NCLEX SET 1

The client receives 300 mg phenytoin by mouth daily for seizures and the pharmacy sent phenytoin 125 mg/5 mL suspension.How many mL of suspension will the nurse administer?

mL/day rationale Left side of the equation:This is what you are solving for or what you want. For this problem, you want to know how many mL of suspension to administer in a day. Right side of the equation: Available information, related to unit of measure on the left side of equation. For this problem you know that there is 125 mg/5 mL. You want the unit of measure from the left side of the equation to be the denominator on the right side of the equation, which will allow the unit of measure (mg) to be cancelled out. Set up the rest of the problem so that you can solve for mL/day and cancel out everything else. Set up the problem: Cancel out the matching information: Multiply the information in the numerator: Multiply the information in the denominator: Divide the numerator by the denominator: The correct answer is 12 mL.Solution: The nurse will administer 12 mL of phenytoin elixir in a day. Correct

Order: Acetaminophen elixir 100 mg by mouth every four hours as needed for pain. Available concentration of acetaminophen is 80 mg/0.8 mL.How much acetaminophen elixir will the nurse administer?

1 M rationale ount desired = 100 mg Amount on hand = 80 mg in 0.8 mL Set up equation: (desired) (have on hand) Cross multiply: Solve for x: The correct answer is 1 mL.Solution: The nurse will administer 1 mL acetaminophen elixir Incorrect

The nurse understands that which situations require hand hygiene such as handwashing or hand sanitation?

After contact with objects in the immediate vicinity of the client Before having direct contact with a client After cleaning a wound Prior to and after eating Handwashing is still the simplest and most effective strategy to prevent the spread of infection. It is necessary to wash one's hands to protect oneself prior to eating, after removing gloves following any client procedure and even after having contact with intact skin or objects in the client's room. However, it is not necessary to wash hands after handling every chart (although using an alcohol-based hand rub would be advisable).

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 rationale 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.

The nurse is assisting in developing a plan of care for a client who is on complete bedrest due to a spinal cord injury. Which intervention is most important for the nurse to include?

Apply pneumatic compression devices to both legs. rationale Clients on complete bedrest are at risk for several complications related to immobility, including a venous thromboembolism (VTE). Therefore, it is most important to apply pneumatic compression devices to the legs. Turning and repositioning should be done at minimum every two hours to prevent skin breakdown. Inserting a urinary catheter and routinely administering an enema should be avoided and only be done if medically-indicated

The nurse is reviewing prescribed medications with a client. Which information should the nurse reinforce about captopril?

Avoid using salt substitutes. rationale Captopril is an angiotensin converting enzyme (ACE) inhibitor. It reduces aldosterone secretion, thereby reducing sodium and water retention. Captopril is used to treat hypertension and heart failure. Because it can cause an accumulation of serum potassium (i.e., hyperkalemia), clients should avoid the use of salt substitutes, which often contain potassium instead of sodium chloride. The other information does not apply to captopril.

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 rationale Beef and beans are an excellent source of protein, as is skim milk. Strawberries are a good source of vitamin C.

A hospitalized, school-age child with a spica cast says to the nurse "I am bored." Which type of activity would be most appropriate for the nurse to implement for this child?

Board games School-age children enjoy activities which promote physical growth, intellectual ability and fantasy. With the spica cast, vigorous physical activity will be limited. Quiet activities include reading, arts and games. The nurse should discourage unlimited television or electronic screen time. Push-pull toys would be more appropriate for younger children, such as toddlers.

The cardiac monitor of a client admitted with unstable angina displays a rhythm that appears to be ventricular fibrillation. Which action should the nurse take first?

Check if the client is responsive. rationale Electrical interference can be mistaken for ventricular fibrillation, in which case the client would respond when checked. Therefore, the first action should be to check whether or not the client is responsive. It would be inappropriate to initiate CPR (chest compressions or rescue breaths) without first determining that the client is unresponsive. Notifying the HCP should be done after completing emergency treatment for the client.

The nurse is caring for a group of clients when a fire alarm sounds in the hospital cafeteria. What should the nurse do next?

Close all doors in the area. The nurse should act immediately to protect the clients under their care. This begins with closing all doors to prevent the fire from spreading. It is not necessary to evacuate the clients because they are not in immediate danger. The fire extinguisher is not needed since there is no active fire in this area. Removing oxygen devices is not required.

A client is admitted to the emergency department with acute onset of left hemiplegia. The nurse should prepare the client for which diagnostic procedure?

Computerized tomography scan Acute onset hemiplegia is indicative of a stroke and a computerized tomography (CT) scan without contrast is the most commonly used diagnostic test to determine if a client suffered a stroke. The other diagnostic tests are not indicated at this time.

The nurse is caring for a client who suddenly develops slurred speech and a facial droop. What diagnostic test would the nurse expect to be performed first?

Computerized tomography scan rationale The client's symptoms are indicative of an acute stroke. The nurse would anticipate that a non-contrast computerized tomography (CT) of the head will be done first because time is of the essence with an acute stroke. The other tests may or may not be indicated for this client.

The nurse is preparing to administer digoxin to a client with heart failure. To obtain an apical pulse, which is the best anatomical location for the nurse to place the stethoscope?

D rationale Digoxin is a cardiac glycoside used in the treatment of heart failure. It slows down the heart rate. Before giving digoxin, the nurse should obtain an apical pulse and count for an entire minute. Digoxin should not be given if the pulse is less than 60 beats per minute. The point of maximal impulse is usually found located on the left anterior chest, at the midclavicular line and fifth intercostal space. This is the best place to auscultate heart sounds and obtain an apical pulse.

A client is admitted for hypovolemia associated with multiple draining wounds. Which is the best method for the nurse to use to evaluate the client's fluid balance?

Daily weight rationale Daily weight is the most easily obtained and accurate means of assessing a client's fluid volume status. Skin turgor varies considerably with age. Marked excess fluid volume may already be present before fluid moves into the interstitial space and causes edema. Although very important, hourly urine outputs do not take into account fluid intake or fluid loss through insensible loss, sweating or loss from the gastrointestinal (GI) tract or wounds.

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 rationale 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.

The nurse notices bone growths on the distal interphalangeal joints of a client with osteoarthritis. How should the nurse document these findings?

Heberden's nodes rationale Bony outgrowths found on the distal interphalangeal joint (closest to the fingernail and furthest away from the body) are called Heberden's nodes. If the bony outgrowth was found on the proximal interphalangeal joint (the middle joint of the finger, closest to the body), they would be Bouchard's nodes.

The nurse is preparing a client for an intravenous pyelogram (IVP) test. What information is most important for the nurse to obtain prior to the procedure?

History of allergies rationale An IVP requires the injection of a dye. Although all of the information is important for the nurse to obtain and review, dye or contrast media used during a diagnostic test can cause an allergic reaction or anaphylaxis. Therefore, it is most important for the nurse to review any allergies with the client, especially any reaction to previous tests that use a dye or contrast media.

The nurse is stuck in the hand by an exposed needle that was accidentally left in the client's bed. What action should the nurse take first?

Immediately wash hands vigorously with soap and warm water. The immediate action of vigorously washing the hands will help reduce the risk of potential exposure to bloodborne pathogens. The nurse should then follow the facility's policy and procedure for employee needlestick injury.

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 rationale 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.

A client has been diagnosed with hypothyroidism. Which medication should the nurse administer to treat the client's bradycardia?

Levothyroxine rationale The treatment for bradycardia from hypothyroidism is to treat the hypothyroidism using levothyroxine sodium, a T4 replacement hormone. If the heart rate were so slow that it causes hemodynamic instability, then atropine or epinephrine might be an option for short-term management. Adenosine slows atrioventricular (AV) conduction in the heart and would be contraindicated for a client with bradycardia.

A nurse working in a nursing home is caring for an older adult client who has been diagnosed with a urinary tract infection. Which finding should be of greatest concern to the nurse?

Low blood pressure rationale Having a low blood pressure should be the greatest concern to the nurse. Clients with a urinary tract infection (UTI) are at risk of developing urosepsis, an infection of the blood, which can quickly lead to septic shock. Low blood pressure can be a sign of urosepsis and the beginning stage of shock. Confusion, suprapubic pain and cloudy urine are expected signs and symptoms of a UTI.

he nurse is assisting with meal planning for a client with cholelithiasis. Which food items would be most appropriate for this client? (Select all that apply.)

Low-fat dairy products Unsalted soups Whole grain bread rationale The most common cause of gallbladder disease is from stones that block the biliary ducts. Other causes are due to inflammation, infection, tumors or decreased blood flow due to damaged vessels. Intake of high cholesterol or fatty foods can increase the risk of gallbladder inflammation. To avoid inflammation, the client should follow a low cholesterol, low-fat diet and limit their intake of fried and processed foods such as breakfast cereals, lunch meats and microwavable meals.

The nurse is caring for a client with paraplegia due to a spinal cord injury at the T-7 level. Which nursing intervention should be a priority for this client?

Obtain a pressure-reducing mattress for the client's bed. rationale Clients with a spinal cord injury are at risk for skin breakdown, such as pressure injuries, due to immobility and decreased sensation. A pressure-reducing cushion should be used on the wheelchair and the bed should have an air- or pressure-reducing mattress. The other interventions should also be included, but maintaining skin integrity is the highest priority.

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 rationale 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.

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 rationale 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 client is being treated for diabetic ketoacidosis (DKA). A basic metabolic panel (BMP) was drawn and the nurse notes that the client's serum glucose is 650 mg/dL. Which other serum lab result is a priority for the nurse to review?

Potassium level rationale Hyperglycemia induces osmotic diuresis, which causes water and electrolyte loss, especially potassium. Clients with DKA will have moderate to severe dehydration and will be initially treated in an intensive care unit. The client is usually given intravenous (IV) fluids with potassium to replace the fluid and electrolyte loss. Creatinine measures kidney function but is not a priority in this situation. Neither are the calcium and magnesium level.

The nurse is caring for a client who has been diagnosed with Cushing syndrome. Which medication most likely contributed to this condition?

Prednisone rationale Cushing syndrome results from the excess intake of exogenous glucocorticoids. Glucocorticoid drugs (e.g., cortisone, prednisone) are nearly identical to the glucose-regulating steroids produced by the adrenal cortex. They can be used to treat adrenocortical insufficiency or inflammatory disorders (e.g., asthma, rheumatoid arthritis) and certain cancers.Pantoprazole is a proton-pump inhibitor used for acid reflux. Paroxetine is a selective serotonin reuptake inhibitor (SSRI) antidepressant. Pravastatin is an antilipemic used for hyperlipidemia.

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 rationale 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.

The school nurse in an elementary school identifies an outbreak of head lice (pediculosis). What interventions should the nurse implement to prevent the spread of the infestation? (Select all that apply.)

Reassure students that itching of the scalp is a most common symptom. Instruct school parents, teachers and volunteers on how to detect lice and nits. Provide individual headsets or ear buds for each student. Do not permit children to share bike helmets. rationale Sharing items that touch the head, such as helmets, headsets, hats, combs, towels, etc., is a primary source of spreading pediculosis. Itching is a common and early sign of infestation and should be investigated immediately. Instructing parents and school personnel how to detect lice and nits will foster early recognition and treatment.Head lice is not a reportable disease.

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 rationale 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.

The nurse is collecting data about a 20-year-old female client who has been prescribed isotretinoin for severe acne. The client states that she does not understand why she has to be seen monthly in the office to obtain a refill. What is the best response from the nurse?

"A monthly pregnancy test is required for all refills of this medication." rationale Isotretinoin is highly teratogenic. The administration of isotretinoin is therefore closely monitored by the iPledge program, which has rules for the client, prescriber, pharmacist and wholesaler. The iPledge program is a pregnancy prevention program for isotretinoin, which has been linked to serious birth defects such as facial malformation, hydrocephalus and cardiac defects.

The nurse is caring for a client who is taking leuprolide for endometriosis. The nurse should monitor the client for which side effects? (Select all that apply.)

Hot flashes Emotional lability Amenorrhea Vaginal dryness rationale Endometriosis is a benign gynecologic condition in which endometrial tissue grows outside of the uterus. It can be controlled, but not cured, by drug therapy. Drugs commonly used include oral contraceptives and GnRH agonists such leuprolide and nafarelin. GnRH drugs result in amenorrhea (absence of menstruation) and other symptoms that mimic menopause such as hot flashes, vaginal dryness and emotional lability. Anorexia (lack of appetite) is not a side effect usually seen with leuprolide. Leuprolide does not increase fertility.

The nurse is concerned that a client with a history of anorexia nervosa may be experiencing a recurrence of the condition. Which of the following findings would support the nurse's concern? (Select all that apply.)

Weight loss Correct Response Recent hair loss Correct Response Constipation. Correct Response rational Hair loss, constipation and weight loss are all potential manifestations of anorexia nervosa. Excessive exercising, not a lack of exercise, is often associated with anorexia nervosa. Elevated blood pressure is not a clinical manifestation of anorexia nervosa.

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?" Correct! rationale 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.

When planning care for a client at risk for pulmonary embolism, the nurse shall make which intervention a priority?

Apply sequential compression devices to the legs. rationale Deep vein thrombosis (DVT) is the primary cause of pulmonary embolism (PE). Preventing a DVT with the use of sequential compression devices, early ambulation and prophylactic use of anticoagulant medications should be priority nursing interventions. Bedrest will increase the risk for a DVT and PE. Pulmonary hygiene interventions do not prevent a DVT or PE from occurring.

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).

An adult client in the waiting room of an outpatient clinic is found to have become unresponsive. Their carotid pulse cannot be palpated. Emergency medical services have been requested by calling 911. What should the nurse do next?

Begin chest compressions. rationale According to basic life support (BLS) guidelines by the American Heart Association (AHA), chest compressions are the next step in initiating cardiopulmonary resuscitation (CPR) for an unresponsive client in whom a carotid pulse cannot be palpated. After the initial round of 30 chest compressions, the nurse should open the client's airway with a head tilt-chin lift maneuver (or a jaw-thrust maneuver if spinal cord injury is suspected) and deliver two breaths. It would not be appropriate to wait to start CPR until emergency medical services technicians arrive because immediate action is needed.

A client has a family history of coronary artery disease (CAD). Which of the following findings should be of concern to the nurse?

Blood pressure of 154/78 Hypertension is a major risk factor for CAD, and a blood pressure of 154/78 would indicate the presence of hypertension. Of the choices given, this finding would be of the greatest concern to the nurse. Elevated LDL cholesterol is a risk factor for CAD; however, an LDL level of 80mg/dL is not elevated. Similarly, while diabetes mellitus is a risk factor for increased rates of CAD, a glycosylated hemoglobin (Hb A1C) of 4.8% is a normal value. A serum creatinine of 0.4mg/dL is a normal value

The nurse is talking with a client who suddenly becomes tearful and stares out the window after seeing a rose on the lunch table. The client has a history of sexual abuse. Which intervention should the nurse include in the plan of care for this client?

Determine if the client is having a flashback Clients who have experienced a traumatic experience such as sexual abuse often experience flashbacks as a result of a trigger. Triggers can be visual, auditory, tactile or olfactory. The other interventions are not appropriate.

The nurse is monitoring a 45-year-old client who just underwent a cardioversion for dysrhythmias. The client's respirations are 12 per minute. Which action should the nurse take next?

Continue to monitor the client. rationale Clients undergoing a cardioversion often receive a mild sedative such as a benzodiazepine (e.g., midazolam). Benzodiazepines can cause respiratory depression. The client is exhibiting a respiratory rate that is considered within normal limits for an adult. Normal respirations range from 12 to 20 per minute; respirations of eight or less per minute would be a cause for concern. Nevertheless, the nurse should continue to monitor the client until the sedative has worn off. The other actions are not appropriate in this situation.

During a 12-hour shift, a client who underwent a transurethral resection of the prostate (TURP) had an IV fluid intake of 1,200 mL, an oral intake of 400 mL, continuous bladder irrigation of 2,400 mL, two antibiotic piggybacks of 50 mL each and an indwelling urinary catheter output of 3,000 mL. What is the end-of-shift intake/output (I/O) balance? (Write the answer using a whole number.

Correct answer = 1100 mLThe amount of irrigation fluid must be included in the client's intake. Only the urine collected from the indwelling urinary catheter is considered output. net output, or I/O balance. 1200ml+400ml+2400ml+50ml+50ml=4100 4100ml-3000ml=1100ml

The provider orders 500 mg erythromycin suspension per gastrostomy tube every six hours for a client with pneumonia. The supplied suspension contains 250 mg/5 mL. How many mL should the nurse administer for each dose? (Report your answer as a whole number.)

Correct answer: 10 mL

A client has a new prescription for sertraline, a selective serotonin reuptake inhibitor (SSRI) antidepressant. After reviewing the client's medical record, which data is the nurse most concerned about?

Current prescription for phenelzine rationale Phenelzine is a monoamine oxidase inhibitor (MAOI) antidepressant. Combining MAOIs with SSRIs and other serotonergic drugs poses a risk of serotonin syndrome. Accordingly, these combinations should be avoided. The MAOI should be gradually discontinued before starting the SSRI. Alprazolam is a benzodiazepine and can be taken concurrently with MAOI or SSRI antidepressants. The other data in the client's history do not represent a contraindication for the use of a SSRI. The nurse should clarify the new prescription with the prescribing health care provider (HCP).

The nurse is admitting a client who has had watery stools for several days. Which clinical manifestations would indicate a complication from the diarrhea?

