NCLEX REVIEW

The nurse cares for the client receiving pain medication via a patient controlled analgesia (PCA) pump. The syringe contains hydromorphone 6 mg in 30 mL. The client is prescribed hydromorphone 0.2 mg/hour IV per the PCA pump. How many milliliters per hour does the client receive?

1 Set the answer up as a ratio proportion. The answer is being calculated from the concentration of hydromorphone available in order to figure out the hourly rate to be set on the pump. You will have a drop-down calculator on the computer to use while taking the NCLEX-RN examination.

A client is admitted to the unit for treatment of acute glomerulonephritis. The nurse teaches the client about the disease and the treatment required. The nurse determines that teaching is successful if the client makes which statement? 1."Who would have thought that a sore throat 2 weeks ago would cause this!" 2."I may have acquired the glomerulonephritis from unprotected sex decades ago." 3."I'm glad that I don't have to restrict my activities." 4."My roommate is going to bring me a double cheeseburger with bacon."

1. Acute glomerulonephritis is usually caused by beta-hemolytic streptococcal infection; signs and symptoms include fever, chills, azotemia, hematuria, proteinuria, oliguria, weakness, headache, malaise, flank pain, weight gain, edema, hypertension, and auscultation of rales.

The nurse at the community mental health center cares for a client diagnosed with depression. The health care provider prescribes amitriptyline. One week after starting amitriptyline, the client reports to the nurse that there has been no improvement. Which statement, if made by the nurse, is most accurate? 1."It takes at least four weeks for the medication to work." 2."You may need to take more medication." 3."Your depression is probably worsening." 4."This medication probably is not the right one for you."

1. Amitriptyline: tricyclic antidepressant; take full dose at bedtime; delay of 4-8 weeks before effects seen; adverse effects: drowsiness, dizziness, orthostatic hypotension, blurred vision, dry mouth, urinary retention, constipation, and sweating; nursing responsibilities: monitor for risk of suicide.

The client comes to the emergency department reporting chest pain that occurs nightly while the client is at rest. The nurse instructs the client about how to decrease attacks of angina. Which client statement indicates that teaching is successful? 1."I am going to sign up for meditation classes at the community center." 2."I am going to take a brisk walk after dinner every night." 3."I am going to take a part-time job at a day care center." 4."I am going to take over-the-counter diet pills to lose weight."

1. Angina is chest pain due to ischemia that does not cause permanent damage; symptoms include pain that may radiate down left arm; associated with stress, exertion, or anxiety; nitroglycerin commonly prescribed to treat angina; percutaneous transluminal coronary angioplasty (PTCA), coronary artery bypass graft surgery (CABG) may be performed.

The nurse observes the behavior of a client seen in the emergency department. Which signs indicate that the client is experiencing a panic level of anxiety? 1.Unproductive relief behaviors, distorted perception, behavioral disorganization. 2.Behavioral disorganization, inability to negotiate simple life demands, increased ability to concentrate. 3.Improved self-control, impaired cognitive function, distorted perception. 4.Increased pulse, increased muscle tension, rate of speech and volume adequate for communication.

1. Anxiety is feeling of dread or fear in the absence of external threat, or disproportionate to the nature of the threat. In panic level anxiety, the client may not be in control, and the client lacks the ability to adequately function. Assess level of anxiety, decrease environmental stimuli, use unhurried approach, and stay with the client.

The nurse cares for a client who is being treated for heart failure (HF) and atrial fibrillation. The provider orders digoxin 0.25 mg PO daily. Prior to administering the medication, the nurse assesses that the client's heart rate is 98/minute and irregular. Which action does the nurse take first? 1.Administer the digoxin and document the rhythm. 2.Hold the digoxin until the client's pulse slows down. 3.Hold the digoxin until the client's pulse increases. 4.Call the health care provider to clarify the digoxin prescription.

1. Atrial fibrillation: rapid, irregular depolarization of atria. Results in irregular and rapid pulse (if uncontrolled). Treatment: digoxin (strengthens the myocardial contraction and slows the rate of conduction), calcium channel blockers (e.g., diltiazem), beta-blockers (e.g., metoprolol), anticoagulant therapy (warfarin is medication of choice for chronic atrial fibrillation), cardioversion.

The nurse cares for an unresponsive client admitted with a suspected brain injury from a motor vehicle accident. It is most important for the nurse to intervene if a staff member performs which assessment of pupillary activity? 1.Doll's eye oculocephalic reflex. 2.Direct light response. 3.Conjugate gaze. 4.Corneal reflex.

1. Brain injuries include concussion, contusion, laceration, and hematoma; evaluate level of consciousness, perform neurological assessment, elevate head of bed 30 degrees to decrease intracranial pressure, closely monitor intake and output.

The nurse cares for a toddler who is admitted to the hospital with a diagnosis of congenital hip dislocation. The toddler is placed in Bryant's traction. The nurse recognizes that the toddler should be maintained in which position? 1.Buttocks slightly elevated off the bed. 2.Buttocks flat on the bed. 3.Knee flexion 140 degrees. 4.Hips fully extended.

1. Bryant's traction: type of running traction primarily used to reduce congenital hip dislocations; adhesive strips are applied to both legs and secured with elastic bandages wrapped from foot to groin; both legs are suspended by weights and pulleys.

The nurse performs discharge teaching for the client diagnosed with chronic kidney disease (CKD). The nurse recognizes that teaching has been successful if the client makes which statement? 1."I will weigh myself daily, before I eat breakfast." 2."I will restrict my sodium and protein intake." 3."I will take my anti-vomiting pills right after I eat." 4."I will avoid between-meal snacks."

1. CKD is the slow progressive loss of renal function; gain of 2 pounds or more in 24 hours indicates fluid retention; antiemetics can be taken 30 to 60 minutes before meals; to increase nutritional balance, potassium may not be restricted (if kidneys are able to excrete potassium) and between-meal snacks are encouraged. However, a high-protein diet is contraindicated for the client diagnosed with CKD. Furosemide, a loop diuretic, is often prescribed to rid the body of extra fluid.

The nurse cares for a client diagnosed with chronic obstructive pulmonary disease (COPD). The client constantly rings the call bell and rattles the bed rails. Which action by the nurse is most appropriate? 1.Check the client's oxygen saturation. 2.Send an unlicensed assistive personnel (UAP) to sit with the client. 3.Seat the client in a chair next to the nurses' station. 4.Request the client's family come to the hospital to sit with the client.

1. COPD is a group of conditions associated with obstruction of air flow entering or leaving the lungs; signs and symptoms include change in skin color, weakness, weight loss, dyspnea, cough, abnormal ABGs, and use of accessory muscles to breathe.

The nurse manager reviews infection prevention practices with the staff caring for clients with central venous catheters (CVCs). Which statement by a staff member indicates the best understanding of the precaution required to prevent infections for these clients? 1."If the dressing is wet or soiled, I will change it immediately." 2."I will apply an antibiotic ointment to the insertion site during dressing changes." 3."I will assess for swelling in the shoulder, neck, chest, and arm at least twice per shift." 4."I will flush the catheter with normal saline at regular intervals."

1. CVC used to deliver parenteral nutrition; complications of insertion of CVC include pneumothorax and infection; perform daily review of CVC necessity.

The client is reporting persistent lower back pain. The nurse places the client in semi-Fowler's position with the hips and knees moderately flexed. The nurse recognizes the primary rationale for this position is to accomplish which of these? 1.Relieve tension at the lumbo-sacral region. 2.Maintain proper alignment of the vertebral joints. 3.Improve breathing for better oxygenation of the back. 4.Increase blood flow to the spinal cord.

1. Causes of low back pain: herniated nucleus pulposus, muscle sprain. Signs and symptoms: knifelike pain, sensory changes. Diagnosis: CT scan or MRI. Treatment: muscle relaxants, nonsteroidal anti-inflammatory drugs (NSAIDs), analgesics, heat, traction (separates vertebrae to relieve pressure on nerve), transcutaneous electrical nerve simulation (TENS), surgery.

The home care nurse visits a client diagnosed with non-Hodgkin's lymphoma who is receiving chemotherapy. After the second round of chemotherapy, the client reports a sore mouth and loss of taste. Which action does the nurse take first? 1.Examine the client's oral cavity and mouth. 2.Instruct the client to use a saline rinse. 3.Obtain a diet history from the client. 4.Instruct the client to avoid spicy foods.

1. Chemotherapy causes stomatitis; assess frequently; good oral hygiene; use soft-bristled toothbrush; avoid dental floss, water pressure gum cleaners, and mouthwashes containing alcohol or glycerin.

A client with peripheral vascular disease is returned to the room after a right below-the-knee amputation (BKA). During the first 24 hours postoperatively, how should the nurse position the client's residual limb? 1.Elevate the stump by raising the foot of the bed on blocks. 2.Dangle the stump over the side of the bed. 3.Abduct the stump by placing pillows between the legs. 4.Place the stump in correct anatomical alignment.

1. Common complication after amputation is hip flexion contracture, resulting from elevation of stump on pillows.

A client is admitted to the hospital with a ruptured ectopic pregnancy. A laparotomy is scheduled. The nurse recognizes it is most important to include which goal on the client's preoperative care plan? 1.Fluid replacement. 2.Pain relief. 3.Emotional support. 4.Respiratory therapy.

1. Dehydration can become a serious danger in a preoperative client, especially if bleeding occurs. Fluid replacement prevents that complication. Pain relief can be well handled in the postoperative period. Emotional support, while important, is a lower priority than ensuring that the client's life is not in danger.

The client is admitted for a colon resection. Two days postoperatively, the client becomes confused and agitated. It is determined that the client is delirious. Which statement best describes delirium? 1.Delirium is characterized by acute onset with symptoms lasting for hours or weeks. 2.Delirium is characterized by gradual onset with symptoms lasting for months or years. 3.Delirium is characterized by either acute or gradual onset with symptoms lasting from several months to several years. 4.Delirium is characterized by either acute or gradual onset with symptoms lasting for several days.

1. Delirium: onset rapid, often at night; manifestations fluctuate over 24-hour period: awareness, orientation, recent memory, sleep/wake cycle disturbed; associated with illness or medications. Dementia: onset insidious, develops over years, not associated with physical illness. Alertness not impaired. Nursing responsibilities: ensure safety, meet client's physical needs.

The client with a history of heart failure (HF) is admitted with flu-like symptoms. The nurse learns that the client has been taking digoxin 0.125 mg PO daily for 3 years. Last month, the health care provider (HCP) changed the prescription for digoxin to 0.25 mg PO daily and prescribed furosemide 40 mg daily. The nurse expects the HCP to prescribe which laboratory tests? 1.Serum electrolytes and digoxin level. 2.Complete blood count and differential. 3.Cardiac enzymes and an arterial blood gas. 4.Blood cultures and urinalysis.

1. Digoxin: cardiac glycoside works by strengthening myocardial contraction and slowing conduction through the AV node. Furosemide: acts at proximal and distal tubules and ascending loop of Henle to inhibit reabsorption of sodium, chloride; adverse effects: agranulocytosis (decreased WBC), hypokalemia. Heart failure (HF): failure of heart to adequately pump blood. Signs and symptoms: dyspnea, weight gain, edema, and crackles. Treatment: cardiac glycosides (digoxin), diuretics, and sodium-restricted diet. Nursing responsibilities: promote rest, give oxygen as prescribed, and teach about medications/diet.

The nurse cares for a client at 37 weeks gestation. The nurse is most concerned by which finding? 1.The client reports right quadrant pain. 2.The client's BP is 150/95 mm Hg. 3.The client has 1+ proteinuria. 4.The client has 3+ pitting edema of the ankles.

1. Eclampsia: seizures in a pregnant woman not related to a pre-existing brain condition. Interventions should occur before progression to eclampsia. Preeclampsia causes hypertension, proteinuria, and edema; symptoms of severe preeclampsia include BP 160/110 mm Hg (x 2 readings, at least 4 hours apart, while client is on bed rest), greater than 3+ proteinuria in random sample, headache, epigastric pain; treatment for severe preeclampsia includes bed rest, monitoring of vital signs and fetal heart tones, intake and output monitoring, seizure precautions, administration of magnesium sulfate (prevents seizures) and hydralazine (for BP control).

The nurse cares for a child diagnosed with epilepsy. Which of these items does the nurse have available at the client's bedside? 1.Suction machine and oxygen setup. 2.Urinary catheterization set. 3.Intermittent positive pressure breathing machine (IPPB). 4.Wrist restraints and mittens.

1. Epilepsy: seizure disorder characterized by abnormal, recurring, excessive, and self-terminating electrical disturbances; diagnosis made after two or more seizures; strong genetic component.

The nurse in the well child clinic receives a call from a parent stating the parent's child attended a birthday party the day before with a child who had a facial rash and erythema infectiosum (fifth disease). The parent is concerned that the child may develop the disease. Which of these responses by the nurse is best? 1."Your child will not develop the disease." 2."Look for a rash in 4 to 14 days." 3."Bring your child into the clinic this afternoon." 4."Does your child have a facial rash now?"

1. Erythema infectiosum (fifth disease) is a virus caused by human parvovirus B19; symptoms include erythema on face, lacy red rash on trunk and limbs. May have cold-like symptoms prior to onset of rash; treatment includes antipyretics, analgesics, and anti-inflammatory medications.

The nurse plans care for the client diagnosed with Graves' disease. The nurse includes which of these in the client's plan of care? 1.Frequent rest periods. 2.Two meals per day. 3.Extra clothing for warmth. 4.Caffeinated beverages.

1. Graves' disease, an autoimmune disorder, causes hyperthyroidism; assessment includes hyperactivity, sensitivity to heat, rest and sleep disturbances, increased perception of stimuli, weight loss, and tachycardia.

A male client is admitted for evaluation of hematuria. An intravenous pyelogram (IVP) is ordered. The client asks the nurse to explain what will happen to him during the IVP. Which explanation by the nurse is most accurate? 1."An intravenous line will be inserted, dye injected into it, and then x-rays will be taken of your kidneys, ureters, and bladder." 2."A scope will be inserted into your penis and up to the bladder so that the inside of your bladder can be visualized." 3."An indwelling urinary catheter will be inserted, dye will be injected into it, and then x-rays will be taken of your bladder and ureters." 4."A small incision is made in the kidney, dye injected into it, and then x-rays will be taken of your kidneys, ureters, and bladder."

