Nclex review

A client has had a positive reaction to purified protein derivative (PPD). Which statement made by the client suggests the client understands the teaching by the registered nurse (RN)?

"I have been exposed to mycobacterium tuberculosis." The PPD skin test is used to determine the presence of tuberculosis antibodies and a positive result indicates that the person has been exposed to mycobacterium tuberculosis. Additional tests, such as a chest x-ray, are needed to determine if active tuberculosis is present

A client exhibits many delusional thoughts. As the nurse assists the client to prepare for breakfast, the client comments, "Don't waste good food on me. I'm dying from this disease I have." Which response by the nurse would be the best?

"I know you believe that you have an incurable disease The correct response is one that does not challenge the client's delusional system and provides some reassurance of a desire to help the client. The comment does not confirm the client's comment but simply reflects that the nurse has listened and heard the comment.

A client asks the nurse for information about a living will. Which statement made by the client demonstrates an understanding of a living will? (Select all that apply.)

"I should sit down and discuss my wishes for end-of-life care with my loved ones." "A living will is a legal document that becomes a permanent part of my health care record." "My wishes for end-of-life treatment are stated in writing "I will need to identify someone to be my health care proxy." An advance health care directive is also known as a living will. It is a legal document in which a person specifies his or her wishes concerning medical treatments at the end-of-life, when s/he is unable to make those decisions. Advance care planning involves sharing personal values and wishes with loved ones and selecting someone, (called a medical power of attorney or health care proxy) who will eventually make medical decisions on the client's behalf. A living will does not expire; it remains in effect unless it is changed. A living will does not include information regarding assets or a person's estate.

A nurse has reinforced teaching for a client who is being discharged after an arterial revascularization of the right lower extremity. Which statement made by the client is incorrect and requires further discussion with the nurse?

"I will put my right leg through a full range of motion." To prevent arterial occlusion after arterial revascularization, the nurse should have the client avoid full range of motion. This prevents stress or kinking of the grafts. A throbbing pain may indicate that the blood supply is increasing in the surgical area and this is a desired effect. Smoking causes vasoconstriction and will contribute to occlusion. Coughing and deep breathing are important after any surgery.

A pregnant client asks the nurse about the scheduled blood test for alpha-fetoprotein (AFP). The nurse's explanation should include which of these comments?

"It can help identify potential neurological defects." AFP is a substance made in the liver of the fetus. A fetus with neural tube defects, such as spina bifida and anencephaly, loses AFP to the amniotic fluid and, consequently, to maternal blood. The blood test is performed between the 15 and 17 weeks of pregnancy and can be used as part of a screening test to find chromosomal problems, such as Down sydrome.

The registered nurse is teaching a childbirth education class about postpartum depression. Which statement, made by a class member, indicates that more teaching is needed?

"It's common for women with postpartum depression to have delusions about the infant." Postpartum depression symptoms include sleep and appetite disturbances, uncontrolled crying, with feelings of guilt and/or worthlessness. Although postpartum depression typically occurs within the first three months after delivery, it can occur up to a year later. A new mother who has symptoms of postpartum depression should take steps to get help right away. Delusions are associated with postpartum psychosis, not depression.

The client calls the clinic nurse and reports nausea, headache and fatigue. The client also reports seeing yellow halos around lights. What is the best response by the nurse?

"Tell me about your prescription for digoxin. Are you still taking the medication?" Nausea, headache and fatigue are vague symptoms that could be associated with many different causes. However, seeing yellow halos around lights is an early sign of digitalis toxicity. The nurse should ask the client if s/he is still taking digoxin. If s/he is still taking the medication, the nurse should ask the client to come in to the clinic right away for further assessment, as well as lab tests (serum digoxin level, electrolytes and renal function studies) and an ECG.

A client is scheduled for a percutaneous transluminal coronary angioplasty (PTCA). What should the nurse understand about the purpose of this procedure?

A process to compress arterial plaque to improve blood flow PTCA is performed to improve coronary artery blood flow in a diseased artery. It is performed during a cardiac catheterization.

When reviewing the medication lithium with a client, the client asks, "How long will it take before I can feel the effects of the medication?" Which response by the nurse is the best?

About two weeks" Lithium is a fast-acting mood stabilizer and quite effective in controlling mania soon after starting the medication. But it may take several weeks for it to reach maximum effectiveness.

The nurse is planning the therapeutic milieu and the various activity groups for a client. What is the primary goal for the nurse to consider?

Achieve a client's therapeutic goals Milieu therapy is the scientific planning of an environment for therapeutic purposes. Activity groups are used to enhance the therapeutic milieu and to meet the clinical and social needs of clients, to minimize withdrawal and regression while learning to more effectively interact with and relate to others, to develop self care skills, etc. A successful therapeutic milieu is a safe and trusting environment where all participants have a voice in decision making.

A client has a percutaneous endoscopic gastrostomy (PEG) tube that is used to administer feedings and medications. Which nursing action is best to ensure patency of the tube?

Adequately flushing the tube with water before and after use Prior to using the tube, it must be checked to make sure it is free from obstruction and leaks. Milking the tube may help dislodge an obstruction, but flushing the tube before and after use is the best way to ensure patency (while providing hydration). Liquid medication preparations are best, but tablets and pills can be dissolved in water (and flushed with 30-50 mL of water afterwards.) If the client experiences abdominal bloating, the nurse can encourage the client to cough, which will speed up the removal of excessive air, but the tube still needs to be flushed with water before and after use.

The client needs to be moved up in bed. The client is able to partially assist and weighs 135 pounds. Which action by the nursing staff best supports an awareness of ergonomics and safe client handling? (Select all that apply.)

Adjust the height of the bed for caregivers Move the bed into the flat position Use a friction-reducing device The algorithm for safe client handling and repositioning a client from side-to-side or up in bed states: use 2 to 3 caregivers for a client who can partially assist and who weighs less than 200 pounds, use a friction-reducing device, move the bed so that it's flat and at a comfortable height for the caregivers. The client should not be pulled from the head of the bed. There really is no safe method to manually lift another adult.

The nurse is caring for a client diagnosed with acute angina. The client reports substernal chest pain, diaphoresis and nausea. What should be the first action by the nurse?

Administer PRN pain medication as ordered In a client with a diagnosis of acute angina, chest pain means the heart is deprived of oxygen. The priority action would be to give the prescribed pain medication, which will improve oxygenation to the heart. Detailed assessment of the pain, lab tests and ECG can be done once the medication is given. Mostly likely this client would also have a standing order for nitroglycerin.

A nurse is caring for a client who has been diagnosed with acute sickle cell vaso-occlusive crisis. Which intervention by the nurse would be most important?

Administer analgesic treatment as ordered Pain is very severe in sickle cell crisis, and is a priority in care. The main objectives in the treatment of a sickle cell crisis is providing analgesics for pain, adequate hydration, oxygenation, bed rest, electrolyte and blood replacement, and antibiotics to treat any existing infection that could have contributed to the crisis. Because pain causes sympathetic stimulation, which results in vasoconstriction, pain management is the most important nursing action among the given choices. Clear liquids, bed rest and temperature control measures assist in reducing the ischemia associated with a sickle cell crisis. You will note that this is a specific question, requiring a specific answer. When deciding on which option to select, you should conclude that pain control should take priority over the other options.

A newborn is diagnosed with hypothyroidism. In discussing the condition and treatment with the family, the nurse should emphasize which point?

Administration of a thyroid hormone will prevent problems You will notice that only one option (the correct response) includes the word "thyroid." Associate this with the content of this question, which is hypothyroidism. This option also addresses replacing something that is missing (hypo) making it a "treatment" for the content of this question. Early identification and lifetime treatment with hormone replacement therapy (levothyroxine) corrects this condition

The nurse is caring for the neonate immediately following a vaginal delivery. Which of the following interventions will promote temperature regulation in the neonate? (Select all that apply.)

After drying off the wet amniotic fluid, placing the neonate under the radiant warmer or placing the neonate skin to skin against the mother will provide a source of heat for the neonate. Wrapping the neonate in blankets will help to reduce heat loss. The neonate should not be bathed until the temperature is stabilized.

A nurse is talking to a group of parents about how to reduce risks in the home. What is the most important factor for the nurse to consider during the discussion?

Age of children in the home Age and developmental level of the child are most important considerations when providing a framework for anticipatory guidance to reduce risks for harm. When considering the answer to this question, look for options that are similar but dissimilar and are the options focusing on children. To decide between these two options, consider the factor that might have a greater impact on risks in the home: age or number of children.

A client is admitted with diagnosis of a right upper lobe infiltrate and to rule out active tuberculosis (TB). Which type of precautions will be needed for this client?

Airborne Airborne precautions include an OSHA mandated/NIOSH certified respirator, negative pressure in a private room with the door closed or a semiprivate room with both clients diagnosed with the same disease (called cohorts), and limited movements or transport of the client. If these clients have to leave the room, they must wear a mask. A tight fitting, high-efficiency mask, such as the particulate HEPA filtered respirator mask, is required when caring for clients who have suspected communicable disease of the airborne variety. Active TB, measles and chicken pox require airborne precautions. Droplet precautions are used for influenza, whooping cough and mumps. Contact precautions are for active HSV lesions, VRE, MRSA, lice, scabies, RSV and impetigo.