Dark, concentrated urine Dry mucous membranes Poor skin turgor rationale Acute diarrhea can last up to and beyond 14 days. Acute diarrhea can be caused by viruses, bacteria, medications and food intolerances. The clinical manifestations that may occur with this illness include frequent, watery stools, abdominal pain and cramping, low-grade fever, nausea and vomiting. Leukocytosis is often present due to the body's inflammatory/infectious response to an acute illness.Frequent, watery stools and vomiting may lead to severe dehydration. Manifestations of dehydration include poor skin turgor, dry mucous membranes, orthostatic changes in pulse and blood pressure and decreased, concentrated urine.

A client with a history of bipolar disorder is admitted to the hospital after a suicide attempt. Which of the following interventions should the nurse include in the client's plan of care?

Develop a contract with the client that states they will not harm themselves. The nurse should develop a temporary contract with the client that states they will not harm themselves. The contract will allow the client to assume responsibility for their safety.The nurse should actively listen to the suicidal client and encourage them to express their feelings and emotions. Expressing emotions will allow the client to resolve unhealthy hostility and take control of their life.The nurse should closely observe a client who is at risk for suicide. Place the client in a room close to the nurses' station and do not assign them to a private room.To create a safe environment, the nurse should perform room searches as needed to keep harmful objects away from the client (e.g., glass items, alcohol, sharp objects and belts).

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

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

Dry, nonproductive cough rationale 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 is reviewing the chart of a client with suspected osteoporosis. Which diagnostic test to confirm the diagnosis should the nurse plan for?

Dual-energy X-ray absorptiometry scan rationale Osteoporosis is a metabolic disease in which bone mineralization results in decreased bone density. A dual-energy X-ray absorptiometry (DEXA) scan is a painless scan that measures bone mineral density (BMD) in the hip, wrist or vertebral column. It is the recommended test for the diagnosis of osteoporosis. Magnetic resonance imaging (MRI), computerized axial tomography (CAT) and positron-emission tomography (PET) scans are imaging tests used for evaluating a range of musculoskeletal diseases, but they are not typically used to diagnose osteoporosis.

The nurse is reinforcing education to a group of parents on how to treat accidental poisoning of children in the home. What information should the nurse include?

Empty the child's mouth of any poisonous substance still present. Emptying the mouth of the poison prevents any further ingestion. It should be done first to minimize further contact with and absorption of the substance. The parent should call the Poison Control Center before giving any treatment. Never induce vomiting unless instructed to do so by the Poison Control Center or a health care provider. The same applies for giving the child milk to drink because not all poisons are neutralized that way.

A nurse is working with parents to plan home care for a toddler with a heart problem. What should be the priority nursing intervention on the plan of care?

Encourage the parents to enroll in child cardiopulmonary resuscitation (CPR) class rationale While all suggestions are appropriate, the priority education focus of the parents/caregivers should include techniques of CPR in order to provide for emergency care for their child. When all the options are correct, you need to decide which option is the most important and most closely associated with the client or problem. You will also note that three of the options deal with play, the caregivers, and the parents/toddler respectively. Only the correct response relates to heart activity (CPR).

A postoperative client has a prescription for acetaminophen with codeine for pain relief. The nurse understands which action to be the primary purpose of this drug combination?

Enhanced pain relief rationale Codeine is an opioid analgesic. It is considered a moderate opioid, similar to morphine in most respects. It is used for relief of mild to moderate pain. Codeine is formulated alone and in combination with non-opioid analgesics such as aspirin or acetaminophen. Because codeine and non-opioid analgesics relieve pain by different mechanisms, the combinations can produce greater (enhanced) pain relief than either agent alone. The onset of action, risk of tolerance and side effects are the same as with other oral, opioid medications.

A nurse is working to establish a therapeutic relationship with a client. Which action would support the nurse's goal?

Establish trust and rapport with the client. In order to establish a therapeutic relationship with a client, the nurse must first work on creating a foundation of trust and rapport. The nurse must be careful not to over-identify with what the client is feeling. This can create countertransference and impede the therapeutic nature of the client-nurse relationship. Discussing problem-solving techniques and offering praise are actions appropriate to a later stage of the therapeutic relationship (the working phase).

The nurse is reinforcing teaching for a client who has a diagnosis of gout. Which foods should be restricted in the client's diet? (Select all that apply.)

Liver Shrimp Sardines Gout is a systemic disease in which urate crystals deposit in the joints and other body tissues, causing inflammation. High levels of uric acid in the blood are found in clients who have gout. Clients with gout should follow a low-purine diet. Purine-rich foods such as organ meats (liver), shellfish (shrimp), red meat and oily fish with bones (sardines) should be restricted. Vegetables and dairy, including eggs, do not need to be restricted or limited with gout.

The nurse is caring for a client diagnosed with end-stage heart failure (HF). The family members are distressed about the client's impending death. Which action should the nurse take initially?

Explore the family's past patterns for dealing with death. Correct! rationale The nurse will follow the nursing process and initially collect accurate data. This is important so that the nurse can identify priorities and ensure that the client's and the family's needs are addressed. By identifying the family's past experiences with death, the nurse can develop an individualized plan of care for the client and client's family. Depending on the family's needs, the other actions would be performed during the implementation step of the nursing process.

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 rationale 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 documents the following in the client's medical record: "Effective use of guided imagery to change report of pain from a level of 4 to 1 on the numeric pain scale." Which definition best describes this non-pharmacological technique?

Focusing on pleasant mental pictures of a relaxing scene. rationale Guided imagery is a non-pharmacologic technique that uses pleasant mental visuals of a relaxing scene, which can be recalled by the client to reduce stress, anxiety or pain. Repeating a word to oneself describes meditation. Closing the eyes or focusing on a blank screen is another form of meditation, in which a person uses a mental picture of a blank black screen and attempts to think of nothing. Counting while breathing is considered slow deep breathin

The clinic nurse is meeting with a client who wants to talk about her and her partner's plan for a future pregnancy. What information is important for the nurse to give to the client?

Folic acid should be started before the client has a confirmed pregnancy. Women should start to take folic acid prior to pregnancy to decrease the risk of neural tube defects. Preconception care involves a complete review of both partners' medical history. Medications, supplements, nutrition and psychosocial concerns should be reviewed. Risk factors which impact pregnancy, such as alcohol, drug use, medications, infections, etc., should be identified and avoided. Immunizations should be reviewed and encouraged before pregnancy.

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 1 rationale 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 assisting a client with gastroesophageal reflux disease in choosing an appropriate meal for dinner. Which is the best meal choice for this client?

Grilled chicken with steamed green beans. rationale Gastroesophageal reflux disease (GERD) occurs as a result of the backward flow of gastrointestinal contents into the esophagus. The most common cause of GERD is inappropriate relaxation of the lower esophageal sphincter (LES). The client should be advised to limit or eliminate food that decreases LES pressure such as chocolate, fat and mints. The client should also restrict fried, spicy and acidic foods. Tomato sauces in pasta and pizza should be avoided. Fried foods, including French fries, should also be avoided. The best meal choice for this client is grilled chicken, which is a lean meat choice, and steamed green beans.

The nurse is caring for a client admitted to the hospital with a history of post-traumatic stress disorder (PTSD). Which of the following actions by the nurse would represent appropriate care of the client?

Identify coping strategies used by the client when stressful situations arise. Post-traumatic stress disorder (PTSD) is a reaction to a trauma (e.g., rape, kidnapping, war, etc.) that can last up to months or even years. Characteristics of PTSD include depression, aggressive behavior, survivor's guilt, nightmares, flashbacks, destructive behavior, emotional outbursts, etc.Clients with PTSD have difficulties forming trusting relationships. In order to facilitate trust between the client and the nursing staff, assign the same staff member to the client as often as possible.The nurse should stay with the client during periods of flashbacks and nightmares to help allay fears and reassure the client that they are safe.Allow the client to express feelings about the trauma at their own pace. Acknowledge and validate the client's concerns.Discuss the client's coping strategies developed in response to trauma and stressful situations. Identify the difference between using helpful and maladaptive strategies.

The nurse is evaluating a client who has been diagnosed with heart failure (HF) to gauge their understanding of the required diet modifications. Which menu items selected by the client indicate to the nurse that the client understood the teaching?

Leftover turkey on a sandwich and fresh pineapple rationale Clients with HF should adhere to a low-sodium diet to prevent fluid volume excess. A sodium-restricted diet should consist of less than 2 grams of sodium per day. (A regular diet should include 4 to 6 grams of sodium per day.) A turkey sandwich is the healthiest meat choice and fresh pineapple is low in sodium. Any food with more than 480 mg of sodium per serving, such as pizza, processed cheese or meats, are considered high-sodium foods and should be avoided.

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 rationale 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.

The nurse is assigned to care for a client with end-stage liver failure and portal hypertension. Which clinical manifestations would the nurse expect to see with these conditions? (Select all that apply.)

Increased abdominal girth Increased weight gain Shortness of breath The clinical manifestations, common with end-stage liver disease, include yellowing of the skin (jaundice), ascites, dependent edema, bleeding and loss of appetite. The client will have an increased abdominal girth due to the ascites and weight gain related to fluid retention. With ascites, the client may experience shortness of breath. Having diminished pedal pulses is not a common with liver failure. Clients with liver failure will have decreased, not elevated, serum albumin levels.

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 rationale 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 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 Rationale: 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.

The office nurse is discussing how to prevent an acute gouty attack with a client who has gout. Which actions should the nurse recommend to the client? (Select all that apply.)

Limit their consumption of alcohol. Limit their intake of shellfish and red meats. Implement stress reduction techniques. rationale Gout is a disease where uric acid crystals form and accumulate in joints and other tissues. Gout attacks may be brought on by excessive alcohol intake, increased stress and a diet high in purine. Clients should be encouraged to have a low-purine diet by limiting red meats and shellfish, along with drinking alcohol in moderation. The client should be encouraged to drink at least 2,000 mL of water daily to maintain hydration and prevent the buildup of uric acid. Stress management can decrease the likelihood of triggering an acute attack. Prednisone is used during an acute attack, but it does not prevent an attack from occurring.

The nurse is caring for a comatose client. To prevent keratitis, moisturizing ointment should be prescribed for which body site?

Lower eyelids rational Unconscious or comatose clients are often unable to close their eyes or do not have a functioning blink reflex. When the eye remains open for a prolonged time, the cornea will dry out, causing irritation or ulceration. Preventative treatment includes the application of moisturizing ophthalmic ointment and drops to the exposed cornea and the use of a protective shield and moistened eye patch.

The nurse initiates continuous enteral feeding at 8 am at 50 mL/hour for a client with malnutrition. It is now noon. What priority action should the nurse take at this time?

Measure the gastric residual volume. rationale It is important to determine if the client is tolerating the continuous enteral feeding. The nurse should check the gastric residual volume. The client will have received approximately 200 mL of enteral nutrition from 8 am to noon and should have a GRV of no more than 150 mL. A higher GRV might indicate delayed gastric emptying. Although the other actions are also appropriate, measuring the GRV takes priority to reduce the risk of vomiting, regurgitation and aspiration.

The nurse in the emergency department is admitting a client with a reduced level of consciousness due to severe hypothyroidism. Which interventions should the nurse implement first?

Monitor O2 saturation and provide supplemental oxygen. rationale Myxedema coma is a complication of poorly treated hypothyroidism, and occurs when levels of thyroid hormone are critically low. Low thyroid levels can result in a reduction in metabolism and significant cardiac dysfunction. This can result in decreased cardiac output, poor oxygenation to tissues and organs, and ultimately tissue and organ failure. For those with myxedema coma, appropriate interventions include administration of propranolol, utilization of warming blankets to prevent hypothermia and reorientation to person, time and place. However, the priority is to maintain respiratory functioning and to provide airway support. Therefore, monitoring oxygen saturation levels and providing supplemental oxygen should be done first.

The nurse is caring for a client who is experiencing excessive bleeding after receiving unfractionated heparin sodium. Which orders should the nurse anticipate from the health care provider? (Select all that apply.)

Obtain activated partial thromboplastin time (aPTT). Administer protamine sulfate. rationale Protamine sulfate is the antidote used to reverse the anticoagulant effects of heparin. A serum aPTT or PTT lab test is used to evaluate the anticoagulation effect of heparin. Vitamin K is the antidote for warfarin. A serum PT/INR lab test is used to monitor the therapeutic effectiveness of warfarin. Enoxaparin is another type of heparin and would be contraindicated for this client.

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." rationale 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...").

The hospice nurse is visiting a client diagnosed with end-stage lung cancer and metastases to the bone. What should the nurse keep in mind when planning for effective pain management?

Pain therapy is based on the client's report of pain. rationale Every person's pain experience is unique and should be treated based on the individual's goals for pain management. Therefore, the amount of medication needed is dependent on the client's needs and reports of pain relief. The nurse should not assume that high doses of analgesics will be needed to alleviate the client's pain. Immediate or quick pain relief might be difficult to achieve, especially in light of the client's type of cancer and bone metastases. Addiction is a psychological condition and not a concern for this client. However, the client may develop a physical dependence and tolerance to pain medications that may require an increase in dosage to manage pain effectively.

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 rationale 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.

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 Correct! rationale 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 transesophageal echocardiogram (TEE) is ordered for a client with possible endocarditis. Which action included in the TEE orders should the nurse implement first?

Place the client on NPO status. rationale The client will need to be NPO for six hours preceding the TEE, so the nurse should place the client on NPO status as soon as the order is received. The other actions also will need to be accomplished but not until just before or during the procedure.

The nurse is caring for a client with congestive heart failure. Which task can the nurse delegate to the unlicensed assistive person (UAP)?

Record and report the client's intake and output. The nurse is always responsible for any type of physical, social, emotional or environmental assessment. The nurse must assess the client for edema and also any learning needs the client may have. Furthermore, the nurse would also need to assess the status of an IV site for complications such as infiltration or phlebitis. The UAP is able to assist in direct client care activities such as bathing, ambulating, feeding, obtaining vital signs and recording intake and output.

The off-duty nurse is helping to administer first aid following a mass casualty incident in the community. Emergency medical personnel at the scene have started to triage victims, using a common, color-tagging system. Which tag color usually indicates the highest priority for a victim to receive care?

Red rationale In a mass casualty incident (MCI), first responders often use a color-tagging system to facilitate rapid triage of victims. Generally speaking, a green tag would indicate minor injuries, a yellow tag would indicate more significant but not expected to be life-threatening injuries, a red tag would indicate life-threatening injuries, and a black tag would identify a victim who has died, is near death or has the lowest chance for survival. Victims assigned a red tag are the highest priority for care and transport to the nearest hospital.

The nurse is reviewing the laboratory results for a client diagnosed with dehydration. Which result is most important to communicate to the health care provider?

Serum creatinine level of 2.8 mg/dL rationale The client with dehydration will show certain increased lab values that are due to hemoconcentration - an imbalance in the ratio of plasma to solutes in the blood. Dehydration will cause a decrease in fluid, i.e., plasma, in the blood. This decrease will make the concentration of solutes such as glucose, potassium and hemoglobin appear higher than they actually are. Creatinine is excreted solely by the kidneys and is proportional to renal function. Thus, with normally functioning kidneys, the creatinine level should remain within a normal range of 0.5 to 1.2 mg/dL in adults. Dehydration can contribute to impaired renal function. A creatinine level of 2.8 mg/dL is significantly elevated and indicative of renal impairment. Therefore, the creatinine value is the most important result for the nurse to report to the HCP

The nurse is discussing an illness with a 10 year-old child. What should the nurse keep in mind about this child's ability to understand the information at this stage of development?

Thinks logically to organize facts rationale According to Piaget, the child is in the concrete operational stage and is capable of mature thought when allowed to manipulate and organize objects or thoughts. School-age children tend to focus on "rules," which helps to organize facts. The other options are either too advanced or not advanced enough.

The nurse is concerned that a client with a history of anorexia nervosa may be experiencing a recurrence of the condition. Which of the following findings would support the nurse's concern? (Select all that apply.)

Weight loss Recent hair loss Constipation. Hair loss, constipation and weight loss are all potential manifestations of anorexia nervosa. Excessive exercising, not a lack of exercise, is often associated with anorexia nervosa. Elevated blood pressure is not a clinical manifestation of anorexia nervosa.

The nurse in the neurology office is reviewing information about levetiracetam with a 30-year-old female client with a history of seizures. Which instruction about the medication should the nurse make sure to include?

"Call the office immediately if you feel like hurting or killing yourself." rationale Levetiracetam is an anti-convulsant medication used to prevent seizures. One of the significant side effects is behavioral changes and suicidal ideations. It is important to notify the provider office immediately if the client experiences these thoughts. The other instructions do not apply to this particular medication.

During a conversation with a client who has osteoarthritis, the client says, "I am so frustrated with this disease and my disabilities." What is the best response by the nurse?

"Can you tell me more about what is frustrating you?" rationale Osteoarthritis (OA) is characterized by the progressive deterioration and loss of cartilage in one or more joints. OA is a chronic condition that may cause permanent changes in lifestyle. In this scenario, the nurse should collect more data about the specific cause of the client's frustration and disabilities to help develop an appropriate plan of care. The other options about pain medications, assistive devices and spousal support are relevant but the nurse first needs to collect more data about what specifically is frustrating the client.

The nurse is reinforcing the correct use of a metered-dose inhaler (MDI) for a client newly-diagnosed with asthma. The client asks, "how will I know the canister is empty?" What is the best response by the nurse?

"Count the number of doses as the inhaler is used." rationale Floating an MDI in water, or shaking it to listen for fluid movement to determine how much medication is left, is not recommended. MDIs that count down the number of remaining doses are available, however, these mechanisms are not always accurate. Therefore, it is best to calculate how long the inhaler will last by dividing the number of doses in the container by the number of doses the client takes per day. For example, a client who needs to take two puffs of albuterol, four times a day, will take a total of eight puffs per day. The MDI contains a total of 200 puffs. Divide 200/8 = 25 days. The inhaler in this example will last 25 days. To ensure that the client does not run out of medication, the client should obtain a refill at least 7 to 10 days before it runs out. The pharmacy would not be able to determine if the canister is empty.