1. Hematuria: blood in the urine. IVP: radiographic exam of the kidney, ureter, bladder. Prep: check for sensitivity to contrast medium, iodine, shellfish; prep bowel (laxatives, enemas); usually NPO. Post-test: force fluids.

The nurse cares for a client being discharged after a transurethral prostatectomy (TURP). The nurse's discharge teaching plan reinforces adherence to which measure? 1.Avoiding vigorous exercise for 3 weeks. 2.Avoiding cold foods for 1 week. 3.Avoiding hot baths for 1 month. 4.Avoiding high-residue foods for 2 weeks.

1. Hemorrhage most common complication after a TURP. During first 3 weeks post-op, avoid: lifting no more than 5-10 lbs (2.27-4.54 kg), mowing lawn, riding in car more than 25 minutes, climbing stairs quickly, sexual intercourse, straining to have a bowel movement, and engaging in sports.

The nurse conducts the admission interview of a client scheduled for surgical repair of an inguinal hernia. Which client statement most concerns the nurse? 1."I am allergic to bananas." 2."I am allergic to shellfish." 3."I am allergic to peanuts." 4."I am allergic to milk."

1. Indication of latex allergy includes urticaria, rash, wheezing, rhinitis, conjunctivitis, bronchospasm, and anaphylactic shock; instruct client to avoid latex products.

The nurse cares for a client diagnosed with vaginal cancer who is being treated with an internal radium implant. The nurse determines that which action is appropriate? 1.The LPN/LVN wears a dosimeter film badge when in the client's room. 2.The client is assigned to a roommate with radiation safety precautions posted on the door. 3.The client's 10-year-old grandchild visits for 20 minutes. 4.The unlicensed assistive personnel (UAP) stands next to the bed when talking with the client.

1. Internal radiation is a sealed source placed in a body cavity or tumor. Place client in private room; save all dressings and bed linens until source is removed; then, discard dressing and linens as usual; rotate staff caring for client.

The nurse teaches a client who is lactose intolerant about alternative ways to obtain adequate amounts of calcium in the diet. Which items, if selected by the client, indicate understanding of appropriate foods to eat? 1.Eggs and green leafy vegetables. 2.Instant breakfast mixes and skim milk. 3.Cottage cheese and yogurt. 4.Custard and mashed potatoes.

1. Lactose intolerance: inability of intestine to absorb milk due to deficiency in enzyme that breaks down milk sugar (lactase). Calcium: milk, cheese, yogurt, sardines and canned salmon, cereals, and dark green leafy vegetables such as spinach, kale, and mustard greens. Yogurt and hard cheeses may be tolerated because of how they are processed.

The client is admitted to the hospital for evaluation of a gangrenous right foot and venous stasis ulcers of the right leg. A right below-the-knee amputation is scheduled. The client asks, "Why can't they just amputate my foot instead of my leg?" Which response by the nurse is best? 1."It is necessary to have good circulation in your leg for healing to occur." 2."It will be easier to fit you with a prosthesis." 3."This is the best method to control the infection." 4."This will prevent further circulatory problems in your leg."

1. Most amputations of lower extremities are a result of peripheral vascular disease resulting from diabetes mellitus or cardiac disease.

The nurse cares for the client after an above-the-knee amputation. The client has a closed rigid cast dressing in place. Several days after surgery, the nurse enters the client's room and finds that the cast has come off. Which action does the nurse take first? 1.Wrap residual limb with a compression bandage. 2.Monitor the residual limb for swelling. 3.Contact the orthopedic surgeon. 4.Ask the client how the cast came off.

1. Observe for signs of oozing; elevate residual limb for first 24 hours; turn client prone (30 minutes, 3-4 times daily) to prevent flexion contractures; client ambulates early with rigid cast dressing because it functions as a socket for fitting of a prosthetic immediately post-op.

Which sequence represents the order in which the nurse performs an assessment of a client's abdomen? 1.Inspect, auscultate, percuss, and palpate. 2.Auscultate, inspect, percuss, and palpate. 3.Palpate, percuss, auscultate, and inspect. 4.Percuss, palpate, auscultate, and inspect.

1. Percussion and palpation alter the mobility of the bowel and heighten bowel sounds. Use the diaphragm of a stethoscope because sounds are high pitched. Percuss, checking for tympany (hollow sound) and dullness (high-pitched sound). To palpate, depress abdominal wall 1 cm using the pads of your fingers.

A client with a fractured right femur has traction applied through the use of a Steinmann. Balanced suspension traction is used with a Thomas splint and a Pearson attachment. The nurse explains to the client that the purpose of the pin is which of these? 1.To maintain alignment of the fracture. 2.To hold the Thomas splint in place. 3.To hold the Pearson attachment in place. 4.To immobilize the fractured femur.

1. Pin: inserted directly through skin into the bone. Nursing responsibilities: check skin for redness, odor, and drainage. Change dressing and clean with normal saline if prescribed.

An older adult client is admitted to the hospital. On admission, the client appears disheveled and is restless and confused. It is most important that the nurse obtain the answer to which of these questions? 1.Which medications is the client taking? 2.What is the medical history of the client's family? 3.What was the client's previous occupation? 4.Has the client smoked cigarettes in the past?

1. Polypharmacy, the taking of multiple medications, is common in elderly adults, accounting for the dispensing of one-third of prescribed medications. Decreases in kidney and liver functioning can allow a buildup of toxic chemicals.

The nurse teaches the client how to increase dietary potassium. The client knows bananas are high in potassium but does not like their taste. Which foods should the nurse recommend the client include in the diet? 1.Potatoes, spinach, and raisins. 2.Rhubarb, tofu, and celery. 3.Carrots, broccoli, and yogurt. 4.Onions, corn, and oatmeal.

1. Potassium helps regulate water balance in cells, protein synthesis, and heart contractility; primary sources include grains, meats, vegetables, and fruits.

The nurse has completed discharge instructions for the primigravida client at 29 weeks gestation who is hospitalized for treatment of deep vein thrombosis (DVT). Which statement, if made by the client to the nurse, indicates that teaching has been successful? 1."I will give myself heparin every day." 2."I should check my leg once a week." 3."I will massage my leg nightly." 4."I can take Pepto-Bismol for diarrhea."

1. Pregnancy, immobility, obesity, and major surgery are risk factors for DVT. Heparin sodium is anticoagulant that deactivates thrombin, preventing conversion of fibrinogen to fibrin; adverse effects include hematuria and bleeding gums; monitor partial thromboplastin time (PTT).

The nurse cares for the 4-year-old client with a fractured pelvis due to an automobile accident. The nurse prepares the child for the application of a hip spica cast. Which is most important for the nurse to include in the child's plan of care? 1.Obtain a doll with a hip spica cast in place. 2.Tell the child that the cast will feel cold. 3.Reassure the child that the cast application is painless. 4.Introduce the child to another child who has a hip spica cast.

1. Preschool children (3-4 years of age) fear injury, mutilation, and punishment; allow child to play with models of equipment; encourage expression of feelings; spica cast immobilizes the hip and knee.

The client receives morphine sulfate postoperatively for pain. Since the client is receiving morphine sulfate, which of these medications is most important for the nurse to have available? 1.Naloxone. 2.Disulfiram. 3.Methadone. 4.Epinephrine.

1. Remember that an overdose of morphine sulfate causes respiratory depression; need availability of the antidote in case of overdose.

The nurse teaches a group of parents of toddlers how to prevent accidental poisoning. Which of these suggestions does the nurse give regarding medications? 1.Lock all medications in a cabinet. 2.Childproof all the caps to medication bottles. 3.Store medications on the highest shelf in a cupboard. 4.Place medications in different containers.

1. Remember that no bottle's cap can be made totally childproof; only a locked cabinet can provide protection. Even the highest shelf is no barrier for some climbing toddlers. Changing the containers will only make life difficult for the parents; it will not prevent accidental poisoning.

The nurse cares for the client 1 hour after a percutaneous liver biopsy. The nurse is most concerned if which of these is observed? 1.The client coughs frequently after deep breathing. 2.The client lies on the right side with a pillow under the costal margin. 3.The LPN/LVN obtains the client's vital signs every 15 minutes. 4.The client reports mild pain radiating to the right shoulder.

1. Sampling of hepatic tissue by needle aspiration; needle inserted between 6th and 7th or 8th and 9th intercostal spaced on right side of abdomen; ensure consent form signed; preparation for procedure includes blood testing to assess blood clotting (IM vitamin K may be indicated), NPO 6 hours before exam (generally), instruct client to hold breath after expiration when needle is inserted; post-procedure nursing care includes position on right side for 2 hours, maintain bed rest in flat position for 12-14 hours, obtain frequent vital signs to monitor for hemorrhage; discourage lifting more than 15 to 20 pounds for 1 week.

The nurse evaluates the progress of a client diagnosed with depression. The nurse considers which statement by the client as an indication of improvement? 1."I slept well last night." 2."I can't seem to stop eating." 3."I feel tired." 4."I am feeling sad."

1. Signs and symptoms: unkempt appearance, lack of energy, change in sleep pattern, weight gain or loss, decreased concentration, and slowed motor activity.

The nurse manager evaluates the care given by staff on a medical-surgical unit. The nurse manager should intervene if which action is observed? 1.An unlicensed assistive personnel (UAP) disposes of a client's used tissue in the bedside container before opening the roommate's milk carton. 2.A student nurse washes hands for 20 seconds after removing gloves following insertion of an indwelling urinary catheter. 3.A nurse puts on a gown, gloves, mask, and goggles prior to inserting a nasogastric (NG) tube. 4.An LPN/LVN visits with a client diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) wound infection while the client eats lunch.

1. Standard precautions are used to prevent hospital-acquired infections; perform hand hygiene as soon as gloves are removed, between contact with clients, between procedures or tasks with same client, when touching blood, body fluids, or contaminated surfaces; masks, goggles, and gown if in danger of splashes.

The nurse cares for a client who is brought to the hospital by the spouse. The spouse states that since retirement, the client has been listless and roams around the house complaining of nothing to do. The client states, "Without a job, I have no purpose in life." The spouse adds that the client recently lost 10 pounds and sleeps for only 2 to 3 hours each night. To prioritize the client's nursing care, which should the nurse assess first? 1.Suicidal ideation. 2.Client's insight about problems. 3.Nutritional deficiencies. 4.Motivation to solve own personal problems.

1. Symptoms of depression: regressive behavior, obsessive thoughts, unkempt appearance, insomnia, withdrawn behavior. Nursing responsibilities: assess for suicidal ideations, report behavioral changes, meet physical needs, structure simple routines, use touch judiciously, encourage expression of feelings. Treatment: antidepressants; group, individual, and family therapy.

At the advice of the health care provider, a client diagnosed with hypertension attends smoking cessation classes. One month later when the client visits the clinic, the nurse notes a package of cigarettes in the client's pocket. Which statement, if made by the nurse, is most appropriate? 1."I see that you have cigarettes in your pocket." 2."Please give me the cigarettes." 3."I will have to report this to the health care provider." 4."You need to enroll in another smoking cessation class."

1. Therapeutic communication is listening to and understanding the client while promoting clarification and insight; important for nurse to understand the client's verbal and nonverbal messages, listen for client's perception of the problem, and facilitate verbalization.

The nurse cares for a client reporting fatigue and weight loss. Physical examination reveals pallor and multiple bruises on the arms and legs. The results of the client's tests reveal acute lymphocytic leukemia and thrombocytopenia. Which nursing diagnosis most accurately reflects the client's condition? 1.Potential for injury. 2.Self-care deficit. 3.Potential for self-harm. 4.Alteration in comfort.

1. Thrombocytopenia: decreased platelet count increases the client's risk for injury, normal count: 150,000-450,000 per mm3 (150-450 × 109/L). Leukemia: group of malignant disorders involving overproduction of immature leukocytes in bone marrow; this shuts down normal bone marrow production of erythrocytes, platelets, normal leukocytes; causes anemia, leukopenia, and thrombocytopenia leading to infection and hemorrhage. Symptoms: pallor of nail beds and conjunctiva, petechiae (small hemorrhagic spots on skin), tachycardia, dyspnea, weight loss, fatigue. Treatment: chemotherapy, antibiotics (to treat bacterial infections), blood transfusions, bone marrow transplantation. Nursing responsibilities: private room, no raw fruits or vegetables, small frequent meals, oxygen, good skin care.

The nurse cares for clients in the orthopedic clinic. The nurse is most concerned if which of these is observed? 1.A client who is 5'8" tall places the crutches about 2" to the side of the feet when ambulating with them. 2.A school-aged child who is 4'8" tall flexes the elbows about 20 degrees when ambulating with crutches. 3.A client who is 5'10" tall advances the crutches first when walking down the stairs. 4.A client who is 5'6" tall uses a 4-point gait when ambulating with crutches.

1. To determine crutch height, measure two fingers below axilla; support weight on hand pieces, not on axilla; crutches should be kept 6 inches in front of and to the side of each foot (provides wider base of support and improves balance).

The nurse on the surgical unit is assigned to care for two clients in traction. The nurse recognizes that when caring for clients in traction, it is most important to take which action? 1.Allow the weight to hang freely at all times. 2.Teach the client to limit body movements. 3.Remove the weights if the client reports discomfort. 4.Give the client pain medication regularly.

1. Traction reduces fractures, alleviates pain and muscle spasms, prevents or corrects deformities, and promotes healing; maintain straight alignment of ropes and pulleys, ensure that weights hang freely, frequently inspect skin for areas of breakdown, maintain position for countertraction.

The nurse plans care for a client admitted for fever, vomiting, and diarrhea. The nurse writes this nursing diagnosis on the client's care plan: "Fluid volume deficit." Which of these changes in laboratory values best demonstrates improvement in the client's condition? 1.Decreased specific gravity of urine, decreased hematocrit. 2.Increased specific gravity of urine, increased hematocrit. 3.Decreased specific gravity of urine, increased hematocrit. 4.Increased specific gravity of urine, decreased hematocrit.

