client safety.

A nurse is caring for an elderly client with a pressure ulcer on the sacrum. When teaching the client about dietary intake, which foods should the nurse emphasize? a. Legumes and cheese b. Whole grain products c. Fruits and vegetables d. Lean meats and low-fat milk

You Selected: Fruits and vegetables Correct response: Lean meats and low-fat milk Explanation: Although the client should eat a balanced diet, including foods from all food groups, the diet should emphasize foods that supply complete protein, such as lean meats and low-fat milk. Protein helps build and repair body tissue, which promotes healing. Legumes provide incomplete protein. Cheese contains complete protein, but it also includes fat, which should be limited to 30% or less of caloric intake. Whole grain products supply incomplete proteins and carbohydrates. Fruits and vegetables provide mainly carbohydrates.

A nurse obtains a fingerstick glucose level of 45 mg/dl (2.47 mmol/L) on a client newly diagnosed with diabetes mellitus. The client is alert and oriented, and the client's skin is warm and dry. How should the nurse intervene? a. Give the client 4 oz (120 mL) of milk and a graham cracker with peanut butter. b. Obtain a serum glucose level. c. Obtain a repeat fingerstick glucose level. d. Notify the physician.

You Selected: Give the client 4 oz (120 mL) of milk and a graham cracker with peanut butter. Correct response: Obtain a repeat fingerstick glucose level. Explanation: The nurse should recheck the fingerstick glucose level to verify the original result because the client isn't exhibiting signs of hypoglycemia. The nurse should give the client milk and a graham cracker with peanut butter or a glass of orange juice after confirming the low glucose level. It isn't necessary to notify the physician or to obtain a serum glucose level at this time.

The nurse notes that a client taking antipsychotic medications becomes agitated, fearful, and panicky when his neck twists to one side and his eyes forcefully draw upward toward the ceiling. Which medication should be administered to the client? a. Benztropine b. Haloperidol c. Paliperidone d. Diazepam

You Selected: Haloperidol Correct response: Benztropine Rationale: Benztropine is an anticholinergic drug used to counteract the dystonic reactions and adverse reactions of antipsychotic drugs. If the client experiences difficulty swallowing, benztropine may be administered by injection. Haloperidol is an antipsychotic medication used to control tics and vocal utterances that are part of Tourette's syndrome. Paliperidone is used to treat mania, and at low dosage, is used as a maintenance medication for bipolar disorder, schizophrenia and schizoaffective disorder. Diazepam is a benzodiazepine. Each of these medications require a provider's order.

A nurse is preparing to palpate a client's thyroid gland. Which action by the nurse is appropriate? a. Have the client flex his neck onto his chest and cough while she palpates the anterior neck with her fingertips. b. Place her hands around the client's neck, with the thumbs in the front of the neck, and gently massage the anterior neck. c. Encircle the client's neck with both hands, have the client slightly extend his neck, and ask him to swallow. d. Have the client hyperextend his neck and take slow, deep inhalations while she palpates his neck with her fingertips.

You Selected: Have the client hyperextend his neck and take slow, deep inhalations while she palpates his neck with her fingertips. Correct response: Encircle the client's neck with both hands, have the client slightly extend his neck, and ask him to swallow. Explanation: When palpating the thyroid gland, the nurse should encircle the client's neck with both hands, have the client slightly extend his neck, and ask him to swallow. As the client swallows, the gland is palpated for enlargement as the tissue rises and falls. Having the client flex his neck wouldn't allow for palpation. Massaging the area or checking during inhalation doesn't allow for the movement of tissue that swallowing provides.

The nurse determines that a multigravid client in active labor is about to give birth. The nurse has no health care provider immediately available. After calling for assistance, what should the nurse do first? a. Have the client push with a contraction. b. Ask the client to take a deep breath and hold it. c. Prepare a clean area on which to receive the neonate. d. Lower the head of the bed to a flat position

You Selected: Have the client push with a contraction. Correct response: Prepare a clean area on which to receive the neonate. Explanation: Because the birth is imminent and no additional help is available, the nurse should immediately prepare a clean area for childbirth. Most agency labor units have emergency birth packs with sterile towels, a bulb syringe, and a cord clamp. Having the client push with a contraction may push the head out quickly, resulting in tearing of the perineum. The nurse should instruct the client to pant or pant/blow to decrease the urge to push. Trying to delay the birth is contraindicated. The head of the bed should be elevated to about 45 degrees, not lowered. The client should assume a position of comfort.

A female client is readmitted to the facility with a warm, tender, reddened area on her right calf. Which contributing factor should the nurse recognize as most important? a. History of increased aspirin use b. Recent pelvic surgery c. An active daily walking program d. A history of diabetes mellitus

You Selected: History of increased aspirin use Correct response: Recent pelvic surgery Explanation: The client shows signs of deep vein thrombosis (DVT). The pelvic area has a rich blood supply, and thrombophlebitis of the deep veins is associated with pelvic surgery. Aspirin, an antiplatelet agent, and an active walking program help decrease the client's risk of DVT. In general, diabetes mellitus is a contributing factor associated with peripheral vascular disease

When caring for a client with nonresectable colon cancer, which nursing diagnosis requires the nurse to function collaboratively to achieve the best outcome related to client comfort? a. Risk for deficient fluid volume b. Acute pain c. Activity intolerance d. Imbalanced nutrition: Less than body requirements

You Selected: Imbalanced nutrition: Less than body requirements Correct response: Acute pain Explanation: A nurse must collaborate with a physician to achieve the best pain control for the client. A nurse may not give medications, such as analgesics and antibiotics, without a physician order, and she assesses the client's response to pain medications and provides feedback to the physician. The nurse may assist the client with nonpharmacologic activities for pain control. She may implement independent nursing interventions, such as performing assessments, providing appealing fluids, pacing nursing care to promote rest and minimize client fatigue, and providing small frequent meals to address Risk for imbalanced fluid volume, Activity intolerance, and Imbalanced nutrition.

A nurse practicing in a nurse-managed clinic suspects that an 8-year-old child's chronic sinusitis and upper respiratory tract infections may result from allergies. She orders an immunoglobulin assay. Which immunoglobulin would the nurse expect to find elevated? a. Immunoglobulin E b. Immunoglobulin D c. Immunoglobulin G d. Immunoglobulin M

You Selected: Immunoglobulin G Correct response: Immunoglobulin E Explanation: The nurse would expect elevated immunoglobulin (Ig) E levels because IgE is predominantly found in saliva and tears as well as intestinal and bronchial secretions and, therefore, may be found in allergic disorders. IgD's physiologic function is unknown and constitutes only 1% of the total number of circulating immunoglobulins. IgG is elevated in the presence of viral and bacterial infections. IgM is the first antibody activated after an antigen enters the body, and is especially effective against gram-negative organisms.

While caring for a client in the transition phase of labor, the nurse notes that the fetal monitor tracing shows moderate variability with a baseline of 142 beats per minute (bpm). Which of the following interventions should the nurse include in the client's plan of care? Select all that apply. a. Providing encouraging labor support b. Administering oxygen via face mask c. Changing the client's position d. Increasing the client's IV rate e. Documenting the findings

You Selected: Increasing the client's IV rate Changing the client's position Administering oxygen via face mask Providing encouraging labor support Documenting the findings Correct response: Providing encouraging labor support Documenting the findings Explanation: During the transitional phase of labor, the client may feel frustration and will need encouragement. Moderate variability and a baseline of 142 bpm are normal and should be documented. There is no indication to give oxygen, change the client's position, or increase the IV rate.

The nurse is caring for a client with gestational trophoblastic disease (GTD). Which of the following interventions will the nurse include in the client's plan of care? Select all that apply. a. Measure fundal height. b. Monitor potassium levels. c. Administer ondansetron IV. d. Monitor fetal heart tones every 4 hours. e. Assess vaginal discharge for infection.

You Selected: Measure fundal height. Monitor fetal heart tones every 4 hours. Monitor potassium levels. Administer ondansetron IV. Assess vaginal discharge for infection. Correct response: Measure fundal height. Administer ondansetron IV. Explanation: The uterus measures large, human chorionic gonadotropin levels are high with GTD. Hyperemsis gravidarum is present with GTD, and ondansetron would be an appropriate intervention for this client. Fetal heart tones are absent and hydropic vesicles may be passed with GTD.

The nurse learns that a client who is scheduled for a tonsillectomy has been taking 40 mg of oral prednisone daily for the last week for poison ivy on the leg. What should the nurse do first? a. Document the prednisone with current medications. b. Notify the surgeon of the poison ivy. c. Notify the anesthesiologist of the prednisone administration. d. Send the client to surgery.

You Selected: Notify the surgeon of the poison ivy. Correct response: Notify the anesthesiologist of the prednisone administration. Explanation: The nurse should notify the anesthesiologist because supplemental prednisone suppresses the adrenal cortex's natural ability to produce increased corticosteroids in times of stress such as surgery. The anesthesiologist may need to prescribe supplemental steroid coverage during the perioperative period. The nurse should document the prednisone with current medications, but it is a priority to inform the anesthesiologist. Because the poison ivy is not in the surgical field, the surgeon does not need to be called regarding the skin disruption.