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." rationale 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 client has received instructions for the management of osteoarthritis. Which statement by the client would indicate a need for additional teaching?

"Early surgical intervention is the preferred treatment." rationale Clients with osteoarthritis experience the erosion of cartilage in their joints, which leads to pain and swelling of the joints. Weight loss has shown to decrease pressure on the joints, which can decrease pain. Balancing exercise and rest periods allows the client to be active to help decrease joint stiffness while decreasing the likelihood of more inflammation in the joint. Cyclobenzaprine is a muscle relaxant used to manage pain and muscle spasms in clients with osteoarthritis. Cyclobenzaprine can cause drowsiness, fatigue and dizziness. For safety reasons, the client should not drive after taking cyclobenzaprine. Initial management of osteoarthritis includes physical therapy, medications and weight loss. Surgical management is typically not considered until all medical interventions have failed.

The nurse in the outpatient clinic is assisting in the admission of a client scheduled for a prostatectomy this morning. Which statement by the client should be of greatest concern to the nurse?

"I have not had to urinate since yesterday evening." rationale The client's statement about not having urinated in over 12 hours should be the greatest concern to the nurse. Urinary retention is a complication of an enlarged prostate gland and the nurse will need to further evaluate the client. The client may require a bladder ultrasound (bladder scan) to determine the amount of urine retained and the insertion of a catheter to drain the bladder may be indicated. The health care provider should also be notified. The nurse will then follow up on the client's other statements.

The nurse is caring for a client with a new sigmoid colostomy. Which statement(s) by the client will require additional teaching by the nurse? (Select all that apply.)

"I plan on going back to work right away." "I should only change the pouch when it starts to fall off." "I'm sad that I cannot go swimming anymore." "The stool consistency should be liquid and green or yellow in color." Correct! rationaleColostomies are temporary or permanent surgical openings created in the abdominal wall to allow fecal elimination. The portion of the ostomy that is visible is called the stoma. A sigmoid colostomy is the most common type of ostomy and tends to produce more solid stool than all other colostomies. Normal stool is brown in color. Green or yellow, liquid stool can indicate a gastrointestinal (GI) infection.A small amount of bleeding from the stoma while cleaning is normal due to the vascularity of the bowel. However, a large amount of bleeding from the stoma may indicate a GI bleed or coagulopathy. A viable stoma should be rosy pink to red in color, not pale or dark. A pale pink stoma may indicate anemia (i.e., blood loss), while a dark grey/purple stoma may indicate poor blood flow to the bowel (i.e., ischemia or necrosis).Individuals with a new colostomy should avoid heavy lifting. They may resume normal activities of daily living within 6 to 8 weeks of colostomy formation. Individuals with colostomies can swim as long as their ostomy pouch is intact.A patient with a sigmoid colostomy can use a drainable pouch or closed end pouch. The current recommendations state that drainable pouches should be changed every 4 to 7 days and closed end pouches should be changed daily. Incorrect

The nurse is caring for a client who was recently diagnosed with hypopituitarism. Which client statements would indicate additional teaching is needed? (Select all that apply.)

"I should expect to feel more thirsty throughout the day." "I should expect breast swelling or tenderness." Clients with hypopituitarism are at-risk for diabetes insipidus, in addition to increased levels of prolactin and subsequent breast tenderness, swelling and leakage. Both of these findings are abnormal and should be evaluated by a health care provider (HCP). Thus, additional teaching is required for a client who states that breast swelling or tenderness is expected or that increased thirst is expected. For the same reason, changes in frequency of urination may indicate diabetes insipidus and should be reported to a HCP. Clients with hypopituitarism should expect to see an improvement in symptoms within a few weeks. Additionally, clients are at-risk for osteoporosis and may need calcium and vitamin D supplements.

The nurse in the urgent-care clinic is reviewing discharge instructions with a client who is prescribed doxycycline. Which statement by the client indicates understanding of the instructions?

"I will apply sunscreen when outside to prevent a sunburn." rationale Doxycycline is a tetracycline antibiotic. All tetracyclines can increase the sensitivity of the skin to ultraviolet light. The most common result is a sunburn. Clients on these types of medications should prevent sunburn by avoiding prolonged exposure to sunlight, wearing protective clothing and applying sunscreen to exposed skin while outdoors. This drug should be taken two hours before or after antacids, not with them. Hypoglycemia is not a common side effect of doxycycline. Wearing contact lenses is not contraindicated with this medication.

The nurse in the ambulatory care center is assisting in the discharge of a client following a colonoscopy. Which statement by the client requires additional teaching?

"I will be careful when I drive myself home." rationale A colonoscopy is an endoscopic examination of the entire large bowel. The procedure is performed under sedation. Due to the anesthetics used during the procedure, the client should not drive themselves home. Other teaching that should be given to the client includes reminding the client that fullness, mild abdominal cramping and passage of flatus are expected. Since air is instilled in the bowel during the procedure, it is normal and encouraged for a client to pass flatus after the procedure. The client should rest for the remainder of the day since they have received a sedative medication.

A client has been hospitalized for pneumonia. Which statement indicates that the client has a good understanding of the discharge instructions given by the nurse?

"I will continue to do the deep breathing and coughing exercises at home." rationale Clients should continue to cough and perform deep breathing exercises after discharge. Fatigue is expected for several weeks. Home oxygen therapy is not needed with successful treatment of pneumonia. The pneumovax and influenza vaccines can be given at the same time, once the client is fully recovered.

The nurse in an urgent care clinic is evaluating a client's understanding of discharge instructions for a second-degree ankle sprain. Which statement by the client requires follow-up by the nurse?

"I will do gentle stretching and range of motion exercises daily." rationale A sprain is excessive stretching of the ligament with tearing of the ligament fibers. Twisting motions from a fall or sports activity typically precipitate the injury. A second-degree sprain is classified as moderate. Second-degree sprains require immobilization with an elastic bandage and ankle brace, splint or cast. Recommendations for caring for a client with a sprain include rest, use of ice for the first 24 to 48 hours, application of a compression bandage for a few days to reduce swelling and provide joint support and elevation of the affected extremity (RICE). It is recommended not to stretch or use the sprained joint for approximately a week, sometimes longer, to allow it to heal properly. The nurse should follow up and advise the client not to perform stretching and range of motion exercises.

A client who has just given birth asks the nurse what an Apgar score means. The correct response by the nurse should be:

"The score is a general overview of how well your newborn is doing." The Apgar score gives the health care team a general overview of how well the newborn is acclimating. It is not a predictor of future problems or lack thereof. Although the score is most meaningful to the health care team, the role of the nurse is to educate and answer client questions as appropriate.

The nurse is reinforcing discharge instructions for a client with pernicious anemia. Which statement by the client demonstrates understanding of the at-home medication regimen?

"Initially, I will need weekly injections of vitamin B12 and then monthly injections for maintenance, which will be a lifelong requirement." rationale A patient with pernicious anemia cannot absorb vitamin B12 through the GI system, due to the lack of intrinsic factor needed to absorb B12. So taking supplements of vitamin B12 orally would not help with pernicious anemia. Therefore, the typical regimen for a patient with pernicious anemia is to receive vitamin B12 through injections. Typically, the client will receive weekly injections until the hemoglobin is normal and then monthly, as maintenance. Clients with this type of anemia usually require lifelong treatment.

A client with diabetes mellitus is being discharged home. Which statement by the client demonstrates an understanding of the nurse's teaching?

"It is important I check my blood glucose every 3-4 hours when I'm sick." rationale The client's blood glucose levels can change rapidly when the body is under stress. It is critical that the client monitor their blood sugars closely when they are sick to be able to adjust to the changes if needed.

The nurse is reviewing information with a client about their new ileostomy. Which statement by the client suggests that they understand the teaching?

"It is normal for my stoma to remain red in color. rationale The stoma will remain red in color because it is very vascular. If the client needs to empty the pouch every thirty minutes that would be considered too frequent. A full bowel assessment should be obtained to gather more data. Laxatives are contraindicated with ostomies.

A nurse is caring for a client who is being treated for major depression. During which time period is the client most likely to be at the highest risk for attempting suicide?

1 to 2 weeks after initiating antidepressant medication. Suicide risk assessment is an ongoing process, and a client's level of risk can increase or decrease over time. It is impossible to predict the greatest risk 6 to 12 months later. Certain anniversaries can trigger thoughts of suicide, e.g., death of a loved one or the loss of a relationship. The client's own birthday is less likely to be a trigger. If all facility policies for suicide prevention such as one-on-one observation are adhered to, the client should not be able to harm themselves. As the symptoms of depression decrease due to treatment and medications, the client may acquire the energy to develop a plan and follow through with a suicide attempt. Therefore, the nurse should monitor for sudden changes in behavior, such as excessive happiness and other warning signs that are potential indicators that the client has decided on a suicide plan.

An 82-year-old male client is admitted with benign prostatic hyperplasia (BPH). Which finding by the nurse will require immediate action?

A bladder ultrasound value of 900 mL rationale Complications of BPH include acute urinary retention. Urinary retention is the accumulation of urine in the bladder due to bladder outlet obstruction caused by the enlarged prostate gland. Acute urinary retention is a medical emergency that requires prompt bladder drainage.The elevated heart rate and blood pressure and the severe abdominal pain are signs and symptoms of the acute retention. They will most likely resolve when the retention is resolved. The high bladder scan/ultrasound value confirms the retention of a large volume of urine that will require catheterization.

A client recovering from hip replacement surgery is taking acetaminophen with codeine every three hours for pain. For which side effect should the nurse monitor the client?

A client recovering from hip replacement surgery is taking acetaminophen with codeine every three hours for pain. For which side effect should the nurse monitor the client? rationale Codeine is an opioid analgesic and antitussive (cough suppressant). For analgesic use, codeine is formulated alone and in combination with non-opioid analgesics (either aspirin or acetaminophen). Because codeine and non-opioid analgesics relieve pain by different mechanisms, the combination can produce greater pain relief than either agent alone. Opioids such as codeine slow down the function of the central nervous system. This can affect involuntary movements in the body, such as peristalsis. As the movement of food through the intestinal tract is slowed down, the walls of the intestine absorb more fluid. With less fluid in the intestines, stool becomes hard and constipation develops. The other side effects are not usually seen with codeine.

The nurse is reviewing the medical record of a client who has been diagnosed with systemic lupus erythematous (SLE). The nurse would expect which findings associated with this disease? (Select all that apply.)

A temperature of 100.6° F (38° C) A red, raised rash on the face Reports of pain in the hands and knees Generalized weakness rationale Systemic lupus erythematous (SLE) is an autoimmune, inflammatory disorder of the connective tissue. It can affect multiple organs. This disorder has remission periods and flare-ups. A client who was recently diagnosed often presents during an exacerbation. Common assessment findings during exacerbation include a red, raised, rash on the face, commonly known as the "butterfly rash" and generalized weakness that can be associated with the fever and joint inflammation that are also present. SLE most frequently affects small joints (such as the hands) and the knees. Clients tend to experience anorexia which often leads to reports of weight loss, not weight gain. Polydipsia (excessive thirst) is not associated with SLE.

A pregnant woman in the third trimester is admitted with a report of painless vaginal bleeding that started several hours ago. The nurse should prepare the client for what procedure?

Abdominal ultrasound rationale Third-trimester painless vaginal bleeding is suggestive of a complication such as placenta previa. Placenta previa is diagnosed through an abdominal ultrasound. This may be followed up with a transvaginal ultrasound. The health care provider (HCP) should not perform a pelvic exam because the client is actively bleeding. If the bleeding cannot be stopped and/or the fetus is determined to be in distress, an emergency C-section will be required.

The LPN/VN assists the RN in evaluating the plan of care for clients. What action does the LPN focus on during the evaluation phase?

Achievement or status of progress related to prior goals rationalEvaluation process of the clinical problem-solving process (the nursing process) should focus on the clients' status, progress toward goal achievement and ongoing re-evaluation of the plan of care. LPN/VN's gather, observe, record and communicate client responses to nursing interventions.

Where should the nurse administer the annual purified protein derivative (PPD) to the client with a left arm Permcath™? Use your cursor to select an area on the image below.

Always avoid using the arm with a shunt so as to prevent restriction of blood flow and possible clotting or rupture of the fistula. Using the opposite forearm for the PPD administration also reduces the chance for infection.

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

The nurse working in a medical office answers a phone call from a client. The client asks how to improve symptoms of their migraine headache. The nurse should advise the client to use which interventions? (Select all that apply.)

Apply a cold cloth to their forehead. Wear sunglasses while indoors. Take 600 mg ibuprofen as prescribed. Lie down in a darkened room. Migraine headache is an episodic familial disorder manifested by unilateral, frontotemporal, throbbing pain in the head, which is often worse behind one eye or ear. It is often accompanied by sensitive scalp, anorexia, photophobia, phonophobia and nausea, with or without vomiting. The priority for interdisciplinary care of the client experiencing a migraine is pain management, which may be achieved by abortive and preventative drug therapy, as well as non-drug measures. The client may be able to alleviate pain by lying down in a dark room. The client may want both eyes covered and a cool cloth on their forehead. If the client falls asleep, they should remain undisturbed until awakening. Sunglasses may eliminate symptoms of photophobia. Bright lights and noise should be avoided (watching television). Alcohol is a migraine trigger and should be avoided.

The nurse is assisting in the admission of a 73-year-old client who has a fractured right hip. Which interventions should the nurse include in the client's plan of care? (Select all that apply.)

Ask about the client's pain level with every set of vital signs. Correct! Palpate the client's bilateral pedal pulses every four hours. Place the client on continuous pulse oximetry. rationale The client with a hip fracture is at risk for impaired perfusion to the affected extremity. Monitoring bilateral pedal pulses allows the nurse to compare the pulse strength in the injured site with that in the non-injured site. A decrease in the injured leg could signal a decrease in circulation that would require immediate intervention. A fat embolism is also a risk with a hip fracture and continuous pulse oximetry would allow the nurse to identify hypoxia quickly which could be associated with a fat embolism. Clients with a hip fracture usually experience great pain and assessing pain with each set of vital signs is key to effective pain management. Circulation, motion and sensation checks should be completed at least every four hours, not daily. Repositioning the client every hour is unnecessary and will only increase the client's pain level even more.

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 client in the physical therapy room tells the licensed practical/vocational nurse (LPN/VN), "I feel like I'm going to have a seizure." Which intervention should the nurse implement first?

Assist the client to a safe position, away from hazards. rationale Clients with seizure disorders (or epilepsy) often experience symptoms that warn them that a seizure is going to happen, called an aura. The first action to implement in this situation is to place the client in a safe position, so if a seizure occurs, the client will not be injured. The LPN/VN should stay with the client and send someone to notify the RN, who can bring medication to prevent seizure activity. Noise and light reduction may be beneficial in preventing an impending seizure, but they are not the priority. The priority is to ensure the client's safety.

A client has been diagnosed with emphysema. Which intervention should the nurse implement when caring for this client?

Assist the client with enrolling in a smoking cessation program. rationale By the time the client is diagnosed with emphysema, lung damage is usually permanent and a common cause of disability. Smoking is the most common risk factor for developing emphysema and the client should stop smoking. Participating in a structured program increases the client's chance for successful smoking cessation. Scheduling a lung cancer screening and asking about a power of attorney are not appropriate interventions for the client at this time.

The nurse enters the room of an adult client in cardiac arrest with cardiopulmonary resuscitation already in progress. The client's bedside telemetry monitor shows ventricular fibrillation. What should the nurse do next?

Assist with preparing the client for defibrillation. rationale Ventricular fibrillation (V-Fib) is a life-threatening dysrhythmia that requires immediate defibrillation to attempt to restore a viable cardiac rhythm. V-Fib will cause death within minutes due to the complete lack of cardiac output and tissue perfusion. The other actions should be implemented after defibrillation has been performed or attempted.

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 rationale 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.

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 Rationale 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.

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.

The nurse is talking with a client during a home health visit. The client states, "my right arm and right leg are beginning to feel heavy." The nurse notices the client is having trouble speaking and has stopped moving the right side of their face. What action the nurse should take first?

Call 911. rationale The client is exhibiting signs of an acute stroke. A stroke is caused by a disruption in the normal blood supply to the brain. A stroke is a medical emergency. The nurse in the home health setting should call 911 first. While waiting for emergency medical help to arrive, the nurse should gather additional data by obtaining vital signs and evaluating the client's neurological status. The data should be recorded in the medical record.

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 rationale 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).

An off-duty nurse witnesses a person collapse in a grocery store, and the individual is now unresponsive. Multiple bystanders are present. What should the nurse do first?

Check for a carotid pulse and instruct a bystander to call 911. rationale The off-duty nurse's first action when encountering this unresponsive individual who just collapsed should be to check for a pulse and to ensure the activation of 911 emergency response. While chest compressions may very well be needed, the nurse should first check for a carotid pulse. If a carotid pulse cannot be palpated in this unresponsive individual, cardiopulmonary resuscitation (CPR) chest compressions should be initiated. An automated external defibrillator (AED) should be incorporated into the response once it is available. However, the nurse should stay with the victim, begin CPR and assign the task of obtaining the AED to someone else at the scene.

The nurse is caring for a postoperative client following an appendectomy. The client has a nasogastric tube connected to low, continuous suction. Twice during the shift, the nurse irrigated the nasogastric tube with 50 mL of sterile water each time. At the end of the shift, the nurse empties a total of 450 mL from the drainage container. How much actual gastric drainage did the client have for the nurse's shift?