1. Urine specific gravity depends on hydration; normal: 1.010-1.030; will increase if client is dehydrated. Hematocrit measures % volume of RBCs in whole blood; normal: men 42-52% (0.42-0.52), women 35-47% (0.35-0.47); increases in severe dehydration.

The nurse cares for a client who is prescribed warfarin sodium. Which of these is the mechanism of action of warfarin sodium? 1.It inhibits prothrombin synthesis. 2.It prevents conversion of fibrinogen to fibrin. 3.It inactivates thrombin. 4.It inhibits platelet aggregation.

1. Warfarin sodium: long-acting anticoagulant that inhibits vitamin K-dependent clotting factors. Adverse effects: excessive dosage may cause hemorrhage, rash, and fever. Prothrombin time (PT) or international normalized ratio (INR) used to control dosage. Therapeutic range for PT is 1.5-2 times normal level; goal INR typically 2-3 for most clients. Antidote vitamin K (phytonadione). May eat consistent amounts of green leafy vegetables containing vitamin K; fluctuating the amount in diet will cause fluctuation of PT/INR.

After assessing a 3-year-old, the nurse instructs the child's parent about safety precautions. The nurse determines teaching is effective if the parent makes which statement? (Select all that apply.) 1."My child wears a helmet while riding in the bike seat on the back of my bike." 2."Our cleaning products at home are in a closed cabinet below the kitchen sink." 3."Our medications are kept in childproof containers in a locked cabinet." 4."My child sits in a forward-facing seat with a harness while riding in the car." 5."Since we call vitamins 'candy,' our child eagerly takes them each day." 6."The telephone number of local poison control is posted on our refrigerator."

1. 3. 4. 6. Unintentional injury is the leading cause of death among children aged 1-4 years, accounting for about one-third of their deaths.

A client diagnosed with acute glomerulonephritis reports dark urine, fever, and flank pain. Which finding does the nurse expect? 1.Polyuria. 2.Oliguria. 3.Polydipsia. 4.Enuresis.

2. Acute glomerulonephritis is usually caused by beta-hemolytic streptococcal infection; signs and symptoms include fever, chills, azotemia, hematuria, proteinuria, oliguria, weakness, headache, malaise, flank pain, weight gain, edema, hypertension, and auscultation of rales.

The nurse cares for clients in the labor and delivery unit. The nurse notes that a client's membranes have ruptured and the amniotic fluid is meconium-stained. The nurse determines that there is no prolapsed cord. Which of these actions does the nurse take next? 1.Contact the health care provider. 2.Assess fetal heart tones. 3.Start an intravenous line. 4.Obtain the client's pulse and BP.

2. Amniotic fluid is straw-colored and pale; meconium-stained fluid (greenish-brown) indicates fetus has probably experienced recent hypoxic episode; however, meconium-stained fluid may be normal finding in breech presentation; ensure appropriate supplies and equipment are gathered for possible neonatal resuscitation (endotracheal intubation may be necessary).

The nurse cares for clients in the psychiatric unit. When administering antipsychotic medication, the nurse observes for tardive dyskinesia. Which of these is characteristic of tardive dyskinesia? 1.Masklike face and shuffling gait. 2.Involuntary grimacing and protrusion of the tongue. 3.Motor restlessness and pacing. 4.Severe muscle contractions of the face.

2. Antipsychotics are major tranquilizers used to treat psychotic symptoms; examples are chlorpromazine, thioridazine, fluphenazine, haloperidol, clozapine, and risperidone.

The nurse cares for the woman who has just delivered her first child, a boy weighing 6 lb 2 oz. The Apgar scores at 1 and 5 minutes are 8 and 9. The nurse recognizes that these scores indicate which of these findings? 1.An isolette should be ready in the nursery for close observation of this infant. 2.The newborn is making an optimal transition to extrauterine life. 3.The parents will need emotional support to deal with a less than perfect infant. 4.Apgar scores correlate well with future emotional and intellectual development.

2. Apgar scores, checked at 1 and 5 min, are used to assess a newborn's initial adaptation to extrauterine life. There are five categories, each of which gets a score of 0-2: heart rate, respiratory effort, muscle tone, reflex irritability, and color. A total score between 0 and 3 indicates severe distress, a total score between 4 and 6 indicates moderate difficulty, and a total score between 7 and 10 is reassuring.

The nurse cares for a postoperative client receiving cephalexin 500 mg PO four times daily. The nurse schedules the administration of this medication at which of these times? 1.Prior to each meal. 2.6 A.M., 12 P.M., 6 P.M., 12 A.M. 3.9 A.M., 1 P.M., 5 P.M., 9 P.M. 4.After administration of an antacid.

2. Cephalexin is a first-generation cephalosporin antibiotic; adverse effects include anaphylaxis, Clostridium difficile-associated diarrhea, gastrointestinal (GI) distress, elevated liver enzymes, nephritis, rash, Stevens-Johnson syndrome; may take with or without food, avoid alcohol while taking medication; assess for penicillin allergy (up to 20% have cross-allergy).

The nurse teaches the parent of a child about readiness for toilet training. The nurse recognizes that further teaching is necessary if the parent makes which statement? 1."I can consider toilet training when my child's diaper is dry after naps." 2."I can begin toilet training when my child begins to walk." 3."I can consider toilet training when my child can pull his pants up and down." 4."I need to make sure that I have the time to spend in toilet training my child."

2. Child must be able to control anal and urethral sphincters, recognize the urge to void and defecate, and be able to communicate the need to the parents; readiness occurs around 18-24 months; practice sessions should be limited to 5-10 minutes, and a parent should stay with the child.

The nurse counsels the client in the outpatient psychiatric clinic for treatment of aquaphobia. The nurse recognizes that a phobia can best be described as which of these? 1.A form of sublimation that is adaptive to the client. 2.A persistent fear that is excessive and unrealistic. 3.A persistent uncontrolled thought precipitated by anxiety. 4.A manipulative behavior used to achieve secondary gain.

2. Client feels apprehension, anxiety, helplessness when confronted with the feared object; nursing considerations include: avoid confrontation and humiliation, do not focus on trying to stop the client from being afraid, use systematic desensitization, try relaxation techniques.

An older adult client is brought to the clinic due to poor food intake. The client is otherwise healthy and does not take any medications. The nurse determines that which meal will best meet the client's nutritional needs? 1.Grilled cheese sandwich, cookie, and tea. 2.Broiled chicken, broccoli, and skim milk. 3.Raisin toast, tapioca pudding, and apple juice. 4.Liver and onions, decaffeinated coffee, and jell-o.

2. Clients with anorexia (poor appetite) need nutrient-dense, high-calorie diet. Nutritionally well-balanced diet contains foods from six basic food groups: bread, cereal, rice, and pastas (6-11 servings); vegetable group (3-5 servings); fruit group (2-4 servings); milk, yogurt, cheese group (2-3 servings); meat, poultry, fish, dry beans, eggs, nuts group (2-3 servings); fats, oils, and sweets (use sparingly).

The nurse reviews client assignments made by the student nurse. The nurse determines that assignments are appropriate if an unlicensed assistive personnel (UAP) is assigned to which client? 1.The client who is scheduled for an MRI. 2.The unconscious client who requires mouth care. 3.The client admitted for uncontrolled seizures. 4.The client with diabetes mellitus who requires foot care.

2. Delegate standard, unchanging procedures to a UAP that do not require assessment, teaching, evaluation, or nursing judgment.

The nurse develops a care plan for a client diagnosed with dementia. The nurse recognizes that it is most important to include which of these measures in the plan? 1.Leave the television on in client's room all day. 2.Reorient the client to the surroundings as needed. 3.Provide client with newspapers and magazines. 4.Assign a staff member to stay with client while client is awake.

2. Dementia: progressive loss of cognitive function. Decline in memory, learning, attention, judgment, orientation and language skills. Most common type is Alzheimer's disease. Affects 5 million people in U.S. Usually lasts between 7 and 15 years before death.

The nurse cares for a client with depression who frequently verbalizes a negative self-image. Which nursing intervention is most appropriate for the client? 1.Help the client identify areas of weakness. 2.Help the client identify unrealistic expectations. 3.Ask the client to identify goals for the next 2 years. 4.Tell the client to stop having negative thoughts.

2. Depression may be a response to a real or imagined loss; it may result from anger and aggression toward self that results from feeling of guilt about negative or ambivalent feelings; nursing considerations include being alert for signs of self-destructive behavior, promoting eating and rest, supporting self-esteem.

The client is admitted for evaluation of a seizure disorder. An electroencephalogram (EEG) is scheduled. The client asks the nurse how an EEG is performed. Which of these explanations by the nurse is accurate? 1."Several small electrical shocks are given that feel like pinpricks." 2."Electrodes are attached to the head and the electrical activity of the brain is evaluated." 3."A radiopaque substance is injected into an artery and x-rays are taken." 4."A radioactive material is injected intravenously followed by a brain scan."

2. EEG: recording of electrical activity of brain. Electrodes attached to scalp, waveforms recorded. Activation procedures performed to evoke abnormal electrical discharges (hyperventilating, looking at bright, flashing lights). Sleep EEG may also be performed. Preparation: kept awake night before, shampoo hair. Stimulants (tea, coffee, alcohol, cola, cigarettes), antidepressants, tranquilizers, anticonvulsants withheld 24-48 hours before test. After test, seizure precautions and wash hair. Seizure: uncontrolled discharge of electrical activity from brain.

The child is brought to the emergency department by the parents, who state the child fell off a bicycle. Upon examination, the nurse notes several bruises, lacerations, and burns in various stages of healing on the child's body, and the child is hypervigilant to touch. The nurse suspects child abuse. Which of these statements most accurately reflects the nurse's responsibility in cases of suspected child abuse? 1.The nurse should not report child abuse suspicion without actual proof. 2.The nurse should report a case of suspected child abuse to proper authorities. 3.The nurse should not report suspected child abuse without discussing it with the child's parents first. 4.The nurse should confirm the child abuse with at least two other staff members before reporting it.

2. Each state has laws that specify the individuals who are "mandated reporters." Nurses are in this category. The laws also direct the nurse to the relevant place to make a report. Ongoing education by hospitals makes this responsibility clear.

A woman is brought to the emergency department reporting severe left lower quadrant pain. She tells the nurse that she performed a home pregnancy test and believes she is 8 weeks pregnant. On admission, the client's vital signs are heart rate 90/minute, BP 110/70 mm Hg, respirations 20/minute, temperature 98 °F (36.7 °C). Thirty minutes later, her vital signs are heart rate 120/minute, BP 86/50 mm Hg, respirations 26/minute, temperature 98.2 °F (36.8 °C). The nurse recognizes that the change in the client's vital signs indicates which of these findings? 1.The client's pain may have increased. 2.The client may be bleeding internally. 3.The client may be frightened. 4.The client may have an infection.

2. Ectopic pregnancy: fetus implanted outside of uterus, usually the fallopian tube.

The nurse educator presents an in-service for staff on family dynamics. The nurse educator identifies which behavior as being associated with a functional family process related to communication? 1.Acknowledgment of personal needs and role responsibilities. 2.Congruence between verbal and nonverbal messages. 3.Ability to meet emotional needs of family members. 4.Appropriate responsibility for other family members' needs.

2. Family function is how individual members relate to each other; functional communication is characterized by clear direct messages and by requesting and receiving feedback; dysfunctional communication is characterized by double-bind communication, contradictions, inconsistencies, obscure speech, and misunderstandings.

The nurse cares for the client diagnosed with genital herpes. After the client is informed of the diagnosis, the client begins crying. Which response by the nurse is best? 1."We have support groups that may help you talk about some of your feelings." 2."I see that you are upset. Share with me your thoughts." 3."While herpes is a difficult disease, at least you don't have AIDS." 4."I think the health care provider should give you more information about genital herpes.

2. Genital herpes: caused by herpes simplex virus type 2; symptoms: painful, vesicular genital lesions and difficulty voiding; nursing care: offer emotional support, sitz baths, monitor Pap smears on a regular basis; treatment: acyclovir.

The nurse cares for clients in the outpatient clinic. Which is the most important, immediate nursing goal for a client just diagnosed with normal tension glaucoma? 1.Prepare for required surgery. 2.Prevent further deterioration of the vision. 3.Assist the client to deal with the inevitable blindness. 4.Improve vision by decreasing intraocular pressure.

2. Glaucoma is an abnormal increase in intraocular pressure that can lead to visual disability and blindness; there are different types of glaucoma (normal tension glaucoma, acute angle-closure glaucoma, subacute angle-closure glaucoma, chronic angle-closure glaucoma); signs and symptoms include cloudy, blurry vision or loss of vision; artificial lights appear to have rainbows or halos around them; decreased peripheral vision; pain; headache; and nausea/vomiting; pharmacologic treatment with miotics; laser trabeculoplasty or iridotomy may be indicated.

The home care nurse assesses the client diagnosed with gout. The nurse is most concerned if the client makes which statement? 1."I drink at least 1 liter of fluids each day." 2."I am losing 3 pounds per week." 3."I limit my protein intake to 3 to 4 ounces per meal." 4."I have quit drinking beer."

2. Gout is a type of acute arthritis; results in hyperuricemia and deposition of uric acid crystals in one or more joints; causes joint pain, swelling, limitation of movement, nodules over bony prominences; treatment includes colchicine, allopurinol, febuxostat, probenecid, nonsteroidal anti-inflammatory drugs (e.g., naproxen), and corticosteroids (e.g., prednisone).

The nurse cares for a client who reports abdominal cramping and generalized weakness. When the nurse sends a stool sample to the laboratory for a guaiac test, which positive finding would be expected? 1.White blood cells. 2.Red blood cells. 3.Ova and parasites. 4.Mucoid feces.

2. Guaiac fecal occult blood test (G-FOBT): occult means hidden, often done as a screening test for colon cancer. Positive indicates need for further studies.