When reinforcing teaching about a new prescription for nortriptyline to a client diagnosed with depression. What information should the nurse emphasize?

Alcohol use is to be avoided Alcohol potentiates the action of tricyclic, as well as other, antidepressants such as nortriptyline (Pamelor). If the medication is unknown, focus on what is known. The client has been diagnosed with depression and is likely on an antidepressant. Then think about what you know about antidepressants and each of the options. Select the response with "alcohol" because this is the more common substance to avoid with most medications.

A nurse is preparing to take a toddler's blood pressure for the first time. Which action should the nurse perform first?

Allow the child to handle the equipment before applying the cuff The best way to gain the toddler's cooperation is to encourage handling the equipment. Detailed explanations are not helpful. This is the best and most age-appropriate response.

The client is diagnosed with Parkinson's disease (PD) and takes more than one hour to dress for scheduled therapies. Based on this finding, what is the most appropriate nursing intervention?

Allow the client the time needed to dress Parkinson's disease is a degenerative neurological disorder resulting from nerve cells in the brain not producing enough dopamine, which regulates movement. People with PD experience tremors, muscle stiffness, slow movement, rigidity and poor balance and coordination. With careful planning and activity modification, the client can maintain his ability to safely care for himself. The nurse should plan for and allow enough time for the client to meet his own needs when dressing, toileting and bathing.

The nurse is caring for a hospitalized adolescent. The nurse recognizes that which of these concerns will be the greatest for a hospitalized adolescent?

Altered body image Hospitalized adolescents may see all of these issues as a concern when they are hospitalized. However, the major threat is the fear of an altered body image because of the emphasis on physical appearance during this developmental phase.

pyloric stenosis

Although some spitting up (vomiting) is expected in newborns, a significant finding in pyloric stenosis is that mild regurgitation or spitting up progresses to projectile vomiting. Pyloric stenosis is a narrowing of the pylorus, which is the opening from the stomach into the small intestine. This prevents stomach contents from emptying into the small intestine. Treatment involves surgical intervention. For future reference, associate the word "projectile" with the words "pyloric stenosis" or increased intracranial pressure because these are the only two situations in which projectile vomiting occurs.

The ICU nurse works in a rural hospital that has a remote electronic ICU monitoring system (eICU.) What is one of the best reasons for having access to an eICU?

An ICU nurse and intensivist remotely monitor ICU clients around the clock Using cameras, microphones, and high-speed computer data lines, the eICU involves having an experienced ICU nurse and practicing intensivist monitoring ICU clients in remote locations around the clock. The eICU does not change the ratio of nurses to clients at the bedside, but it does make the nurse's bedside time more productive and assistance from their remote colleagues is only a push button away.

A client with a fracture of the radius had a plaster cast applied two days ago. The client calls the clinic to report constant pain and swelling of the fingers since the cast was applied. What should be the next action of a nurse?

Ask if numbness is present in the fingers and if the client can move the fingers A deterioration in neurovascular status indicates the potential development of compartment syndrome (elevated tissue pressure within a confined area with resultant of nerve and vessel compression), which requires immediate pressure reducing interventions such as a fasciotomy. The nurse should question the client about impaired neuro findings such as numbness, tingling and inability to move fingers. Remember the first action is usually to gather data. The word "ask" in the option is a data collection word, suggesting that this option is the correct answer.

A 28-year-old is transferred to the emergency department (ED) via ambulance with a traumatic head injury. The client is awake and reports having a headache and some amnesia. What are the priority nursing interventions for this client? (Select all that apply.)

Assess the wound for presence of drainage or bruising on the head Assess vital signs and neurological function Assess the airway Prepare for CT imaging of the head Remember primary emergency trauma assessment using "A, B, C, D and E". The ED nurse will assess airway, breathing, circulation, and disability/neurological function on a person who has experienced a traumatic head injury. The nurse will also examine the client for the presence of any bruising or drainage, particularly of the ears and nose. A supine position is best; the head of the bed may be elevated slightly if not contraindicated. A CT scan is required if the client presents with an abnormal mental status, clinical signs of skull fracture, history of vomiting, or headache.

A practical nurse (PN) team member identifies that the fundus is boggy for a woman who is gravida 4 para 4 and is two hours after a spontaneous vaginal delivery. The fundus is displaced slightly above and to the right of the umbilicus. What should be the initial nursing action?

Assist the woman to empty her bladder A full bladder can displace the uterus and prevent contraction. After the woman empties the bladder, the fundus should be assessed again. The most common deviation of the fundus by a full bladder is upward and to the right.

Autistic

Autism, also called autism spectrum disorder (ASD), is a complicated condition that includes problems with communication and behavior. It can involve a wide range of symptoms and skills. ASD can be a minor problem or a disability that needs full-time care in a special facility.

The nurse is reinforcing dietary instructions to the parents of a child diagnosed with cystic fibrosis. The nurse will emphasize which of the following characteristics of this diet?

Balanced, high calorie diet with extra fat, salt, protein and calcium A child with cystic fibrosis needs a well-balanced, high calorie diet that includes extra fat, salt, and protein. Children with CF are at risk for osteoporosis, which is why they need full fat dairy products. Carbohydrate counting is recommended for children with diabetes. Foods low in sodium, potassium and phosphorus are tips for people with chronic kidney disease. A gluten-free diet is the only treatment for celiac disease.

The parents of a school-age child are providing information to the nurse about their child. Which of these health issues should the nurse recognize as a finding that could suggest type 1 diabetes?

Bedwetting In school-aged children, warning signs of type 1 diabetes include: fatigue, frequent urination (also bed wetting), unusual thirst, extreme hunger, and weight loss. Also, diabetics usually have dry skin. The parents may not initially think anything of the polyphagia or polydipsia, but bed wetting in a school-age child (who previously did not wet the bed at night) would prompt the parents to seek medical intervention.

A pregnant woman has been advised to alter her diet during pregnancy by increasing the intake of protein and vitamin C to meet the needs of the growing fetus. Which diet choice would best meet the woman's needs?

Beef, one-half cup of lima beans, glass of skim milk, three-fourths cup of strawberries. Beef and beans are an excellent source of protein, as is skim milk. Strawberries are a good source of vitamin C.

A client is receiving digoxin

Both medications decrease the heart rate. Metoprolol (Lopressor) affects blood pressure. Therefore, the heart rate and blood pressure must be within normal range (HR 60-100; systolic BP over 100) in order to safely administer both medications

The nurse discovers an unresponsive client and determines there is no pulse. This nurse then activates the code notification button to alert all personnel about the code and begins chest compressions. What is the function of the second nurse on the scene?

Bring the code cart Typically, the second person on the scene brings the code cart and then assists with CPR. In larger facilities, a code team assists with the code and each nurse has a specific duty. Cardiopulmonary resuscitation should not be started on a client who is a DNR, but if it is started, then CPR has to be continued.

The client is seen in the emergency one day after falling in his bathroom at home. The client reports having "a few drinks" prior to the fall. Which finding requires the nurse's immediate attention?

Bruise behind one ear Bruising behind one ear (over the mastoid process) requires the nurse's immediate attention. Known as "Battle's sign", this injury is seen a day or so following a basilar skull fracture. A CT scan of the brain will confirm a skull fracture. The client may report loss of hearing, smell or vision and he may have blood leaking from the ear. The vomiting and headache could be due to his alcohol intake, as well as the skull fracture.

The nurse is assessing a client who has been treated long-term with glucocorticoid therapy. Which finding might the nurse expect?

Buffalo hump The most common side effects of glucocorticoid therapy include increased appetite (and weight gain), increased blood sugar, change in body shape (increase in fatty tissue on the trunk with thinner legs and arms), acne, thinning of the skin and easy bruising. The client may also have a hump behind the shoulders; the hump is an accumulation of fat on the back of neck.

There's a new order to apply one-inch of nitroglycerin paste to the client's chest every 12 hours, but the medication is not in the automatic medication dispensing system's drawer for this client. What should the nurse do next?

Call the pharmacy to send up a tube of nitroglycerin paste The nurse must call the pharmacy and ask to have the medication sent to the floor. It is never acceptable to borrow another client's medication; this is an example of at-risk behavior, commonly referred to as a "workaround." The nurse can never substitute one formulation of a medication for another, without a specific order to do so. Giving a medication without an order would be considered a medication error and is an example of working outside the nurse's scope of practice.

A nurse gathers data related to delayed gross motor development in a 3 year-old client. Which observation by the nurse should confirm this finding?

Cannot stand on one foot At this age, gross motor development allows a child to balance on one foot. A child who is 3 years old should be able to hop, ride a tricycle and throw a ball (but they would have trouble catching it). Most young children with fetal alcohol syndrome, for example, show delays in motor skill development (both fine and gross motor).