Correct answer: 350 mLAfter surgery, a nasogastric (NG) tube is placed to decompress the stomach and prevent abdominal distension. The nurse should carefully monitor and record the amounts of gastric drainage from the NG tube.Drainage Container Total - Irrigation Volume Total = Shift TotalTotal drainage was 450 mLIrrigation was 50 mL x 2 occurrences = 100 mL

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 rationale 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 working with a couple who is experiencing intense anxiety after their home was completely destroyed by a fire. The nurse should implement which initial intervention?

Determine what community housing resources are available. The couple has experienced a crisis, i.e., sudden loss event that has resulted in disequilibrium. The most important initial crisis intervention focuses on identifying resources and obtaining assistance for housing and other immediate needs. The other interventions would be appropriate after meeting the couple's immediate need for shelter.

A nurse is caring for a client with a personality disorder. He comments to the nurse that she "doesn't know what she is doing because all the other nurses let him take his coffee into his room. Most of them will even bring me coffee in my room!" The nurse recognizes that this is what type of behavior?

Manipulative behavior Correct Response rational Many clients with personality disorders have self-esteem issues related to dependency. Because of this, clients may manipulate staff in this way. Attempts to manipulate are attempts to show superiority and deny one's own feelings.

The nurse is evaluating the plan of care for a client with benign prostatic hyperplasia (BPH). For which prescribed medication should the nurse notify the health care provider (HCP)?

Diphenhydramine rationale Diphenhydramine is a first generation histamine1 receptor antagonist or antihistamine, commonly used for relief from symptoms of mild to moderate allergic disorders. H1 blockers have anticholinergic effects or atropine-like responses and can cause urinary hesitancy or retention. A client with BPH is already at risk for urinary retention and should not receive an antihistamine such as diphenhydramine without clarification from the HCP first. Metoprolol is a beta blocker, which does not affect the bladder. Finasteride and terazosin are drugs commonly used to treat BPH.

The nurse is speaking at a senior citizen community center on how to prevent constipation. What information should the nurse include? (Select all that apply.)

Drink 2 to 3 liters of fluids per day. Exercise regularly such as walking for 30 minutes 3 to 5 times a week. Eat foods high in fiber, such as fresh fruit and whole grains. rationale Constipation is hardened, formed stool in the bowel and can cause the client to be uncomfortable and have difficulty passing stool. To prevent constipation, it is important to consume at least 2 liters of fluid a day, eat a diet high in fiber and whole grains, and be active, which will help with peristalsis. Taking a daily laxative will cause the body to rely on the laxative and will actually increase the likelihood of constipation. Taking iron supplements or increasing the intake of dairy products will not help prevent constipation.

The nurse is reviewing a client's dietary history. The nurse understands that which factors will influence the clients' dietary intake? (Select all that apply.)

Education Personal feelings Personal feelings Culture ratoinale Dietary choices or restrictions are influenced by economics, culture, religion and personal feelings and meanings associated with food. The financial income of the client or the client's household can directly impact the ability to purchase sufficient food and/or food of high nutritional value. Diverse lifestyles and eating habits directly impact a person's nutritional health and well-being. Religious restrictions and beliefs or cultural practices may affect the client's acceptance of, response to and compliance with dietary therapies. Health care providers (HCP) need to understand a client's cultural values, beliefs and practices to provide culturally acceptable care (Taylor, p. 1212).Anthropometric measures are used to measure growth rate, body protein and fat stores. They do not directly influence dietary intake.

The nurse is planning care for a client newly diagnosed with essential hypertension. Which interventions should the nurse include in the client's plan of care? (Select all that apply.)

Evaluate the client's understanding of a low-sodium diet. Evaluate the client's ability to take their own blood pressure. Encourage the client to take daily, 30-minute walks. Explain the negative effects of hypertension on the body. rationale Hypertension can occur when the resistance to blood pumping through the arteries increases. Risk factors for the development of hypertension include older age, smoking, salt intake, family history and ethnicity. The client should be advised on the negative effects of hypertension on the body, such as kidney failure and cardiovascular disease. The client should know how to correctly check their blood pressure at home. Clients with hypertension should not only limit smoking, but should not smoke at all due to the vasoconstrictive effects of nicotine. Clients should understand what foods are appropriate for a reduced- or low-sodium diet and how engaging in regular physical activity can help manage their disease. Complete abstinence from alcohol is not required.

The nurse is caring for a client who has a history of heavy alcohol use. Which findings would indicate that the client is probably experiencing delirium tremens (DTs)?

Excitability, disorientation, tremors and tachycardia rationaleDTs is a severe form of alcohol withdrawal that usually occurs within 72 hours after the client ingests their last drink. During DTs, the person experiences both physical and mental hyperexcitability. Common findings include agitation, confusion, disorientation and hallucinations. The physical component of DTs includes diaphoresis, tachycardia, hypertension, tremors and fever and eventually, if not treated, seizures, severe dehydration and death. The other clinical manifestations are more indicative of gastrointestinal (GI) bleeding, a stroke or myocardial infarction (MI).

A child diagnosed with thalassemia has received several blood transfusions during the past three days. What lab value is the priority for the nurse to monitor with this client?

Hemoglobin level rational Beta thalassemia, also called Cooley's anemia, is a genetic defect that causes anemia, i.e., a condition in which the blood contains below-normal hemoglobin levels. Hemoglobin is the oxygen-carrying protein component of the red blood cell (RBC). A normal hemoglobin range for children is approximately 11 to 13 gm/dL. The only treatments for this disease include regular blood transfusions or a bone marrow transplant. Monitoring the hemoglobin level for this client will determine the effectiveness of the treatment or the need for an additional blood transfusion.

The nurse comes upon an 85-year-old client lying on the bathroom floor. The nurse observes a deformity in the left leg and the client is unable to move the leg. The client is alert and oriented but in severe pain. Which action should the nurse take first?

Immobilize the fracture with a splint. rationale It appears that the client suffered a bone fracture in the left leg. After confirming that the client's respiratory and neurologic status is stable, the nurse should immobilize the fracture with a splinting device. This will prevent movement of the extremity by the client and further pain or bleeding along the fracture into the surrounding tissues. Next, the nurse will notify the health care provider and implement the other actions as prescribed and appropriate.

A nurse is caring for a client who is experiencing alcohol withdrawal symptoms. Which nursing considerations are most appropriate? (Select all that apply.)

Implement seizure precautions Administer prescribed medication Monitor vital signs Orient the client frequently There are multiple interventions that the nurse must consider when caring for a client who is experiencing alcohol withdrawal. Vital signs may become unstable and the cardiac rhythm can become irregular. Seizures are a great risk in withdrawing clients and must be prevented. Clients often become confused and disorientated during withdrawal and it is necessary for the nurse to frequently orient them. Administering medications such as benzodiazepines, anticonvulsants and vitamins (thiamine, B12, folic acid) will help with symptom management. A nurse should only apply restraints if the client is in danger of harming themselves or others. A no-visitor policy would not be appropriate.

A nursing student asks the licensed practical nurse (LPN) to explain the forces that drive health care reform. When responding to the student's question, what information should the nurse emphasize?

Increase in health care spending that's growing faster than the economy rationale One of the most significant reasons for health reform is the need to control costs. Health care spending continues to grow at a faster rate than the economy. Other reasons contributing to increased health care spending includes a decrease in the number of people with health care insurance and decreased competition in both insurer and provider markets. End-of-life care is expensive, but it is too narrow a focus to be the correct response.

The nurse is providing information to a pregnant client about the potential risks of an amniocentesis. Which risk factors shall the nurse include?

Preterm labor Spontaneous abortion Premature rupture of membranes During an amniocentesis, amniotic fluid is removed from the uterus through the insertion of a hollow needle through the abdominal wall and into the uterus. Reasons include genetic testing, fetal lung testing, and removal of excess amniotic fluid (polyhydramnios). Amniocentesis carries various risks, including: leaking amniotic fluid, rupture of amniotic membrane, miscarriage or spontaneous abortion, preterm labor, needle injury to the fetus, Rh sensitization and infection.

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 rationale 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.

The nurse is caring for a client diagnosed with a chlamydial infection. Which of the following should the nurse plan to include in the client's education to prevent further transmission of the infection?

Retesting after treatment is necessary to confirm that reinfection has not occurred. The client should not have sexual activity until at least seven days after completing the course of antibiotics. The client's sexual partners also need to receive antibiotic treatment for chlamydia. Chlamydia is a bacterial, sexually transmitted infection (STI). The client's sexual partners must also be given antibiotics to prevent further transmission and reinfection and to treat the sexual partners' infections if diagnosed. In order to decrease the risk of reinfection, the client must wait to have sexual activity at least seven days after completing the course of antibiotics and all sexual partners must also have completed their treatment. There currently is no vaccine available for chlamydia. There is a high rate of reinfection with chlamydia after the initial diagnosis, and retesting is necessary.

When taking a client's blood pressure (BP) after a parathyroidectomy, the nurse notes that the client's hand has gone into flexion contractions. Which laboratory result does the nurse correlate with this condition?

Serum calcium level of 6.9 mg/dL rationale The parathyroid glands maintain calcium and phosphate balance through release of parathyroid hormone (PTH) that acts directly on the kidney, causing increased kidney reabsorption of calcium and increased phosphorus excretion.After surgical removal of the parathyroid glands, a hypocalcemic crisis can occur due to the absence of PTH. Hypocalcemia destabilizes excitable membranes and can lead to muscle twitches, spasms and tetany.The flexion contractions that occur while measuring BP (Trousseau's sign) indicate hypocalcemia, not the other electrolyte imbalances, which include hypokalemia, hyperkalemia and hyponatremia.

The nurse is monitoring a UAP as they provide perineal care to a client who suffers from urinary incontinence. What action by the UAP would require intervention by the nurse?

The UAP cleanses the urinary meatus and then the labia majora and minora. rationale It is critical that the UAP provides appropriate care, which reduces the risk of infection and loss of skin integrity. Perineal care should be performed by cleansing from anterior to posterior and outside to inside. This should be done using a clean portion of the washcloth for each wipe. Cleansing the urinary meatus and then the labia majora and minora increases the risk of spreading microorganisms from the protective structures of the labia to the urinary meatus.

The nurse recognizes that which finding indicates a child has attained the developmental stage of concrete operations, according to Piaget?

The child makes the moral judgment that "stealing is wrong." The stage of concrete operations is characterized by logical thinking and moral judgments. This stage is associated with school-aged children from about age 7 to 11. Exploring the environment is seen in the sensorimotor stage (birth to 24 months). Mental symbolization is seen in the preoperational stage (2 to 4 years). Formal operational thought is seen with adolescents, who might reason that homework is necessary.

The nurse is observing a new graduate nurse preparing to administer bumetanide 4 mg orally to a client with heart failure. Which client finding requires the nurse to intervene immediately?

The client's most recent serum potassium level is 2.9 mg/dL. rationale Bumetanide is a powerful, potassium-wasting loop diuretic. It promotes diuresis in clients suffering from heart failure (HF) and fluid retention. Prior to administration, the nurse should verify that the client's potassium level is within normal range (3.5 to 5.0 mg/dL). A serum potassium level of 2.9 mg/dL is very low. The new graduate nurse should hold the bumetanide and notify the health care provider (HCP) immediately. Bibasilar crackles and pitting edema are expected findings for a client with HF and are indications for the use of diuretics. Although loop diuretics can cause hypotension related to diuresis, a BP of 96/60 is within acceptable limits for a client with HF.

The nurse is reinforcing teaching about levothyroxine for a client newly-diagnosed with hypothyroidism. Which information should the nurse make sure to reinforce about this medication?

The medication should be taken in the morning. rationale A thyroid supplement, such as levothyroxine, should be taken on an empty stomach in the morning. Morning dosing minimizes the side effect of insomnia and an empty stomach facilitates absorption. The medication does not need to be stored in a dark container. Levothyroxine will cause an increase in the client's energy level and heart rate.

Which of the following actions by the nurse indicates a need for additional education on the prevention of health care-associated infections (HAIs)?

The nurse uses their own stethoscope to assess the lung sounds of a client placed on contact precautions for Methicillin-resistant Staphylococcus aureus (MRSA) infection. rationale The nurse should advocate for clients by requesting removal of an indwelling urinary catheter as soon as possible to reduce the risk of catheter-associated urinary tract infections (CAUTI). C. difficile bacteria is not killed by alcohol-based preparations and the nurse should wash their hands for 60 seconds or more with soap and water. Clients with a VRE infection should be placed in contact precautions, which require the use of personal protective equipment (PPE), including a gown and gloves. A client in contact precautions should, ideally, have dedicated equipment such as a disposable stethoscope and blood pressure cuff placed in the room for the nurse, unlicensed assistive personnel (UAP) or HCP to use. The nurse should keep their own stethoscope out of the room to reduce the risk of contamination and transmitting the infection to other clients.

A nurse is caring for a client who is receiving enteral nutrition. Before starting the next bolus feeding, what action should the nurse take?

Verify correct tube placement. rationale Before the nurse administers anything through a feeding tube, they need to verify correct placement of the tube. The recommended angle for the head of bed (HOB) while receiving tube feedings is 30 to 45°. It is no longer considered a best practice to add dye or food coloring to tube feeding as a way to monitor for aspiration. Food coloring has been associated with the development of diarrhea. Irrigation of the tube is not indicated at this time and it should not be done vigorously.

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 rationale 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.

A client is taking diphenhydramine for seasonal allergic rhinitis. The nurse should reinforce teaching for the client about which possible side effects? (Select all that apply.)

Urinary retention Dry mouth Drowsiness Constipation rationale Diphenhydramine is an over-the-counter (OTC) drug commonly used for allergic rhinitis and the common cold. It is a first-generation H1 antagonist or antihistamine. Sedation and sleepiness are the most common side effects of this antihistamine. Due to the anticholinergic effects of H1 blockers, constipation, dry mouth and urinary retention are potential side effects. Urinary frequency is not an expected finding.

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 with adrenal insufficiency. The nurse understands that the hormone cortisol is controlled by a cascade of events in specific organs. Beginning with the organ that responds first to low cortisol levels, place the following events in the correct order.

hypotalamus is stimulated cortisol releasing hormone is released Anterior pituitary is stimulated Adrenocorticotropic hormone is released Adrenal cortex is stimulated cortisol released cortisol level returns to adequate range rationale Adrenal insufficiency (Addison's disease) is caused by a decrease in adrenocortical hormones, such as cortisol and aldosterone. Adrenal insufficiency is characterized by muscle weakness, fatigue, hypotension and electrolyte imbalances. This hormone cascade is controlled by the hypothalamic-pituitary axis. In this negative feedback loop, the hypothalamus is stimulated by low cortisol levels, which causes a release of cortisol releasing hormone (CRH). CRH stimulates the anterior pituitary to release adrenocorticotropic hormone (ACTH). ACTH stimulates the adrenal cortex to release cortisol. Finally, adequate levels of cortisol cause the hypothalamus to stop releasing CRH.

The nurse is caring for a client with orders for oxygen (O2) per nasal cannula at 5 L/min. Approximately what fraction of inspired oxygen (FiO2) is the client receiving?

40% Correct Response rationale Room air has an O2 concentration of approximately 21%. Supplemental O2 therapy is prescribed when the client's oxygenation needs are not met by room air. A nasal cannula can provide O2 at 0.5 to 6 L/min, corresponding to a FiO2 range of 25% to 40%. At 5 L/min, the client would be receiving approximately 40% O2. If the client's oxygenation needs are still not met, the O2 delivery system should be changed from a low-flow system like a nasal cannula to a high-flow system such as a nonrebreather mask. FiO2 DELIVEREDNasal Cannula 24%-40% FiO2 at 1-6 L/min ≈ 24% at 1 L/min ≈ 28% at 2 L/min ≈ 32% at 3 L/min ≈ 36% at 4 L/min ≈ 40% at 5 L/min ≈ 44% at 6 L/min

The nurse is beginning a shift caring for a group of adult clients on a neurological unit in an acute care hospital. Which client should the nurse see first?

A client admitted several hours ago with a subdural hematoma due to an unwitnessed fall at home rationale After an unwitnessed fall, the nurse must consider the possibility of head injury. Due to the elevated risk for worsening bleeding and increased intracranial pressure because of the fall and pre-existing head injury, the client with a subdural hematoma should be seen first. A blood pressure of 158/64 in a client with an ischemic stroke would not represent an urgent situation, and an elevated ammonia level would not be unexpected for a client with hepatic encephalopathy. While the results of an echocardiogram with a bubble study would be relevant to the care of client with a transient ischemic attack (TIA), this client is not showing signs of a worsening condition requiring urgent assessment.

A 50-year-old male client with a family history of prostatic hyperplasia asks the nurse how the health care provider will screen him for the disease. Which is the best response by the nurse?

A digital rectal exam rationale A digital rectal exam is the most effective way to determine if the prostate gland is enlarged. The prostate-specific antigen (PSA) test is a blood test used primarily to screen for prostate cancer, not benign prostatic hyperplasia (BPH). A history of symptoms will also be completed, however many symptoms of BPH are similar to other conditions. A biopsy is usually done to determine the presence of cancer.

A client presents at an urgent care center after burning their hand while cooking. The client's burn wound has an intact skin surface, with redness and blistering that covers their posterior hand. How should the nurse describe this wound when documenting in the client's medical record?

A partial-thickness wound rationale Burn wounds are classified as superficial-thickness, partial-thickness, full-thickness and deep full-thickness. The wound described here is a partial-thickness wound. It involves the entire epidermis and varying depths of the dermis. These wounds are red, moist and blanch when pressure is applied. When small vessels are damaged, they may leak plasma, causing blister formation. The correct answer is a partial-thickness wound.

The chest X-ray report for a client shows a right basilar pleural effusion. The nurse would monitor the status of breath sounds in that area by placing the stethoscope at which location?