The nurse cares for a client receiving heparin 5000 units subcutaneously every 12 hours. The nurse should assess the client for which of these? 1.Pallor. 2.Ecchymosis. 3.Varicose veins. 4.Edema.

2. Heparin: anticoagulant that inactivates thrombin and prevents the conversion of fibrinogen to fibrin. Adverse effects: hemorrhage, thrombocytopenia, and hypersensitivity. Nursing responsibilities: check partial thromboplastin time (PTT) to monitor effect: therapeutic range is 1.5-2.5 times baseline values. Give subcutaneous into abdomen. Leave needle in place for 10 sec. Do not massage. Rotate sites. Never "piggyback" with other meds. Protamine sulfate is the antidote. Terminology: ecchymosis = bruise; petechiae = pinpoint hemorrhages; melena = black, tarry stool; epistaxis = nosebleed; hematuria = blood in urine.

The school nurse observes a group of school-aged children playing. A child begins to cry and reports being stung by a bee. Which action does the nurse take first? 1.Administer IM epinephrine. 2.Remove the stinger. 3.Apply a warm compress. 4.Wash with soap and water.

2. Hymenopteran stings (bees, wasps, hornets, yellow jackets, and fire ants) inject venom through a stinging apparatus; local reaction includes small red area, wheal, itching, and heat. Assess for systemic reaction and instruct client about how to avoid contact.

The nurse manager notes that one of the staff members is frequently absent, and this has adversely affected the quality of care given to clients on the unit. When initially counseling the staff member, which of these approaches by the nurse manager is best? 1.Inform the staff member that the next missed day will be grounds for termination. 2.Talk with the staff member and remind the staff member of the standards of the facility. 3.Give the staff member a written reminder of the standards of the facility. 4.Document the staff member's absenteeism and inform Human Resources.

2. If the staff member does not clearly understand what is expected, the staff member may feel role strain, which might cause withdrawal from the work situation.

The nurse teaches a client with an ileostomy. The nurse includes which statement in the teaching? 1."Change the appliance every day." 2."The ileostomy does not require irrigation." 3."Decrease your fluid intake." 4."Increase your intake of cabbage and spinach."

2. Ileostomy is an opening into the ileum from the abdominal wall for evacuation of feces; indications for an ileostomy include ulcerative colitis, Crohn's disease, cancer, trauma; drainage bag with pectin-based skin barrier must be worn at all times.

The nurse cares for the client who returns to the nursing unit in stable condition after having a myelogram using a water-soluble dye. The client is receiving IV fluids. The nurse recognizes that which of these is the primary purpose of the IV fluids? 1.To replace blood lost during the procedure. 2.To enhance excretion of the dye. 3.To restore cerebrospinal fluid levels. 4.To increase blood flow to the brain.

2. In a myelogram, contrast dye is injected into the spinal column. This causes the tissue under study to be visible. The spinal cord, subarachnoid space, and other surrounding structures can be visualized more clearly than in standard x-rays. After the procedure is completed, an IV infusion enhances renal excretion of the dye.

The client scheduled for a cardiac catheterization says to the nurse, "I know you were in here when the doctor had me sign the consent form for the test. I thought I understood everything, but now I'm not so sure." Which response by the nurse is best? 1."Why didn't you listen more closely when the doctor was here?" 2."You sound as if you would like to ask more questions." 3."I'll get you a pamphlet about cardiac catheterization." 4."That often happens when this procedure is explained to clients."

2. Informed consent is obtained by the individual who will perform the procedure; explanation of the procedure and expected results, anticipated risks, discomforts, potential benefits, and possible alternatives are discussed; consent can be withdrawn at any time.

The home care nurse visits the client who has been receiving lithium carbonate for 3 weeks. The client reports blurred vision and intense dizziness. Which action does the nurse take first? 1.Encourage the client to increase fluid intake. 2.Notify the client's primary health care provider. 3.Instruct the client to breathe into a paper bag. 4.Teach the client about relaxation techniques.

2. Lithium used to treat bipolar disorder; has a narrow therapeutic range; initial management goal level: 1-1.5 mEq/L (1-1.5 mmol/L); maintenance goal level (0.8-1.2 mEq/L (0.8-1.2 mmol/L); lithium levels should be monitored every 1 to 2 months or as needed (initially, twice per week until the client and lithium levels are stable); adverse effects include dizziness, headache, impaired vision, fine hand tremors, and reversible leukocytosis; nursing considerations include monitoring blood levels frequently, encouraging 2500-3000 mL fluids daily.

The nurse auscultates the abdomen of the pregnant woman at 38 weeks gestation to determine fetal heart rate. If the fetal heartbeat is located in the right lower quadrant, which of the following is most likely the presenting part? 1.Shoulder. 2.Head. 3.Feet. 4.Buttocks.

2. Lower quadrant heartbeat indicates vertex or head/cephalic presentation; fetal heartbeat is best heard over the fetus's back.

The nurse prioritizes the needs of the client who has been raped. Which of these is most important initially? 1.Emotional needs. 2.Physical needs. 3.Hygiene needs. 4.Legal needs.

2. Major effort in working with a person who has been raped concentrates on first collecting physical evidence, such as proof of injuries and possible specimens for DNA testing. Rape is an emotionally charged crime.

The nurse administers morphine sulfate as prescribed to the client reporting severe pain. Which of these indicates morphine toxicity? 1.The client has blurred vision. 2.The client's pupils are pinpoint. 3.The client's pupils are unequal. 4.The client's pupils are dilated.

2. Morphine: opioid analgesic used for severe pain. Adverse effects: sedation, hypotension, nausea and vomiting, urinary retention, and physical dependence. Nursing responsibilities: check pupils, respirations, blood pressure; take measures to avoid aspiration.

The client diagnosed with multiple myeloma is admitted to the unit after developing pneumonia from Haemophilus influenzae. When the nurse enters the client's room wearing a mask, the client says in an irritated tone of voice, "Why are you wearing that mask?" Which of these responses by the nurse is best? 1."The chest x-ray taken this morning indicates you have pneumonia." 2."What have you been told about the x-rays that were taken this morning?" 3."You have been placed on contact precautions due to your infection." 4."I am trying to protect you from the germs in the hospital."

2. Multiple myeloma is a neoplastic disease that infiltrates bone and bone marrow, causes anemia, renal lesions, and high globulin levels in blood. Pneumonia is an inflammatory process that results in edema of lung tissue and extravasation of fluid into alveoli, causing hypoxia

The nurse cares for a client receiving neomycin sulfate. The nurse recalls that this medication is given for which of these reasons? 1.To increase digestive functioning by supporting intestinal bacteria. 2.To decrease postoperative wound infection by suppressing intestinal bacteria. 3.To serve as an adjunct to systemic antibiotic therapy. 4.To prevent the occurrence of ulcerative colitis.

2. Neomycin sulfate is an aminoglycoside antibiotic used to treat infections caused by Pseudomonas and Escherichia coli (abbreviated as E. coli), used to suppress intestinal bacteria, and as adjunct treatment for hepatic coma; adverse effects include ototoxicity and nephrotoxicity; nursing considerations include checking hearing and renal function, encouraging fluids, and offering small, frequent meals.

The nurse cares for a client diagnosed with arteriosclerotic heart disease (ASHD) and angina. Upon discharge, the client is prescribed. Which statement does the nurse include in the discharge teaching? 1."Store the nitroglycerin tablets in a special clear plastic pillbox with a bright lid." 2."Take a nitroglycerin tablet before engaging in any activity that may produce chest pain." 3."Swallow the nitroglycerin tablets, but do not take with water or any other liquids." 4."You will not have to renew your prescription for nitroglycerin for the next 12 months."

2. Nitroglycerin is an antianginal that relaxes vascular smooth muscle; adverse effects include flushing, hypotension, headache, tachycardia, dizziness, and blurred vision.

The nurse is working with the family of a client diagnosed with Parkinson's disease. The nurse knows that the client has autonomic system dysfunction. Which manifestation is caused by autonomic system dysfunction? 1.Watery diarrhea. 2.Postural hypotension. 3.Depression. 4.Limb flaccidity.

2. Parkinson's disease (PD) is a progressive, degenerative neurological disorder characterized by tremors, muscle rigidity, bradykinesia, and postural instability. Three kinds of dysfunctions: motor, autonomic system, and cognitive/psychologic. Protect client from falls. Primary treatment for symptomatic clients is levodopa with carbidopa.

The nurse cares for a client diagnosed with Parkinson's disease who is receiving levodopa. The nurse recalls that levodopa works by which of the following actions? 1.It blocks central cholinergic receptors. 2.It restores dopamine levels in extrapyramidal centers. 3.It releases dopamine from neuronal storage sites. 4.It activates dopaminergic receptors in the basal ganglia.

2. Parkinson's disease: caused by impairment of dopamine-producing cells in the brain. Levodopa is converted to dopamine in the body to supply the extrapyramidal centers in the brain. Adverse effects: hemolytic anemia, aggressive behavior, dystonic movements, depression, hallucinations, dizziness, and orthostatic hypotension.

The nurse cares for the postoperative client who is scheduled to receive psyllium. When administering psyllium, the nurse uses which technique? 1.Mix with 6 ounces (180 mL) of orange juice; let stand for 1 minute, then administer it. 2.Mix with 8 ounces (240 mL) of water; administer it immediately followed by another 8 ounces (240 mL) of water. 3.Sprinkle on the client's food; add 4 ounces (120 mL) of water and mix until well blended. 4.Pour into 8 ounces (240 mL) of milk; let it stand for 1 minute, then administer it.

2. Psyllium: bulk-forming laxative used to treat constipation; on contact with water, it forms a bland, gelatinous bulk that promotes peristalsis; can be mixed with water, milk, or fruit juice.

The client in the clinic asks the nurse, "What is the difference between rheumatoid arthritis and osteoarthritis?" Which response by the nurse is best? 1."Rheumatoid arthritis is quickly progressive, and osteoarthritis has periods of remission." 2."Rheumatoid arthritis is a systemic disease, and osteoarthritis is deterioration of the synovial joints." 3."Rheumatoid arthritis is often treated surgically, and osteoarthritis is treated by medication." 4."There is very little clinical difference between rheumatoid arthritis and osteoarthritis."

2. Rheumatoid arthritis is an autoimmune, chronic systemic disease that causes inflammatory changes in joints; osteoarthritis is nonsystemic and degenerative (due to "wear and tear" of the joints); symptoms include joint pain, swelling, and limitation of movement; nursing care includes pain management, rest, activity, and exercise.

The nurse cares for clients on the surgical unit. When planning care, the nurse anticipates that which client will have the most difficulty adjusting psychologically? 1.The 13-year-old girl who has a wart removed from her nose. 2.The 26-year-old man who has palliative surgery for stage IV cancer of the pancreas. 3.The 42-year-old woman who has an elective abdominal hysterectomy. 4.The 60-year-old man who has a colostomy for severe diverticular disease.

2. Stages of body image readjustment include psychological shock, withdrawal, acknowledgment, and integration.

The nurse cares for clients being treated for opioid abuse. Which data obtained during a client history presents the highest risk for the client to develop a disease process? 1.The use of multiple drugs. 2.Intravenous administration of opioids. 3.Unsuccessful efforts to decrease drug use. 4.Legal difficulties encountered as a result of drug use.

2. Symptoms of opioid abuse include marked respiratory depression, hyperpyrexia, seizures, ventricular dysrhythmias, pinpoint pupils, and stupor leading to coma.

The nurse cares for a client after a cholecystectomy. The client has a nasogastric tube connected to suction, an IV infusion of D5W, and a T-tube and Penrose drain in place. Which finding most concerns the nurse? 1.Systolic blood pressure is 10 mm Hg lower than it was preoperatively. 2.100 mL of blood-tinged drainage from the T-tube during the first 24 hours. 3.30 mL of serosanguineous drainage in the Penrose drain during the first 24 hours. 4.Cient experiences a 1 degree temperature increase in the evening after surgery.

2. T-tube ensures drainage of bile from common bile duct until edema in area decreases; protect skin around incision from bile drainage irritation; observe for jaundice.

The nurse teaches a group of men about testicular cancer and testicular self-examination. The nurse instructs the men to perform testicular self-examination at which frequency? 1.Weekly. 2.Monthly. 3.Yearly. 4.Biannually.

2. Testicular cancer most common in men 15-34 years of age; best to do after a shower when the body is warm, relaxed, and the scrotal skin is less thick; hold scrotum in the palm of hand; roll each testicle between thumb and fingers. Symptoms of cancer: painless enlargement or heaviness in testicle.

The father of the day-old infant tells the nurse that he will be driving his wife and infant home from the hospital. It is most important for the nurse to make which of these recommendations for how the infant should be transported? 1.In a front-facing infant car seat in the back seat. 2.In a rear-facing infant car seat in the back seat. 3.In an infant seat on the wife's lap. 4.In the wife's arms in the back seat.

2. The American Academy of Pediatrics recommends that children under 2 years of age use a rear-facing infant car seat. Children should ride in the rear of a vehicle until they are 13 years old.

The parents of the 6-month-old bring the infant to the pediatrician's office for a routine immunization. The nurse is to administer the immunization by intramuscular (IM) injection. Which of these is the preferred site for an IM injection in an infant? 1.Deltoid. 2.Vastus lateralis. 3.Dorsogluteal. 4.Gluteus maximus.

2. To determine where to give injection, consider: amount and type of med, size and condition of muscle, and the ability to access site. Inject up to 0.5 mL in infant and 1 mL in child.

A client is placed in balanced suspension traction with a Thomas splint and Pearson attachment. The client's nurse is teaching a student nurse about traction. The student nurse asks, "Where is the pulling force of the traction applied?" Which response by the nurse is most accurate? 1."It is applied to the quadriceps muscle." 2."It is applied to the bone distal to the fracture site." 3."It is applied to the bone proximal to the fracture." 4."It is applied to the knee."

2. Traction: pulling force on part of the body. Used to reduce, align, and immobilize fractures, and to relieve muscle spasms. Balanced suspension traction: exerts pull on affected part and supports extremity in hammock or splint; the splint is held in place by balanced weights attached to overhead bar. Traction provided by system of ropes, pulleys, and weights. Countertraction provided by client's body weight and slings or splints. Client can move some without disrupting line of pull.