What should the nurse teach a client about how to avoid the dumping syndrome? Select all that apply. a. Consume three regularly-spaced meals per day. b. Eat a diet with high carbohydrate foods with each meal. c. Reduce fluids with meals, but take them between meals. d. Obtain adequate amounts of protein and fat in each meal. e. Eat in a relaxing environment.

You Selected: Obtain adequate amounts of protein and fat in each meal. Eat in a relaxing environment. Correct response: Reduce fluids with meals, but take them between meals. Obtain adequate amounts of protein and fat in each meal. Eat in a relaxing environment. Explanation: Dumping syndrome results in excessive, rapid emptying of gastric contents. The nurse should instruct the client to avoid dumping syndrome by eating small, frequent meals rather than three large meals, having a diet high in protein and fat and low in carbohydrates, reducing fluids with meals but taking them between meals, and relaxing when eating. The client should eat slowly and regularly and rest after meals.

An 8-week-old infant with congenital heart disease is being discharged. What is the most important information for the nurse to convey regarding feeding? a. Allow the infant 1 hour to complete each feeding. b. Position the infant in an upright position after each feeding. c. Give feedings per nasogastric tube to conserve energy. d. Provide a higher calorie formula or fortified breast milk.

You Selected: Position the infant in an upright position after each feeding. Correct response: Provide a higher calorie formula or fortified breast milk. Explanation: Infants with congenital heart disease often have difficulty feeding and gaining weight. They will tire quickly during the feeding. Most will do well with smaller, more frequent feedings. The infant with a congenital heart defect should not be given more than 20 minutes per feeding. Fortified breast milk or a high calorie formula will help the infant gain weight and conserve energy. Prolonging the feeding to an hour will merely tire the infant. Positioning the infant in an upright position is recommended for infants with gastrointestinal reflux. Some infants with a congenital heart defect may not consume adequate amounts of calories through breast- or bottle-feeding and may require supplemental feeding through a nasogastric tube; however, nasogastric tube feedings are not necessary for all infants with congenital heart defects.

A client with manic episodes is taking lithium. Which electrolyte level should the nurse check before administering this medication? a. Calcium b. Sodium c. Chloride d. Potassium

You Selected: Potassium Correct response: Sodium Explanation: Lithium is chemically similar to sodium. If sodium levels are reduced, such as from sweating or diuresis, lithium will be reabsorbed by the kidneys, increasing the risk of toxicity. Clients taking lithium should not restrict their intake of sodium and should drink adequate amounts of fluid each day. Calcium, chloride, and potassium are important for normal body functions but sodium is most important to the absorption of lithium.

A nurse has been teaching a new mother how to feed her infant who was born with a cleft lip and palate. Which action by the mother indicates that the teaching has been successful? a. Placing the baby flat during feedings b. Providing fluids with a small spoon c. Placing the nipple in the cleft palate d. Burping the baby frequently

You Selected: Providing fluids with a small spoon Correct response: Burping the baby frequently Explanation: Because an infant with a cleft lip and palate can't grasp a nipple securely, he may swallow a large amount of air during feedings and, therefore, require frequent burping. An infant with a cleft lip and palate should be fed in an upright position to reduce the risk of aspiration. Spoons shouldn't be used. A neonate with a cleft lip and palate may use specially prepared nipples for feeding. Placing the nipple in the cleft palate increases the risk of aspiration

The client with a nasogastric (NG) tube has abdominal distention. What should the nurse do first? a. Call the health care provider (HCP). b. Irrigate the NG tube. c. Check the function of the suction equipment. d. Reposition the NG tube.

You Selected: Reposition the NG tube. Correct response: Check the function of the suction equipment. Explanation: When a client with a NG tube exhibits abdominal distention, the nurse should first check the suction machine. If the suction equipment is functioning properly, then the nurse should take other steps, such as repositioning the tube or checking tube patency by irrigating it. If these steps are not effective, then the HCP should be called

A client in home hospice care verbalizes to her caregiver that she wants to meet with her minister. The caregiver, who does not want the minister to visit or to interact with the minister because of her different values and beliefs, asks the home health nurse how to handle this situation. To prevent further disagreement between the client and caregiver, what is the best recommendation for the nurse to implement? a. Explain to the caregiver how to be assertive without being insensitive to the client's wishes. b. Arrange for an alternative caregiver to be available for the client when the minister visits. c. Discuss other options for spiritual counseling that may be appropriate to the client and caregiver. d. Resolve with the client and caregiver the concerns related to the minister making a home visit.

You Selected: Resolve with the client and caregiver the concerns related to the minister making a home visit. Correct response: Arrange for an alternative caregiver to be available for the client when the minister visits. Explanation: It is important that both the client's spiritual needs be met and the caregiver's opinions and needs be respected. Therefore, arranging for an alternative caregiver to be there during the visit is a reasonable solution. Teaching the caregiver to be assertive and discussing other spiritual counseling options does not meet the client's need. Since both the client and caregiver have different positions it would require time to resolve the underlying issues. Also, the client is currently on hospice and it is important to find a reasonable compromise to allow the client's needs to be addressed.

The client with Cushing's disease needs to modify dietary intake to control symptoms. In addition to increasing protein, which strategy would be most appropriate? a. Increase calories. b. Restrict sodium. c. Restrict potassium. d. Reduce fat to 10%.

You Selected: Restrict potassium. Correct response: Restrict sodium. Explanation: A primary dietary intervention is to restrict sodium, thereby reducing fluid retention. Increased protein catabolism results in loss of muscle mass and necessitates supplemental protein intake. The client may be asked to restrict total calories to reduce weight. The client should be encouraged to eat potassium-rich foods because serum levels are typically depleted. Although reducing fat intake as part of an overall plan to restrict calories is appropriate, fat intake of less than 20% of total calories is not recommended.

Which would be most helpful when coaching a client to stop smoking? a. Review the negative effects of smoking on the body. b. Discuss the effects of passive smoking on environmental pollution. c. Establish the client's daily smoking pattern. d. Explain how smoking worsens high blood pressure.

You Selected: Review the negative effects of smoking on the body. Correct response: Establish the client's daily smoking pattern. Explanation: A plan to reduce or stop smoking begins with establishing the client's personal daily smoking pattern and activities associated with smoking. It is important that the client understands the associated health and environmental risks, but this knowledge has not been shown to help clients change their smoking behavior

A client is diagnosed with obsessive-compulsive disorder. Which intervention should the nurse include when developing the care plan for this client? a. Setting strict limits on compulsive behavior b. Giving the client time to perform rituals c. Increasing environmental stimulation d. Preventing ritualistic behavior

You Selected: Setting strict limits on compulsive behavior Correct response: Giving the client time to perform rituals Explanation: The nurse should give the client time to perform rituals because this reduces anxiety. Setting strict limits, increasing environmental stimulation, or preventing ritualistic behavior would increase the client's anxiety.

A nurse is caring for a newborn who has developed sepsis. The healthcare provider has given the following orders. Which order will the nurse implement first? a. Obtain blood cultures b. Start ampicillin 125 mg IV now c. Give a 10 mL/kg bolus of fluid d. Place a urinary bag for drug screening

You Selected: Start ampicillin 125 mg IV now Correct response: Obtain blood cultures Explanation: All of the orders that the healthcare provider initiated are important, but the nurse should obtain the blood culture before starting any other interventions—especially before starting the ampicillin. If the culture is obtained after a dose of ampicillin has been given, the results of the culture could be altered and unreliable

Twenty minutes after a transfusion of packed red blood cells is initiated, a client reports shivering, headache, and lower back pain. The vital signs show a normal temperature and increased pulse and respiratory rate. What should be the first nursing actions? a. Stop the transfusion, continue with saline infusion, and notify the physician regarding a suspected hemolytic reaction. b. Slow the transfusion, notify the physician regarding a possible febrile reaction, and follow the physician's orders. c. Slow the transfusion, give an antihistamine as ordered, and notify the physician regarding a possible allergic reaction. d. Stop the transfusion, check the oxygen saturation levels, and check the urine volume.

You Selected: Stop the transfusion, check the oxygen saturation levels, and check the urine volume. Correct response: Stop the transfusion, continue with saline infusion, and notify the physician regarding a suspected hemolytic reaction. Explanation: Hemolytic reaction is one of the most severe blood reactions, so prompt action to stop the transfusion is very important, followed by ensuring the IV access is preserved.

An older adult client seeks help for chronic constipation. Which recommendation would be most beneficial for the nurse to suggest? a. Ask your health care provider about cutting back on the diuretic you are taking. b. Try eating an apple each day with peanut butter. c. Take a stool softener when you are feeling bloated. d. Consider abdominal strengthening exercises each day rather then walking.

You Selected: Take a stool softener when you are feeling bloated. Correct response: Try eating an apple each day with peanut butter. Explanation: Causes of constipation include inadequate hydration, fiber intake, and lack of exercise. Fruits, vegetables, and grains are a good source of fiber which will increase bulk. Decreasing a diuretic would not be recommended in an elderly person. A stool softener is needed regularly for effect and cannot be used on an as-needed basis. Exercise for constipation needs to increase heart rate to improve perfusion to the intestine.