A pleural effusion means that fluid has accumulated in the pleural space and is most often found in the bases. The nurse uses auscultation to assess the movement of air through the tracheobronchial tree and detect absent or adventitious sounds. When auscultating the anterior chest of the client with a right basilar effusion, the stethoscope should be placed on the right side of the chest, near the fifth or sixth intercostal space. That area corresponds to the base of the right lung. The areas near the clavicle correspond to the apex or apices of the lungs.

Which of the following can a client with a primary TB infection expect to develop:

A positive skin test rationale A primary TB infection occurs when the bacillus has successfully invaded the entire body after entering through the lungs. At this point, the bacilli are walled off and skin tests read positive. However, all but infants and immunosuppressed people will remain asymptomatic. The general population has a 10% risk of developing active TB over their lifetime, which in many cases occurs because of a break in the body's immune defenses. The active stage shows the classic symptoms of TB: fever, hemoptysis and night sweats.

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 rationale PTCA is performed to improve coronary artery blood flow in a diseased artery. It is performed during a cardiac catheterization.

A newly pregnant woman asks the nurse what to expect in the early stages of pregnancy. Which developmental task will the client need to accomplish during this stage?

Accepting the pregnancy and the physical changes involved. During the first trimester, the maternal focus is directed toward acceptance of the pregnancy and adjustment to the minor discomforts. The other developmental tasks will be accomplished later in the pregnancy.

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 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.

A client with a known large abdominal aortic aneurysm develops a sudden change in level of consciousness and tachycardia. The client's blood pressure is 72/48. What should the nurse do first?

Activate the hospital's emergency response team. rationale The client is exhibiting signs and symptoms of an abdominal aortic aneurysm (AAA) rupture. The nurse's first action should be to activate the hospital's emergency response team, as this client needs immediate advanced care. The nurse is anticipating the need for rapid action and surgical intervention to avoid the death of the client. While notifying the client's health care provider and obtaining a 12-lead electrocardiogram (ECG) may be needed, activating the emergency response team should be done first. Similarly, the nurse does not have time complete a head-to-toe physical assessment before activating the emergency response team.

A nurse is providing home care for a client diagnosed with chronic heart failure and episodes of pulmonary edema. Which nursing diagnosis should the nurse expect as a priority in the plan of care?

Activity intolerance related to an imbalance of oxygen supply and demand rationale The primary problem resulting from a decreased cardiac output in heart failure is activity intolerance. Dyspnea and fatigue are common, worsening as the heart function worsens; therefore, changes in activity tolerance are important indicators of problems with or improvement in the heart's condition. This option is the only nursing diagnosis that addresses both the cardiac and pulmonary aspects of the question.

The nurse is assisting in developing as plan of care for a postoperative client following a radical left mastectomy. Which nursing problem should be the priority for this client?

Acute pain related to the surgery rationale A radical mastectomy is performed to treat invasive breast cancer and involves the removal of the breast, the nipple and areola, as well as a portion of the axillary lymph nodes. Using Maslow's Hierarchy of Needs to prioritize nursing care and interventions, the acute post-surgical pain (a basic, physiological need) is the priority problem. Next, the nurse should focus on prevention of lymphedema, alleviating the client's anxiety and monitoring for signs of infection at the surgical site.

A nurse is administering the influenza vaccine in an occupational health clinic. Within 10 minutes of giving the vaccine to a middle-aged adult male, the man reports having itchy and watery eyes, feeling anxious and short of breath. What should the nurse do first?

Administer SQ epinephrine. rationale The man is exhibiting signs and symptoms of an anaphylactic reaction. Although all of the interventions are correct, the nurse should first administer epinephrine to stop the bronchial constriction and airway obstruction that is occurring.

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.

The nurse is providing care for a 40-year-old client suspected of having Guillain-Barré syndrome. Which intervention should the nurse plan for?

Administration of immunoglobulins Guillain-Barré Is a syndrome with an unknown etiology occurring after a bacterial or viral infection. It is characterized by muscle weakness and paralysis that occurs in an ascending manner. It may result in paralysis of the respiratory muscles requiring mechanical ventilation for the client. Intravenous immunoglobulins (IV Ig) are used to treat Guillain-Barré in the early phase. They are believed to interfere with antigen presentation and help to modulate the body's immune response. The other interventions are not appropriate or necessary for this condition.

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 rationale 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 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 rationale 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 rationale 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 client newly diagnosed with generalized anxiety disorder (GAD) who has been prescribed alprazolam by the health care provider (HCP). Which of the following statements best describes this medication in the treatment of GAD?

Alprazolam provides short-term treatment but is less effective than other drug therapy. The most effective pharmacological treatment for generalized anxiety disorder is considered to be SSRI or SNRI therapy. Benzodiazepines like alprazolam may be used for fast-acting pharmacological treatment. However, SSRIs or SNRIs are considered to be more effective than benzodiazepines.Clients can develop a chemical dependency to benzodiazepines, and these medications can become less effective over time because clients can develop a tolerance to its therapeutic effect.

The nurse is caring for a client newly diagnosed with generalized anxiety disorder (GAD) who has been prescribed alprazolam by the health care provider (HCP). Which of the following statements best describes this medication in the treatment of GAD?

Alprazolam provides short-term treatment but is less effective than other drug therapy. Correct! The most effective pharmacological treatment for generalized anxiety disorder is considered to be SSRI or SNRI therapy. Benzodiazepines like alprazolam may be used for fast-acting pharmacological treatment. However, SSRIs or SNRIs are considered to be more effective than benzodiazepines.Clients can develop a chemical dependency to benzodiazepines, and these medications can become less effective over time because clients can develop a tolerance to its therapeutic effect.

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 rationale 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.

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

Monitor vital signs using post-op protocols rationale 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.

Which condition should the nurse correlate with the following arterial blood gas values: pH 7.48, HCO3 22 mEq/L, PCO2 28 mm Hg, PO2 98 mm Hg?

Anxiety-induced hyperventilation rationale The elevated pH indicates alkalosis. The bicarbonate level is normal, and so is the oxygen (O2) partial pressure. Loss of carbon dioxide (CO2) is the cause of the alkalosis, which would occur in response to hyperventilation. Diarrhea and vomiting would cause metabolic alterations. COPD would lead to respiratory acidosis due to retention of CO2. A client with diabetic ketoacidosis, a metabolic acidosis, will have a pH less than 7.35. The client's arterial blood gas (ABG) values indicate a respiratory alkalosis due to hyperventilation.

The nurse is caring for a client with a dry chest tube drainage system due to a left tension pneumothorax. Two hours ago, the health care provider (HCP) changed the chest tube prescription to water seal only. When entering the client's room, the nurse finds the client to be short of breath, tachypneic and with an oxygen saturation (SpO2) of 84%. On auscultation, the nurse notes absent breath sounds to the left upper lobe. What action should the nurse take first?

Apply oxygen via nasal cannula rationale A chest tube system is usually changed from wall suction to water seal only when the pleural space has re-expanded after a pneumothorax and in preparation for removing the chest tube. Shortness of breath, tachypnea, absent breath sounds and hypoxemia indicate a recurrence of the pneumothorax. This is a life-threatening medical emergency that requires the nurse to prioritize. Using the Airway-Breathing-Circulation (ABC) decision-making strategy, the nurse should first provide the client with supplemental oxygen and then immediately notify the HCP. A chest X-ray will be required to determine the cause of the client's change in condition. After the client's urgent needs have been addressed, the nurse should then document all interventions implemented in the client's medical record.

The nurse in a rehabilitation facility is caring for a client who had a total left hip arthroplasty, using a posterior approach, three days ago. Which intervention should the nurse make sure to include in the client's plan of care?

Apply an abduction pillow while the client is in bed. rationale Clients who have had a total hip arthroplasty (THA), i.e., hip replacement, are at risk for post-operative hip joint dislocation. An abduction pillow should be used to prevent the client from closing or crossing their legs while in bed, causing adduction beyond the midline of the body, which can lead to dislocation of the new joint. The client's heels should be elevated off the bed, not flat on the bed, to prevent pressure injury to the heels. The affected hip should not be flexed to 90 degrees. Even crossing the legs at the ankles should be discouraged and prevented with this type of hip surgery.

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 rationale 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.

The nurse in the primary care office is reviewing after-visit instructions with a client who was recently diagnosed with gastroesophageal reflux disease (GERD). Which action should the client implement to decrease the symptoms associated with GERD?

Avoid caffeinated and carbonated beverages. rationale GERD means the chronic backward flow (reflux) of stomach contents into the esophagus. This reflux produces symptoms (i.e., heartburn) by exposing the esophageal mucosa to the irritating effects of acidic gastric or duodenal contents, resulting in inflammation. The most common cause of GERD is excessive relaxation of the lower esophageal sphincter (LES). Because caffeinated beverages, such as coffee, tea and cola, and the carbonation in carbonated beverages will further lower the LES pressure, increasing the risk for gastric reflux and esophageal irritation, those drinks should be avoided. The other actions will not help with the symptoms of GERD.

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 rationale 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 home health nurse is reviewing the medical record of a client with recurring oral candidiasis. Which prescribed medication is most likely causing the client's condition?

Budesonide (inhaler) rationale Budesonide is an inhaled glucocorticoid used in the treatment of asthma and chronic obstructive pulmonary disease (COPD). The most common adverse effects are oropharyngeal (oral) candidiasis and dysphonia (hoarseness and difficulty speaking). Both effects result from local deposition of inhaled glucocorticoids. To minimize these effects, clients should rinse the mouth with water and gargle after each administration. Using a spacer device can help too. If candidiasis develops, it can be treated with an antifungal drug. The other medications are not likely to cause oral candidiasis.

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

Buffalo hump rational 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.

The nurse is evaluating a client's understanding of appropriate dietary choices with chronic kidney disease. Which food choices by the client indicate an understanding of the teaching? (Select all that apply.)

Baked chicken Unsalted pretzels Fresh apples rationale A client with chronic kidney disease (CKD) must limit intake of potassium, sodium, phosphorus and protein. In CKD, the kidneys are unable to adequately excrete these components. Foods low in potassium include: apples, grapes, lettuce and cauliflower. Foods high in potassium include: bananas, oranges, potatoes and spinach. Foods low in phosphorus include: chicken, shrimp, crab and rice. Foods high in phosphorus include: organ meats, salmon, scallops, nuts and cheese.

Which of the following actions performed by the nurse indicates that additional education on ergonomic principles is needed to reduce the risk of injury?

Bend and twist at the waist when assisting a client in transferring to the chair. The health care worker (HCW) should use the long, strong muscles in their arms and legs to move items, pushing or rolling when possible instead of pulling and relying on their back muscles. The HCW should also flex their knees and the object being lifted should be held as close to the body as possible. Bending at the waist and holding an item away from the body can strain muscles. The HCW should face the direction of the intended movement because twisting at waist-level can cause back injuries.

A nurse is caring for a client after a tonsillectomy. The nurse observes the client swallowing frequently between sips of water. The nurse understands that this could be a sign of:

Bleeding rationale The nurse will assess for frequent swallowing because if bleeding is the cause, an intervention may be necessary. Postnasal drip may also cause excessive swallowing, but it is not a complication that the nurse is looking for. Anxiety symptoms typically don't include frequent swallowing. Swallowing is not a sign of aspiration.

A nurse is caring for a client with continuous bladder irrigation (CBI), following a transurethral resection of the prostate. Which finding would indicate the need for the nurse to increase the flow of the CBI?

Blood clots in the catheter tubing rationale For benign prostatic hyperplasia, a transurethral resection of the prostate (TURP) may be performed. After this surgical procedure, the nurse should be aware of potential complications, including hemorrhage, urinary retention and/or infection. After a TURP, CBI through a three-way catheter is typically initiated to irrigate the bladder of any obstruction such as blood clots and maintain patency of the urethra. Having pink-tinged urine, bladder spasms, a low-grade fever and discomfort at the catheter site are common after the procedure, but increased bleeding and blood clots indicate that the CBI flow is not sufficient and should be increased. A clogged catheter is a medical emergency and immediate steps must be taken to prevent this from happening.

The nurse is caring for a client who was admitted for hyperglycemic hyperosmolar state (HHS). Which clinical finding would support this diagnosis?

Blood sugar > 600 mg/dL Client's who suffer from type 2 diabetes mellitus are at risk for having hyperglycemic hyperosmolar state (HHS). HHS has a gradual onset with precipitating factors including poor fluid intake, infections or stress. While these are similar etiologies to diabetic ketoacidosis (DKA), there are some differences. Blood sugar levels with HHS are generally much higher (> 600 mg/dL) when compared to DKA (> 300 mg/dL). A deep, rapid breathing pattern (i.e., Kussmaul's) is associated with DKA. The serum pH for HHS is usually normal, since there is an absence of ketones and acidosis.

A newborn born prematurely is to be fed breast milk through a nasogastric tube. Why is breast milk preferred over formula for premature infants?

Breast milk provides antibodies Breast milk is ideal for the preterm baby who needs additional protection against infection through maternal antibodies. It is also much easier to digest. Therefore, less residual is left in the infant's stomach.

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.

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 rationale Notice that only two of the options focus on cast care. Of those two options, the crossbar on the cast should never be used to lift or move the child. 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.

A client's family member calls for an update on the client's condition. What should the nurse do first before providing information to the caller?

Check with the client and obtain permission to provide the caller with the requested information. rational The nurse must have permission from the client to release information to the caller. If the client is unable to give permission and has a power of attorney for health care (POAH), then information shall only be given to the POAH. Family members can obtain updates from that person. Remember, it is difficult to know who is calling over the phone. The nurse should also be familiar with the organization's policy on requests for information over the phone.

The nurse is administering medication to a client who does not speak English. Which of the following strategies should the nurse implement to ensure the client understands the purpose of the medication? (Select all that apply.)

Communicate through a facility-approved interpreter. Correct! Use the translation phone line to interpret information between the client and nurse. Maintain eye contact with the client, even when speaking to an interpreter. Plan to take a longer amount of time than usual for medication administration. rationale There are several tools available for the nurse to help the client who does not speak English. These include translation phone lines and facility-approved interpreters. The nurse should maintain eye contact with the client throughout the communication and should be prepared for the encounter to take additional time. Medical terminology should be kept to a minimum during communication with clients in general, but especially for clients with limited English proficiency.

The nurse is reviewing a prescription of enoxaparin 40 mg subcutaneously once a day for a post-operative client. Enoxaparin is supplied from the pharmacy in a prefilled syringe that contains 60 mg/2 mL. How many mL will the nurse administer? (Round the number to the nearest tenth and report your answer with the decimal.)

Desired: Supplied: , divided by 6080 divided by 60 = 1.333

A client is admitted with deep vein thrombosis (DVT). The health care provider (HCP) orders the immediate administration of an intravenous bolus of heparin sodium 200 units/kg . The client weighs 187 lbs. How many mL should the nurse draw up from the supplied 10 mL vial that contains 5,000 units per mL? Do not round.

Correct answer: 3.4 mLFirst, the nurse needs to convert pounds (lbs.) to kilograms (kg). 1 kg = 2.2 lbs. 187 lbs. divided by 2.2 = 85 kg. Then, the nurse should multiply 85 kg by the prescribed drug amount (200 units) per one kg. 85 x 200 = 17,000 units.The supplied vial contains a total of 10 mL (50,000) units of heparin or 5,000 units per mL. The nurse will administer a partial dose from the vial. If 10 mL contain 50,000 units, then how many mL contain 17,000 units? Calculation: 17,000 x 10 = 174,000, divided by 50,000 = 3.4.Alternate calculation: If 5,000 units in 1 mL, how many mL would contain 17,000 units? Divide 17,000 by 5,000 = 3.4 mL.

A client has an order for ibuprofen oral drops, 10 mg/kg of body weight. The client weighs 62 lbs. The medication is supplied in a bottle containing 40 mg/mL. How many mL will the nurse administer? (Round your answer to the nearest whole number.)

Correct answer: 7 mLDimensional analysis:Ratio:

The health care provider (HCP) prescribes amoxicillin 120 mg PO every six hours for a client diagnosed with acute otitis media. The medication label reads amoxicillin 80 mg/5 mL. How many mL should the nurse administer to the client with each dose?

Correct answer: 7.5 mLDosage Calculation:Ration and Proportion:

A client is scheduled for a computerized tomography (CT) scan of the abdomen with contrast. What action should the nurse take before sending the client to the imaging department?

Confirm that a signed consent is in the chart. rationale A signed consent is required due to the fact that contrast media will be used. Usually the client is NPO prior to a CT scan, particularly when contrast material is being used. Allergies and past reactions to contrast media should be reviewed with the client. Any metal, including body piercings, jewelry, hearing aids and removable dental work should be removed and safely stored prior to the test. Keeping the client on bedrest, inserting a catheter or holding medications are usually not required and could actually cause harm to the client. Correct!

The nurse is preparing to administer an enoxaparin injection to a client who is immobilized after a cerebrovascular accident. The client voices concern and refuses to take the medication. What actions should the nurse take? (Select all that apply.)

Confirm the client understands the risks associated with not taking the medication. Clarify the reason why the client is refusing the medication. Ensure the client correctly understands the medication's purpose. rationale The client has a right to refuse any medication or treatment. If the client refuses a medication, the nurse should identify the reason for refusal and ensure the client understands the purpose of the medication and potential risks of not taking the medication. Refusing the enoxaparin places the client at an increased risk for developing a venous thromboembolism (VTE). The ordering health care provider (HCP) is the only person who can discontinue the medication. Enoxaparin is only available to be given as a subcutaneous injection.

A client with pneumonia is prescribed guaifenesin 1.2 grams orally, twice daily as needed for cough. The pharmacy delivers guaifenesin in 600 mg tablets. How many tablets should the nurse administer for each dose?