The nurse performs discharge teaching for a client receiving trifluoperazine hydrochloride. The nurse determines that teaching is successful if the client makes which statement? 1."I should take an extra pill at night if I have difficulty sleeping." 2."I cannot breastfeed my baby while I am taking this medication." 3."I may experience frequent tearing in my eyes." 4."I will have to increase my calorie intake daily."

2. Trifluoperazine hydrochloride is an antipsychotic phenothiazine; can treat schizophrenia and other psychotic disorders; adverse effects include pseudoparkinsonism, dystonia, akathisia, and tardive dyskinesia; instruct client to avoid alcohol, report urine retention or constipation, use sunblock, and chew sugarless gum or suck on hard candy to relieve dry mouth.

he nurse cares for a client who has a tracheostomy tube. The nurse discovers that the tracheostomy tube has become dislodged and that the client is having difficulty breathing through the stoma. Which action does the nurse take first? 1.Perform mouth-to-stoma breathing. 2.Hyperextend the client's neck. 3.Place the client in high-Fowler's position. 4.Administer oxygen via tracheostomy mask.

2. Tube extubation may occur during change of ties or coughing.

The nurse cares for a client in the outpatient clinic who has received a prescription for verapamil 80 mg PO three times daily. The nurse includes which instruction when teaching the client about the medication? 1."Drink lots of fluids during the day to prevent liver and kidney damage." 2."When you awaken, sit on the side of the bed for a few minutes before standing." 3."If you are feeling stressed and develop symptoms, take an extra dose of verapamil." 4."Take the medication before meals on an empty stomach."

2. Verapamil: calcium channel blocker used to treat angina, atrial flutter/atrial fibrillation, hypertension, prevention of paroxysmal supraventricular tachycardia; adverse effects include transient hypotension, heart failure, AV block, ventricular asystole, ventricular fibrillation, pulmonary edema, dizziness, headache, constipation, rash; instruct client to take medication with food, monitor vital signs, and instruct not to chew or divide sustained-release medication.

The home care nurse assesses an older adult client diagnosed with type 2 diabetes mellitus and hypertension. The client is following an 1800-calorie American Diabetes Association (ADA) diet and taking furosemide 40 mg PO daily. The client's adult child tells the nurse that the parent has been reporting dizziness. Which action does the nurse take first? 1.Request that a CT scan of the head be prescribed. 2.Advise the client to drink more fluids with meals. 3.Obtain the client's orthostatic blood pressures. 4.Measure the client's serum potassium level.

3. 2018 hypertension guidelines state: criteria for Stage 1 hypertension include systolic blood pressure (SBP) of 130 to 139 mm Hg or diastolic blood pressure (DBP) of 80 to 89 mm Hg. Stage 2 hypertension criteria include SBP of 140 mm Hg or greater or DBP of 90 mm Hg or greater. Blood pressure is considered elevated if SBP is between 120 and 129 mm Hg and DBP less than 80 mm Hg. Furosemide is a loop diuretic that can cause hypotension, hypokalemia, hyperglycemia, GI upset, and muscle weakness.

Arterial blood gas (ABG) analysis is prescribed for a client diagnosed with pneumonia. After obtaining the blood sample, it is most important for the nurse to take which action? 1.Obtain ice for the specimen. 2.Apply a sterile dressing to the site. 3.Apply direct pressure to the site. 4.Observe the site for hematoma formation

3. ABGs: measurement of partial pressure of oxygen, carbon dioxide, and pH of blood; assessment of acid-base status of body; use a heparinized syringe; needle inserted 45-60 degrees to skin surface and advanced into radial artery; apply pressure after needle removed; put specimen on ice.

The nurse prepares to teach a client who is scheduled for an amniocentesis. It is most important for the nurse to include which statement? 1."The test assesses gestational age of the fetus using the biparietal circumference." 2."The test determines the gender of the baby." 3."The test is used to detect possible birth defects." 4."The test should not be completed if you have a history of previous miscarriages."

3. Amniotic fluid is aspirated by needle inserted through the abdominal and uterine walls and is done after 14 weeks gestation to diagnose genetic disorders (e.g., Down syndrome) or neural tube defects; instruct client to empty bladder.

The nurse plans discharge teaching for a client diagnosed with coronary artery disease (CAD). The client will continue taking warfarin sodium at home. Which instruction does the nurse include in the teaching? 1.Have CBC drawn every 1-4 weeks. 2.Test stools daily for blood. 3.Wear a MedicAlert bracelet. 4.Stop the warfarin before going to the dentist.

3. CAD: narrowing of coronary arteries due to atherosclerosis. Risk factors: hereditary, smoking, age, gender (men higher risk), race (white higher risk), hypertension, elevated serum cholesterol, diabetes mellitus. Warfarin sodium: smoking increases required dose; vitamin K antagonizes effect of warfarin sodium; consult with health care provider before taking over-the-counter medications, including herbal medications.

The nurse plans to administer furosemide 20 mg IV to a client diagnosed with chronic kidney disease (CKD). Which of these is the primary purpose of furosemide? 1.To increase the blood flow to the renal cortex. 2.To decrease serum potassium levels. 3.To increase excretion of sodium and water. 4.To decrease the workload on the heart.

3. CKD is progressive, irreversible kidney injury caused by hypertension, diabetes mellitus, lupus erythematosus, and chronic glomerulonephritis; signs and symptoms include anemia, acidosis, azotemia, fluid retention, and urinary output alterations; nursing care includes monitoring potassium levels, daily weight, intake and output; diet teaching: avoid high-protein diet, initiate fluid restriction for clients receiving hemodialysis; sodium and potassium restrictions may be necessary, but these restrictions can contribute to malnutrition. Furosemide is a loop diuretic. Monitor blood pressure, serum electrolytes, weight, and intake and output. Do not give at bedtime.

The nurse has just administered a subcutaneous injection to a client. Which immediate follow-up action does the nurse take? 1.Remove and discard gloves in the designated receptacle. 2.Perform hand hygiene, then discard the used syringe in the designated receptacle. 3.Discard the uncapped needle with the syringe in the designated receptacle. 4.Cap the needle, then discard the syringe in the designated receptacle.

3. Capping a needle can lead to a needlestick injury. Gloves kept on until syringe disposal, as a safety precaution. Hand hygiene after all other steps.

The nurse assesses a child diagnosed with attention deficit hyperactivity disorder (ADHD). The nurse expects to observe which of finding? 1.Feeding difficulties. 2.Head banging. 3.Easy distractibility. 4.Rigid arms and legs.

3. Characteristics of ADHD include distractibility, immaturity relative to chronologic age, impulsivity, and learning disabilities; nursing considerations include reducing frustration, providing safety and security, and administering prescribed medications (e.g., methylphenidate, clonidine).

The nurse reviews the charts of four antepartal women. The nurse recognizes that which woman is at most risk for having a child with a cleft lip and palate? 1.An Asian woman who is having a girl. 2.An African American woman who is having a boy. 3.A Native American woman who is having a boy. 4.A Caucasian woman who is having a girl.

3. Cleft lip: small or large fissure in facial process of upper lip or up to nasal septum, including anterior maxilla; cleft palate: midline, bilateral, or unilateral fissures in hard and soft palate.

The emergency department (ED) nurse is assigned to care for four clients. Which client does the nurse see first? 1.The client who reports being raped 30 minutes ago and is exhibiting self-blame and anxiety. 2.The client who reports a miscarriage last evening and has spotting of blood on her underwear. 3.The client who told the family of intent to commit suicide and has easy access to a gun. 4.The client who witnessed a child stabbed to death and is experiencing anxiety and difficulty coping.

3. Clients with physical needs take priority over clients with psychosocial needs.

The nurse cares for an emaciated client with Crohn's disease. The nurse expects the client to be placed on which diet? 1.High-calorie, high-protein, high-residue. 2.Low-calorie, low-protein, low-residue. 3.High-calorie, high-protein, low-residue. 4.Low-calorie, low-protein, high-residue.

3. Crohn's disease (regional enteritis): inflammatory bowel disease most commonly affecting distal ileum, but can occur anywhere along the gastrointestinal (GI) tract. The entire wall of the colon is affected. Restricts absorption of nutrients. Signs and symptoms: cramping right lower quadrant abdominal pain, diarrhea, weight loss, low-grade fever. Remissions and exacerbations seen. Treatment: medications are preferred treatment (aminosalicylates, antimicrobials, corticosteroids, immunosuppressants, biologic therapies).

The nurse cares for a client with a cuffed tracheostomy tube and mechanical ventilation in progress. The nurse recalls that the purpose of the cuff on a tracheostomy tube is to accomplish which of these? 1.Prevent displacement of the tracheostomy tube. 2.Maintain the alignment of the trachea with the lungs. 3.Separate the upper and lower airways. 4.Maintain the patency of the trachea.

3. Cuff: plastic balloon that encircles the tracheal tube to form a seal between the outer cannula and the trachea.

The nurse approaches the paranoid schizophrenic client on the psychiatric unit to perform a prescribed venipuncture to obtain a blood specimen. The client becomes agitated and says to the nurse, "You pretend to take blood, but I know you really want to inject me with a poison that will kill me." Which response by the nurse is best? 1."No, I do not want to kill you. Why do you think that drawing blood is going to kill you?" 2."Calm down. I drew your blood last week and nothing bad happened to you, did it?" 3."You sound frightened. The health care provider wants to ensure that your medications are working properly." 4."Look, the tube is empty. I can't inject you with anything if the tube is empty."

3. Delusions are persistent false beliefs; allow client to verbalize delusion, do not argue or try to convince client that delusion is not real. Point out feeling tone of delusion and provide activities to divert attention from delusion.

The nurse in the same-day surgery department cares for a client after a sigmoidoscopy. Which symptom, if exhibited by the client an hour after the procedure, would most concern the nurse? 1.Fullness and pressure in abdomen. 2.Grogginess and thirst. 3.Lightheadedness and dizziness. 4.Mild abdominal pain and cramping.

3. Direct visualization of the sigmoid colon, rectum, and anal canal; can examine (or diagnose) polyps, tumors, diverticula, strictures, ulcers, inflammation; laxative night before exam and enema or suppository morning of procedure; NPO at midnight. Post-procedure: allow client to rest; observe for rectal bleeding and signs of perforation; encourage fluids.

The nurse conducts the family therapy session with a client being treated for depression. During the therapy session, the client verbally expresses love toward the mother, but has an angry facial expression and pounds the table with a fist. The nurse understands that the discrepancy between the client's body language and spoken language is best characterized as which of these? 1.Ambivalence. 2.Scapegoating. 3.Double-bind communication. 4.Loose associations.

3. Double-bind communication is characterized by simultaneous communication of two mutually conflicting verbal and nonverbal messages

The nurse teaches the parent of the young child who has recently been diagnosed as having epilepsy. Which statement, if made by the parent, indicates that further teaching is necessary? 1."Epilepsy does not affect my child's mental capacities." 2."Epilepsy is common in clients with autism spectrum disorder." 3."Epilepsy is a form of mental illness." 4."Epilepsy can be controlled with medication."

3. Epilepsy: seizure disorder, characterized by abnormal, recurring, excessive, and self-terminating electrical disturbances; diagnosis made after two or more seizures; strong genetic component.

The nurse plans postoperative care for a client scheduled for a stapedectomy. When the client is returned to the unit after surgery, the nurse expects to observe which of these? 1.Client's hearing is completely restored. 2.Client is still drowsy from the general anesthesia. 3.Client experiences vertigo, nausea, and vomiting. 4.Client has drains in both ears.

3. Excision of stapes with or without prosthesis to correct hearing loss; during first 24 hours post-op, position client flat in bed with minimal head movement; instruct client to not blow nose or sneeze; assess for facial nerve damage or muscle weakness or changes in taste.

The nurse cares for clients in the outpatient clinic. The client diagnosed with glaucoma experiences severe restrictions of peripheral vision and asks the nurse if the vision will improve. Which statement by the nurse is best? 1."If you continue to take your medication, the pressure in your eyes will decrease. Your vision will improve." 2."The health care provider will perform surgery to remove the lens in your eyes. This will increase your vision." 3."The current damage to your vision is permanent. Continued use of the eye drops will prevent further damage." 4."After the eye pressure is stabilized, the health care provider will reevaluate your vision. Your vision can possibly be corrected with glasses."

3. Glaucoma is abnormal increase in intraocular pressure leading to visual disability and blindness; signs and symptoms include: cloudy, blurry vision or loss of vision; artificial lights appear to have rainbows or halos around them; decreased peripheral vision; pain; headache; and nausea/vomiting; pharmacologic treatment with miotics; laser trabeculoplasty or iridotomy may be indicated.

The nurse cares for a client admitted for severe abdominal cramping and diarrhea. The nurse evaluates the effectiveness of the client's intravenous therapy. The nurse recalls that which laboratory test best reflects hydration status? 1.Erythrocyte sedimentation rate (ESR). 2.White blood cell count (WBC). 3.Hematocrit (HCT). 4.Serum glucose.

3. Hematocrit measures % volume of RBCs in whole blood; normal: men 42-52% (0.42-0.52), women 35-47% (0.35-0.47); increases in severe dehydration.

A client is brought to the emergency department with a compound fracture of the left femur. Vital signs are BP 80/60 mm Hg, pulse 120/minute, respirations 26/minute, temperature 99.0 °F (37.2 °C). The nurse anticipates the health care provider will initially prescribe which IV fluid? 1.10% dextrose in water. 2.5% dextrose in water. 3.Lactated Ringer's. 4.0.45% NaCl.

3. Hypovolemic shock occurs because bone is vascular; can rapidly develop; nursing considerations: immobilize joint below and above fracture; assess for signs and symptoms of shock: tachycardia, hypotension, cool and clammy skin, restlessness, and decreased alertness; administer large amounts of isotonic fluids, such as normal saline or lactated Ringer's.