The pregnant woman asks how a health care provider (HCP) can tell she is pregnant "just by looking inside." What is the best explanation for this?

Chadwick's sign is a bluish-purple coloration of the cervix and vaginal walls. It develops after the 6 to 8 weeks and is caused by increased blood supply to the area. Other early signs of pregnancy include Hegar's sign (a softening of the cervical isthmus) and Goodwell's sign (a softening of the cervix), but the HCP would need to compress the tissue to assess these findings. The HCP would not see the mucus plug; the mucus plug dislodges, breaks up and passes out of the body just prior to labor.

A 6 month-old infant is being treated for developmental hip dysplasia and has been placed in a hip spica plaster cast. Which discharge information is important for the nurse to reinforce with the parents?

Check frequently for swelling in the baby's feet The parents of a child in an initial hip spica cast must check for circulatory impairment. The nurse should reinforce the importance of observing the extremities for swelling, discoloration, movement and sensation. Remember to look for the six Ps of impaired tissue perfusion: pain, paresthesia, pallor, pulselessness, paralysis and poikilothermia (coolness). Sometimes blowing cold air (never warm or hot) from a hand-held hair dryer into the cast can help with itching, but care should be taken never to insert anything into the cast.

The registered nurse (RN) has initiated the administration of an intravenous vesicant chemotherapeutic agent to a client. Which finding during the care by a practical nurse (PN) would require the PN to immediately notify the RN?

Complaints of pain at the infusion site A vesicant is a chemotherapeutic agent capable of causing blistering of tissues and possible tissue necrosis if there is extravasation. These agents are irritants that cause pain along the vein wall, with or without inflammation. When deciding on the best response, think about which option would create the worst outcome for the client receiving IV medication.

The nurse is caring for a client diagnosed with acute pancreatitis. After pain management, which topic should be reinforced during a client conference

Cough and deep breathe every two hours Respiratory infections are common with this diagnosis because of fluid in the retroperitoneum pushing up against the diaphragm causes shallow respirations. Encouraging the client to cough and deep breathe every two hours will diminish the occurrence and risk of this complication. Nutrition should include eating foods high in B-vitamins and iron, avoiding refined foods and caffeinated beverages, and eating fewer red meats. During the acute phase of this diagnosis, the client will be NPO to promote healing of the pancreas.

Diagnosed with heart failure, the client had an implantable cardioverter-defibrillator (ICD) implanted several years ago. The client now has end-stage heart failure and is receiving home hospice care. Which end-of-life care option could have the greatest impact on client comfort?

Deactivating the implantable cardioverter-defibrillator (ICD) Family or caregivers can help the client to sit upright, which will help decrease cardiac workload and facilitate breathing, but oxygen and morphine are also needed to help with shortness of breath and comfort. Eating several smaller meals of appealing and easily digestible food is recommended, but caregivers should not try to force the client to eat because it does not help the person live longer and may be uncomfortable. Discussing advanced directives can provide some peace of mind for the client and family, but this client would have a do-not-resuscitate order. Deactivating the ICD will have the greatest impact on comfort. Repeated shocks delivered by an ICD can be painful for the client and difficult for the family to witness, which is why the health care provider should discuss and encourage deactivating the ICD.

Lactulose has been prescribed for a client with advanced liver disease. Which finding should the nurse use to evaluate the effectiveness of this treatment?

Decreased lethargy Lactulose is a synthetic sugar used to treat constipation and reduce the amount of ammonia in the blood of clients with liver disease. It works by drawing ammonia from the blood into the colon, where it is removed by the body. Hepatic encephalopathy (HE) occurs in people with end-stage liver disease. People with HE may experience problems with memory, concentration and may experience drowsiness and lethargy; lactulose is used to help manage these symptoms. Lactulose is not used to treat edema or jaundice.

The nurse is reinforcing information about the side effects of fluoxetine to a client. Which group of findings should be included?

Diarrhea, dry mouth, weight loss, reduced libido Fluoxetine (Prozac) is a selective serotonin reuptake inhibitor (SSRI). it is used to treat depression, obsessive-compulsive disorder, some eating disorders and panic attacks. Commonly reported side effects include diarrhea, dry mouth, weight loss and reduced libido.

An 80 year-old client is scheduled for a cardioversion. The nurse is reviewing the client's medication administration records for the previous 24 hours. Which medication would prompt the nurse to notify the health care provider?

Digoxin increases ventricular irritability and increases the risk of ventricular fibrillation following cardioversion. The other medications do not increase ventricular irritability.

A 2 day-old infant born with spina bifida and meningomyocele is recovering after an initial surgery. As the nurse accompanies the grandparents for their first visit since the child's birth, which of these responses might the nurse expect from the grandparents?

Disbelief The first phase of the grieving process is shock, disbelief or denial. The next steps in the process of grief are anger, bargaining, depression and then acceptance

A couple experienced a miscarriage at seven months of pregnancy. The nurse makes a home visit one week after discharge from the hospital. What intervention should the nurse emphasize to the couple during the home visit?

Discuss feelings with support persons and each other With therapeutic communication the nurse should help the couple begin the grief process by suggesting they seek family, friends and support groups to listen to their feelings and thoughts. The more talking that is done, the more the couple can work through feelings of grief and sadness.

A client with heart failure is newly referred to a home health care agency. The nurse determines that the client has not been following the prescribed diet. It would be most appropriate for the nurse to take which action at this time?

Discuss the diet with the client to learn the reasons for not following the diet When new problems are identified, a nurse should collect more data and verify accurate information. Before reporting findings to a health care provider, a complete understanding of the client's behavior and feelings are needed. This information serves as a basis for interventions and future reinforcement of teaching.

The nurse is assisting with the delivery of a newborn infant. What is the priority nursing intervention for a normal newborn immediately after delivery?

Dry off infant with a warm blanket or towel The priority interventions are in recovering a normal newborn. Maintaining the infant's temperature by drying, warming, and removing any wet blankets or towels are the priority interventions. All interventions are correct, but warming and drying would be the priority.

A nurse is caring for a child who has been recently diagnosed with cystic fibrosis. Which finding should the nurse anticipate?

Dry, nonproductive cough Noisy respirations and a dry nonproductive cough are usually the first respiratory findings to appear in a newly diagnosed cystic fibrosis client. Because the question relates to a respiratory condition, you should select a respiratory option (and there is only one option related to the respiratory system).

The nurse assesses a client who has been taking haloperidol for several months. Which adverse effect must be immediately reported to the health care provider?

Dystonias often involve tongue protrusions and muscle rigidity. Dystonias usually resolve after the medication is discontinued, but the client may require antihistamine and antiparkinsonian therapy. Dystonic movements have the potential of becoming irreversible and must be immediately reported to the health care provider. Some of the more common side effects of haloperidol include nausea, vomiting, diarrhea, dry mouth, nervousness, drowsiness, insomnia, and blurred vision.

The nurse is caring for a client who is diagnosed with chronic renal failure with hemodialysis three times per week. The client becomes confused and irritable six hours before the next treatment. Which of these findings might explain the reason for the client's behavior?

Elevated blood urea nitrogen (BUN) Confusion and irritability are findings of renal encephalopathy secondary to elevated levels of BUN and creatinine in the blood. Potassium levels are generally high in renal failure along with phosphate levels. Calcium may be low in chronic renal failure. However, the side effects of low calcium levels are exhibited as abdominal or muscle cramping, parasthesias of the extremities, and hyperactive reflexes. Metabolic acidosis, not alkalosis, results from renal failure.

A 16 month-old child has just been admitted to the hospital. As the nurse assigned to this child enters the hospital room for the first time, the toddler runs to the mother, clings to her and begins to cry. What should be the next action of the nurse?

Explain to the parent that this behavior is expected During normal development, fear of strangers becomes prominent beginning around age 6 to 8 months. Such behaviors include clinging to parent, crying and turning away from the stranger. These fears and behaviors extend into the toddler period and may persist into preschool.

A practical nurse (PN) is observing an 8 month-old infant in the clinic waiting room. Which activity should be reported to the registered nurse (RN)?

Falls forward when sitting Sitting without support is normal for infants between seven to nine months of age. You will note that the question implies there is a problem. As you read each answer, ask yourself if the behavior is normal for an 8 month-old child. You will also note that there are two options with neurologic components and two options focusing on musculoskeletal development. Because the nervous system would be a priority over the musculoskeletal system, you should then identify the 8 month-old who cannot sit up as the abnormal condition.

The nurse works in a psychiatric inpatient setting. What information should the nurse be aware of as one of the most frequent reasons for suicide in adolescents?

Feelings of alienation or isolation from peers The isolation may occur gradually resulting in a loss of all meaningful social contacts. Isolation can be self-imposed or can occur as a result of the inability to express feelings. Notice that two of the options deal with "feelings." When deciding between the two, ask yourself which feelings would "most frequently" lead to suicide - anger or isolation?