Correct answer: 2 tabletsFirst, the nurse will convert the prescribed dose from grams to milligrams. 1.2 grams x 1,000 = 1,200 mg. Then, the nurse will divide the ordered dose by the supplied dose: 1,200 divided by 600 = 2.

A client is prescribed acetaminophen, 325 mg two tabs orally, every 4 to 6 hours as needed for minor pain. What is the total, maximum dose of acetaminophen that the client would receive in a 24-hour period? Report your answer as a whole number.

Correct answer: 3,900 mg per dose. 24 hours divided by every four hours = 6 doses in a 24-hour period. total in a 24-hour period.Overdose of acetaminophen can cause severe liver injury. Recommendations are to take no more than 4,000 mg of acetaminophen a day. Clients with liver disease or impaired liver function should check with their health care provider (HCP) before taking any acetaminophen-containing drugs. Incorrect

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 Correct! 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."

The nurse is providing care to an 80-year-old client with the diagnosis of advanced Parkinson's disease. The nurse should know that the greatest risk to the client is related to which finding?

Drooling and coughing when eating rationale Although all of the findings pose a safety risk to the client, drooling and coughing while eating are indicative of dysphagia. Dysphagia, a common finding with advanced Parkinson's disease, puts the client at an increased risk for aspiration of oral secretions or choking on food, which can cause airway and/or breathing problems. Using the ABC prioritization strategy, the nurse should recognize this finding as the greatest risk.

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) rationale 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.

A client with a history of bipolar disorder is admitted to the hospital after a suicide attempt. Which of the following interventions should the nurse include in the client's plan of care?

Develop a contract with the client that states they will not harm themselves. Correct! rational The nurse should develop a temporary contract with the client that states they will not harm themselves. The contract will allow the client to assume responsibility for their safety.The nurse should actively listen to the suicidal client and encourage them to express their feelings and emotions. Expressing emotions will allow the client to resolve unhealthy hostility and take control of their life.The nurse should closely observe a client who is at risk for suicide. Place the client in a room close to the nurses' station and do not assign them to a private room.To create a safe environment, the nurse should perform room searches as needed to keep harmful objects away from the client (e.g., glass items, alcohol, sharp objects and belts).

The nurse in a walk-in care clinic is reviewing the medical record of a client who is being treated for frostbite on their toes. Which medical condition most likely placed the client at a higher risk for this type of injury?

Diabetes mellitus rationale Diabetic neuropathy is a complication of diabetes mellitus that is characterized by decreased sensation in the lower extremities. Clients with diabetic neuropathy are at risk for hypothermal tissue injuries (i.e., frostbite) because they may not feel the pain associated with cold exposure, making them unaware of soft tissue injury until it is severe. The diabetes most likely contributed to this client's frostbite injury. There is no immediate increased risk for hypothermal tissue injuries with the other conditions.

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 rationale 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.

The nurse is planning care for a client diagnosed with Guillain-Barré syndrome. Which problem should the nurse identify as a priority?

Difficulty breathing rationale Guillain-Barré syndrome (GBS) is an acute autoimmune disorder characterized by varying degrees of motor weakness and paralysis. Difficulty breathing is the priority problem because acute respiratory failure due to muscle weakness and respiratory paralysis can occur, requiring ventilatory support. The other problems are also potential problems but are not life-threatening. The nurse should prioritize using the ABC decision-making approach.

A client is being admitted to the hospital with complaints of bloody stools for several days. Which interventions should the nurse expect to be prescribed for this client? (Select all that apply.)

Discontinuation of all NSAID medications Administration of pantoprazole Collection of a stool sample for occult blood testing Peptic ulcer disease (PUD) can affect the gastric, duodenal or esophageal areas of the gastrointestinal (GI) tract. Peptic ulcers cause erosions in the lining of the GI tract and can causing bleeding. PUD may be caused by increase gastric acid, intake of NSAID medications or other irritating agents. The nurse should anticipate the client being started on a proton-pump inhibitor, such as pantoprazole, to decrease the gastric acid levels. All NSAID medications should be discontinued to prevent further disruption of the GI mucosa. To validate the client's claim of bloody stools, the nurse would expect to obtain a stool sample. The nurse should not expect to administer enoxaparin, an anticoagulane often prescribed for venous thromboembolism (VTE) prophylaxis, since that would aggrevate the bleeding in the GI tract. A surgical consult would be premature at this time.

A client refuses to take the medication prescribed because the client prefers to take an herbal preparation instead. What is the first action the nurse should take?

Discuss with the client to find out about the preferred herbal preparation Remember, the collection of additional data is typically the initial approach when problems arise. Although the client has the right to refuse the medication, it's possible that the herbal preparation does not have the intended purpose of the prescribed medication or may even have unintended side effects.

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.)

Document the administration of carvedilol (Coreg) Notify the nurse manager Monitor and document the client's blood pressure Notify the health care provider rationale 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).

The nurse in a long-term care facility is preparing to administer medications. Which physiological changes does the nurse know will affect medication pharmacokinetics in older adults?

Due to a decrease in renal drug excretion, a greater risk for adverse medication effects exist. rationale Due to the physiological changes that occur as a person ages, older clients tend to be more sensitive to medications. Therefore, older clients must be monitored more closely for both desired and adverse responses, and their medication regimen must be adjusted accordingly. Aging-related organ decline affects drug absorption, distribution, metabolism and (especially) excretion. Although gastric acidity is reduced in older adults, altering the absorption of certain drugs, prescribing higher doses would not be appropriate. Because rates of hepatic drug metabolism tend to decline with age, prescribing a drug more frequently would lead to drug toxicity and adverse drug effects (ADEs). Renal drug excretion progressively declines due to a decrease (not an increase) in filtration rate as the person ages, placing elderly clients at greater risk for drug accumulation and ADEs.

The nurse is reviewing the electronic medical record of a client diagnosed with endometriosis. The nurse should expect which findings with this diagnosis? (Select all that apply.)

Dyspareunia Dysmenorrhea Infertility rationale The following findings that would indicate the client has endometriosis are pain with menstruation (dysmenorrhea), pain with intercourse (dyspareunia), excessive bleeding, and infertility. The client may also complain of pelvic and/or back pain, along with pain during bowel movements. The endometrial tissue that implants outside the uterus may cause mild to severe pain, fluctuations in menstrual cycles and fibroids that can cause infertility. Endometriosis often times is mistaken for pelvic inflammatory disease (PID), which causes inflammation of the pelvis, irritable bowel syndrome (IBS) or ovarian cysts. A urinary tract infection and amenorrhea (absence of menstruation) are not usually seen with endometriosis.

A client is admitted to the medical-surgical unit following a motor vehicle accident. Twelve hours after admission the client becomes diaphoretic, tremulous and irritable, and the client's pulse and blood pressure are elevated. The client states to the nurse, "I have to get out of here." What is the most likely cause for the client's symptoms and behavior?

Early stage of alcohol withdrawal The client is exhibiting signs and symptoms of alcohol withdrawal, such as sweating, tremors, hyperactivity, hypertension and tachycardia. The client most likely wants to leave the hospital to obtain alcohol. The client must be monitored very closely for progression to more severe alcohol withdrawal symptoms, including seizures and delirium tremens (DTs). Not being satisfied with the care, anxiety or shock related to the accident are unlikely to be the cause for the physical and behavioral manifestations that the client is exhibiting.

Question Review The nurse is evaluating a client's ability to perform basic activities of daily living (ADLs). Which of the following tasks should the nurse observe the client performing? (Select all that apply.)

Eating a meal independently Using the bathroom Getting fully dressed Basic activities of daily living (ADLs) include feeding, moving, toileting, grooming, bathing and putting on clothes. More complex skills, such as using a telephone, shopping, doing housework, preparing meals, handling finances and taking medications correctly might be evaluated to determine if the client can live independently. Driving is not considered an ADL.

The nurse is caring for a client who is recovering from a right total hip arthroplasty. The client reports a sudden onset of chest pain and difficulty breathing. What action should the nurse take first?

Elevate the head of the bed. rationale The client is exhibiting clinical manifestations of a pulmonary embolism (PE). A PE is a medical emergency, which requires immediate action from the nurse. Deep vein thromboses (DVTs) can occur after a total hip arthroplasty due to immobilization during and after surgery. By elevating the head of the bed, the nurse will decrease dyspnea associated with the PE. The nurse should then assess the client and report the clinical manifestations to the HCP.

The nurse on the mental health unit is assigned to a client diagnosed with post-traumatic stress disorder (PTSD). What priority interventions shall the nurse include in the client's plan of care? (Select all that apply.)

Encourage the client to talk about the trauma at their own pace. Stay with the client during periods of flashbacks and nightmares. Assign the same staff to the client as often as possible. Discuss the coping strategies the client is using in response to the trauma. rational Trauma-related disorders such as PTSD can be described as the client's reaction to an extremely distressing experience, such as natural or man-made disasters, combat, serious accidents, witnessing the violent death of others, or being the victim of torture, terrorism, rape or other crimes that cause severe emotional shock and have long-lasting psychological effects.Interventions that are considered trauma-informed highlight the importance of respect for the client, collaboration and connection, providing information about the connections between trauma and other health concerns, instilling hope and empowering the trauma survivor to guide and direct their recovery plan.A PTSD client may be suspicious of others in their environment. It is a priority to facilitate building a trusting relationship. The presence of a trusted individual may reassure the client and calm their fears for their personal safety. Debriefing or talking about the traumatic event is the first step in the client's progression toward resolution. The long-term resolution of the client's post-traumatic response is largely dependent on the effectiveness of the client's coping strategies.Interventions such as seclusion may be retraumatizing to a client with a history of trauma and are only indicated if the client exhibits behavior that presents imminent risk of harm to themselves or others.Administering a sedative without a clear, clinical indication is considered a chemical restraint. This should never be used for the convenience of the staff or as a punishment. The nurse should first try other measures to decrease agitation such as talking down (verbal intervention). .

The nurse in the primary health care provider's office is speaking with a 40-year-old male client whose most recent hemoglobin A1C level was 9%. The client states that he is motivated to make lifestyle changes to better manage his disease. What interventions should the nurse recommend for this client? (Select all that apply.)

Engage in regular physical activity, such as walking. Schedule an appointment with a registered dietitian. Start a weight loss program until BMI is below 25. Check the blood sugar several times a day, ideally before eating. rationale The client's hemoglobin A1C level indicates the client is not managing their diabetes well. An A1C level of 7% or less is the goal for clients with diabetes. Effective diabetes management should include daily or more frequent blood sugar monitoring, learning how to count carbohydrates and eat appropriately-sized meals, maintaining a healthy weight (i.e., a BMI between 18.5 and 24.9, per CDC guidelines) and engaging in regular physical activity. Avoiding caffeine or eliminating all alcoholic beverages is not required.

The nurse is caring for a 60-year-old female client scheduled for abdominal surgery. Which factor in the client's history indicates that the client is at an increased risk for deep vein thrombosis (DVT) in the postoperative period?

Estrogen replacement therapy for the past three years rationale Post-menopausal women using hormone replacement therapy have a higher risk of DVT and pulmonary embolism. The estrogen in hormone replacement therapy (and in birth control pills) can increase clotting factors in the blood, increasing the risk for development of a DVT. The other information in the client's history is unremarkable for postoperative complications such as DVT.

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

Monitor the infant's urine output Rationale 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 who has been diagnosed with Raynaud's disease and hypertension is prescribed nifedipine. For which side effect should the nurse monitor the client?

Facial flushing rationale Nifedipine is a calcium channel blocker (CCB) used in the treatment of Raynaud's disease and hypertension by producing vasodilation. As a result of this vasodilating effect, facial flushing can occur. Cyanosis of the lips and decreased urinary output are not expected findings with nifedipine. Raynaud's disease causes vasoconstriction, resulting in pain in the fingers that should decrease when nifedipine is taken.

The nurse is caring for a client with a calcium imbalance related to hypoparathyroidism. The nurse should anticipate which clinical manifestation in this client?

Facial twitching when the region over cranial nerve VII is tapped rationale Clinical manifestations of hypoparathyroidism are associated with electrolyte imbalances, such as hypocalcemia. Hypocalcemia is characterized by increased neuromuscular excitability, such as a positive Chvostek's sign when cranial nerve VII is stimulated. Decreased neuromuscular excitability, decreased gastrointestinal activity and bounding pulses are associated with hypercalcemia, which is a condition related to hyperparathyroidism.

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 rationale 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.

Which assessment data should make the nurse suspect that the client might have amyotrophic lateral sclerosis?

Fatigue, progressive muscle weakness and twitching rationale Amyotrophic lateral sclerosis (ALS) typically has a gradual onset, which is generally painless. Progressive muscle weakness is the most common initial symptom in ALS. Other early symptoms vary but can include tripping, dropping things, abnormal fatigue of the arms and/or legs, slurred speech, muscle cramps and twitches and/or uncontrollable periods of laughing or crying.

The nurse is evaluating a client who is being physically abused by the client's domestic partner. The client states, "I need a little time away." Which is the most likely response from the partner for which the nurse should prepare the client?

Fear of rejection, resulting in increased rage toward the client Fear of rejection and loss because of the absence of their partner only serves to increase the abuser's rage. Common reactions from an abuser include extreme jealousy, inability to take responsibility for the abuse and denying or minimizing the seriousness of the violence and its effects on the victim.

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 rationale 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.

Sinus dysrhythmias originate in the sinoatrial node and are conducted along the normal conductive pathways.

Figure 8-A.22: ECG strip: Sinus Bradycardia Figure 8-A.21: ECG strip: Sinus Tachycardia Figure 8-A.23: ECG strip: Sinus Arrhythmia

Atrial dysrhythmias occur when abnormal electrical activity results in stimulation outside the sinoatrial (SA) node but within the atria.

Figure 8-A.24: ECG strip: Atrial Flutter Figure 8-A.25: ECG Strip: Atrial Fibrillation Ventricular dysrhythmias occur when one or more ectopic foci arise within the ventricles. This is asystole.

The nurse in the outpatient clinic is reviewing the medical record of a client diagnosed with Raynaud's disease. What information from the client's health history would support this diagnosis? (Select all that apply.)

Fingers become cyanotic when exposed to cold objects. The client complains of brittle fingernails that break easily. The client works in an office setting as a typist. The client smokes two packs of cigarettes per day. rationale Raynaud's disease is considered a vasospastic disorder that affects the small arteries of the fingers and toes. Raynaud's occurs due to an imbalance between vasodilation and vasoconstriction. Cases of Raynaud's are considered either idiopathic or pathologic. Risk factors include occupation-related factors, such as repetitive hand motions (typing, industrial equipment) or hyperhomocysteinemia. Clients with Raynaud's disease may complain of their fingers or toes becoming cyanotic or pale when they come in contact with cold objects or a cold environment. When this occurs, clients may complain of numbness or tingling in the affected digits. Exposure to tobacco, emotions and caffeine have been known to trigger a vasospastic event. Medications that can be used for Raynaud's includes statins, calcium channel blockers and vasodilators. Anticoagulants are not indicated for the treatment or prevention of Raynaud's disease. A construction worker who operates a jackhammer would be at risk for Raynaud's due to the vibrating equipment. Clients who suffer from frequent vasospastic attacks can develop brittle nails.

The nurse is reviewing the medical record of a female client with acute pancreatitis. The nurse should recognize which information as the most likely risk factor for the client's illness?

Gallstones rationale Although a number of factors can cause acute pancreatitis, the most common cause in the U.S. is gallbladder disease and gallstones. The second most common cause is chronic alcohol intake. Obesity is a risk factor for developing gallbladder disease. Elevated blood glucose levels can occur with pancreatitis due to impaired insulin metabolism. Intravenous IV drug use is not typically associated with acute pancreatitis.

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 Rationale 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."

The nurse is caring for a client newly diagnosed with chronic obstructive pulmonary disease (COPD). The nurse reviews the client's medical record and notes which risk factors? (Select all that apply.)

History of smoking tobacco products A family history of COPD History of childhood asthma COPD is a pulmonary disease that is characterized by chronic airway inflammation, mucus hypersecretion, bronchospasms, destruction of alveoli and airflow limitations, leading to chronic carbon dioxide retention. It is primarily caused by cigarette smoking. Other risk factors include genetics, asthma and exposure to occupational chemicals and air pollution. Hyperlipidemia is a risk factor for cardiovascular diseases. Pulmonary embolism and allergic rhinitis are not risk factors for COPD.

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 rationale 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 nurse is caring for a client who complains of pain in the epigastric region. The client has a history of peptic ulcer disease. Which finding should the nurse immediately report to the health care provider?

Hemoglobin level of 7.4 g/dL rationale Peptic ulcer disease (PUD) results when gastric mucosal defenses become impaired and no longer protect the epithelium from the effects of acid and pepsin. A peptic ulcer is a mucosal lesion in the stomach or duodenum. The most serious complication of PUD is hemorrhage. The serum hemoglobin (Hgb) level will drop as a result of bleeding. The normal range for Hgb is 14 to 18 g/dL in males and 12 to 16 g/dL in females. This client's level is 7.4 g/dL, which is low and indicates possible hemorrhage. The normal range for white blood cell count (WBC) is 5,000 to 10,000/µL. The normal range for platelet count (PLT) is 150,000 to 400,000 mm3. Helicobacter pylori infection plays a role in the development of gastric ulcers. While a positive Helicobacter pylori test is pertinent to the client's history of PUD, possible hemorrhage is the most serious problem for this client and should be reported to the health care provider (HCP) immediately.

The nurse is reviewing the chart of a client who was recently diagnosed with coronary artery disease due to atherosclerosis. Which factors most likely contributed to the development of this disease? (Select all that apply.)