The nurse conducts a home care visit on the 3-year-old with a cast on the left arm due to a fracture of the radius. The nurse is most concerned when which of these is observed? 1.The mother wraps the cast with plastic wrap prior to bathing the child. 2.The child elevates the arm on a pillow while watching television. 3.The child sits at the table and plays with small toy figurines. 4.The mother encourages the child to wiggle the fingers on the left hand.

3. Immediate cast care includes avoid covering cast until dry; handle with palms (not fingertips); watch for danger signs, such as pallor or cyanosis of the fingers, pain, numbness, or tingling sensations in affected area; intermediate cast care includes mobilize client, encourage isometric exercises, do not put anything inside cast, keep small items that might be placed inside the cast away from small children.

The nurse assesses a full-term newborn infant. Which finding requires an immediate intervention? 1.The infant's respirations are 36, shallow, and irregular in rate, rhythm, and depth.2.Rapid pulsations are visible in the fifth intercostal space, left midclavicular line.3.The infant's axillary temperature is 96.2 °F (35.6 °C).4.There is asynchronous, spontaneous movement of the infant's extremities.

3. Important to assist newborn with heat regulation: wrap newborn to protect from cold, dry infant after birth, place fabric-insulated cap on head. Cold stress: infant unable to increase activity and lacks a shivering response to cold; causes metabolic acidosis, hypoxia, and hypoglycemia.

The nurse cares for a 19-year-old client admitted to the emergency department after an automobile accident. Even though the client denies drinking alcohol, the nurse notes that the client's breath smells of alcohol, speech is slurred, reflexes are diminished, and the client has difficulty recalling the events of the evening. The health care provider prescribes a magnetic resonance imaging (MRI) scan. Which of these actions should the nurse take first? 1.Explain the MRI procedure and let the client sign the consent. 2.Instruct the client to remove his wrist watch. 3.Contact the client's next of kin to give consent for the MRI. 4.Restrict food and fluid intake for 4 hours.

3. In most states, young adults (18 years and older) can legally give consent; a client cannot give informed consent if s/he has been drinking or is premedicated.

The home care nurse is visiting the 82-year-old client living with the client's adult child. The client appears malnourished and has multiple bruises on the body. Which action by the nurse is most appropriate? 1.Request that the LPN/LVN document the suspected abuse. 2.Discuss the nurse's observation with the client's children. 3.Report the situation to the nursing supervisor. 4.Request that another nurse visit the client.

3. Indications of elder abuse include battering, fractures, bruises, overmedicated or undermedicated, poor nutritional status, dehydration; nursing care includes providing for the client's safety, providing for physical needs, and reporting to appropriate agency.

The nurse cares for the postoperative client who had an abdominal resection and insertion of a Jackson-Pratt drain. The nurse recognizes that which of the following is the primary purpose of the drain? 1.To irrigate the incision with a saline solution. 2.To prevent bacterial infection of the incision. 3.To prevent accumulation of drainage in the wound. 4.To measure the amount of fluid lost after surgery

3. Jackson-Pratt drain: tissue drain used postoperatively to prevent accumulation of fluid in wound.

The nurse teaches a client receiving levothyroxine. The nurse identifies that further teaching is necessary if the client makes which statement? 1."If I have chest pain, I will call my health care provider." 2."If my hands shake, I will call my health care provider." 3."I will take the medication at night before I go to sleep." 4."I will inform all my health care providers about medications that I take."

3. Levothyroxine increases metabolic rate of body and is used as a thyroid replacement; adverse effects include nervousness, tremors, insomnia, tachycardia, palpitations, dysrhythmias (including cardiac arrest), hypertension, heart failure, angina, and dyspnea.

The nurse cares for a client after a below-the-knee amputation. The nurse assesses for infection and is most concerned if which of these is observed? 1.The client appears restless. 2.The client reports a throbbing headache. 3.The client reports persistent pain at the operative site. 4.The client's skin feels cool proximal to the operative site.

3. Major complications after amputation are hemorrhage, infection, and skin breakdown; monitor for bleeding; keep surgical tourniquet at bedside for emergency use; skin hygiene important to prevent skin breakdown; wash and dry residual limb twice per day.

The nurse cares for a client during the acute phase of a stroke. The nurse gives the highest priority to which of these? 1.Maintaining musculoskeletal function. 2.Maintaining nutritional status. 3.Maintaining respiratory function. 4.Maintaining skin integrity.

3. Manifestations of stroke vary with the involved cerebral vessel and the area of the brain affected; women more likely to report nontraditional manifestations; manifestations always sudden in onset, focal, and usually one-sided.

The nurse cares for a client who is prescribed nifedipine. The client asks how the medication works. Which is the best response by the nurse? 1."It constricts the coronary arteries." 2."It increases myocardial contractility." 3."It decreases myocardial oxygen demand." 4."It promotes coronary artery spasms."

3. Nifedipine: antianginal medication that is a calcium channel blocker (inhibits calcium ion flow across cardiac and smooth muscle); may also be prescribed to treat hypertension. Adverse effects: lightheadedness, headache, peripheral edema, weakness, palpitations, hypotension, and hypokalemia (if toxicity occurs). Nursing responsibilities: monitor blood pressure and potassium levels. Multiple medication interactions exist; obtain a detailed medication profile, including herbal medications.

The health care provider prescribes morphine sulfate to be administered using a patient-controlled analgesia (PCA) pump. Which explanation by the nurse best describes this method of pain medication administration? 1."You will contact your nurse when you feel pain, and the nurse will bring pain medication to add to your intravenous pump." 2."You will receive a large dose of pain medication continually from an intravenous pump." 3."You will be able to self-administer a preset dose of pain medication as needed by pressing a button connected to the intravenous pump." 4."You will be able to self-administer an unlimited amount of pain medication as needed by pressing a button connected to the intravenous pump."

3. PCA allows clients to control administration of IV analgesics; preloaded pump system administers preset amount of medication when button is pushed by client; predetermined lock-out time interval is established; amount of medication is displayed on front of machine; to reduce the incidence of respiratory depression, client can only receive a predetermined maximum mg/hr of medication.

The nurse cares for the client receiving morphine sulfate via patient-controlled analgesia (PCA) pump. When making rounds, the nurse observes the client is sleeping and the spouse is at the bedside. The nurse observes that each time the client grimaces, the spouse presses the button on the PCA machine. Which action is most appropriate for the nurse to take? 1.Encourage the spouse to continue this practice as long as the client agrees. 2.Explain to the spouse that this should be done only once every hour while the client is sleeping. 3.Explain the purpose of the patient-controlled analgesia to the spouse. 4.Instruct the spouse to awaken the client when client grimaces and ask if the client is in pain.

3. PCA allows clients to control own administration of IV analgesics.

The nurse cares for a client reporting excruciating pain. If the client's sympathetic nervous system is stimulated, which physiologic response will occur in this client? 1.Decreased blood pressure. 2.Decreased heart rate. 3.Increased blood coagulability. 4.Increased pupillary constriction.

3. Pain causes increased blood pressure and heart rate, which leads to increased blood flow to the brain and muscles; rapid respirations lead to increased oxygen supply to brain and muscles; increased pupillary diameter leads to increased eye accommodation to light; metabolic rate increases.

The nurse observes the student nurse caring for a client with a tracheostomy tube. The nurse intervenes if which action is observed? 1.The student nurse uses clean gloves to remove the tracheostomy dressing. 2.The student nurse cleans the inner cannula by soaking it in hydrogen peroxide. 3.The student nurse removes the soiled tracheostomy ties and then reattaches clean ties. 4.The student nurse replaces the tracheostomy dressing with a pre-cut, folded 4 x 4 gauze.

3. Perform tracheostomy care every 8 hours and as needed; hyperoxygenate client prior to suctioning tracheostomy tube; sterile procedure.

The nurse plans care for an adult client diagnosed with pneumonia. The client is to be suctioned PRN. Which technique most accurately describes proper suctioning? 1.Apply suction with rotation, for no more than 20 seconds, as the catheter is inserted. 2.Apply suction, for no more than 10 seconds, as the catheter is both inserted and withdrawn. 3.Apply suction, for no more than 10 seconds, as the catheter is withdrawn. 4.Apply suction each time the client inhales while the catheter is inserted.

3. Pneumonia: infection of the lungs due to viruses or bacteria, aspiration of food/fluids, or inhalation of toxic chemicals. Signs and symptoms: fever, chills, cough, hemoptysis, dyspnea, and fatigue. Treatment: antibiotics (unless viral). Nursing responsibilities: turn, cough, deep breath, Fowler's position; suction to remove secretions and provide open airway; use 12-14 French catheter; use suction pressure less than 120 mm Hg and gently rotate the catheter 360 degrees. Complications: infection, trauma, hypoxemia, dysrhythmias.

The nurse cares for a client with moderate age-related hearing loss. The nurse teaches the client's family to use which approach when speaking to the client? 1.Raise your voice until the client can hear and speak at a slow rate. 2.Face the client and speak quickly using a high voice. 3.Face the client and speak clearly without exaggerating sounds. 4.Use facial expressions and speak as you would normally.

3. Presbycusis: age-related hearing loss due to inner ear changes (noise exposure thought to be common factor); decreased ability to hear and understand high-pitched sounds (e.g., consonants in language).

A client delivers a 6 lb 10 oz infant. The client observes the nurse in the delivery room place drops in the infant's eyes. The client asks the nurse why this was done. Which response by the nurse is best? 1."The drops will constrict your infant's pupils to prevent injury." 2."The drops will remove mucus from your infant's eyes." 3."The drops will prevent infections that might cause blindness." 4."The drops will prevent allergic conjunctivitis."

3. Prophylactic care of newborn includes administration of antibiotic eye drops containing erythromycin and tetracycline. Eye irritation may occur, but it is not common and is self-limiting.

One afternoon in the hospital day room, the nurse overhears the newly admitted client with chronic schizophrenia say to another client, "I hate you. Get away from me or I'll kill you." Which interpretation of the client's behavior is most accurate? 1.The client dislikes the other person. 2.The client is very angry. 3.The client feels threatened. 4.The client feels powerful.

3. Schizophrenia distorts the way a client thinks, acts, expresses emotions, perceives reality, and relates to others. The client can misinterpret what the other client's behavior meant.

The nurse cares for a 6-year-old child placed in Russell's traction due to a femur fracture. After repositioning the child, it is most important for the nurse to take which action? 1.Administer pain medication. 2.Offer the child a book. 3.Check the position of the left hip. 4.Assess the pin site for infection.

3. Skin traction is used on the lower leg, and a padded sling is placed under the knee; "pulls" contracted muscles; elevate foot of bed with shock blocks to provide countertraction; check popliteal pulse; do not turn from waist down; lift client, not leg, to provide assistance.

A pregnant client is given an epidural anesthetic in preparation for cesarean section. After the administration of the epidural anesthetic, the client's blood pressure falls from 120/84 to 94/50 mm Hg. The nurse recognizes that it is essential to assist the client to which position? 1.Supine. 2.Sitting. 3.Side-lying. 4.Trendelenburg.

3. Spinal anesthetic: local anesthetic injected into the lumbar intervertebral space beyond the dura mater into the subarachnoid space, which blocks pain sensations and movement. Epidural: local anesthetic injected into the lumbar intervertebral space outside the dura mater, which blocks pain sensations only, not movement. Complication of regional anesthetics: sympathetic nerve fibers blocked, hypotension due to loss of vasoconstrictor ability. Prehydrate before regional anesthetic to ensure adequate blood volume.

A client is admitted to the hospital after sustaining a severe head injury in an automobile accident. After the client dies, the nurse observes the client's spouse comforting other family members. Which interpretation of the spouse's behavior is most accurate? 1.The spouse has already moved through the stages of the grieving process. 2.The spouse is repressing anger related to the client's death. 3.The spouse is experiencing shock and disbelief related to the client's death. 4.The spouse is demonstrating resolution of the client's death.

3. Stages of grief, popularly known as DABDA: 1) denial, 2) anger, 3) bargaining, 4) depression, 5) acceptance. However, not every client will go through the stages of grief in this prescribed sequence. Acute period: 4-8 weeks, usual minimum time for resolution: 1 year.

In the dining room of the mental health center, the nurse observes a formerly homeless and malnourished client with chronic schizophrenia putting food into a plastic bag. Which action by the nurse is most appropriate? 1.Reprimand the client for behaving inappropriately. 2.Ask the client why the food is being put into a bag. 3.Inform the client that snacks will be available later. 4.Distract the client and redirect to another activity.

3. The behavior of the client is consistent with a distorted view of reality. Concern about food availability leads to storing a personal cache of food; way of coping with fear.

The nurse prepares to change the central line dressing on a client. Arrange the steps of the procedure in the correct order from first to last. All options must be used. 1. Open supplies to create a sterile field. 2. Apply nonsterile gloves. 3. Apply an occlusive dressing. 4. Remove old dressing and wash hands. 5. Cleanse the area with antiseptic solution (e.g., swab stick with chlorhexidine) in a circular motion. 6. Apply sterile gloves. 1.1, 2, 4, 5, 6, 3 2.1, 4, 2, 6, 5, 3 3.2, 4, 1, 6, 5, 3 4.2, 4, 6, 1, 5, 3

3. The central line dressing needs to be changed regularly, according to institution protocol, using sterile technique. Central line dressing should also be changed when soiled or loose. The site must be cleansed properly, and signs of infection need to be assessed.

The nurse performs a physical assessment on an adult with a history of a mitral valve murmur. Identify the area where the nurse should place the stethoscope to auscultate the mitral murmur. 1.A 2.B 3.C 4.D

3. The following anatomical landmarks are used to evaluate heart sounds. The Angle of Louis is located at the manubrial sternal junction at the second rib. The aortic and pulmonic areas are found at the left and right second intercostal space, alongside sternum. Erb's point is found at the third intercostal space, left sternal border. The mitral area is found at the left fifth intercostal space, midclavicular line. The point of maximal impulse (PMI), or the impulse of the left ventricle, is felt most strongly on an adult at the left fifth intercostal space, midclavicular line.

The nurse cares for a client receiving vincristine sulfate. The nurse recognizes it is most important to assess for which of these? 1.Fatigue and nausea. 2.Polyphagia and polydipsia. 3.Paresthesia and difficulty with gait. 4.Diarrhea and alopecia.