A client diagnosed with gout is admitted with severe pain, swelling and redness in the proximal toe joint of the right foot. The nurse should anticipate that the plan of care would include which focus?

Fluid intake of at least 3000 mL/day Gout is a very painful condition in which uric acid crystals collect in a joint causing severe pain and inflammation. Fluid intake should be increased in the client with gout to prevent kidney stones from precipitation of urate in the kidneys. The diet should be low in purines to prevent uric acid formation. NSAIDs, such as ibuprofen or naproxen, are often prescribed to reduce inflammation and pain. If compresses are used, they would be warm, not hot.

The nurse is giving a morning bath to a client who has a colostomy. While giving the bath, the nurse should reinforce that the collection pouch should be emptied at what time?

Fluid intake of at least 3000 mL/day Gout is a very painful condition in which uric acid crystals collect in a joint causing severe pain and inflammation. Fluid intake should be increased in the client with gout to prevent kidney stones from precipitation of urate in the kidneys. The diet should be low in purines to prevent uric acid formation. NSAIDs, such as ibuprofen or naproxen, are often prescribed to reduce inflammation and pain. If compresses are used, they would be warm, not hot.

The client undergoes a gastrectomy. Several hours after surgery, the nasogastric (NG) tube stops draining. What action does the LPN anticipate the RN will take first?

Gently irrigate the tube with sterile normal saline The RN will assess the position and patency of the NG tube, as well as the color and amount of gastric drainage. The RN can gently irrigate the NG tube with sterile normal saline if it becomes clogged. But if that does not resolve the issue or if repositioning the tube is needed, the RN must call the surgeon. The NG tube inserted in surgery should not be repositioned by a nurse because of the risk of disrupting any internal sutures. It would be contraindicated to increase the suction.

A client diagnosed with head trauma is in a non-responsive state. Vital signs are stable and breathing is regular and spontaneous. What should the nurse document to accurately describe the client's status?

Glasgow Coma Scale 8, respirations regular The Glasgow Coma Scale uses a scoring system based on a scale of 3 to 15 points. It is used to assess a client's neurological condition, based on motor response, verbal response and eye-opening. A low score indicates that coma, and its associated neurological impairment, is present. Using the term "comatose" provides vast opportunity for interpretation and is not precise. Avoid using terms such as "appears" or "ventilator required."

A client diagnosed with head trauma is in a non-responsive state. Vital signs are stable and breathing is regular and spontaneous. What should the nurse document to accurately describe the client's status?

Glasgow Coma Scale 8, respirations regular The Glasgow Coma Scale uses a scoring system based on a scale of 3 to 15 points. It is used to assess a client's neurological condition, based on motor response, verbal response and eye-opening. A low score indicates that coma, and its associated neurological impairment, is present. Using the term "comatose" provides vast opportunity for interpretation and is not precise. Avoid using terms such as "appears" or "ventilator required."

A client is admitted to the hospital with a history of confusion. The client has difficulty remembering recent events and becomes lost when outside of the home. Which statement would provide the best reality orientation for this client?

Good morning. You're in the hospital. I am your nurse Elaine Jones." The best statement is one that provides information in a short and direct manner. Nurses should simply establishes the time, location and state their name. With reality orientation, nurses should be brief and to the point; you will note that each statement uses five or fewer words. These types of statements will enhance recall and memory. For clients who are confused, it's best not to engage in a guessing game and ask if they know where they are, or why they are in the hospital.

A pregnant client comes to the clinic for a first visit. A nurse gathers data about her obstetric history, which includes: three year-old twins at home and a miscarriage at 12-weeks gestation 10 years ago. Which documentation should the nurse make?

Gravida 3 para 2 Gravida is the number of pregnancies and parity or para is the number of pregnancies that reach viability (which is considered 20 weeks). This woman is now pregnant. She has also had two prior pregnancies, with one of those pregnancies reaching viability (the twins). Remember to simply count the number of pregnancies, as well as the number of pregnancies that reached viability; avoid confusing twins or multiple births with the number of viable births. If asked to document information using the five number system, it would be: 3-1-0-1-2 (gravida, term pregnancies, preterm, abortions, living children).

The nurse is to administer meperidine 100 mg, atropine 0.4 mg, and promethazine 50 mg IM to a client preoperatively. Which action should the nurse take initially?

Have the client empty the bladder The first step in the process is to have the client get out of bed to void prior to administering the preoperative medication. For safety purposes, the client will be instructed to stay in bed after the preoperative medication has been given.

The mother of a hospitalized 2 year-old child asks a nurse's advice about the child's screaming every time the mother gets ready to leave the hospital room. The best advice by the nurse would include which approach?

Help the mother understand that this is a normal response to hospitalization The protest phase of separation anxiety is a normal response for a child this age. Separation anxiety is at its peak during toddler years of 12 to 36 months.

The client is receiving a thrombolytic agent to open a clot-occluded coronary artery following a myocardial infarction. Which finding would be the greatest concern and should be immediately reported to the registered nurse?

Hematemesis Frank bleeding should be of the greatest concern. Even though the other options indicate bleeding and would be a concern, they are not as acute or severe as someone who is vomiting blood.

The licensed practical nurse is caring for a client with advanced cirrhosis of the liver. Which finding should receive immediate follow-up by the charge nurse?

Hematemesis Vomiting of blood may indicate hemorrhage, especially from esophageal varices. This condition can be life-threatening, requiring immediate intervention.

Antihistamines, antidepressants and tranquilizers can aggravate urinary incontinence and should be avoided in clients with urinary incontinence

Holding the urine, avoiding high-sodium foods and restricting fluids have not been shown to reduce urinary incontinence.

A child is admitted to the unit with the suspected diagnosis of pertussis (whooping cough). What is the priority nursing intervention for this child?

Implement droplet precautions Although all the responses are appropriate nursing interventions, the priority is to implement strict droplet precautions, in addition to standard precautions. Pertussis is highly contagious and is spread through close contact. Therapeutic management focuses on providing respiratory support and eradicating the bacterial infection (macrolides, such as erythromycin, are the drug of choice). Administer fluids and keep the client hydrated to help thin secretions. It is also important to monitor the client's heart rate, respiratory status and oxygen saturation, especially during coughing paroxysms.

A nurse is caring for a client admitted with the diagnosis of suspected Legionnaire's disease. Which finding would require the nurse's immediate attention?

Increased use of accessory muscles of breathing Legionnaire's disease is a type of acute bacterial pneumonia. Increased use of accessory breathing muscles and labored breathing are indicators of respiratory distress and should be reported immediately. None of the alternative choices are associated with assessment of Legionnaire's disease; however, the other options would require further exploration. Notice that two options address the GI system, another option addresses the neurological and circulatory systems, and the remaining (correct) option addresses the respiratory system.

A 6 year-old child is hospitalized with findings of moderate edema, gross hematuria and mild hypertension associated with the diagnosis of acute glomerulonephritis (AGN). Which nursing intervention would be appropriate for this client?

Institute seizure precautions If AGN is untreated, renal failure, seizures and heart failure may result. Clients with AGN should restrict salt intake during the acute phase to control edema and volume-related hypertension. A protein-restricted diet may also be indicated. Underlying infections would be treated with antibiotics. Nursing care would include frequent monitoring of blood pressure, daily weights, intake and output, and seizure precautions.

The client with coronary artery disease has a prescription for nitroglycerin transdermal patches. What is the best reason the client should not wear a patch for more than 12 to 14 hours each day?

It may no longer work as well Nitroglycerin patches may not work as intended when they are used continuously. To prevent tolerance to the medication, clients should apply a patch once a day and remove it after 12 to 14 hours. Some of the more common side effects of wearing a nitroglycerin patch may include headache, dizziness, lightheadedness, nausea, redness or irritation of the skin that was covered by the patch

A client is admitted with newly diagnosed hypothyroidism. A nurse would expect the client to exhibit which finding until the client achieves a euthyroid state with therapy?

Lethargy Euthyroid is the state of having normal thyroid gland function. Hypothyroidism produces manifestations of a slowed metabolism, including lethargy. Heat intolerance, diarrhea and tachycardia are manifestations of increased metabolism, hyperthyroidism. The key words in this question are "hypothyroidism" and "antated findings." As you read each answer option, ask yourself if it sounds like a "hypo" function of the body - only one option is related to "slowing down."

A young adult seeks treatment in an outpatient mental health center. The client tells a nurse, "I am a government official and spies are following me." Upon further questioning, the client reveals that warnings must be heeded to prevent nuclear war. What is the initial therapeutic approach that the nurse should use?

Listen quietly without comment The client's comments demonstrate grandiose ideas. The most therapeutic response is to listen and avoid being drawn into the delusions. Security should be contacted if a client with delusions of grandeur poses a threat to the nurse or to other health care team members.

The nurse is caring for a client who is experiencing a panic attack. Which action would be the nurse's primary intervention for the client?

Maintain safety for the client Clients who display signs of severe anxiety need to be supervised closely until the anxiety is decreased because they may harm themselves or others. A panic attack is suspected when clients have the feeling that something bad will happen or when they experience a feeling of doom.