A nurse who works in a community-based clinic is implementing primary prevention with the clients who use the clinic. What should the nurse include in primary prevention activities? a. Administering digoxin to a client who has heart failure b. Referring a client who reports joint pain to a healthcare provider specialist c. Teaching a client who has asthma how to use a rescue inhaler d. Obtaining a rubella titer on a woman who is planning to start a family

You Selected: Teaching a client who has asthma how to use a rescue inhaler Correct response: Obtaining a rubella titer on a woman who is planning to start a family Explanation: Obtaining a rubella titer is a primary prevention activity. Rubella may cause birth defects when contracted during the first 3 months of pregnancy. Identifying those who do not have an immunity and then providing the vaccine is a primary prevention activity. The remaining selections fall under secondary and tertiary prevention.

The nurse assesses a client who is receiving a tube feeding. Which situation would require prompt intervention from the nurse? a. The client is sitting upright in bed while the feeding is infusing. b. The feeding that is infusing has been hanging for 8 hours. c. The client has a gastric residual of 25 mL. d. The feeding solution is at room temperature.

You Selected: The client has a gastric residual of 25 mL. Correct response: The feeding that is infusing has been hanging for 8 hours. Explanation: Feeding solutions that have not been infused after hanging for 8 hours should be discarded because of the increased risk of bacterial growth. Sitting the client upright during the feeding helps prevent aspiration of the feeding. A gastric residual of 25 mL is considered acceptable. A gastric residual of 100 to 150 mL, or a residual greater than 100% of the previous hour's intake, indicates delayed emptying. The feeding solution should be at room or body temperature

Which client has a need for prophylactic antibiotic therapy prior to dental manipulations? a. The client who had a TKR (total knee replacement) one year ago b. The client with a left THR (total hip replacement) 3 months ago c. The client with an in ICD (implantable cardiac defibrillator) 2 weeks ago d. The client with an aortic valve replacement 5 years ago

You Selected: The client with a left THR (total hip replacement) 3 months ago Correct response: The client with an aortic valve replacement 5 years ago Explanation: A heart valve prosthesis such as an aortic valve replacement is a major risk factor for the development of infective endocarditis. Preventative measures include antibiotic prophylaxis prior to dental work. Other implanted devices: hip, knee, ICD can increase the risk of infection, but the client with the greatest risk is the one with the valve replacement.

A client with hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome is admitted to the labor and delivery unit. The client's condition rapidly deteriorates and despite efforts by the staff, the client dies. After the client's death, the nursing staff displays many emotions. With whom should the nurse-manager consult to help the staff cope with this unexpected death? a. The human resource director, so she can arrange vacation time for the staff b. The physician, so he can provide education about HELLP syndrome c. The social worker, so she can contact the family about funeral arrangements and pass along the information to the nursing staff d. The chaplain, because his educational background includes strategies for handling grief

You Selected: The human resource director, so she can arrange vacation time for the staff Correct response: The chaplain, because his educational background includes strategies for handling grief Explanation: The chaplain should be consulted because his educational background provides strategies for helping others handle grief. Providing the staff with vacation time isn't feasible from a staffing standpoint and doesn't help staff cope with their grief. The staff needs grief counseling, not education about HELLP syndrome. Asking the social worker to contact the family about the funeral arrangements isn't appropriate.

A physician placed a direct fetal scalp electrode on the fetus. What information should a nurse include when documenting direct fetal scalp electrode placement? a. Time of fetal scalp electrode placement, name of the physician who placed the electrode, and frequency of uterine contractions b. Time of fetal scalp electrode placement, name of the physician who applied the electrode, and the fetal heart rate (FHR) c. The name of the physician who applied the electrode, Doppler transducer placement, and FHR d. The maternal and fetal body movements identified by the direct fetal scalp electrode, time of fetal scalp electrode placement, and FHR

You Selected: The maternal and fetal body movements identified by the direct fetal scalp electrode, time of fetal scalp electrode placement, and FHR Correct response: Time of fetal scalp electrode placement, name of the physician who applied the electrode, and the fetal heart rate (FHR) Explanation: Direct fetal scalp electrode placement is the most accurate way to assess FHR. Documentation should include the time the electrode was placed, the name of the physician or nurse practitioner who performed the procedure, and the FHR. Direct fetal scalp electrodes don't monitor maternal uterine contractions. A Doppler transducer (an external, not internal device) is applied to the mother's abdomen to measure FHR, using high-frequency ultrasound. Unlike the fetal scalp electrode, it doesn't directly measure FHR. The fetal scalp electrode doesn't measure maternal or fetal movements.

A client is 2 months pregnant. Which factor should the nurse anticipate as most likely to affect her psychosocial transition during pregnancy? a. Support from her partner b. The month of her due date c. Previous health promotion activities d. Readiness at home for the baby

You Selected: The month of her due date Correct response: Support from her partner Explanation: Many factors can influence the smoothness of a pregnant client's psychosocial transition. The most important factors are support from her partner, parents, friends, and others; whether the pregnancy was planned or unplanned; and previous childbirth and parenting experiences. Age, socioeconomic status, sexuality concerns, birth stories of family members and friends, and past experiences with health care facilities and professionals may also influence a client's psychosocial transition during pregnancy. The month of her due date and previous health promotion activities don't affect her psychological transition. Readiness for the baby at home usually affects the client during the third trimester, not in the second month.

A primiparous client is on a regular diet 24 hours postpartum. She is from Guatemala and speaks only Spanish. The client's mother asks the nurse if she can bring her daughter some "special foods from home." The nurse responds, based on the understanding about which principle? a. Foods from home are generally discouraged on the postpartum unit. b. The mother can bring the daughter any foods that she desires. c. This is permissible as long as the foods are nutritious and high in iron. d. The client's health care provider (HCP) needs to give permission for the foods.

You Selected: This is permissible as long as the foods are nutritious and high in iron. Correct response: The mother can bring the daughter any foods that she desires. Explanation: On most postpartum units, clients on regular diets are allowed to eat whatever kinds of food they desire. Generally, foods from home are not discouraged. The nurse does not need to obtain the HCP's permission. Although it is preferred, the foods do not necessarily have to be high in iron. In some cultures, there is a belief in the "hot-cold" theory of disease; certain foods (hot) are preferred during the postpartum period, and other foods (cold) are avoided. Therefore, the nurse should allow the mother to bring her daughter "special foods from home." Doing so demonstrates cultural sensitivity and aids in developing a trusting relationship.

Which topic is most important to include in the teaching plan for a client newly diagnosed with Addison's disease who will be taking corticosteroids? a. The importance of watching for signs of hyperglycemia. b. The need to adjust the steroid dose based on dietary intake and exercise. c. To notify the health care provider (HCP) when the blood pressure is suddenly high. d. How to decrease the dose of the corticosteroids when the client experiences stress.

You Selected: To notify the health care provider (HCP) when the blood pressure is suddenly high. Correct response: The importance of watching for signs of hyperglycemia. Explanation: Since Addison's disease can be life threatening, treatment often begins with administration of corticosteroids. Corticosteroids, such as prednisone, may be taken orally or intravenously, depending on the client. A serious adverse effect of corticosteroids is hyperglycemia. Clients do not adjust their steroid dose based on dietary intake and exercise; insulin is adjusted based on diet and exercise. Addisonian crisis can occur secondary to hypoadrenocorticism, resulting in a crisis situation of acute hypotension, not increased blood pressure. Addison's disease is a disease of inadequate adrenal hormone, and therefore the client will have inadequate response to stress. If the client takes more medication than prescribed, there can be a potential increase in potassium depletion, fluid retention, and hyperglycemia. Taking less medication than was prescribed can trigger Addisonian crisis state, which is a medical emergency manifested by signs of shock.

A 10-month-old child has cold symptoms. The mother asks how she can clear the infant's nose. What would be the nurse's best recommendation? a. Use a cool air vaporizer with plain water. b. Use saline nose drops and then a bulb syringe. c. Blow into the child's mouth to clear the infant's nose. d. Administer a nonprescription vasoconstrictive nose spray.

You Selected: Use a cool air vaporizer with plain water. Correct response: Use saline nose drops and then a bulb syringe. Explanation: Although a cool air vaporizer may be recommended to humidify the environment, using saline nose drops and then a bulb syringe before meals and at nap and bed times will allow the child to breathe more easily. Saline helps to loosen secretions and keep the mucous membranes moist. The bulb syringe then gently aids in removing the loosened secretions. Blowing into the child's mouth to clear the nose introduces more organisms to the child. A nonprescription vasoconstrictive nasal spray is not recommended for infants because if the spray is used for longer than 3 days a rebound effect with increased inflammation occurs.

Thirty people are injured in a train derailment. Which client should be transported to the hospital first? a. a 20-year-old who is unresponsive and has a high injury to his spinal cord b. an 80-year-old who has a compound fracture of the arm c. a 10-year-old with a laceration on his leg d. a 25-year-old with a sucking chest wound

You Selected: a 20-year-old who is unresponsive and has a high injury to his spinal cord Correct response: a 25-year-old with a sucking chest wound Explanation: During a disaster, the nurse must make difficult decisions about which persons to treat first. The guidelines for triage offer general priorities for immediate, delayed, minimal, and expectant care. The client with a sucking chest wound needs immediate attention and will likely survive. The 80-year-old is classified as delayed; emergency response personnel can immobilize the fracture and cover the wound. The 10-year-old has minimal injuries and can wait to be treated. The client with a spinal cord injury is not likely to survive and should not be among the first to be transported to the health care facility.