History of diabetes mellitus Low-density lipoprotein (LDL) level of 149 mg/dL Used to smoke 40 packs per year until one year ago Mother died of a myocardial infarction rationale Atherosclerosis arises when plaque (fat, cholesterol and other substances) accumulates inside arterial walls. The plaque limits blood flow through arteries and can eventually lead to tissue and organ ischemia. Atherosclerosis can develop in any artery in the body. Smoking contributes to the development of atherosclerosis by damaging artery walls and triggering vasoconstriction. A family history of heart disease (mother) is a risk factor for the development of atherosclerosis. Diabetes and elevated low-density lipoprotein (LDL) cholesterol levels are closely tied to the development of atherosclerosis. The target LDL level for a client is less than 100 mg/dL. The client's current alcohol consumption is within current daily recommendations of no more than 1 to 2 drinks per day. The D.A.S.H. diet is rich in fruits, vegetables, whole grains and legumes, which can reduce the development and progression of atherosclerosis.

The nurse is caring for a client admitted with sickle cell crisis. Which medication is the drug of choice for pain management with this client?

Hydromorphone rationale Sickle cell disease (SCD) is a genetic disorder that is characterized by hemolysis and sickling of red blood cells. A sickle cell crisis is considered an acute, severe exacerbation of the disease. During a crisis, individuals can develop severe pain and necrosis from the sickled cells that are accumulating within their blood vessels. As a result, clients should be treated with opioid pain medications during a crisis, preferably administered intravenously. Hydromorphone (Dilaudid) is a strong opioid agonist, indicated for moderate to severe pain. The other medications are indicated for more minor to moderate pain. Use of meperidine (Demerol) should be avoided so as to prevent accumulation of normeperidine, a toxic metabolite.

The nurse is caring for a client who had a small bowel resection two days ago. The client reports that the pain has significantly increased over the last two hours and does not get better after receiving an analgesic. Which additional findings are indicative of a postoperative complication the client might be experiencing? (Select all that apply.)

Hyperactive bowel sounds Taut, distended abdomen Nausea and vomiting rationale A non-mechanical obstruction, or paralytic ileus, is a complication of bowel surgery due to the manipulation of the intestines during surgery. The pain associated with a non-mechanical obstruction is constant and diffuse. The client may also have distention in the upper abdominal or epigastric region, decreased or absent bowel sounds, and nausea and vomiting. Increased bowel sounds, especially loud, gurgling sounds, result from increased motility of the bowel (borborygmus) and are sometimes heard above a complete intestinal obstruction. Tenderness at the incision site and serosanguineous fluid in the surgical drain are expected two days after a bowel resection.

A nurse working in a nursing home is caring for an 80-year-old client with diabetes mellitus type 2. The nurse notes that the client is exhibiting new confusion, polyuria, an elevated temperature and hypotension. What is the most likely cause of the client's symptoms?

Hyperosmolar hyperglycemic state rationale The client is exhibiting signs of hyperglycemic-hyperosmolar state (HHS). HHS is a hyperosmolar (increased blood osmolarity) state caused by hyperglycemia. HHS occurs most often in older clients with type 2 diabetes mellitus (DM). HHS results from a sustained osmotic diuresis. As serum concentrations of glucose exceed the renal threshold, the kidney's capacity to reabsorb glucose is exceeded, resulting in polyuria. The osmotic diuresis/polyuria will lead to decreased blood volume, dehydration, hypotension, shock and death if not caught early and treated aggressively. The other answers are incorrect.

A client reports to the nurse the passage of hard dry stools at least twice a week. Which of these actions should the nurse suggest that the client take first to improve their bowel function?

Increase daily fiber intake to at least 20 grams. rationale Incorporating high-fiber foods into their diet, especially whole grains, fruits and vegetables, should be the client's first step to improve their bowel function. A regular recommended diet of about 2,000 calories a day should include about 25 grams of fiber. The client should also increase their fluid intake and avoid food that tends to bind or reduce the water content of stool, such as cheese. Although physical activity will promote peristalsis and reduce the risk of constipation, the effect is more indirect and less effective than increasing fiber intake. Laxatives should be used as a last resort.

The home health nurse is reviewing the plan of care for a client experiencing acute attacks of Ménière's disease. What is the priority intervention for this client?

Instruct the client not to drive a motor vehicle. Ménière's disease is a condition affecting the inner ear, resulting in vertigo, tinnitus (ringing in the ears) and temporary hearing gloss. Vertigo is a sense of whirling or turning in space. The vertigo can be so intense that, even while lying down, the client has to hold on to something or lay on the ground to keep from falling. Severe vertigo usually lasts 3 to 4 hours, but the client may feel dizzy long after the attack. Nausea and vomiting, rapid eye movement (nystagmus) and severe headaches often accompany vertigo. Although all of the interventions should be implemented, driving while the client is experiencing these symptoms is dangerous and could lead to an accident. The priority is for the client not to drive until the attacks have completely resolved.

The nurse is caring for a client who has stomatitis caused by Candida albicans. Which intervention should the nurse include in the client's plan of care?

Instruct client to "swish and swallow" the prescribed nystatin solution. rationale Stomatitis is a broad term that refers to inflammation within the oral cavity. A common type of secondary stomatitis is caused by Candida albicans. Candida is sometimes present in small amounts in the mouth, especially in older adults. Long-term antibiotic therapy destroys other normal flora and allows the Candida to overgrow. The result can be candidiasis, a fungal infection that is very painful. Candidiasis is also common in those undergoing immunosuppressive therapy, such as chemotherapy, radiation and steroids. Oral fungal infections are treated with antifungals such as nystatin. The goal of the "swish and swallow" technique is to expose all of the oral mucosa to the antifungal agent. The client should continue to perform regular oral care, including brushing teeth. Oral candidiasis is not a transmittable disease and does not require the client to consume only liquids.

The home health nurse is caring for a 6-year-old client with cerebral palsy. The client's parent reports to the nurse that the child's older sibling was just diagnosed with impetigo. What priority intervention should the nurse add to the client's plan of care?

Instruct the parent to provide the infected child with washcloths and towels separate from the client's. rationale Impetigo is a common and highly contagious, bacterial skin infection that mainly affects infants and children. Impetigo usually appears as red sores on the face, especially around a child's nose and mouth, and on hands and feet. The sores burst and develop honey-colored crusts. The priority nursing functions related to bacterial skin infections are to prevent the spread of infection and to prevent complications. Impetigo can easily spread and hand washing is mandatory before and after contact with an affected child. The infected child should be provided with washcloths and towels separate from those of other family members and the infected child's clothes should be changed daily and washed in hot water. A topical bactericidal ointment can be used if the client becomes infected too. An anti-inflammatory cream such as hydrocortisone will not prevent the client from becoming infected. Antibiotics should not be prescribed for prevention in this situation. Oral or parenteral antibiotics (penicillin) are reserved for severe cases of an actual infection. Keeping the client isolated is not necessary or appropriate in a home setting.

A client of Chinese descent is admitted with a diagnosis of generalized anxiety disorder (GAD). Based on traditional Chinese medicine (TCM), what should the nurse expect the client to believe about this illness?

It is caused by an imbalance in yin/yang. TCM involves the complementary yet opposing yin and yang life forces, and the balance and harmony of the vital energy, or life force (qi), circulating through the body's pathways. Good health is believed to come from a balance of yin (negative, dark and feminine) and yang (positive, bright and masculine). Acupuncture is not considered to cause an illness, instead it is used to treat certain illnesses in TCM. The belief about the "evil eye" or mal de ojo is seen more often with individuals from a Latin American background. Mono- or polytheistic belief systems found in Sub-Saharan Africa consider illness to be a "curse" from a supernatural being.

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 Rationale: 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.

The nurse is planning the care for a client who was admitted with complications related to chronic diabetes insipidus. Which interventions are a priority for this client? (Select all that apply.)

Measure blood pressure and heart rate. Monitor urinary specific gravity. Weigh the client every morning. Monitor fluid intake and output. Evaluate the moisture level of mucous membranes. Chronic diabetes insipidus is a disorder associated with an inadequate level of antidiuretic hormone or the decreased ability for the renal tubules to respond to antidiuretic hormone. Clinical manifestations of this disorder are related to dehydration due to the large amounts of diluted urine being excreted. For clients with diabetes insipidus, priority interventions within the plan of care should focus on fluid balance, including blood pressure and heart rate, fluid intake and output, inspecting the mucous membranes, weighing the client daily and monitoring urinary specific gravity. Fluid restrictions are contraindicated for this client and could lead to severe dehydration. Additionally, diabetes insipidus is not associated with blood glucose imbalance.

The nurse is collecting data on a group of clients in a long-term health care facility. Which client is at a highest risk for the development of pressure ulcers?

Malnourished older adult client who is on bed rest Rationale Weighing significantly less than ideal body weight increases the number of bony prominences. Thus, malnutrition is a major risk factor for pressure ulcer development, due in part to poor hydration and inadequate protein intake. The other clients would also be at risk, but the malnourished older client is at a higher risk of developing skin breakdown.

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 rationale 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.

he nurse is caring for a client who has been diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). Which interventions are appropriate for this client? (Select all that apply.)

Monitoring of intake and output Implementation of a fluid restriction Administration of a loop diuretic Syndrome of inappropriate antidiuretic hormone (SIADH) is the result of excess antidiuretic hormone secretion, leading to fluid retention, fluid volume overload and dilutional hyponatremia. Appropriate interventions include closely monitoring intake and output and restricting fluids. Furthermore, administering a diuretic will promote diuresis and help get rid of excess fluid. Vasopressin is an analog of antidiuretic hormone (ADH) and would worsen the client's condition. Vasopressin is used with diabetes insipidus, not SIADH. The client should be eating foods high in sodium, not low, to help with the hyponatremia.

The nurse is collecting data about a client admitted with cardiomyopathy. How should the nurse document the low pitch, blowing sound the nurse heard when auscultating near the apex of the heart?

Murmur rationale Murmurs reflect turbulent blood flow through normal or abnormal heart valves. They are classified according to their timing in the cardiac cycle: systolic murmurs (e.g., aortic stenosis and mitral regurgitation) occur between S1 and S2, whereas diastolic murmurs (e.g., mitral stenosis and aortic regurgitation) occur between S2 and S1. They are also graded by the provider according to their intensity. The quality of murmurs can be further characterized as harsh, blowing, whistling, rumbling or squeaking. They are also described by pitch, which is usually high or low. An auscultatable murmur near the apex of the heart or the left fifth intercostal space is most likely related to mitral valve problems that could have led to cardiomyopathy. Stridor and wheeze are abnormal sounds found with auscultation of the lungs and are airway-related. Pulsus paradoxus is obtained during a blood pressure measurement and is indicative of cardiac tamponade.

The nurse is caring for a female client with a body mass index (BMI) of 45. Which conditions should the nurse plan to discuss with the client due to the risks associated with her weight? (Sele

Obstructive sleep apnea (OSA) Coronary artery disease (CAD) Gallstones Breast cancer rational A client with a BMI of 40 or greater is considered extremely (i.e., morbidly, severely) obese. A number of health risks are associated with obesity, including OSA, colorectal and breast cancer, gallstones and cardiovascular diseases, such as hypertension, atherosclerosis and CAD. COPD is associated with smoking or exposure to smoke. Hyperthyroidism is not associated with being overweight or obese.

A client who is receiving continuous oxygen therapy by nasal cannula for an acute respiratory problem is becoming increasingly confused. What should the nurse do first?

Obtain a pulse oximeter reading. rationale Cerebral hypoxia can be a cause of confusion and is an indicator that the client requires more oxygen. By following the nursing process, the nurse should first determine the client's current oxygen saturation. The nurse should then notify the health care provider of the change in the client's condition and implement the other interventions if appropriate.

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 rationale 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 nurse is evaluating the effectiveness of therapy for a client who received albuterol via nebulizer during an acute episode of shortness of breath due to asthma. Which finding is the best indicator that the therapy was effective?

Oxygen saturation is greater than 90%. rationale The goal for treatment of an asthma attack is to relieve bronchospasms and keep the oxygen saturation greater than 90%. Albuterol is a short-acting inhaled beta2-adrenergic agonist and the treatment of choice for an acute asthma attack. Pulse oximetry is an objective data point that the nurse should use to determine oxygenation status of the client. The other client data may occur when the client is too fatigued to continue with the increased work of breathing required in an asthma attack and, therefore, should not be used to evaluate effectiveness of treatment.

The nurse on the inpatient unit is expecting the admission of a client with a new onset of seizures and instructs the unlicensed assistive person (UAP) to prepare the client's room. Which piece of equipment should the UAP make sure to place in the room?

Pads to be placed over the bed's side rails rationale Maintaining safety is the primary concern for the health care team when caring for a client with seizures. The room should be set up with equipment to have readily available in case the client has a seizure. Soft pads placed over the bed's side rails will help protect the client from injury should a seizure occur while the client is in bed. The other pieces of equipment are not appropriate or indicated for seizure precautions.

The nurse is caring for a client who suffered second-degree burns over 50% of their body. The nurse understands that which medication is used for the prevention of stress ulcers for this client?

Pantoprazole 40 mg IV daily rationale Curling's ulcers are stress ulcers that occur in clients with severe burns. These ulcers occur within 24 hours of the injury due to the decreased blood flow to the gastrointestinal tract. This leads to a reduction in the protective layer of mucosa, while a simultaneous increase in hydrogen ions occurs. Curling's ulcers generally manifest themselves as gastric bleeding and are prevented by administering proton-pump inhibitors, such as pantoprazole. Other factors that prevent these stress ulcers are early enteral feeding, H2 histamine blockers and medications that protect the mucosa. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, should be used with caution due to the risk of further decreasing the protective gastric mucosa. In severe burn clients the priority is fluid resuscitation and increasing cardiac output. Therefore, diuretics such as furosemide or bumetanide are contraindicated.

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 rationale 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 nurse is preparing interventions for a client with major depression who has been showing signs of impaired social interaction. Which of the following nursing interventions is initially appropriate for this client?

Provide activities that require minimal concentration Correct Response rational Clients with depression who are struggling to interact with others should be given time to adjust to the therapeutic environment or milieu. The nurse will accomplish this initially by providing the client activities that require minimal concentration. Once the client shows signs of improved mood and concentration, the nurse should implement the other interventions.

A client has been diagnosed with dysphagia due to a stroke. What nursing intervention should the nurse implement for this client?

Position the client in an upright position while they are eating rationale Dysphagia means difficulty swallowing and it is often associated with a stroke. Clients with dysphagia are at risk of aspirating foods and fluids into their lungs. Interventions that reduce the risk for aspiration include positioning the client in an upright sitting position, offering the client puréed or soft food, thickening liquids (if indicated) and instructing the client to swallow one bite at a time and not mix solid foods with liquid. Straws are contraindicated for clients with dysphagia because they increase the risk of aspiration. The client should tuck in their chin and not tilt their head back to facilitate swallowing and prevent aspiration while they are swallowing.

The nurse is reviewing the medical record of a client with diabetes who was admitted for a surgical site infection. Which findings should the nurse report to the health care provider? (Select all that apply.)

Positive glucose in the urine Hemoglobin A1C of 8% Serum glucose level of 220 mg/dL Correct! In reviewing the lab values, the nurse should notify the HCP of the positive glucose in urine (normally, glucose is not seen in urine), A1C of 8% (desired range for a client with diabetes is 7% or less), and the serum glucose level of 220 mg/dL, which is higher than the normal range of 70 to 110 mg/dL. These abnormal lab results indicate that the client's diabetes is not managed well and most likely contributed to the client developing an infection. The BUN, ALT and urine pH listed are considered within normal limits.

The client diagnosed with paranoid-type schizophrenia is sitting alone, intently staring at and watching other clients and staff members. The client becomes hostile when approached with medication and claims that the medication controls the mind. What type of symptom(s) does the nurse recognize that this client is exhibiting?

Positive symptoms The nurse must be familiar with behaviors common to the disorder. Symptoms of schizophrenia are commonly described as positive or negative. Positive symptoms are behaviors and experiences present in a person with schizophrenia that would not be present in a person without the illness. These are sometimes described as features that are "added" by the illness. In contrast, negative symptoms are those that reflect a decrease in normal functions, or abilities that have been "taken away." Positive symptoms of schizophrenia include delusions, hallucinations, hypervigilance and disorganized thinking.

The nurse is reviewing the chart of a client with Parkinson's disease. Which manifestations would the nurse expect to find? (Select all that apply.)

Postural instability Tremors Akinesia Rigidity rationale Parkinson's disease is a result of an imbalance in dopamine and acetylcholine (AcH). In Parkinson's disease, dopamine levels are low and the client loses the ability to refine voluntary movement. AcH secreting neurons remain active, creating an imbalance between excitatory and inhibitory neuronal activity. The resulting excessive excitation of neurons prevents a person from controlling or initiating voluntary movement. Parkinson's disease is characterized by four cardinal symptoms/clinical manifestations: tremors, rigidity, akinesia and postural instability. Jaundice, epistaxis (nosebleed) and anuria (low or no urine output) are not expected manifestations of a client with Parkinson's disease.

The client who was admitted with exacerbation of ulcerative colitis has developed hyperglycemia. Which medication that the client was prescribed most likely caused this adverse drug effect?

Prednisone rationale Prednisone is a corticosteroid, specifically a glucocorticoid. Corticosteroid therapy may be prescribed during exacerbations of ulcerative colitis to decrease inflammation. Common adverse effects include hyperglycemia, osteoporosis, peptic ulcer disease and an increased risk for infection. The nurse should monitor clients who are receiving prednisone for hyperglycemia. Dicyclomine hydrochloride and diphenoxylate with atropine are cholinergic blocking drugs prescribed for gas (flatus) and diarrhea, commonly seen with ulcerative colitis. Acetaminophen is a non-narcotic analgesic given for mild-to-moderate pain. None of those drugs are known to cause an elevated blood sugar.

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 rationale 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)?