A client returns from the operating room after a right orchiectomy. What is the priority nursing intervention during the immediate postoperative period?

Manage postoperative pain Due to the location of the incision, pain management is the priority. Bladder spasms are more related to postoperative prostate surgery than testes removal.

The client is diagnosed with heart failure and oral digoxin is prescribed. What is the priority nursing assessment for this medication?

Measure apical pulse prior to administration Digoxin is an antiarrhythmic and an inotropic drug. It works to increase cardiac output and slow the heart rate, which is why the nurse should measure the apical pulse for one minute prior to administering the drug. The nurse will withhold the dose and notify the health care provider if the apical heart rate is less than 60 bpm (adult). Intake and output ratios and daily weights should be monitored for clients in heart failure, but this is not the priority. Impaired renal function may contribute to drug toxicity, which is why the nurse should monitor serum electrolytes, creatinine and BUN; the nurse should also monitor serum digoxin levels.

The client has an order for intermittent gastrostomy tube (G-tube) feedings. What is the priority action by the nurse to accurately assess correct placement of the G-tube?

Measure the pH of stomach content aspirate When pH strips are available, the priority action is to measure the aspirate's pH. Prior to each intermittent feeding, gastric pH is usually less than or equal to 5. Do not use an auscultation method to check tube placement because it is not reliable. The nurse should also assess bowel sounds; in the absence of bowel sounds, the nurse should hold the feeding and notify the charge nurse. Additionally, the nurse should verify that the external length of the tube has not changed.

A client has an indwelling catheter with continuous bladder irrigation after undergoing a transurethral resection of the prostate (TURP) 12 hours ago. Which finding at this time should be reported to the registered nurse (RN) charge nurse?

Minimal drainage into the urinary collection bag The LPN should report minimal drainage in the urinary collection bag because this puts the client at risk for bladder rupture. The flow rate of the continuous irrigation would need to be slowed until the health care provider is notified. If an order to irrigate the system is written, sterile technique would be used. The other options are all expected findings after this procedure

The medication benztropine mesylate (Cogentin) is ordered, but the nurse incorrectly administers carvedilol (Coreg). What are the most important actions the nurse should take after making this medication error? (Select all that apply.)

Monitor and document the client's blood pressure Notify the health care provider Notify the nurse manager Document the administration of carvedilol (Coreg) When a nurse makes a medication error, the client's safety and well-being are the top priority. The nurse will document giving the beta-blocker carvedilol and as well as any effects the medication has on the client. The health care provider must be notified; the nurse will document that the provider was called and that orders were implemented. The nurse manager must also be notified. Once the client is stable, the nurse will complete an incident/variance/quality-assurance report (usually within 24 hours of the incident.) The initial disclosure of the medication error with the client should occur as soon as reasonably possible after the event (usually within 1-2 days after the event).

A hospitalized infant is receiving gentamicin. Which nursing intervention should receive priority in the plan of care?

Monitor the infant's urine output Toxicity from aminoglycoside results in increased serum creatinine levels. Decreased urine output is one of the first findings of nephrotoxicity and renal failure. You will note that two of the options focus on "output." Remember that a priority intervention typically begins with data gathering; the word "monitor" is a "data collecting" word.

A client has completed a renal biopsy. Which nursing intervention is appropriate after a renal biopsy?

Monitor vital signs using post-op protocols The potential complication of this procedure is internal hemorrhage. Monitoring vital signs is critical to detect early indications of bleeding. The dressing should have no drainage, nor should it become saturated. No reason exists to keep the client NPO for 24 hours or to walk within four hours.

A 14 month-old child ingests a half a bottle of baby aspirin (81 mg) tablets. Which finding should a nurse expect to see in the child?

Nausea and vomiting Some of the earliest signs of salicylate toxicity include nausea, vomiting, diaphoresis and tinnitus. Other findings include hyperventilation, tachycardia and hyperactivity. As toxicity progresses, there may be agitation, delirium, hallucinations, convulsions, lethargy and stupor. With the large ingestion of the aspirin, which is an acid, the temperature may rise from the severe acidosis that increases metabolic rate. Hyperventilation may be present from the attempt of the body to rid the acid via carbon dioxide.

The client undergoes a laparoscopic removal of the appendix. Which postoperative instructions will the nurse reinforce? (Select all that apply.)

No showering for 48 hours after surgery Some shoulder discomfort can be expected Use 2 tablespoons of Milk of Magnesia if no bowel movement 3 days after surgery Restrict diet to bland, easily digestible food for a few days Laparoscopic surgery involves using carbon dioxide gas to open the inside of the abdomen, which pushes up the diaphragm; this may cause shoulder discomfort postoperatively. Clients should keep the dressings clean and dry for 48 hours before they can shower, but no tub baths for a few weeks. If "skin glue" is used over the incision(s), the client should not try to scrub it off because it will wear off on its own. Clients may resume normal activities as soon as they are able but no heavy lifting or aerobic exercise for about 2 weeks. If they do not have a BM after 2-3 days, clients can take 2 tablespoons of MOM several times a day until they have a BM. Diet can be advanced as tolerated but it's best to stick to non-greasy, non-spicy foods for a few days. Incorrect

A client becomes acutely short of breath with an SpO2 (oxygen saturation) of 82%. Which oxygen delivery system should the nurse apply that would provide the highest concentrations of oxygen to the client?

Non-rebreather mask When a tight seal is achieved using a non-rebreather mask, up to 100% of oxygen is available. The venturi mask, partial rebreather mask and simple mask cannot deliver oxygen concentrations as high as the non-rebreather mask. If you are unsure of the correct response, you should know that because the question is asking for the highest concentration of oxygen delivery, it would be unlikely that something with the words "partial" and "simple" would be correct, so you can eliminate those options. A Venturi mask can deliver a fixed concentration of oxygen, but in increments no higher than 40%.

An 80 year-old client is hospitalized for a chronic condition. The client informs family members that a living will has been prepared and the client wants no life-prolonging measures performed. The client's condition deteriorates and the client becomes unresponsive. Which of the following nursing actions is most appropriate?

Notify the attending physician The first action would be to notify the attending physician for further orders. Then the family member(s) can be contacted about his condition. When a client has an advanced directive, it is not appropriate to perform CPR on him.

A nurse is reinforcing information about the administration of an albuterol inhaler to an adult diagnosed with asthma. What should be the priority comment made by the nurse?

Notify the health care provider if your canister lasts only two weeks." If the client notices a need to use the albuterol inhaler more frequently, the health care provider should be notified so that a change in dose or medication can be ordered. If the client is frequently using the inhaler, this may indicate an ineffective medication or subtherapeutic dosage. The first step is to notice that this question is asking for the best ("priority") option where all four options are conceivably correct. Then ask yourself what would be the most serious effect that can happen. If the client runs out of necessary medication, then respiratory distress is possible.

The nurse is caring for a postoperative client following a closed reduction of distal tibia and mid-femur fractures. The client has a long leg plaster cast. Thirty-six hours after surgery, the client suddenly becomes confused, short of breath and spikes a temperature of 103 F (39.4 C). What should be the first action by the nurse?

Obtain the pulse oximetry reading Restlessness, confusion, irritability and disorientation may be the first signs of fat embolism syndrome. The nurse needs to confirm or rule out hypoxia first and then check for infection or sepsis. Fat embolism most often occurs 24 hours after the fracture of the long bones.

The nurse is assisting a withdrawn client to begin to develop relationship skills. Which nursing intervention should be most effective?

Offer the client frequent opportunities to interact with the nurse The withdrawn client is uncomfortable in social interaction. The nurse-client relationship is a corrective relationship in which the client learns both tolerance and skills for relationships within safe realms. To offer frequent interactions initiates the development of relationship skills.

A nurse is caring for a client with a sigmoid colostomy. The client requests assistance in removing the flatus from a one-piece drainable ostomy pouch. Which intervention should the nurse use?

Open the bottom of the pouch to allow the flatus to be expelled The only correct way to vent the flatus from a one-piece drainable ostomy pouch is to instruct the client to obtain privacy (the release of the flatus will cause odor), and to open the bottom of the pouch, release the flatus and then close the bottom of the pouch. Because the colostomy is at the sigmoid level, the stool will most likely be formed stool. Sometimes the bags will have a charcoal filter in the top where flatus can be expelled on a constant basis with minimal odor. Piercing the ostomy pouch is never an option because it could allow stool to leak from the pouch. Although ambulation will help to reduce flatus, this does not address the flatus currently in the pouch.

The client is instructed to collect stool specimens at home using the guaiac test. In addition to explaining how to collect the specimens, the nurse instructs the client to avoid certain substances prior to obtaining the stool specimens. Which of the following substances should the client avoid?