3. Vincristine sulfate is an antineoplastic agent; adverse effects include peripheral neuritis, loss of reflexes, bone marrow depression, alopecia, and gastrointestinal symptoms (including intestinal necrosis); avoid IV infiltration and extravasation; check reflexes, motor and sensory function; allopurinol given to increase excretion and prevent uric acid nephropathy.

The nurse does preoperative teaching with the client scheduled to have a transurethral prostatectomy (TURP) under spinal anesthesia. Which statement about the result of the spinal anesthesia does the nurse include in the teaching? 1."You will be unable to move your arms or legs immediately after surgery." 2."You will require analgesics to relieve pain in your back." 3."You will be unable to move your legs immediately after surgery." 4."You will require a special machine to help you breathe immediately after surgery."

3. Spinal anesthesia: injection into the subarachnoid space. Complications: nausea, vomiting, headache, respiratory paralysis, muscular weakness in legs. TURP: removal of enlarged portion of the prostate by the use of a resectoscope inserted through the urethra.

The nurse assesses a child who is taking phenytoin at home to treat epilepsy. Which statement, if made by the parent, indicates a potential side effect of phenytoin? 1."My child's teeth have become discolored." 2."My child has developed strange food cravings." 3."My child has become more interactive with others." 4."My child has not had a bowel movement in 3 days."

4. 1) Epilepsy: uncontrolled, abnormal discharge of electrical activity in the brain. 2) Sequence of seizures: prodromal stage: vague change in emotions, aura: brief sensation, epileptic cry, convulsion, postictal: change in consciousness. 3) Phenytoin: anticonvulsant. Adverse effects: adverse effects include drowsiness, ataxia, nystagmus, blurred vision, gingival hyperplasia, pancytopenia.

A client tested positive for human immunodeficiency virus (HIV). The client asks the nurse what this means. Which of these statements accurately describes an HIV-positive test result? 1.The client has acquired immunodeficiency syndrome (AIDS). 2.The client will develop AIDS within the year. 3.The client has been exposed to the HIV virus. 4.The client has been infected with the HIV virus.

4. AIDS is caused by HIV. Alters the functioning of the immune system. Transmission: contact with blood and body fluids, such as semen. Test that detects presence of antibodies: enzyme-linked immunosorbent assay (ELISA). Test that confirms presence of virus: Western blot.

The nurse cares for a client admitted to the intensive care unit (ICU) with a diagnosis of acute respiratory distress syndrome (ARDS). Positive end-expiratory pressure (PEEP) is initiated. Because the client "fights" the ventilator, the health care provider prescribes vecuronium bromide. After administering the medication, it is most important for the nurse to take which action? 1.Administer analgesia, as prescribed. 2.Explain all procedures to the client. 3.Initiate airborne precautions. 4.Obtain prescription for eye lubricant.term-117

4. ARDS is characterized by dyspnea and tachypnea, followed by progressive hypoxemia despite oxygen therapy; PEEP: positive pressure is exerted during the expiratory phase of ventilation; vecuronium bromide is a neuromuscular blocking agent used to provide skeletal relaxation during mechanical ventilation.

The parent of an adolescent being admitted to the psychiatric unit reports that the adolescent has become increasingly withdrawn at home. During the admission interview with the nurse, the client says, "When I look in the mirror, I cannot see myself." The nurse recognizes that the client is experiencing which of these? 1.Displacement. 2.Dissociation. 3.Denial. 4.Depersonalization.

4. Adolescence provides a time for development of a healthy self-concept and discovering one's role in life. If the road to these discoveries is blocked, the person experiences depersonalization.

The nurse cares for a client who experiences severe panic attacks when planning to go grocery shopping. The nurse expects which medication will be prescribed for the client? 1.Chlorpromazine. 2.Carbamazepine. 3.Flurazepam. 4.Imipramine.

4. Anxiety is feeling of dread or fear in the absence of external threat or disproportionate to the nature of the threat; in panic level anxiety, the client is unable to see, hear, or function; assess level of anxiety, decrease environmental stimuli, use unhurried approach, and stay with the client.

The school nurse conducts a prevention program at the high school and discusses risks for suicide. The nurse recognizes that further teaching is necessary if a student makes which statement? 1."Some adolescents are at high risk." 2."Depressed people are at high risk." 3."History of previous suicide attempts put people at high risk." 4."Those who are grieving due to a loss for 9 months are at high risk."

4. Be alert for signs of self-destructive behavior; behavioral clues of impending suicide include any sudden change in behavior; client becomes energetic after period of severe depression, finalizes business or personal affairs, withdraws from social activities and plans; presence of weapon, razors, or pills, has a death plan.

The nurse cares for a client after a transurethral prostatectomy (TURP). The client has a continuous bladder irrigation (CBI). When changing the client's bed, the nurse notices that the sheets are wet. Which of these best explains this finding? 1.The client is experiencing acute urinary retention. 2.The client is experiencing autonomic dysreflexia. 3.The client has a urinary tract infection. 4.The client is having bladder spasms.

4. Benign prostatic hyperplasia (BPH): enlargement of the prostate gland that obstructs the urethra. TURP: removal of enlarged portion of the prostate by the use of a resectoscope inserted through the urethra. No incision is made. During the first 24-48 hours post-op, a CBI using isotonic fluids (normal saline) is used to keep catheter patent and remove clots and sediment. It should be regulated to provide for clear or pink urine. Traction may be applied to the catheter (by the health care provider) and the catheter tubing secured to the thigh or abdomen. This prevents hemorrhage by applying pressure to the blood vessels. The indwelling urinary catheter is usually removed after 2-3 days. Teaching: may initially have burning on urination, frequency, dribbling. Force fluids to 3000 mL/day. Avoid alcohol, spicy foods, strenuous activities for 2-3 weeks.

The nurse cares for a client diagnosed with schizophrenia. The nurse recognizes that the client has developed parkinsonian adverse effects of chlorpromazine. The nurse expects which medication will be prescribed for the client? 1.Diazepam. 2.Haloperidol. 3.Amitriptyline. 4.Benztropine.

4. Benztropine: anticholinergic, antiparkinsonian agent; adverse effects include drowsiness, blurred vision, nausea, constipation, urinary retention, dry mouth, agitation; nursing considerations include monitor intake and output, monitor for muscle weakness or inability to move certain muscle groups, monitor for central nervous system depression or stimulation, and provide sugarless gum or lozenges for dry mouth.

The client with a history of cholelithiasis and recurrent urinary tract infections is admitted with reports of fatigue. A small lump is discovered in the client's neck. The nurse recognizes that which test should be performed first? 1.Cholecystogram. 2.Intravenous pyelogram (IVP). 3.Myelogram. 4.Thyroid scan.

4. Cholelithiasis is presence of stones in the gallbladder; symptoms include intolerance to fatty foods, indigestion, nausea, vomiting, flatulence, eructation, and severe pain in the upper-right quadrant of the abdomen.

The client admitted for treatment of pneumonia reports an allergy to sulfa drugs and penicillin. The nurse recognizes that which medication is most appropriate for this client? 1.Piperacillin and tazobactam. 2.Trimethoprim-sulfamethoxazole. 3.Cephalexin. 4.Ciprofloxacin.

4. Clients with a sensitivity to penicillin should take cephalosporin medications cautiously due to a risk for cross-allergy. Clients with an allergy to sulfa drugs should not take any sulfa-containing medications.

The nurse screens clients for risk of developing deep vein thrombosis (DVT). Which of these clients has the lowest risk profile for DVT? 1.A 67-year-old carpenter undergoing a left total knee replacement. 2.A 22-year-old woman who weighs 230 lb (104.3 kg) and is 2 months pregnant with her second child 3.A 44-year-old woman with ovarian cancer experiencing vomiting from chemotherapy. 4.A 50-year-old executive following removal of cataracts.

4. DVT can cause pulmonary embolism; risk factors include surgery (particularly orthopedic surgery), age (greater than age 40), obesity, pregnancy, taking prescribed hormonal medications, history of a clotting disorder, and varicose veins. To prevent DVT, early ambulation, antithrombosis stockings, and anticoagulants are used.

The nurse cares for a multipara client who comes to the hospital at 29 weeks gestation with reports of backache and pelvic pressure "on and off all day." Which assessment is most important in determining if the client is in premature labor? 1.The client's report of her subjective symptoms. 2.The cervix is 50% effaced, 1 centimeter dilated. 3.The presenting part is at -1 station. 4.Regular contractions are noted on a monitor tracing.

4. Effacement: shortening and thinning of the cervix. Dilation: enlargement of opening of cervix from a few mm to an opening large enough to allow for passage of infant. Station: indicates progress of labor; relationship of presenting fetal part to imaginary line between ischial spines of pelvis in the mother. Signs and symptoms of premature labor: abdominal pain resembling menstrual cramps, dull backache, pelvic pressure.

The client is being treated for heart failure (HF) and is placed on a 2-gram sodium diet. The nurse performs dietary teaching. Which statement, if made by the client, indicates that further teaching is necessary? 1."Some medications and seasonings contain sodium." 2."Vegetable juices and deli meats are high in sodium." 3."I need to avoid soups and seasoned rice when eating at a restaurant." 4."I can eat any food I like as long as I don't add additional salt to my food."

4. Foods to avoid on a low-sodium diet: cured or smoked meat or fish, Kosher meats, peanut butter, processed cheese, salted crackers, seasoning mixes, tomato juice, canned foods.

Two days after a hemicolectomy, the client awakens frightened and agitated. The client climbs out of bed, removes the indwelling urinary catheter, and runs down the hall screaming. Which of these actions is most appropriate for the nurse to take initially? 1.Call the health care provider and request a sedative for the client. 2.Return the client to bed and apply physical restraints immediately. 3.Replace the client's indwelling urinary catheter. 4.Return the client to bed and assess the client's condition.

4. Hemicolectomy: removal of half or less of the colon in order to remove tumors.

The home care nurse cares for a child diagnosed with hemophilia who is recovering from the acute phase of spontaneous bleeding into the joints. It is most important for the nurse to give the parents which instruction? 1.Administer ibuprofen for pain. 2.Apply ice to the joints. 3.Use hard-bristle toothbrush. 4.Encourage active range-of-motion exercises.

4. Hemophilia is a bleeding disorder caused by deficiency of factor VIII (most common) or factor IX; signs and symptoms include easy bruising, joint pain with bleeding, and prolonged internal or external bleeding.

A neighbor calls the nurse stating that a piece of glass is embedded in their child's eye. Which of these instructions by the nurse is most important? 1.Irrigate the injured eye with warm normal saline and apply a dressing. 2.Place a pressure dressing on the injured eye and take the child to the emergency department. 3.Remove the piece of glass from the child's eye using a gloved hand. 4.Put an eye patch over both eyes and immediately take the child to the emergency department.

4. If non-penetrating contusion, apply cold compresses and take analgesics; if penetrating injury, cover with patch and refer to surgeon.

A woman in her second trimester of pregnancy tells the clinic nurse that her 5-year-old son has been asking questions "about sex." The client asks the nurse what she should tell her child. Which of these statements, if made by the nurse, is best? 1."Buy a book about sex designed for young children and read it with your son." 2."Have your son touch your abdomen and tell him about your pregnancy." 3."Tell your son that this subject is complicated, and you will discuss it as he gets older." 4."Answer your son's questions matter-of-factly, in words that he can understand."

4. Important to determine what the child knows and thinks and to offer honest explanations.

The nurse observes the newly licensed LPN/LVN prepare to administer iron dextran intramuscularly (IM) to a client with iron deficiency anemia. It is most important for the nurse to give which instruction to the LPN/LVN? 1."Massage the injection site for 1 minute after the injection of the medicine." 2."Tap out the air bubble prior to administering the medication." 3."Release the skin prior to withdrawing the needle." 4."Change the needle after drawing up the medication."

4. Iron dextran is a hematinic used to treat iron deficiency anemia; administer using Z-track method; select large, deep muscle; pull skin and subcutaneous tissue 1.5 inches to the side; release skin after withdrawing needle. The Z-track method reduces leakage of medication through subcutaneous tissue and decreases skin lesions at the injection site.

The nurse manager observes the staff nurse assist the health care provider with a lumbar puncture (LP). The nurse manager determines that care is appropriate if the staff nurse does which of these? 1.Instructs the client to hyperventilate. 2.Instructs the client to maintain a full bladder. 3.Explains to the client that the LP is always painless. 4.Assists the client into a fetal position.

4. LP is the insertion of needle into subarachnoid space to obtain specimen, relieve pressure, inject dye or medication. Preparation for procedure: explain procedure, confirm that consent has been signed, position in lateral recumbent fetal position (alternative position: sitting on edge of bed with arms draped over bedside table). Post-procedure nursing care: position flat for at least 1 hour to prevent post-LP headache (some health care providers recommend 4-8 hours; time may vary depending on reason for LP); encourage increase in PO fluids, neurological assessment every 15-30 minutes until stable. Oral analgesics for headache.

The nurse cares for a client receiving lansoprazole. The nurse recognizes that lansoprazole has which effect on the gastrointestinal (GI) system? 1.Increases bowel motility. 2.Reduces bowel motility. 3.Neutralizes gastric acid secretion. 4.Decreases gastric acid secretion.

4. Lansoprazole is a proton pump inhibitor used to treat and prevent stomach and intestinal ulcers. It reduces gastric acid production. Instruct client to take lansoprazole 30 to 60 minutes before a meal for best results.

A client is admitted to the hospital for a myelogram using a water-soluble dye. Which information is most important for the nurse to obtain about the client's medication history? 1.Is the client currently taking any antihypertensives? 2.Is the client currently taking any opioid analgesics? 3.Is the client currently taking any oral antibiotics? 4.Is the client currently taking any antidepressants?

4. Medications that lower the seizure threshold, such as phenothiazines (chlorpromazine), monoamine oxidase (MAO) inhibitors (phenelzine), tricyclic antidepressants (imipramine, amitriptyline), central nervous system stimulants, psychoactive medications (methylphenidate) should be held for 48 hours before and 24 hours after myelogram. The reason to stop such medications is that their presence could increase the risk of seizures.