A client with diabetes has been diagnosed with hypertension, and the health care provider (HCP) has prescribed atenolol, a beta-blocker. When performing discharge teaching, it is important for the nurse to emphasize that the addition of atenolol can cause: a. a decrease in the hypoglycemic effects of insulin. b. an increase in the hypoglycemic effects of insulin. c. an increase in the incidence of ketoacidosis. d. a decrease in the incidence of ketoacidosis.

You Selected: a decrease in the hypoglycemic effects of insulin. Correct response: an increase in the hypoglycemic effects of insulin. Explanation: There is a direct interaction between the effects of insulin and those of beta blockers. The nurse must be aware that there is a potential for increased hypoglycemic effects of insulin when a beta blocker is added to the client's medication regimen. The client's blood sugar should be monitored. Ketoacidosis occurs in hyperglycemia. Although a decrease in the incidence of ketoacidosis could occur when a beta blocker is added, the direct result is an increase in the hypoglycemic effect of insulin. ((Google described it as: beta blockers increase the release of insulin, therefore increasing the risk of hypoglycemia))

A multipara at 16 weeks' gestation is diagnosed as having a fetus with probable anencephaly. The client is a devout Baptist and has decided to continue the pregnancy and donate the neonatal organs after the death of the neonate. The nurse should: a. explore the nurse's own feelings about the issues of anencephaly and organ donation. b. contact the client's minister to discuss the client's options related to the pregnancy. c. advise the client that the prolonged neonatal death will be very painful for her. d. ask the client if her family agrees with her decision.

You Selected: advise the client that the prolonged neonatal death will be very painful for her. Correct response: explore the nurse's own feelings about the issues of anencephaly and organ donation. Explanation: Anencephaly is a neural tube defect that is not compatible with life, although some of these infants live for several days before death occurs. When the client has decided to continue the pregnancy and donate the neonatal organs after the death of the neonate, the nurse should remain nonjudgmental. The nurse should explore his or her feelings about the issue of anencephaly and organ donation. The nurse should not make judgments about the client's position, nor should the nurse try to persuade the client to terminate the pregnancy. Contacting the client's minister to explore the client's options is not appropriate. As a devout Baptist, the client probably has already discussed the matter with her minister. Telling the client that the neonatal death will be prolonged and painful to her is not helpful. Death may occur very soon after birth. Asking the client about her family's opinion does not help the support the client's decision.

The nurse is admitting a 4-year old with a possible meningococcal infection. Which type of isolation is indicated? a. airborne precautions b. contact precautions c. droplet precautions d. standard precautions

You Selected: airborne precautions Correct response: droplet precautions Explanation: Meningococcal infections are spread through close mucous membrane or respiratory contact with large respiratory droplets. Meningococcal infections are not spread by small airborne organisms or contact with a person's skin or contaminated items. Standard precautions, used when touching body fluids, are not sufficient to prevent the spread of meningitis.

The client with a major burn injury receives total parenteral nutrition (TPN). The expected outcome is to: a. correct water and electrolyte imbalances. b. allow the gastrointestinal tract to rest. c. provide supplemental vitamins and minerals. d. ensure adequate caloric and protein intake.

You Selected: allow the gastrointestinal tract to rest. Correct response: ensure adequate caloric and protein intake. Explanation: Nutritional support with sufficient calories and protein is extremely important for a client with severe burns because of the loss of plasma protein through injured capillaries and an increased metabolic rate. Gastric dilation and paralytic ileus commonly occur in clients with severe burns, making oral fluids and foods contraindicated. Water and electrolyte imbalances can be corrected by administration of IV fluids with electrolyte additives, although TPN typically includes all necessary electrolytes. Resting the gastrointestinal tract may help prevent paralytic ileus, and TPN provides vitamins and minerals; however, the primary reason for starting TPN is to provide the protein necessary for tissue healing.

Before advising a 24-year-old client desiring oral contraceptives for family planning, the nurse would assess the client for which signs and symptoms? a. anemia b. hypertension c. dysmenorrhea d. acne vulgaris

You Selected: anemia Correct response: hypertension Explanation: Before advising a client about oral contraceptives, the nurse needs to assess the client for signs and symptoms of hypertension. Clients who have hypertension, thrombophlebitis, obesity, or a family history of cerebral or cardiovascular accident are poor candidates for oral contraceptives. In addition, women who smoke, are older than 40 years of age, or have a history of pulmonary disease should be advised to use a different method. Iron-deficiency anemia, dysmenorrhea, and acne are not contraindications for the use of oral contraceptives. Iron-deficiency anemia is a common disorder in young women. Oral contraceptives decrease the amount of menstrual flow and thus decrease the amount of iron lost through menses, thereby providing a beneficial effect when used by clients with anemia. Low-dose oral contraceptives to prevent ovulation may be effective in decreasing the severity of dysmenorrhea (painful menstruation). Dysmenorrhea is thought to be caused by the release of prostaglandins in response to tissue destruction during the ischemic phase of the menstrual cycle. Use of oral contraceptives commonly improves facial acne.

A nurse is teaching a client with multiple sclerosis (MS). When teaching the client how to reduce fatigue, the nurse should tell the client to: a. take a hot bath. b. rest in an air-conditioned room. c. increase the dose of muscle relaxants. d. avoid naps during the day.

You Selected: avoid naps during the day. Correct response: rest in an air-conditioned room. Explanation: Fatigue is a common symptom in clients with MS. Lowering the body temperature by resting in an air-conditioned room may relieve fatigue; however, extreme cold should be avoided. A hot bath or shower can increase body temperature, producing fatigue. Muscle relaxants, ordered to reduce spasticity, can cause drowsiness and fatigue. Frequent rest periods and naps can relieve fatigue. Other measures to reduce fatigue in the client with MS include treating depression, using occupational therapy to learn energy-conservation techniques, and reducing spasticity.

A client's blood pressure is elevated at 160/90 mm Hg. The health care provider (HCP) prescribed "clonidine 1 mg by mouth now." The nurse sent the prescription to pharmacy at 0710, but the medication still has not arrived at 0800. The nurse should do all except: a. check all appropriate places on the unit to which the drug could have been delivered. b. check the client's blood pressure. c. call the pharmacy. d. go to the pharmacy to obtain the drug.

You Selected: check all appropriate places on the unit to which the drug could have been delivered. Correct response: go to the pharmacy to obtain the drug. Explanation: Although the nurse needs to obtain and administer the medication as soon as possible, it is inappropriate for the nurse to go to the pharmacy and request the drug without first calling the pharmacy and checking to see whether the medication was delivered. The drug may have been delivered to several appropriate spots on the unit, such as the client's drug bin, the transport system, or the delivery box. The nurse should assess the client's blood pressure to determine the immediacy of the condition for which the medication was prescribed.

A 37-year-old client of Native American/First Nations/Aboriginal descent visits the clinic for the first time. She is about 12 weeks pregnant, and this is her first pregnancy. The nurse instructs the client that one test that will most likely be prescribed is a: a. glucose tolerance test. b. chorionic villi sampling. c. urine culture and sensitivity. d. hepatitis D test.

You Selected: chorionic villi sampling. Correct response: glucose tolerance test. Explanation: There is a greater incidence of both gestational diabetes and preexisting diabetes among women older than 35 years. In addition, clients of Native American, Aboriginal/First Nations, and Hispanic/Latin descent have a greater incidence of gestational diabetes than the general population. The client does not present symptoms that would warrant testing of chorionic villi. The client does not present symptoms that would warrant a urine culture and sensitivity test. The client does not present symptoms that would warrant testing for hepatitis D.

Following a subtotal thyroidectomy, the nurse asks the client to speak immediately upon regaining consciousness. The nurse does this to monitor for signs of: a. internal hemorrhage. b. decreasing level of consciousness. c. laryngeal nerve damage. d. upper airway obstruction.

You Selected: decreasing level of consciousness. Correct response: laryngeal nerve damage. Explanation: Laryngeal nerve damage is a potential complication of thyroid surgery because of the proximity of the thyroid gland to the recurrent laryngeal nerve. Asking the client to speak helps assess for signs of laryngeal nerve damage. Persistent or worsening hoarseness and weak voice are signs of laryngeal nerve damage and should be reported to the health care provider (HCP) immediately. Internal hemorrhage is detected by changes in vital signs. The client's level of consciousness can be partially assessed by asking her to speak, but that is not the primary reason for doing so in this situation. Upper airway obstruction is detected by color and respiratory rate and pattern

The nurse manager on a psychiatric unit is reviewing the outcomes of staff participation in an aggression management program. What indicator would the nurse used to evaluate the effectiveness of such a program? a. fewer client injuries during restraint procedures b. a reduction in the number of complainsts by clients' relatives c. fewer staff injuries during restraint procedures d. a reduction in the total number of restraint procedures

You Selected: fewer client injuries during restraint procedures Correct response: a reduction in the total number of restraint procedures Explanation: The primary goal of an aggression management program is to prevent violence. This goal is evidenced by a reduction in the total number of restraint procedures used or needed. Although fewer client and staff injuries are important, these goals are secondary to prevention. Reduction in the number of complaints by clients' relatives is affected by more variables than just restraint procedures.