Oranges Marinated cauliflower and broccoli Grilled sirloin steak Foods like beef, which contain hemoglobin, will result in a false positive test and should be avoided for at least 3 days before the fecal occult blood test; chicken, pork and seafood can be consumed. Fruits and vegetables with high peroxidase activity, such as red radishes, broccoli, and cauliflower should also be avoided several days prior to obtaining specimens. Clients should also limit their intake of vitamin C because too much can lead to a false negative result. Aspirin and other nonsteroidal anti-inflammatory drugs can cause bleeding and should be avoided at least 7 days before the test; acetaminophen does not affect the test.

When a client returns from surgery after an open reduction with cast application for a femur fracture, a small blood stain is noted on the cast by the nurse. Four hours later, the nurse observes that the stain has doubled in size. What is the initial action for the nurse to take at this time?

Outline the spot with a pen and note the time and date on the cast Marking the outline of the drainage is a good way to assess the amount of bleeding over a period of time. The bleeding does not appear to be excessive; some bleeding is expected with open reduction surgeries. The nurse should inform the RN and then record the finding.

A nurse is assigned to care for a 10 month-old infant with the new diagnosis of anemia. Which of these findings should the nurse anticipate?

Pale mucosa inside the mouth In iron-deficiency anemia, the physical exam reveals a pale, tired-appearing child with mild to severe tachycardia. The skin may have a waxy appearance. Anemia that is severe can cause a lack oxygen to the body, causing the skin color to become an ashen, dusky gray instead of the classic skin color of cyanosis with oxygen deficiency. The hemoglobin level would be low rather than high in anemia.

A nurse is monitoring the client's initial postoperative condition after a total thyroidectomy. Which findings should the nurse expect as complications and report immediately to the registered nurse (RN)?

Paresthesia and muscle cramping Because the parathyroid gland may be damaged in this surgery, secondary acute hypocalcemia may occur. Findings of hypoparathyroidism include tetany, paresthesia, muscle cramps and seizures. Mild dysphagia and hoarseness is an expected postoperative finding and may last for six to eight weeks after surgery.

The client is diagnosed with asthma. What information should the nurse reinforce that the client should monitor on a daily basis?

Peak air flow volume The peak air flow volume decreases about 24 hours before clinical findings occur for acute asthma attacks. A peak flow meter is a small, hand-held device used to manage asthma by monitoring air flow through the bronchi and thus the degree of restriction in the airways. The peak flow meter measures the client's maximum ability to expel air from the lungs, or peak expiratory flow rate (PEFR or PEF). Peak flow readings are higher when clients have normal airways and lower when the airways are constricted. Most have colors to help explain the results: green = good or 80 to 100% of normal air flow; yellow = therapy (inhaler) needed 50 to 80% of normal air flow; and red = rapid response needed/medical alert or less than 50% of normal air flow.

A 3 year-old child is brought to the health clinic. The grandmother reports that the child is always "scratching his bottom" and is "extremely irritable." Based on this information, which health issue would the nurse assess for initially?

Pinworm Findings of pinworm infection include intense perianal itching. The itching is usually worse at night, which is why the child will also exhibit poor sleep patterns, general irritability, restlessness, bedwetting, distractibility and a short attention span. The eggs will stick to a piece of clear cellophane tape placed against the rectum and the eggs can be seen under a microscope. The nurse can also take some samples from under the child's fingernails to look for eggs. Recall tip: the "P in worms" are found where the "pooh" comes out - the anal/rectal area. Scabies is an itchy skin condition caused by a tiny mite that burrows under the skin, causing small, itchy bumps or blisters; the most commonly affected areas of the body are the hands and feet. Ringworm is a fungus with characteristic round, itchy irritations on the skin.

A school nurse monitors a child with a history of tonic-clonic seizures. The school nurse should inform teachers that if the child falls to the floor and experiences a seizure while in the classroom, which of the following would be the most important action to take during the seizure?

Place the hands or a folded blanket under the head of the child The priority during seizure activity is to protect the child from physical injury. Place a pillow, folded blanket or the hands under the child's head to prevent concussion or further head trauma. The other body parts are at less risk for injury.

A client diagnosed with autism begins to eat with both hands. The nurse can best handle the behavior by using which approach?

Placing the spoon in the client's hand and stating "Use the spoon to eat your food." By placing the spoon in the client's hand while giving basic instructions to the client identifies a need for adaptive behavior with instruction and a verbal expectation. This response is the most client-centered and therapeutic for the autistic child. Punitive responses should always be eliminated ("I believe you know better than to eat with your hands" and "You can't have any more food until...").

A Native American chief visits his newborn son and performs a traditional ceremony that involves feathers and chanting. The nurse comments to a colleague: "I wonder if he has any idea how ridiculous he looks - he's a grown man!" The nurse's comment is an example of what type of attitude?

Prejudice Prejudice is a hostile attitude toward individuals simply because they belong to a particular group presumed to have objectionable qualities. Prejudice refers to preconceived ideas, beliefs or opinions about an individual, group or culture that limit a full and accurate understanding of the individual, culture, gender, race, event or situation. If you are not sure of the correct answer, look at the words in quotation in the question and ask yourself: Does this nurse's statement sound like discrimination (a behavior or action) or prejudice (attitude)?

The nurse is caring for a postmature infant in the newborn nursery. What factor should the nurse recognize as being the primary reason associated with complications of being post-term?

Progressive placental insufficiency A post-term pregnancy is defined as extending 42 weeks and beyond. The placenta functions less efficiently as pregnancy continues beyond 42 weeks. If the fetus does not receive adequate nutrition, it will utilize its subcutaneous fat stores for energy. Consequently, post-term infants are susceptible to hypoglycemia because of the rapid use of glycogen stores. Also, the risk of meconium aspiration and umbilical cord compression increases past 41 weeks, predisposing the newborn to hypoxia. Chronic intrauterine hypoxia causes increased fetal erythropoietin and red blood cell production, resulting in polycythemia.

A nurse discusses the healthy use of both conscious and unconscious defense mechanisms with a group of clients. An appropriate goal for these clients would be to use these mechanisms for which purpose?

Protect the ego and diminish anxiety Ego defense mechanisms are unconscious proactive barriers that are used to manage instinct and affect the presence of stressful situations. Healthy reactions that use both types of defense mechanisms are those in which clients admit that they are feeling various emotions.

A client is diagnosed with a severe mental illness. What is the priority goal of involuntary hospitalization?

Protection from harm to self and others Involuntary hospitalization may be required for clients considered dangerous to self or others, or for individuals who are considered severely disabled by their illness. Remember that safety is always a priority. Although one of the goals of hospitalization is to restore maximum independent living as quickly as possible, this the reason why a person is involuntarily hospitalized.

The nurse calls for help after finding an unresponsive adult client in a hospital room. What action should the nurse take next for the client who has no pulse and is not breathing?

Provide a cycle of 30 compressions followed by two breaths The sequence of CPR should now be C-A-B, emphasizing circulation - providing chest compressions to maintain perfusion of the brain and vital organs. The nurse should first perform chest compressions, followed by opening the airway and then breathing. The ratio is 30 compressions to two breaths, regardless of how many rescuers there are (adult CPR). The American Heart Association promotes compression-only CPR for lay persons.

The client underwent a total hip arthroplasty 48 hours ago. The client has been up in a chair and is prescribed physical therapy twice daily. What type of nursing care is needed for this client? (Select all that apply.)

Provide a seat riser for the toilet or commode Place a soft foam triangular pillow between the client's legs when in bed Encourage client to perform leg exercises when in bed On the first post-operative day following a total hip arthroplasty, the client will be up in a chair. The client should bend the affected leg at the knee when sitting in a chair - not keep it straight. Two days after surgery, the client will be walking in the hallway. When in bed, the client should continue to perform leg exercises and use a pillow or foam wedge between his or her legs (to keep the legs abducted.) The drain is usually removed the second day after surgery; there should be little-to-no drainage on the second post-op day. The client can eat a regular diet after surgery.

A newborn has hyperbilirubinemia and is being treated with a biliblanket. Which intervention is indicated during this therapy?

Provide more frequent feedings A biliblanket consists of a fiber-optic pad and a portable illuminator. This form of phototherapy allows the baby to be diapered, clothed, held, and nursed during treatment. Frequent feedings of breast milk or formula are necessary to help with bowel motility, which, in turn, should increase excretion of bilirubin from the body. Discontinuing breastfeeding will disrupt the establishment of milk production. It is not necessary to rotate the baby during treatment.

A 12 year-old child, admitted with a broken arm, is waiting for a scheduled surgery. The nurse finds the child crying and unwilling to talk. What would be the most appropriate initial response by the nurse?

Provide privacy with encouragement to work through feelings A 12 year-old child needs the opportunity to express emotions privately. The incorrect responses may provide distraction and are not client-focused to deal with the observed behavior of crying.

A client is admitted to the mental health inpatient unit with a diagnosis of major depression after a suicide attempt. In addition to expressions of sadness and hopelessness, the nurse anticipates observing which characteristics?