A client is scheduled for a myelogram. The client asks the nurse if there will be any discomfort during the test. Which response by the nurse is most accurate? 1."No, this procedure will not hurt at all." 2."Yes, this is one of the most painful procedures." 3."This is an uncomfortable procedure, but you will receive general anesthesia so you will not be aware of the pain." 4."This is an uncomfortable procedure, but you will be given medication before the test to lessen the discomfort."

4. Myelogram: insertion of contrast medium into the subarachnoid space of spine via a lumbar puncture in order to visualize the vertebral column; can diagnose herniated discs, tumors, spinal cord narrowing; indicated when MRI is contraindicated. Pretest: encourage fluids, verify allergies; multiple medications, including many antidepressants and psychoactive medications, should be held for 48 hours prior to and 24 hours after procedure. Diazepam can be given preoperatively. Post-test: position the client in a supine position with the head elevated 30 degrees for several hours.

The nurse cares for the client diagnosed with asthma. The health care provider prescribes neostigmine IM. Which of these actions by the nurse is most appropriate? 1.Administer the medication. 2.Check the blood pressure and heart rate. 3.Ask the pharmacist if neostigmine can be given orally. 4.Contact the health care provider.

4. Neostigmine is a cholinergic medication (parasympathomimetic) used to treat myasthenia gravis and is an antidote for nondepolarizing neuromuscular blocking agents; adverse effects include nausea, vomiting, abdominal cramps, respiratory depression, bronchoconstriction, hypotension, and bradycardia. Nursing considerations include monitoring vital signs frequently, having atropine injection available, and taking with milk to decrease adverse effects.

The nurse cares for a client in the post-anesthesia care unit (PACU) after a total left hip replacement. The nurse positions the client in which position? 1.On the right side with the head of the bed slightly elevated and the left hip adducted. 2.On the left side with the head of the bed slightly elevated and the hips flexed 120 degrees. 3.Supine with the knee gatch elevated to 30 degrees and the left hip extended. 4.Supine with the head of the bed slightly elevated and an abduction pillow between the legs.

4. Nursing care includes abduction of affected extremity using splints, wedge pillow or 2-3 pillows between legs, turn client as prescribed, ice to operative site, do not sleep on operative side, do not flex hip more than 45-60 degrees.

The client is postoperative orthopedic surgery. The health care provider prescribes morphine sulfate to be administered using a patient-controlled analgesia (PCA) pump. The nurse checks the PCA pump to determine how many times the client has triggered the system. Which explanation best explains why the client triggered the PCA button 11 times but received only 6 injections? 1.The client is developing an addiction to morphine sulfate. 2.The client does not understand how to use the PCA. 3.The client is developing a tolerance to morphine sulfate. 4.The client's pain is not fully controlled by the PCA.

4. PCA allows clients to control administration of IV analgesics; preloaded pump system administers preset amount of medication when button is pushed by client; predetermined lock-out time interval is established; amount of medication is displayed on front of machine; to reduce the incidence of respiratory depression, client can only receive a predetermined maximum mg/hr of medication.

The nurse performs a physical assessment on a client. To locate the point of maximum impulse (PMI) of the client's heart, the nurse's fingertips should be placed over which location? 1.The fifth intercostal space directly over the sternum. 2.The second intercostal space to the right of the sternum. 3.The second intercostal space to the left of the sternum. 4.The fifth intercostal space at the midclavicular line.

4. PMI: forward thrust of left ventricle during systole produces normal pulsation on chest wall; indicates size and position of heart; should be felt in one intercostal space; if larger, indicates ventricular enlargement.

The client receiving paroxetine for obsessive-compulsive disorder reports feeling dizzy when standing up from a sitting or lying position. Which statement accurately explains the client's dizziness? 1.Paroxetine can cause hypoglycemia. 2.Paroxetine directly affects the cerebellum. 3.Paroxetine directly affects the auditory nerve. 4.Paroxetine can cause orthostatic hypotension.

4. Paroxetine is a selective serotonin reuptake inhibitor (SSRI) type of antidepressant. Sudden discontinuation could lead to withdrawal symptoms (should be tapered slowly over 1-2 weeks).

The nurse instructs the client on how to perform breast self-examination. The nurse should include which instructions about examining the breasts in front of a mirror? 1."Stand with arms at your sides. Bend from the waist to the left side. Bend from the waist to the right side." 2."Stand with both arms above your head. Lower the right arm and keep the left arm raised. Lower the left arm and raise the right arm." 3."Stand with your hands on your hips. Clasp you hands behind your back." 4."Stand with arms at your sides. Place hands on your hips and bow slightly toward the mirror. Clasp hands behind your head and press hands forward. "

4. Perform breast self-examination monthly beginning at age 20; after inspecting breasts in the mirror, client should palpate the breasts (begin at outer edge of breast, carefully and thoroughly feeling entire breast using three or four fingers) when standing and lying down; feel for unusual lumps or masses under skin.

The nurse cares for the client receiving phenytoin intravenously. The nurse recognizes that the medication is administered in which of these IV fluids? 1.5% dextrose in water (D5W). 2.Lactated Ringer's (LR) solution. 3.10% dextrose in water (D10W). 4.Normal saline (0.9%).

4. Phenytoin is an anticonvulsant; adverse effects include drowsiness, ataxia, nystagmus, blurred vision, gingival hyperplasia, pancytopenia; instruct about proper oral hygiene; never mix with other medications; use in-line filter; monitor IV site closely because severe tissue damage can occur in the event of extravasation; for adults, infuse no more than 50 mg/minute; for neonates, infuse no more than 1-3 mg/kg/minute.

A client is recovering from a right below-the-knee amputation. The client asks the nurse why a "figure eight" bandage is applied to the residual limb. Which explanation by the nurse accurately explains the primary reason for applying the bandage? 1."It decreases the possibility of infection." 2."It helps to minimize postoperative pain." 3."It reduces the possibility of clot formation." 4."It reduces postoperative swelling."

4. Pressure to an operative site reduces postoperative swelling. To promote a return to better circulation, the pressure bandage is changed at regular intervals. As secondary effects, this activity reduces pain caused by swelling and the possibility of clot formation in the residual limb.

The nurse cares for a client in the labor unit. During the transitional phase of labor, the umbilical cord becomes prolapsed. The nurse should places the client in which position? 1.Lithotomy. 2.Dorsal recumbent. 3.Semi-Fowler's. 4.Trendelenburg.

4. Prolapsed cord: obstetrical emergency in which the umbilical cord is below the presenting part of the fetus. Compression of the cord causes fetal hypoxia, resulting in central nervous system damage or fetal death.

The nurse cares for an infant diagnosed with pyloric stenosis. The nurse recognizes that it is most important to offer which of these feedings? 1.Clear fluids. 2.Continuous nasogastric feedings. 3.Intermittent nasogastric feedings. 4.Small, frequent feedings.

4. Pyloric stenosis is obstruction caused by hypertrophy and hyperplasia of pylorus, the muscular sphincter at the gastroduodenal juncture; projectile vomiting occurs 2-4 weeks after birth; surgery needed: pyloromyotomy (ensure NPO 6 hours before); postoperative care includes provide parenteral fluids as prescribed, check incision site, monitor warmth, offer clear liquids with glucose or electrolyte solution first; if tolerated, infant begins formula or breast feeding.

The nurse cares for a client who has syndrome of inappropriate antidiuretic hormone (SIADH). Which findings does the nurse recognize as consistent with this diagnosis? 1.Increased urine output; decreased serum sodium. 2.Decreased urine output; increased serum sodium. 3.Increased urine output; increased serum sodium. 4.Decreased urine output; decreased serum sodium.

4. SIADH: seen with head injury, encephalitis, brain tumors, lung cancer, and myxedema (among others). Excessive amounts of antidiuretic hormone (ADH) from posterior pituitary results in water imbalance; water intoxication occurs due to fluid retention; opposite of diabetes insipidus (DI). Signs and symptoms: thirst, exertional dyspnea, fatigue, muscle cramping, headache, decreased level of consciousness, cerebral edema secondary to hyponatremia, seizures, coma; normal sodium level 135-145 mEq/L (135-145 mmol/L). Treatment: fluid restriction (500-1000 mL/24 hours depending on degree of hyponatremia), cautious use of 3% sodium chloride (for severe hyponatremia less than 120 mEq/L [120 mmol/L]), diuretics, demeclocycline hydrochloride. Nursing responsibilities: daily weights, neuro checks, I + O, check electrolytes, and position flat in bed unless contraindicated.

The nurse cares for a client who is receiving warfarin sodium. It is most important for the nurse to have which of these medications available? 1.Ferrous sulfate. 2.Protamine sulfate. 3.Vitamin E. 4.Vitamin K.

4. Should check for hematuria (blood in urine), tarry stools, ecchymosis, petechiae, and epistaxis (nosebleed).

The nurse changes the dressing of a client who had a mastectomy two days ago. After the nurse removes the old dressing, the client turns her head away. Which of these nursing diagnoses is most appropriate? 1.Powerlessness. 2.Knowledge deficit. 3.Sexual dysfunction. 4.Body image disturbance.

4. Stages of body image readjustment include psychological shock (denial and anger), withdrawal (passive and dependent), acknowledgment (beginning of grief process), and integration (integrate body changes into new image).

The client is brought to the community mental health center by the spouse. One year ago, the client's youngest child was killed in a car accident. The graduation of the child's high school class triggered feelings of sadness and guilt. As a result, the client has been having severe headaches, insomnia, and poor appetite. In planning care for this client, the nurse recognizes that the symptoms are most likely an example of which of these? 1.Turning aggression inward. 2.Receiving inadequate support. 3.Displacement of anger. 4.Delayed grief reaction.

4. Stages of grief: denial, anger, bargaining, depression, acceptance. At the one-year mark, a client would often be moving toward the stage of grief called acceptance. However, the stages are not sequential and do not have a guaranteed time frame. The client has faced a major anniversary, reminding client of the loss.

The client is admitted due to right-sided weakness and difficulty speaking. The client reports a fall while at home. It is most important for the nurse's initial assessment to include evaluation for which of these? 1.Nutritional deficiencies. 2.Ambulation problems. 3.Hearing difficulties. 4.Head injury.

4. Stroke: caused by thrombosis, embolism, ischemia, or hemorrhage. Signs and symptoms: loss of movement, thought, memory, speech, or sensation. Aphasia: inability to use or comprehend language, due to damage in cerebral hemisphere. Dysarthria: problem with rate, rhythm, or articulation of speech due to loss of motor function of muscles for speech. Expressive aphasia: difficulty speaking. Nursing responsibilities: repeat directions, break down tasks into components, face client, and speak clearly and slowly. Give client time to respond. Assist with facial muscle exercises.

The client is diagnosed with a stroke in the left temporal lobe. When performing an assessment of the client, the nurse expects some impairment in which of these? 1.Control of the left arm. 2.Glucose metabolism. 3.Corneal reflex in both eyes. 4.Speech comprehension.

4. Stroke: disruption in blood supply to brain. Causes: thrombus, embolus, or hemorrhage. Risk factors: hypertension, diabetes mellitus, heart disease, smoking, substance abuse, obesity, stress, lack of exercise, hyperlipidemia. Usually seen after age 65. Signs and symptoms: aphasia (impairment in ability to communicate through speech), alexia (difficulty reading), agraphia (impairment in ability to write), headache, syncope, motor or sensory disturbances (paresthesia, paralysis), facial droop, hemiparesis.

The client with a history of alcoholism is brought to the emergency department in an agitated state. The client is vomiting and diaphoretic. The client had the last drink 5 hours ago. The nurse expects to administer which medication? 1.Disulfiram. 2.Methadone hydrochloride. 3.Naloxone hydrochloride. 4.Chlordiazepoxide hydrochloride.

4. Symptoms of acute alcohol withdrawal include tremors, being easily startled, insomnia, anxiety, anorexia, and hallucinations. Nursing care includes administering sedation as needed, monitoring vital signs, seizure precautions, orienting frequently, and not leaving hallucinating, confused client alone.

The nurse performs screening on a group of older adult male clients. The nurse recognizes that which is the most frequent cause of urinary problems in this population? 1.Degeneration of the renal arteries. 2.Degeneration of prostatic tissue. 3.Hyperplasia of the renal arteries. 4.Hyperplasia of the prostate gland.

4. Symptoms of benign prostatic hypertrophy (BPH) include frequency, urgency, decreased urinary stream, hesitancy, dysuria (occasionally) and nocturia; later symptoms may include cystitis, hydronephrosis, or urinary calculi.

The nurse cares for the client after a ureterolithotomy. The nurse notes that the client has a left ureteral catheter in place. The nurse includes which of these in the client's plan of care? 1.Clamp the catheter for short periods of time. 2.Irrigate the ureteral catheter every 2 hours. 3.Gently advance the catheter if no drainage is observed. 4.Instruct the client that urine from the catheter should be clear.

4. Ureterolithotomy is surgical removal of calculus from the ureter; do not irrigate ureteral catheter; check incisional drain; check surgical dressing; encourage oral fluids.

The nurse conducts a physical assessment of a newly admitted client. When auscultating breath sounds over the trachea, the nurse normally expects to hear sounds that can be best characterized as which of these? 1.Soft and low pitched. 2.Coarse and rumbling. 3.Fine and crackling. 4.Loud and high pitched.

4. Use diaphragm of stethoscope, have client take slow, deep breaths through the mouth. If crackles or wheezes are heard, ask client to cough to see if sound changes.

The nurse cares for a client who will be taking phenelzine sulfate following discharge. Which of these is important information for the nurse to include in the teaching plan regarding this medication? 1.The effects of the medication will be seen immediately. 2.I will follow a low fiber diet while taking the medication. 3.Drinking coffee or carbonated beverages will decrease the effectiveness of the medication. 4.Combining the medication with certain foods significantly increases blood pressure.

4. phenelzine sulfate is a monoamine oxidase (MAO) inhibitor; interacts with foods containing tyramine or medications containing sympathomimetic substances to cause a hypertensive crisis.