The nurse is instructing the client with chronic renal failure to maintain adequate nutritional intake. Which diet would be most appropriate? a. high-carbohydrate, high-protein b. high-calcium, high-potassium, high-protein c. low-protein, low-sodium, low-potassium d. low-protein, high-potassium

You Selected: high-carbohydrate, high-protein Correct response: low-protein, low-sodium, low-potassium Explanation: Dietary management for clients with chronic renal failure is usually designed to restrict protein, sodium, and potassium intake. Protein intake is reduced because the kidney can no longer excrete the byproducts of protein metabolism. The degree of dietary restriction depends on the degree of renal impairment. The client should also receive a high-carbohydrate diet along with appropriate vitamin and mineral supplements. Calcium requirements remain 1,000 to 2,000 mg/day.

The client attends two sessions with the dietitian to learn about diet modifications to minimize gastroesophageal reflux. The teaching would be considered successful if the client decreases the intake of which foods? fats high-sodium foods carbohydrates high-calcium foods

You Selected: high-sodium foods Correct response: fats Explanation: Fats are associated with decreased esophageal sphincter tone, which increases reflux. Obesity contributes to the development of hiatal hernia, and a low-fat diet might also aid in weight loss. Carbohydrates and foods high in sodium or calcium do not affect gastroesophageal reflux.

A client has a history of heart failure and has been prescribed furosemide, digoxin, and potassium chloride. The client has nausea, blurred vision, headache, and weakness. The nurse notes that the client is confused. The telemetry strip shows first-degree atrioventricular block. The nurse should assess the client for signs of: a. hyperkalemia. b. digoxin toxicity. c. fluid deficit. d. pulmonary edema.

You Selected: hyperkalemia. Correct response: digoxin toxicity. Explanation: Early symptoms of digoxin toxicity include anorexia, nausea, and vomiting. Visual disturbances can also occur, including double or blurred vision and visual halos. Hypokalemia is a common cause of digoxin toxicity associated with arrhythmias because low serum potassium can enhance ectopic pacemaker activity. Although vomiting can lead to fluid deficit, given the client's history, the vomiting is likely due to the adverse effects of digoxin toxicity. Pulmonary edema is manifested by dyspnea and coughing.

A client is receiving chlordiazepoxide as needed for signs and symptoms of alcohol withdrawal. The nurse assesses the client and determines the need for medication when the client displays: a. mild tremors, hypertension, tachycardia. b. bradycardia, hyperthermia, sedation. c. hypotension, decreased reflexes, drowsiness. d. hypothermia, mild tremors, slurred speech.

You Selected: hypothermia, mild tremors, slurred speech. Correct response: mild tremors, hypertension, tachycardia. Rationale: Chlordiazepoxide is given during alcohol withdrawal. Symptoms that indicate a need for this drug include tremors, hypertension, tachycardia, and elevated body temperature. Bradycardia, sedation, hypotension, decreased reflexes, hypothermia, and slurred speech aren't symptoms of alcohol withdrawal.

A client's serum ammonia level is elevated, and the health care provider (HCP) prescribes 30 mL of lactulose. Which effect is common for this drug? a. increased urine output b. Improved level of consciousness c. increased bowel movements d. nausea and vomiting

You Selected: increased urine output Correct response: increased bowel movements Explanation: Lactulose increases intestinal motility, thereby trapping and expelling ammonia in the feces. An increase in the number of bowel movements is expected as an adverse effect. Lactulose does not affect urine output. Any improvements in mental status would be the result of increased ammonia elimination, not an adverse effect of the drug. Nausea and vomiting are not common adverse effects of lactulose

When teaching the parents of an infant how to perform back slaps to dislodge a foreign body, what should the nurse tell the parents to use to deliver the blows? a. palm of the hand b. heel of the hand c. fingertips d. entire hand

You Selected: palm of the hand Correct response: heel of the hand Explanation: Back slaps are delivered rapidly and forcefully with the heel of the hand between the infant's shoulder blades. Slowly delivered back slaps are less likely to dislodge the object. Using the heel of the hand allows more force to be applied than when using the palm or the whole hand, increasing the likelihood of loosening the object. The fingertips would be used to deliver chest compressions to an infant younger than 1 year of age.

A client begins taking haloperidol. After a few days, he experiences severe tonic contractures of muscles in his neck, mouth, and tongue. The nurse should recognize this as: a. psychotic symptoms. b. parkinsonism. c. akathisia. d. dystonia.

You Selected: parkinsonism. Correct response: dystonia. Explanation: These symptoms describe dystonia, which commonly occurs after a few days of treatment with haloperidol. Mistaking the symptoms for psychotic symptoms can lead to misdiagnosis. Parkinsonism results in muscle rigidity, shuffling gait, stooped posture, flat-faced affect, tremors, and drooling. Signs and symptoms of akathisia are restlessness, pacing, and inability to sit still.

During dialysis, the client has disequilibrium syndrome. The nurse should first? a. administer oxygen per nasal cannula. b. slow the rate of dialysis. c. reassure the client that the symptoms are normal. d. place the client in Trendelenburg's position

You Selected: place the client in Trendelenburg's position. Correct response: slow the rate of dialysis. Explanation: If disequilibrium syndrome occurs during dialysis, the most appropriate intervention is to slow the rate of dialysis. The syndrome is believed to result from too-rapid removal of urea and excess electrolytes from the blood; this causes transient cerebral edema, which produces the symptoms. Administration of oxygen and position changes do not affect the symptoms. It would not be appropriate to reassure the client that the symptoms are normal

A multigravid client is admitted at 4-cm dilation and is requesting pain medication. The nurse gives the client nalbuphine 15 mg. Within five minutes, the client tells the nurse she feels like she needs to have a bowel movement. The nurse should first: a. have naloxone hydrochloride available in the birthing room. b. complete a vaginal examination to determine dilation, effacement, and station. c. prepare for birth. d. document the client's relief due to pain medication.

You Selected: prepare for birth. Correct response: complete a vaginal examination to determine dilation, effacement, and station. Explanation: The feeling of needing to have a bowel movement is commonly caused by pressure on the receptors low in the perineum when the fetal head is creating pressure on them. This feeling usually indicates advances in fetal station and that the client may be close to birth. The nurse should respond initially to the client's signs and symptoms by checking to validate current effacement, dilation, and station. If the fetus is ready to be born, having the room ready for the birth and having naloxone available are important. Naloxone completely or partially reverses the effects of natural and synthetic opioids, including respiratory depression. Documenting pain relief takes time away from the vaginal examination, preparing for birth, and obtaining naloxone. The birth may be occurring rapidly. Being prepared for the birth is a higher priority than documentation for this client.

When preparing discharge instructions for a client after an abdominal hysterectomy, the nurse should first: a. have the client watch an educational video. b. assess the client's available social supports. c. call the social worker to evaluate the client. d. read the discharge instructions to the client.

You Selected: read the discharge instructions to the client. Correct response: assess the client's available social supports. Explanation: Assessment is the first step in planning client education. Assessing social support resources is a key aspect of discharge planning that begins when the client is admitted to the hospital. It is imperative to know what assistance and support the client has at home. Assessment includes obtaining data about any family or home responsibilities the client is concerned with during the recovery period. It is within the scope of nursing practice to provide discharge instructions. A social worker is not needed at this time. The nurse should assess the client's needs before determining whether using a video or reading instructions to the client is appropriate.

A breastfeeding primiparous client who gave birth 8 hours ago asks the nurse, "How will I know that my baby is getting enough to eat?" Which guideline should the nurse include in the teaching plan as evidence of adequate intake? a. six to eight wet diapers by the fifth day b. three to four transitional stools on the fourth day c. ability to fall asleep easily after feeding on the first day d. regain of lost birth weight by the third day

You Selected: regain of lost birth weight by the third day Correct response: six to eight wet diapers by the fifth day Explanation: The nurse should instruct the client that the baby is getting enough to eat when there are six to eight wet diapers by the fifth day of age. Other signs include good suckling sounds during feeding, dripping breast milk at the mouth, and quiet rest or sleep after the feeding. By the fourth day of age, the infant should have soft yellow stools, not transitional (greenish) stools. Falling asleep easily after feeding on the first day is not a good indicator because most infants are sleepy during the first 24 hours. Most infants regain their lost birth weight in 7 to 10 days after birth. An infant who has gained weight during the first well-baby checkup (usually at 2 weeks) is getting sufficient breast milk at feedings.