Psychomotor retardation, agitation Somatic or physiologic findings of depression include fatigue, psychomotor retardation or psychomotor agitation, chronic generalized or local pain, sleep disturbances, disturbances in appetite, gastrointestinal complaints and impaired libido. Notice the data given in the stem relates to feelings and the question is asking: what findings other than feelings might be observed? Because two of the options deal with feelings or emotions, these can be eliminated. Compare the remaining options and determine which behavior is most likely to occur with a diagnosis of depression - attention to grooming and hygiene or psychomotor retardation and agitation.

An 18 year-old client is admitted to intensive care from the emergency department after a diving accident. The injury to the spinal cord is suspected to be at the level of the second cervical vertebrae (C-2). When collecting data, which issue should be the priority focus?

Respiratory function Spinal injury at the C-2 level results in quadriplegia, with compromise of the neurologic control of breathing. Clients with this type of injury require mechanical ventilation to support their breathing. While the client will experience all of the problems identified, respiratory function is the highest priority.

The family member tells an admitting nurse that the client values the practice of Chinese medicine. The nurse must understand that for this family and client a priority goal should take which focus?

Restore yin and yang For followers of Chinese medicine, health is maintained through balance between the forces of yin and yang. The key here is the term "Chinese medicine." The word "restore" in correct option can be associated with the word "medicine" in the stem because medicine restores function.

A nurse is caring for a client with pneumococcal pneumonia. Which breath sounds would the nurse expect to disappear as the client responds to the antibiotic treatment?

Rhonchi Pneumonia causes a marked increase in interstitial and alveolar fluid, producing secretions in the airway, or discolored sputum. Rhonchi are low-pitched, snore-like sounds caused by airway secretions. These abnormal sounds occur in pneumonia and, as the illness subsides, they should disappear, demonstrating the effectiveness of the antibiotic therapy. Friction rubs, diminished sounds, and wheezes are not typically associated with pneumonia. If the lung sounds and other findings were not improving or were getting worse after two to three days of antibiotic therapy, the provider should be notified, as an alternative antibiotic may be needed to treat the organism responsible for the infection.

The nurse assists with the reinforcement of information about breast self-examination to a group of college students. A female student asks when to perform the monthly exam. The appropriate reply by the nurse should include which statement?

Right after the period, when your breasts are less tender." The best time for a breast self exam (BSE) is at the end of the menstrual cycle, when the breasts are no longer swollen and tender from hormone elevation. BSE is to be avoided during the first two days of the menses.

A nurse is caring for a woman two hours after a vaginal delivery. Documentation indicates that the membranes ruptured 36 hours prior to delivery. Which of these nursing diagnoses should the nurse expect the charge nurse to list as a priority at this time?

Risk for infection Membranes that ruptured more than 24 hours prior to birth greatly increase the risk of infection to both the mother and the newborn. You will notice that the three incorrect options are more acute in focus and would probably occur well before 36 hours postpartum.

The nurse is caring for a client who has just been admitted to the inpatient mental health unit with severe depression. Which concern should be a priority of care?

Safety Safety is a priority of care for a client with severe depression. Precautions to prevent suicide must be a part of the plan of care.

A nurse is discussing with a group of parents when they can begin teaching their preschool children about injury prevention. Which approach should the nurse reinforce?

Set good examples themselves through their actions The preschool years is the time for parents to initially emphasize safety education; setting a good example is important because preschoolers imitate what they see. No parents can insulate their child from outside influences nor can they expect their child to remember "all" the safety rules. The option related to consequences is too high a cognitive level for a preschooler.

A nurse is observing an 8 month-old client. Which behavior would the nurse anticipate the infant to be able to display?

Sit without support The age that a normal child develops the ability to sit steadily without support is from seven to eight months.

A pregnant woman in the third trimester reports having severe heartburn. What action should a nurse remind the client to take?

Sleep with head propped on several pillows Heartburn is a burning sensation caused by regurgitation of gastric contents. It is best minimized by sleeping in a semi-upright position, eating small frequent meals, or eating at least three hours before sleeping. Drinking plenty of water will help with digestion but drinking too much water at one time may actually worsen heartburn symptoms. Medications need to be approved by the health care provider.

A child has severe burns to the lower extremities. A diet high in protein and carbohydrates is recommended. The nurse should care for this client with the knowledge that the most important reason for such a diet is to achieve which result?

Spare protein catabolism to meet metabolic and healing needs Because of the severe burn injury, the child has an increased metabolism and catabolism. By providing a high-carbohydrate diet, the breakdown of protein for energy is avoided. Proteins are then used to restore and aid in the healing of tissues. Notice that the correct response includes a word used in the question ("protein").

The LPN is assisting the RN to provide care for a client diagnosed with a traumatic brain injury. Using the Glasgow Coma Scale, when the client does not obey verbal commands to move, which technique will the RN use to evaluate motor function?

Squeeze the trapezius muscle firmly If there is no spontaneous movement and the client does not obey verbal commands to move, the RN can provide central pain stimulation to assess motor function. The trapezius pinch is the preferred method. If there is no response to the trapezius pinch, and there are no facial fractures, the nurse can then apply pressure to the supraorbital notch to elicit a response. Using the Glasgow Coma Scale, the client's response on the motor scale is scored from 1 (no movement) to 6 (obeys 2-part verbal request). Rubbing the sternum with the knuckles is no longer used since it can easily bruise the soft tissue. Observing for pronation and drift is used in neurologic assessments to detect subtle arm movement in clients who can obey commands.

SR mean

Sustained release

A child, after swallowing a household cleaner, is admitted to the pediatric unit. Which of the following signs and symptoms would the nurse expect to find with a child who ingested a corrosive substance?

Swallowed corrosive substances burn the skin and lining of the lips, mouth, tongue and digestive tract. Household cleaners are often alkaline in pH and are just as irritating as acidic substances.

The client is prescribed alendronate (Fosamax). What information about medication administration should the nurse be sure to reinforce?

Take on an empty stomach Fosamax should be taken first thing in the morning, with a full glass of water, and at least 30 minutes before other medication or food. Fosamax, a bone reabsorption inhibitor, is used for postmenopausal bone thinning osteoporosis and to treat Paget's disease. Clients should remain in an upright position for at least an hour after taking this medication.

A client with testicular cancer has had a unilateral orchiectomy. Prior to discharge the client expresses his fears related to the prognosis. Which statement should be the initial response by a nurse?

Testicular cancer has a very high cure rate with early diagnosis and treatment." With early detection, diagnosis and treatment, the cure rate in testicular cancer is around 95%. The other comments are correct about testicular cancer but would not be the initial response to the client's question.

The nurse has established a therapeutic relationship with a client. Which observation would indicate that the nurse-client relationship has passed from the orienting phase to the working phase?

The client recognizes feelings and expresses them appropriately During the working phase, problems are identified and the client is able to focus on unpleasant feelings and express them appropriately.

Bupropion (Wellbutrin, Zyban) was introduced in the United States in 1985 and was then withdrawn because of the occurrence of seizures in some clients taking the medication.

The medication was reintroduced in 1989 with specific recommendations regarding dosage, i.e., a single dose should be no more than 150 mg and each dose should be separated by six hours, in order to limit the occurrence of seizures. The risk of seizure appears to be strongly associated with higher doses.

The LPN is unsure about an assignment by the charge nurse to hang an intravenous (IV) infusion that contains potassium. What resource should the LPN check first to determine if LPNs can administer IV medications?

The nurse practice act of the state in which the practice takes place A state's nurse practice act will provide the scope of practice conditions regarding IV therapy. What LPNs can and cannot do with respect to intravenous medications and treatments varies from state to state. A policy manual cannot direct nurses to perform skills that are above and beyond their scope of practice. The ANA is a professional organization representing the interests of nurses.

A nurse is reinforcing information to a mother who is breast-feeding a newborn infant diagnosed with oral candidiasis. Which statement by the mother would be incorrect and indicate a need for reinforcement of information?

The therapy can be discontinued when the spots disappear." Antibiotic therapy should be continued as long as prescribed, which is usually longer than when the spots disappear. Nystatin is one of the more traditional medications used to treat oral thrush; it is applied topically, usually four times a day for five to seven days. Also, application of the medication to the mother's nipples may increase the rate of success of therapy (by lessening the likelihood of reintroduction of Candida to the infant).

The nurse is assisting in the application of a plaster cast for a client with a broken arm. Which action is a priority?

The wet cast should be handled with the palms of hands for 48 to 72 hours Handle cast with palms of the hands and lift at two points of the extremity. This will prevent stress at the injury site and indentations that cause pressure areas on the cast. The other options are correct actions, but are not the most important.

haloperidol adverse effect must be immediately reported to the health care provider?

Tongue thrusting and facial grimacing

transurethral resection of the prostate (TURP)

Transurethral resection of the prostate is a urological operation. It is used to treat benign prostatic hyperplasia. As the name indicates, it is performed by visualising the prostate through the urethra and removing tissue by electrocautery or sharp dissection. This is considered the most effective treatment for BPH

A client has chronic renal failure and is being treated at home. During weekly home visits, which factor is the most accurate indicator of fluid balance?