After administering naloxone, an opioid antagonist, the nurse should monitor the client carefully for which problem? a. cerebral edema b. kidney failure c. seizure activity d. respiratory depression

You Selected: seizure activity Correct response: respiratory depression Explanation: After administering naloxone, the nurse should monitor the client's respiratory status carefully because the drug is short acting and respiratory depression may recur after its effects wear off. Cerebral edema, kidney failure, and seizure activity are not directly related to opioid overdose or naloxone therapy

Which finding is the best indication that the goals for total parenteral nutrition (TPN) are being achieved for the client? a. urine negative for glucose b. serum potassium level of 4 mEq/L (4 mmol/L) c. serum glucose level of 96 mg/dL (5.3 mmol/L) d. weight gain of 0.5 lb/day (0.2 kg/day)

You Selected: serum glucose level of 96 mg/dL (5.3 mmol/L) Correct response: weight gain of 0.5 lb/day (0.2 kg/day) Explanation: Steady and progressive weight gain is the best indication that the client's nutritional goals are being met by TPN. The laboratory values are within normal limits but do not indicate attainment of nutritional goals. Hyperglycemia may be a metabolic complication of TPN with concomitant glycosuria. The client's blood glucose level is monitored, and insulin is prescribed as needed. Electrolyte values are assessed daily to determine the client's response to TPN.

A client is receiving chemotherapy that has the potential to cause pulmonary toxicity. Which signs or symptoms indicates a toxic response to the chemotherapy? a. decrease in appetite b. drowsiness c. spasms of the diaphragm d. cough and shortness of breath

You Selected: spasms of the diaphragm Correct response: cough and shortness of breath Explanation: Cough and shortness of breath are significant symptoms because they may indicate decreasing pulmonary function secondary to drug toxicity. Decrease in appetite, difficulty in thinking clearly, and spasms of the diaphragm may occur as a result of chemotherapy; however, they are not indicative of pulmonary toxicity.

The comatose victim of a car accident is to have a gastric lavage. Which position would be most appropriate for the client during this procedure? a. lateral b. supine c. Trendelenburg d. lithotomy

You Selected: supine Correct response: lateral Explanation: An unconscious client is best positioned in a lateral or semiprone position because these positions allow the jaw and tongue to fall forward, facilitate drainage of secretions, and prevent aspiration. Positioning the client supine carries a major risk of airway obstruction from the tongue, vomitus, or nasopharyngeal secretions. Trendelenburg's position, with the head lower than the heart, decreases effective lung volume and increases the risk of cerebral edema. The lithotomy position has no purpose in this situation

A young adult has been bitten by a human, and the skin on the forearm is broken. The client's last tetanus shot was about 8 years ago. The nurse should prepare the client for: a. an injection of tetanus toxoid. b. application of a corticosteroid cream. c. closure of the wound with sutures. d. testing for tuberculosis.

You Selected: testing for tuberculosis. Correct response: an injection of tetanus toxoid. Explanation: Tetanus toxoid is indicated, since there has been no booster in the last 5 years. With a human bite there is a risk of severe infection; application of a steroid cream does not prevent infection. The closure of the wound should be delayed until it is determined that there is no infection, in approximately 24 to 48 hours. Tuberculosis is not transmitted through human bites

A 20-year-old client visiting the clinic requests the use of oral contraceptives. When reviewing the client's history, which finding would alert the nurse to a possible contraindication to using these agents? a. thrombophlebitis b. urinary tract infections c. ulcerative colitis d. menorrhagia

You Selected: ulcerative colitis Correct response: thrombophlebitis Explanation: Oral contraceptives are contraindicated for clients with a history of thrombophlebitis because a serious side effect of oral contraceptives is thrombus formation. Other contraindications include stroke and liver disease. Oral contraceptives are used cautiously in clients with hypertension or diabetes. Close follow-up of these clients is essential. Urinary tract infections (UTIs) do not contraindicate the use of oral contraceptives. If the client is suffering from UTIs, the nurse can instruct her to increase her fluid intake and wipe from front to back after urinating or defecating. Ulcerative colitis does not contraindicate using oral contraceptives. Menorrhagia is typically reduced through the use of oral contraceptives.

The health care provider (HCP) prescribes a urinalysis for a child who has undergone surgical repair of a hypospadias. Which results should the nurse report to the HCP? a. urine specific gravity of 1.017 b. ten red blood cells per high-powered field c. twenty-five white blood cells per high-powered field d. urine pH of 6.0

You Selected: urine specific gravity of 1.017 Correct response: twenty-five white blood cells per high-powered field Explanation: A normal white blood cell count in a urinalysis is 1 to 2 cells/mL. A white blood cell count of 25 per high-powered field indicates a urinary tract infection. A urine specific gravity of 1.017 is within the normal range of 1.002 to 1.030. After urologic surgery, it is not unusual for a small number of red blood cells to appear in the urine. The child's urine pH is within the normal range of 4.6 to 8.

A nurse manager is implementing a plan to improve the use of standard precautions by the staff on the unit. After collecting observational data on the staff's use of personal protective equipment, which behavior would the nurse manager identify as an indication of the need for education? Select all that apply. a. use of gowns when caring for any client b. use of sterile gloves for urine specimen collection c. performance of hand hygiene after removing gloves d. disposal of contaminated dressings into a biohazard receptacle e. recapping of needles after use

You Selected: use of sterile gloves for urine specimen collection use of gowns when caring for any client Correct response: use of gowns when caring for any client use of sterile gloves for urine specimen collection recapping of needles after use Explanation: Standard precautions include: performing hand hygiene after removing gloves, disposing of contaminated dressings in the proper biohazard container, using gowns if there will be splashing or spattering of blood or body fluids, using clean gloves to collect urine specimens, and never recapping needles once used.

After a client undergoes a contraction stress test that is negative, what should the nurse assess next? a. evidence of ruptured membranes b. viability status of the fetus c. indications that contractions have ceased d. fetal heart rate patterns

You Selected: viability status of the fetus Correct response: indications that contractions have ceased Explanation: The contraction stress test simulates labor and determines the fetal response to the labor process and the mother's contractions. Therefore, determining that contractions have ceased after the test is important. Although spontaneous rupture of membranes is a possibility after a contraction stress test, it is not a typical occurrence. The test should not affect the viability of the fetus. Fetal viability is related to gestational age. A fetus of at least 23 weeks' gestation is considered viable, or capable of extrauterine life. Stating that stress test is negative means the fetal heart rate has already been interpreted and has not been found to fall during contractions.

A client with lung cancer is being cared for by his wife at home. His pain is increasing in severity. The nurse recognizes that teaching has been effective when the wife: Select all that apply. a. gives her husband a long-acting or sustained-release oral pain medication regularly around the clock. b. uses an immediate-release medication (oxycodone) for breakthrough pain. c. avoids long-acting opioids due to her concern about addiction. d. uses music for distraction as well as heat or cold in combination with medications. e. substitutes acetaminophen to avoid tolerance to the medications. f. has her husband use a pain-rating scale to measure the effectiveness at reaching his individual pain goal.

You Selected: -uses music for distraction as well as heat or cold in combination with medications. -has her husband use a pain-rating scale to measure the effectiveness at reaching his individual pain goal. -gives her husband a long-acting or sustained-release oral pain medication regularly around the clock. Correct response: -gives her husband a long-acting or sustained-release oral pain medication regularly around the clock. -uses an immediate-release medication (oxycodone) for breakthrough pain. -uses music for distraction as well as heat or cold in combination with medications. -has her husband use a pain-rating scale to measure the effectiveness at reaching his individual pain goal. Explanation: Scheduled use of long-acting opioids and an around-the-clock dosing are necessary to achieve a steady level of analgesia. Whatever the route or frequency, a prescription should be available for "breakthrough" pain medication to be administered in addition to the regularly scheduled medication. Oral drug administration is the route of choice for economy, safety, and ease of use. Even severe pain requiring high doses of opioids can be managed orally as long as the client can swallow medication and has a functioning gastrointestinal system. Tolerance occurs due to the need for increasing doses to achieve the same pain relief and will not be avoided with the use of acetaminophen. Addiction is a complex condition in which the drug is used for psychological effect and not analgesia. Nurses need to educate families about the appropriate use of opioids and assure them that addiction is not a concern when managing cancer pain. Nonpharmacologic methods are useful as an adjunct to assist in pain control. Self-report is the best assessment of pain and is an individual response.

A nurse notices repetitive late decelerations on the fetal heart monitor. The best initial actions by the nurse include: a. prepare for birth, reposition the patient, and begin pushing b. perform sterile vaginal examination, increase IV fluids, and apply O2 c. notify the provider, explain findings to the client, and begin pushing d. reposition the client, apply oxygen, and increase IV fluids

You selected: a Correct response: d Late decelerations on a fetal heart monitor indicate uteroplacental insufficiency. Interventions to improve perfusion include repositioning the client, oxygen, and IV fluids. A sterile vaginal exam is not indicated at this time. Late decelerations are not expected findings and do not indicate an imminent birth.

A client who had a cesarean birth 1 day ago asks for pain medication when the nurse enters the room to perform her shift assessment. The client states that her pain level is an 8 on a 0 to 10 point Cale. The priority of care should be for the nurse to: a. have the client get up to wash so she can make the bed b. start the postpartum assessment c. administer any ordered pain medication d. tell the client the pain will subside if she relaxes

You selected: b Correct réponse: c Pain management is a nursing priority. Pain control enables the client to move, eliminated other potential birth related complications. Additionally, bonding with the neonate occurs more readily if the client isn't uncomfortable. The nurse should initiate the assessment after alleviating the client's pain. Relaxation will act as an adjunct therapy, but relaxation alone won't provide pain management during the postpartum period.