Trends in daily weights The most accurate indicator of changes in fluid balance is the daily weight. A 1-kilogram (or 2.2 pounds) of weight gain is equal to approximately 1000 mL of retained fluid. Other options are considered as part of data collection for fluid balance, but they are not the most accurate indicators of fluid balance.

The nurse is caring for a postoperative client. What is the priority nursing intervention the nurse will reinforce for preventing atelectasis?

Turn, cough and breathe deeply Deep air excursion by turning, coughing and deep breathing will expand the lungs and stimulate surfactant production. This is the best way to prevent atelectasis. The nurse should instruct the client on how to splint the chest when coughing. Humidification, hydration and nutrition all play a part in prevention of atelectasis following surgery. However, they are not the priority.

A nurse is talking to parents about the side effects of routine immunizations. Which finding should the nurse reinforce about calling the health care provider if it occurs within 24 to 48 hours after a routine immunization?

Tympanic temperature of 104 F (40 C) Body temperature greater than 104 F (40 C) should be immediately reported to the health care provider. Another adverse reaction to report is inconsolable crying (sustained crying for more than three hours).

In checking a postpartum client, the nurse palpates a firm fundus. However, the nurse also observes a constant trickle of bright red blood from the vaginal opening. What should the nurse suspect?

Vaginal lacerations Continuous bleeding in the absence of a boggy fundus indicates undetected vaginal tract lacerations. If you are not sure about the correct response, re-read the responses and you should note that three of the (incorrect) options would result in excessive bleeding, and not a "trickle."

A client is diagnosed with a Salmonella infection. What is a primary nursing intervention to be taken to minimize the transmission of disease from this client?

Wash hands thoroughly before and after any client contact Salmonella is usually transmitted to humans by eating food contaminated with animal feces. Thorough hand washing can help prevent the spread of Salmonella. Note that the question asks for the primary action. Also note that it does not state a geographic location, such as in a home or in an acute care agency.

A nurse is caring for a client diagnosed with obesity and osteoarthritis of the knees. During reinforcement of the teaching given by the registered nurse (RN), the practical nurse (PN) should know that which health practice should have the greatest benefit on the client's outcome?

Weight reduction A major contributor to the development of osteoarthritis is excess body weight, due to the ongoing stress placed on joints. Weight reduction can play a key role in promoting the client's long-term health and mobility. Leg elevation is not indicated in osteoarthritis of knees. Joint braces are not a treatment for osteoarthritis. Anti-inflammatory medications play a role in reducing inflammation and pain, but they will not address the cause of the problem.

A client diagnosed with bipolar disorder refuses to take the prescribed medication. Which is the most therapeutic response by a nurse to the client's refusal of the medication?

What is it about the medicine that you don't like?" When a client refuses medication, the next step is to collect data about the problem. Furthermore, the nurse needs to collect data now, and not "tomorrow," as indicated in one of the incorrect responses. You should also notice that two of the responses are punitive or sarcastic in nature; these can be immediately eliminated. The correct response is also the most therapeutic response.

The nurse is giving a morning bath to a client who has a colostomy. While giving the bath, the nurse should reinforce that the collection pouch should be emptied at what time?

When it is one-third to one-half full If the pouch becomes more than half full, it could put pressure on the seal, causing a leak. The pouch may also detach, causing the contents to spill. This will not only irritate the skin but also embarrass the client.

The nurse and client are discussing the client's progress toward understanding the client's behavioral responses to stressful events. This is typical of which phase in the therapeutic relationship?

Working During the working phase of the relationship, alternative behaviors and techniques are explored. The nurse and the client discuss the meaning behind the behavior in this phase of the relationship. The key words in this question are "nurse and client discussing... progress and behavior." Notice that two of the options would have occurred in an earlier stage and another option would happen at the end of the therapeutic relationship (termination). Use common sense and the process of elimination to select the option indicating the current situation - the working phase.

The nurse is caring for a client who is one-day postoperative with a T-tube following a cholecystectomy. What color would the nurse expect the drainage from the client's T-tube to be?

Yellowish-brown Bile, which is yellowish-brown, is the expected drainage from a T-tube. Green is characteristic of normal gastric secretions.

The nurse enters the room of a postpartum mother and observes the baby lying at the edge of the bed while the mother sits in a chair. The mother states, "This is not my baby, and I do not want it." How should the nurse respond?

You seem upset, tell me about how you are feeling"? A nonjudgmental, open-ended response facilitates dialogue between the client and nurse. The correct response is the more general, client-centered option. This type of comment facilitates the flow of communication.

A female client admitted for a breast biopsy says tearfully to a nurse, "If this turns out to be cancer and I have to have my breast removed, my partner will never come near me." What would be the most appropriate response to this statement?

You sound worried that the surgery might change your relationship with your partner. The best response is one that encourages further discussion by making an observation, without focusing on an area that the nurse feels is a problem. The client has the control to direct the focus of the conversation. One incorrect response - elicits a "yes" or "no" answer which blocks rather than supports further discussion. Another incorrect response is confrontational and requires an explanation of a specific focus, rather than prompting client contol of topic. The third incorrect response offers false reassurance and does not engage the client in further discussion.

Varicella (chicken pox), influenza and the cold virus are viral illnesses that have been identified as

increasing the risk for Reye's syndrome in children, particularly when aspirin has been use. Rubeola, meningitis, and hepatitis are not recognized as precursors to Reye's syndrome.

Echolalic

is the unsolicited repetition of vocalizations made by another person

When findings of infection occur in their feet, older clients who have either type of diabetes and/or arterial vascular disease should

seek health care quickly and continue treatment until the infection is resolved

The combination of a viral infection and the administration of aspirin to children from birth to 19 years of age can result in

the development of Reye's syndrome; therefore, aspirin should be avoided during these ages.

A client is scheduled to have blood drawn for serum cholesterol and triglycerides tomorrow morning. What information should the nurse reinforce to the client about the test?

"Do not eat or drink anything but water for 12 hours before the blood test." The client should fast (no fluids or foods, except for water) for 8 to 12 hours prior to sample collection for serum lipid levels (cholesterol, triglycerides, HDL, LDL).

A child is admitted to the hospital for emergency surgery. The child's parent reports several allergies. Which of these allergies should all the operative health care personnel be notified about?

Balloons Allergy to balloons often indicates a latex allergy. All personnel during and after surgery that are in contact with the child will need to be aware of this condition. The need to use non-latex gloves or equipment without latex components should be noted on the chart.

An adolescent client arrives at a clinic three weeks after the birth of her first baby. She tells the nurse she is very worried about not returning to her pre-pregnancy weight. Which approach should the nurse take first?

Encourage her to talk about her self-image Body image is very important to an adolescent. The nurse must acknowledge this and collect more information about the client's self-image before discussing nutritional needs, diet and/or exercise. Adolescents often need more support and information about what to expect after the birth of a child, especially since the postpartum period can be overwhelming for them. Nonjudgmental and developmentally appropriate interactions are needed to care for the physical and emotional needs of adolescents.

A parent expresses frustration and anger about the toddler constantly saying "no" and refusing to follow directions. The nurse should help the parent understand that this behavior meets which developmental need?

Independence Negativism is typical of toddlers. Think of the phrase: "No, me do it" when answering this question. Independence and autonomy versus shame and doubt are the developmental tasks of toddlerhood.

A nurse is caring for a child being discharged after a tonsillectomy. Which instruction is appropriate for the nurse to reinforce with the parents?

Report a persistent cough to the health care provider Persistent coughing should be reported to the health care provider because this may indicate bleeding.

A newly admitted client reports taking phenytoin for several months. Which of the following assessments should the nurse be sure to include in the admission report? (Select all that apply

Report of unsteady gait, rash and diplopia Report of any seizure activity Serum phenytoin levels Serious adverse outcomes of antiseizure medications such as phenytoin (Dilantin) are unsteady gait, slurred speech, extreme fatigue, blurred vision or feelings of suicide. Increased hunger (not anorexia), increased thirst or increased urination are additional serious side effects

A nurse is discussing with a client the precautions with warfarin. The nurse should tell the client to avoid foods with excessive amounts of what substance?

Vitamin K Eating foods with excessive amounts of vitamin K (often contained in green leafy vegetables) may affect anticoagulant effects.

A client has a diagnosis of heart failure. Which intervention is most important for the nurse to implement prior to the administration of digoxin?

Assess the apical pulse, counting for a full 60 seconds It is the nurse's responsibility to take the client's apical pulse before administering digoxin. The correct technique for taking an apical pulse is to use the stethoscope and listen for a full 60 seconds. Digoxin is held for a pulse below 60 beats per minute (bradycardia is a finding in digoxin toxicity).

The nurse is reviewing the history of a pregnant woman. Which factor should the nurse recognize as a priority contraindication for breastfeeding?

Uses cocaine on weekends Binge use of cocaine can be just as harmful to the breast-fed newborn as regular (daily) use of cocaine. Alcohol is also contraindicated. However, between the two substances, cocaine is the more dangerous.