When assessing the FHR tracing, a nurse becomes concerned about the FHR patter. In response to the loss of variability, the nurse repositions the client to her left side and administers O2. These actions are likely to improve: a. fetal hypoxia b. the contraction pattern c. the status of a trapped cord d. maternal comfort

You selected: c Correct response: a These actions, which will improve fetal hypoxia, increase the amount of maternal circulating oxygen by taking pressure created by the uterus off the aorta and improving blood flow. These actions will not improve the contraction pattern, free a trapped cord, or improve maternal comfort.

A client gives birth to a stillborn neonate at 36 weeks gestation. When caring for this client, which strategy by the nurse would be most helpful? a. be selective in providing the information that the client seeks b. encourage the client to see, touch, and hold the dead neonate c. provide information about possible causes of the still birth only if the client requests it d. let the child's father decide what information the client receives

You selected: c Correct response: b When caring for a client who has suffered perinatal loss, the nurse should provide an opportunity for the client to bond with the dead neonate and allow the neonate to become part of the family unit. Parents who aren't given such a chance may experience fantasies about the neonate, which may be worse than the reality. If the neonate has gross deformities, the nurse should prepare the client for these. If the client doesn't ask about her neonate, the nurse should encourage her to do so and provide an information she seems ready to hear. The client needs a full explanation of all factors related to the experience so she can grieve appropriately. Letting the neonate's father decide which information the client receives is inappropriate.

The multigravida client with a hx of rapid labor who is in active labor calls out to the nurse, "the baby is coming?" What should the nurse's first action be? a. inspect the perineum b. time the contractions c. auscultate the FHR d. contact the health care provider

You selected: c correct response: a When the client says the baby is coming, the nurse should first inspect the perineum and observe for crowning to validate the client's statement. If the client is not giving birth precipitously, the nurse can calm her and use appropriate breathing techniques. If birth is imminent, the health care provider should be contacted. Timing contractions is not the priority action. The nurse needs to determine if what the client says is accurate. Monitoring the FHR, including auscultation, occurs throughout the labor process.

A nurse is evaluation the external fetal monitoring strip of a client who is in labor. She notes decreases in the FHR that start with the beginning of the client's contraction and return to baseline before the end of the contraction. What term does the nurse use to document this finding? a. prolonged decelerations b. early decelerations c. late decelerations d. accelerations

You selected: d Correct response: b A deceleration is a decrease in the FHR below the baseline. When decelerations occur at the same time as uterine contractions, they are called early decelerations. Early decelerations result from head compression during normal labor and do not indicate fetal distress. Prolonged decelerations, also known as reflex bradycardia, are decreases in the FHR that last 60 to 90 seconds. These decelerations occur in response to sudden vagal stimulation. Prolonged decelerations may indicate fetal distress. Late decelerations start after the beginning of a contraction. The lowest point of a late deceleration occurs after the contraction ends. Accelerations are transient rises in the FHR that are normally caused by fetal movements and uterine contractions.

A client hospitalized for preterm labor tells the nurse her mother in law blames her for "overdoing it" and causing the preterm labor. Which of the following is the most appropriate response from the nurse? a. "did you think that you did anything you shouldn't have?" b. "your mother in law was wrong. You didn't do anything to cause this" c. "let's talk about how preterm labor occurs, so as to help you understand what causes it" d. "it is natural to blame one another when things become difficult"

Your answer: a Correct answer: c The nurse needs to explore the client's feelings to assist her in understanding what happened and to disperse the blame she is feeling. The other responses do not explore feelings experienced by the client and may stop the dialogue with the nurse from continuing.

The nurse has just received report on a labor client: a G3, T1, P0, Ab1, L1 who is 80% effaced, 3 cm dilated, 0 station. The nurse anticipates the plan of care for the shift will include address what factors? Select all that apply: a. this client will give birth before the change of shift in 12 hours b. pushing the baby out should take 30 minutes or less c. contractions will remain irregular until transition d. transition will be shorter for this multiparous client e. this client will withdraw into herself during transition

Your answer: a, d Correct answer: a, b, d, e A multiparous client usually gives birth within 12 hours of the time labor began. The pushing phase statistically takes 30 minutes or less and many multiparous clients go immediately from 10 cm dilation to birth. Contractions become regular and increase in frequency, intensity, and duration as labor progresses for both primiparous and multiparous clients. Transition will be shorter for a multiparous client than it will for a primiparous client, as the entire labor process takes less time for someone who has had a baby before. This client will withdraw into herself during transition, and this is a common characteristic for those in the transition phase.

Four years after seroconversion, an HIV infected client has a CD4+ cell count of 800 cell/uL. And a low viral load. The nurse teaches the client that a. The client is at risk for development of opportunistic infections because of CD4+ cell destruction. b. The client is in a clinical and biologic latent period, during which very few viruses are being replicated. c. Anti-HIV antibodies produced by B cells enter CD4+ cells infected with HIV to stop replication. d. The body currently is able to produce an adequate number of CD4+ cells to replace those destroyed by viral activity.

Answer = D Rationale: The client in the early chronic stage of infection, when the body is able to produce enough CD4+ cells to maintain the CD4+ count at normal level.

A nurse is providing teaching to a client who has rheumatoid arthritis and a new prescription for methotrexate. Which of the following should the nurse include in the teaching? a. avoid crowds b. expect manifestations to subside in 1 to 2 weeks c. increase intake of vit D d. anticipate constipation

Answer = a Methotrexate can cause leukopenia due to bone marrow suppression, which can increase the client's risk for infection. The nurse should instruct the client to increase his intake of folic acid, not vit D, to help decrease the adverse effects of methotrexate.

The nurse explains to the client newly diagnosed with HIV that prophylactic measures that should be taken as early as possible during the course of the infection include which of the following? (Select all that apply) a. Hepatitis A vaccine. b. Hepatitis B vaccine. c. Pneumococcal vaccine. d. Influenza virus vaccine. e. Trimethoprim sulfamethoxazole. f. Varicella zoster immune globulin.

Answer = A, B, C, D Rationale: Prevention of other infections is an important intervention in client who are HIV positive, and these vaccines are recommended as soon as the HIV infection is diagnosed. Varicella zoster immune globulin is a live virus so it will not be given.

How should the nurse position a preschooler with right lower lobe pneumonia?

Answer: Left Lateral Sims Position Rationale: The child with right lower lobe pneumonia should be placed on his left side. This places the unaffected left lung in a position so that gravity will promote blood flow to the healthy lung tissue, improving gas exchange. Placing the child on the right side, his back, or his stomach doesn't promote circulation to the unaffected lung.

A nurse is planning an education program for a group of high school teachers who will be taking students on a hike. Which of the following information should the nurse include regarding Lyme disease? a. if bitten by a tick, you should be tested immediately b. if you have a tick embedded in your skin, apply a lit match to remove it c. you should wear dark-colored clothing to deter ticks biting d. if you develop pain and stiffness in your joints, you should see your doctor

Answer = d manifestations of Lyme disease include influenza-like symptoms, a "bulls-eye" rash, muscle and joint pain, and stiffness. The nurse should instruct the group to report these findings to a provider. lighting a match could spread infection.

A nurse is educating a client who is scheduled for a kidney transplant. Which of the following information about hyper acute rejection should the nurse include in the teaching? a. hyper acute rejection can occur during the first few weeks after the transplant b. if hyper acute rejection occurs, the kidney can become enlarged c. the organ will need to be removed if hyper acute rejection occurs d. immunosuppressive therapy is given to reverse hyper acute rejection

Answer = C removing the transplanted organ is the only tx for hyper acute rejection, due to the widespread clotting cascade that leads to ischemic necrosis of the transplant kidney hyper acute rejection occurs immediately following transplantation. Acute rejection occurs during the first few weeks following the client's transplant.

A nurse working in the emergency department is concerned that a client, who is in police custody, is handcuffed to the stretcher. The nurse asks the police officer to remove the cuffs, but the officer refuses. What should be the next action by the nurse? a. Continue to assess the client, allowing the officer to assume responsibility for the restraint. b. Call the supervisor and report the officer's decision to keep the cuffs on. c. Ask the physician for an order to remove the handcuffs. d. Refuse to provide care while the client is handcuffed to the stretcher

Answer = a Rationale: In this situation, the police officer has applied the restraint and has taken responsibility for the restraint. The nurse should assess the client for any potential complication from the handcuffs, document the assessment, and provide care to the client as usual. The other options are incorrect because the police officer has assumed responsibility for the restraint. It is unlikely that a physician would order the restraint to be removed against the officer's recommendation, and if the restraints are in place and the officer is present, the nurse can provide care to the client.

A nurse is examining a client's scalp for evidence of lice. The nurse should pay particular attention to which part of the scalp? a. Temporal area b. Top of the head c. Behind the ears d. Middle area

Answer = c You answered: b Rationale: Adult lice usually bite the scalp behind the ears and along the back of the neck. Because such lice are tiny (1 to 2 mm) with grayish white bodies, they are hard to see. However, their bites result in visible pustular lesions. Although lice may bite any part of the scalp, bites are less common on the temporal area, top of the head, and middle area.

The chart entry for a client with chronic pharyngitis reads: Progress notes 10/15/16 0945 A 37-year-old female, who works in a textile factory, has returned to the clinic with symptoms of a persistent sore throat which makes swallowing uncomfortable and congestion that causes frequent episodes of coughing to expel mucous. Based on this chart entry, how should the nurse teach this client how to manage these symptoms? a. Recommend decreasing exposure to environmental irritants by wearing a mask b. Instruct this client to ask the primary care provider for a complete cardiac evaluation c. Suggest that the client increase the frequency of performing oral hygiene d. Address the need to monitor for infection by taking a daily temperature reading

You Selected: Address the need to monitor for infection by taking a daily temperature reading Correct response: Recommend decreasing exposure to environmental irritants by wearing a mask Rationale: Clients with chronic pharyngitis are often exposed to environmental irritants. Minimizing exposure, by wearing a disposable face mask, is a helpful intervention. A cardiac evaluation is not warranted for chronic pharyngitis. Good oral hygiene will decrease the symptoms, but will not address the underlying cause. Daily monitoring of this client's temperature is not warranted.

A nurse is providing discharge teaching for a client who is HIV positive. Which of the following instructions should the nurse include in the teaching? a. clean bathroom surfaces with full strength bleach b. discard beverages that have been unrefrigerated for 1 hr c. wash laundry soiled with a body fluid in warm water d. work in the garden for exercise

Answer = b Bacteria can grow in open, unrefrigerated beverages, which places the client at risk for infection. With laundry HOT water should be used, not warm.

A nurse in the emergency department is assessing a newly admitted client. Which of the following findings places the client at increased risk for contracting hepatitis B? a. residing in an institutional setting b. engaging in unprotected sex c. working with hazardous chemical waste materials d. traveling to a foreign country

Answer = b unprotected sex is a risk for hepatitis B.

A nurse is providing care for four clients. Which of the following is at greatest risk for pneumonia? a. school-age child who has a hx of asthma b. a young adult client living a dorm c. a middle adult client using an incentive spirometer following surgery d. an older adult client who has dysphagia

Answer = d An older adult client who has dysphagia is at greatest risk for pneumonia due to the increased risk for aspiration when eating. asthma child is at risk, however the dysphagia client is higher risk

A client who is diagnosed with AIDS and has developed Kaposi's sarcoma tells the nurse, "I have lots of thoughts about dying. Do you think I am just being morbid?" Which response by the nurse is most appropriate? a. "Thinking about dying will not improve the course of AIDS." b. "Although your diagnosis is serious, there are more treatments available now." c. "Try to focus on the good things in life because stress impairs the immune system." d. "Tell me what kind of thoughts you have about dying."

Answer = D Rationale: More assessment of the client's psychosocial status is needed before taking any other action.

The nurse judges that the mother has understood the teaching about care of an infant with colic when the nurse observes the mother doing which action? a. holding the infant prone while feeding b. holding the infant in her lap to burp c. placing the infant prone after the feeding d. burping the infant during and after the feeding

Answer = d Rationale: Infants with colic should be burped frequently during and after the feeding. Much of the discomfort of colic appears to be associated with the presence of air in the stomach and the intestines. Frequent burping helps to relieve the air. Infants with colic should be held fairly upright while being fed, to help air rise. The preferred position for burping the infant with colic is to hold the infant at the mother's shoulder so that the infant's abdomen lies on the shoulder. This position causes more pressure to be exerted on the infant's abdomen, leading to a more forceful burp. The child should be placed in an infant seat after feedings.

A family member of a resident in a long-term care facility reports to the nurse that her mother's diamond ring is missing. Another resident reported a day earlier that a twenty-dollar bill was missing from his/her night table. What should the nurse do in this situation? a. Report the incidents to the facility's lawyer. b. Remind the residents and family members not to leave valuables unattended. c. Pass the information on to the doctor and the next shift staff. d. Notify the supervisor and call the police

Answer = d Rationale: The supervisor should be made aware of the situation and the police should be called to investigate the potential theft. The other answers do not advocate for the clients and their families. It is the responsibility of the nurse to take action because the nurse was the person to receive the information. This is known as due diligence.

The note on the chart of a client with post traumatic stress disorder reads: <handwriting> During the group therapy session, the client spoke about facts related to the train accident, but did not express his feelings related to the trauma experienced. Based on this chart entry, what is the best strategy for the nurse to use to prompt further discussion during the next group therapy session? a. Encourage the client to explore feelings of survivor guilt and self-blame b. Address the client's struggle to develop coping skills and sources of support c. Determine if a history of child abuse prevents discussion of concerns and life events d. Discuss if the family or other people hold him responsible for what happened

You Selected: Address the client's struggle to develop coping skills and sources of support Correct response: Encourage the client to explore feelings of survivor guilt and self-blame Rationale: The client needs to recognize that his survival may have been due to chance and not due to a personal action or inaction. Developing coping skills and sources of support do not assist this client with his feelings. Determining if the client has a history of being abused as a child is best asked in a one-on-one interaction, or done in an assessment session prior to a group session. Prior to discussing the involvement and feelings of other people, the client needs to express his feelings about the trauma.

A male with an antisocial personality disorder is court-mandated to receive counseling after being detained by law enforcement officials. The chart entry reads: The client came to the group therapy session and was verbally aggressive to other clients. The group leader set limits on his behavior, reinforced the group rules and guidelines. At two different times the client made excuses for his behavior, stating, "I really don't have to be here," and minimized the comments of other group members. Which priority action, by the nurse group leader, must be initiated? a. Obtain an order for medication to be given every morning b. Role-play social skills with client before the next group meeting c. Arrange for a coach to be present with the client at each meeting d. Formulate an individual contract for appropriate behavior during the group

You Selected: Arrange for a coach to be present with the client at each meeting Correct response: Formulate an individual contract for appropriate behavior during the group Rationale: The documented client behavior indicates a need for limits during group. Formulating a contract that addresses the appropriate behavior, and the consequences for violating the contract, is the priority strategy. Medication for a client with antisocial personality disorder is only used to manage the symptoms of depression or disordered thinking. The first action to be taken is setting limits on inappropriate behavior, not role playing skills and arranging for a coach.

A nurse is providing teaching to a client who has rheumatoid arthritis and reports persistent pain. Which of the following responses should the nurse make? a. take a cool bath in the evening b. exercise every other day c. use a pillow to support your joints while in bed d. ask a friend or family member to help with household chores

Answer = d The nurse should instruct the client to allow others to assist with household chores to reduce the risk for joint injury and to give the client the opportunity to rest. The nurse should instruct the client to use on only ONE small pillow, placed behind the head, while in bed to prevent flexion contracture's.

A nurse is reviewing the laboratory report for a client who has Hodgkin's lymphoma. Which of the following findings should the nurse expect? a. overgrowth of B-lymphocyte plasma cells b. Reed-Sternberg cells c. Epstein-Barr virus d. overproduction of blast phase cells

Answer = b Reed-Sternberg cells are cancer cells specific to a client who has Hodgkin's lymphoma. The nurse should expect a client who has multiple myeloma to have an overgrowth of B-lymphocyte plasma cells.

The client with acute lymphocytic leukemia (ALL) is at risk for infection. What action should the nurse take? a. Place the client in a private room. b. Have the client wear a mask. c. Have staff wear gowns and gloves. d. Restrict visitors

Answer = a You answered = b Rationale: Clients with ALL are at risk for infection due to granulocytopenia. The nurse should place the client in a private room. Strict hand-washing procedures should be enforced and will be the most effective way to prevent infection. It is not necessary to have the client wear a mask. The client is not contagious, and the staff does not need to wear gloves. The client can have visitors; however, they should be screened for infection and use hand-washing procedures. ALL: Involves malignant proliferation of white blood cell (WBC) precursors, or blasts, in bone marrow or lymph tissue (T- and B-cell lymphocytes)

Propranolol is used in the mental health setting to: a. treat antipsychotic-induced akathisia and anxiety. b. stabilize mood in the manic phase of bipolar illness. c. alleveiate delusions for clients suffering from schizophrenia. d. reduce ritualistic behavior in clients with obsessive-compulsive disorder (OCD)

Answer = a You answered: b Rationale: Propranolol, a potent beta-adrenergic blocker, produces a sedating effect; therefore, it's used to treat antipsychotic-induced akathisia and anxiety. Lithium is used to stabilize clients with bipolar disorder. Antipsychotics are used to treat delusions. Some antidepressants have been effective in treating OCD.

A nurse is caring for a client who has an elevated prostate-specific antigen level. The nurse should anticipate that the client will undergo which of the following diagnostic tests? a. palpation of testes b. HCG level c. Digital rectal examination d. pelvic ultrasound

Answer = c a digital rectal exam is used to determine the size and consistency of the prostate, assisting with the differentiation between benign prostatic hypertrophy and prostate cancer palpation of the testes is used to screen for testicular cancer, rather than prostate cancer.