When planning care for a client on a mechanical ventilator, the nurse understands that the application of positive end-expiratory pressure (PEEP) to the ventilator settings has which therapeutic effect?

Prevention of alveolar collapse during expiration rationale Positive end-expiratory pressure (PEEP) is positive pressure that is applied to the airway during exhalation. This positive pressure prevents the alveoli from collapsing, improving oxygenation and enabling a reduced fraction of inspired oxygen (FIO2) requirement. The other answers are incorrect.

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 rationale 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 surgical client with acute pain refuses to participate in physical therapy. The client still has pain despite the administration of pain medication. Based on the information provided, which nonpharmacological intervention(s) would be appropriate for the nurse to add to the plan of care? (Select all that apply.)

Provide the client with a light back massage before physical therapy. Correct! Ensure the client's room is kept at a comfortable temperature for physical therapy. Assist the client in meditating before going to physical therapy. raNonpharmacological therapies are essential for pain management. For example, they can minimize the use and duration of use of synthetic medications for pain control, which can minimize medication side effects. Nondrug therapies can increase a client's sense of control and their ability to cope with pain. When using cold therapy, always protect the skin before application of the therapy, and do not apply cold objects or ice to open wounds. Keeping the client's room well-lit, quiet and at a comfortable temperature can also help manage pain. Massage can reduce muscle tension and stress, thus helping reduce pain. Keeping a client on bedrest after surgery is contraindicated because it can lead to complications such as pneumonia, pressure ulcers and deep vein thrombosis. It is also unrealistic for a surgical patient to not have any pain. Relaxation techniques such as music, meditation and deep breathing can help reduce stress and anxiety, alleviate muscle tension and enhance the effectiveness of other pain relief measures.tionale

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 rationale 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.

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 rationale 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.

A 68-year-old, postmenopausal, female client has been prescribed tamoxifen for breast cancer with bone metastases. The nurse should reinforce teaching about which potential adverse drug effect?

Stroke-like symptoms rationale Tamoxifen is an antineoplastic drug, commonly prescribed for clients with breast cancer or for clients who are at high risk for developing breast cancer. The most common adverse drug effects (ADEs) are hot flashes, fluid retention, vaginal discharge, nausea, vomiting and menstrual irregularities. In women with bone metastases, tamoxifen may cause transient hypercalcemia. Because of its estrogen agonist actions, tamoxifen poses a small risk of thromboembolic events, including deep vein thrombosis, pulmonary embolism and stroke. Insomnia and seizures are not known ADEs of tamoxifen.

The nurse is monitoring a client who is caring for their prosthetic limb. Which action by the client demonstrates that the client correctly understands prosthetic limb care?

The client dries the inside of the prosthetic socket after wiping it with soap and water. rationale To decrease the risk of irritation and infections, prosthetic limbs should be maintained by keeping the socket clean and dry. Cleaning prosthetic sockets involves using soap and water daily. The client should change the residual leg sock at least daily and only use products prescribed by the primary HCP. Using baby powder is not appropriate. Periodic adjustments of the sizing or fit of a prosthetic limb are expected and should be done by a professional. Using tape and/or gauze to self-adjust the fit of the prosthetic might cause skin irritation and breakdown.

The nurse is evaluating a client's adherence to the prescribed regimen of antihypertensive medications. Which finding is most indicative of effective hypertension management?

There is no indication of renal impairment. rationale The most common complications of hypertension (HTN) are target organ diseases including of the kidneys. Uncontrolled HTN is the most significant risk factor for the development of chronic kidney disease. Therefore, the absence of renal impairment is a good indicator that the client is adhering to the prescribed medication regimen. A blood pressure of 148/94 is higher than recommended and indicates that the medication regimen may need to be adjusted. A stable weight and absence of edema are indicators often used to evaluate the management of heart failure, not HTN.

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.

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).

The nurse has received the laboratory results for a client who developed chest pain 4 hours ago and may be having a myocardial infarction. Which laboratory result will be most important to review?

Troponin T and I levels rationale Cardiac troponins start to elevate 4 to 6 hours after myocardial injury and are highly specific to myocardium. They are the preferred diagnostic marker for myocardial infarction and therefore the most important lab value for the nurse to review. Myoglobin rises in response to myocardial injury within 30 to 60 minutes. It is rapidly cleared from the body, thus limiting its use in the diagnosis of myocardial infarction. The low-density lipoprotein (LDL) cholesterol level is useful in assessing cardiovascular risk but is not helpful in determining whether a client is having an acute myocardial infarction. The creatine kinase-MB level is also specific to myocardial injury and infarction and increases 4 to 6 hours after the infarction occurs. It is often trended with troponin levels.

The nurse prepares to administer a liquid medication to an infant. At the bedside, the parent states that the infant does not like to take medications. Which action should the nurse perform to ease the medication administration?

Use an oral syringe to administer the medication, alternating with a pacifier. rationale Infants may struggle taking oral medications. Nurses should use a small syringe for liquid medications and administer to the side of the mouth. To encourage sucking, a pacifier or bottle nipple may be used intermittently with the medication. Liquid medications should never be added to a full bottle because the infant may not complete the feeding and receive a partial dose. Nurses should avoid stretching out medications as this will impact medication peak times. Using developmentally appropriate techniques should be used before switching to a more invasive medication route.

The nurse explains a low cholesterol diet to a client diagnosed with heart disease. Which menu selection by the client demonstrates that the client understands the teaching?

Turkey chili made with kidney beans rationale Cholesterol is a fat-like substance found only in animal products. It is not an essential nutrient. The body makes enough good cholesterol (HDL). The American Diabetes Association (ADA) recommends limiting the total intake of dietary cholesterol to less than 300 mg/day. This may help reduce risk factors, such as increased serum cholesterol levels, which are associated with the development of coronary artery disease. Different foods lower cholesterol in various ways. Some deliver soluble fiber, which binds cholesterol and its precursors in the digestive system and drags them out of the body before they get into circulation. Some deliver polyunsaturated fats, which directly lowers bad cholesterol (LDL). Some contain plant sterols and stanols, which block the body from absorbing cholesterol. Canned chicken, unsalted butter and scrambled eggs are all products derived from animals. Legumes are plant based and are especially rich in soluble fiber.

The nurse is caring for a client with a large wound. In order to promote healing. What is the most appropriate meal selection for this client?

Turkey, spinach and orange juice rationale Protein, vitamins A and C and zinc promote wound healing and immune system functioning. Turkey is a poultry source rich in protein. Spinach is rich in vitamin A. Orange juice is a source high in vitamin C. Each food choice in this meal meets important requirements for the client with a large wound in the healing process. Gelatin does not contain any high source of nutrition. Pasta is high in carbohydrates. Apples are a good source of carbohydrates and fiber.

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 rationale 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.

The nurse is caring for an adult client who suffered second degree burns over 25% of their body in a house fire. Which observation best indicates that fluid resuscitation has been effective?

Urine output of 35 mL per hour Correct! rationale Resuscitation for a severe burn requires large fluid volume replacement in a short time to maintain blood flow to vital organs. Monitoring client responses is critical to determine the adequacy of resuscitation for hydration and blood perfusion of the brain, heart and kidneys. Urine output is the most common and sensitive noninvasive assessment parameter for cardiac output and tissue perfusion. The goal is to maintain an hourly urine output of 0.5 mL/hour (about 30 mL/hour) for the average adult.

To evaluate the effectiveness of antiretroviral therapy for a client infected with human immunodeficiency virus (HIV), which laboratory test result will the nurse plan to review?

Viral load test rationale Viral load refers to the amount of HIV circulating in the blood. The effectiveness of antiretroviral therapy (ART) is measured by the decrease in the amount of HIV virus, i.e., viral load, detectable in the blood. The goal is for the viral load to be so low that it is deemed undetectable. An undetectable viral load does not mean that the client is cured or can no longer transmit the disease. The other tests are used to detect HIV antibodies, which remain positive even with effective ART. A nucleic acid amplification test (NAAT) is commonly used to diagnose a gonorrhea infection.

A client has been admitted for the second time to treat tuberculosis (TB). Which referral does the nurse initiate as a priority?

Visiting nurses to arrange for directly observed therapy (DOT) rationale Clients with TB must take multiple drugs for six months or longer, making adherence a very real problem. Non-adherence is the most common cause of treatment failure and relapse. This client has a risk of non-adherence, as evidenced because this is their second admission to treat TB. When the client is discharged, they most likely will need to be placed on DOT to ensure compliance. This is the priority referral in order to prevent transmission of TB to others in the community. The other referrals may also be appropriate depending on the client's needs.

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

The nurse is caring for a client with chronic atrial fibrillation. Which drug does the nurse expect to administer to prevent a common complication of this condition?

Warfarin rationale Atrial fibrillation puts clients at risk for developing emboli and is a major risk factor for an ischemic, i.e., thrombotic stroke. Clients at risk for emboli due to atrial fibrillation are treated with anticoagulants such as warfarin. The other drugs might be used for rate control of atrial fibrillation and as a "cardioprotective" medication, but they do not help prevent the development of a thrombus or embolus.

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 rationale 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.

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 rationale 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 is caring for a client who is recovering from a below-knee amputation. Which is the best way for the nurse to apply the prescribed elastic bandage to the stump?

Wrap the bandage in a figure-eight manner rationale An amputation is the removal of part of the body. The limb should be wrapped with an elastic bandage applied in a figure-eight manner. This approach reduces the risk of cutting off circulation to the stump area. Although wrapping a bandage in a simple spiral, chevron and triangular manner are appropriate techniques in other circumstances, they are not recommended for use on an amputation stump.n

The nurse has given discharge instructions to a client who underwent abdominal surgery. Which of the following statements indicates that the client correctly understands how to manage their pain at home? (Select all that apply.)

"A warm shower before bed might alleviate my pain and help me sleep." "Listening to my favorite music might help control my pain." "Before I take an herbal supplement for pain, I should check with my provider." rationale Nonpharmacological pain-relief methods can help maximize the effects of pharmacological therapies and lessen how much medication a client needs for pain control. Music is considered a form of distraction. It can reduce pain, anxiety and depression. Herbal supplements may interact with prescribed analgesics. Clients need to make sure their health care provider is aware of all the medications they currently take. Oral pain medications usually peak within one hour. Moist heat can alleviate muscle tension and reduce pain. Clients should set a reasonable goal for pain control (e.g., 3/10 or 4/10). It is unrealistic to think that a client will have no pain after surgery. They should set a pain relief goal that will allow them to rest, participate in therapy sessions and perform activities of daily living.

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" rationale 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 reviewing medication safety with a client. Which statements by the client indicate a need for additional teaching? (Select all that apply.)

"Alcohol is safe to drink with my medication." "If I miss a dose, I can double up the next dose." "It will be safe to take vitamins and herbal supplements with the medication." "My diet will not affect the medication." rationale Medication safety includes a number of concepts that the nurse should reinforce with the client. Current medications and allergies should be reviewed for potential interactions. Medications should be taken as prescribed without changing the dose or frequency. If a dose is missed, the client should avoid doubling up doses. Dietary choices, vitamins, herbal supplements and alcoholic beverages should be reviewed for potentially causing adverse reactions or side effects. If an adverse reaction might occur, the client will need to make lifestyle changes. The client should notify the health care provider (HCP) if allergic reactions arise, because the medication will need to be stopped.l

The nurse, following hospital policy, reports an incident of suspected child abuse. The parent of the child becomes upset and demands to know the reason for the nurse's action. Which is the best response by the nurse?

"As a nurse, I am required by law to report incidents of suspected child abuse." All 50 states and the District of Columbia have laws that require reporting of specific health problems and the suspected or confirmed abuse of infants or children. Nurses often are explicitly named within the context of these statutes as one of the groups of designated health professionals who must report the specified problems under penalty of fine or imprisonment. Nurses need not fear legal reprisal from individuals or families who they report to authorities in suspected cases of abuse. Most legislatures have granted immunity from suit when that report is made in good faith, and in compliance with federal and state laws.

The nurse is reviewing a client's medication list and notes the client takes bupropion SR 150 mg oral twice a day. Which question is appropriate for the nurse to ask concerning the purpose of this medication?

"Did your cravings for nicotine decrease after starting this medication?" rationale It is important for the nurse to know the generic name of drugs and their mechanism of action and therapeutic uses. Bupropion, when marketed as Zyban, is used as a nicotine-free method used to aid with smoking cessation. It should be started slowly and the dosage increased, but it should not be given for more than 12 weeks. Bupropion, when marketed as Wellbutrin, is used to treat depression. Side effects of bupropion are the same for either brand and include weight loss and insomnia. An alternative smoking cessation aid, varenicline, is associated with abnormal dreams and nightmares. Bupropion is not used for the treatment of hallucinations.

A client is prescribed trimethoprim/sulfamethoxazole for recurrent urinary tract infections. Which statement by the nurse about this medication is correct?

"Drink at least eight glasses of water a day." rationale Trimethoprim/sulfamethoxazole is a highly insoluble medication and should be taken with a large volume of fluid. This medication can be taken with or without food. The full prescribed amount should be taken at evenly-spaced intervals until the medication is finished. Unlike many other antibiotics, trimethoprim/sulfamethoxazole does not seem to affect hormonal birth control such as the pill, the patch or ring.

A client who is taking duloxetine asks the nurse if the medication treats depression or diabetes. What is the best response from the nurse?

"Duloxetine is used to treat depression but can be used to treat pain that can occur in people with diabetes." Duloxetine is a selective serotonin and norepinephrine reuptake inhibitor (SNRI) that can be used to treat depression but also can be used to treat pain associated with diabetic neuropathy. Duloxetine is not used to lower blood sugar levels.While it is a true statement that duloxetine is an antidepressant, it is not the best response from the nurse since it does not fully address the client's question. The best response is to confirm the use of duloxetine in the treatment of depression and to explain its additional role in treating diabetic neuropathy in some situations.

The nurse should provide which dietary instruction to a client with osteoporosis?

"Eat more dairy products to increase your calcium intake." rationale Osteoporosis causes a reduction in skeletal bone mass, leading to porotic and brittle bones. To offset this reduction, the nurse should advise the client to increase calcium intake by consuming more dairy products, which provide about 75% of the calcium in the average diet. Decreasing vitamin D intake is incorrect as vitamin D helps facilitate calcium utilization. None of the other options would stop osteoporosis from worsening.

The nurse is providing discharge information to a client with glaucoma. Which of the following instructions should the nurse include?

"Eye medications will need to be administered lifelong." rationale The administration of eye drops is a critical component of the treatment plan for the client with glaucoma. The client needs to be instructed that medications will need to be taken for the rest of their life. Limiting fluid and salt intake will decrease systemic fluid volume but is usually not indicated for glaucoma. Overuse of eyes can be misinterpreted and difficult to adhere to.

A newly diagnosed schizophrenic client reports to the nurse that he thinks that the employees at the fitness center are conspiring to have his membership revoked. Which of the following responses by the nurse is the most therapeutic?

"Feeling this way must be frustrating and scary." Schizophrenic clients often feel as if they are being conspired against. The most therapeutic response focuses on empathy for the client. The client feels that these feelings are real and they can't articulate why they feel the way they do, or if they are able, the explanation is delusional. Medication therapy is important with this client but medication therapy takes time to become therapeutic. Additionally, not having taken a medication dose "yet" does not explain the irrational thoughts.

A newly diagnosed schizophrenic client reports to the nurse that he thinks that the employees at the fitness center are conspiring to have his membership revoked. Which of the following responses by the nurse is the most therapeutic?

"Feeling this way must be frustrating and scary." rational Schizophrenic clients often feel as if they are being conspired against. The most therapeutic response focuses on empathy for the client. The client feels that these feelings are real and they can't articulate why they feel the way they do, or if they are able, the explanation is delusional. Medication therapy is important with this client but medication therapy takes time to become therapeutic. Additionally, not having taken a medication dose "yet" does not explain the irrational thoughts.

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." rationale 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 client who lives in an assisted living facility tells the nurse, "I am so depressed. Life isn't worth living anymore." What is the best response by the nurse to the client's statement?

"Have you thought about hurting yourself?" rationale It is most important to determine whether someone who voices thoughts about death is considering suicide (suicidal ideation). Individuals may provide both behavioral and verbal clues as to the intent of their act. Behavioral clues include giving away prized possessions, getting financial affairs in order, writing suicide notes and demonstrating a sudden lift in mood. Verbal clues may be both direct and indirect. An example of a direct statement includes, "I want to die." An example of an indirect statement includes, "I don't have anything worth living for anymore."This client's statement indicates suicidal ideation and the client's safety is the highest priority. The nurse should ask the client directly about thoughts or plans to harm themselves. The other responses are nontherapeutic and will not help identify if the client is at risk for suicide.

The school nurse is teaching a group of teenagers about the prevention of sexually transmitted infections (STIs). Which statement by one of the students indicates an understanding of the teaching?

"Having multiple sexual partners puts me at a higher risk for an STI." rationale While educating individuals on sexually transmitted infections (STIs) and prevention, discussing the risk of exposure should be emphasized. Although the use of condoms has been shown to reduce the risk of infection for both men and women, they do not completely eliminate the risk. The nurse should follow up on the other responses as they indicate a lack of understanding of how an STI is transmitted or prevented.

The nurse is collecting data on a client who is complaining of drowsiness and an inability to concentrate. Which statements by the client's spouse indicate the client might be suffering from obstructive sleep apnea? (Select all that apply.)

"He seems to snore less when he sleeps in a chair." "He stops breathing sometimes at night." "He is very irritable and tired, even when he has slept 12 hours the night before." "He falls asleep anytime he sits down." "He snores really loud during the night. I have to sleep in the other bedroom." rationale The most common clinical manifestation of obstructive sleep apnea (OSA) is daytime sleepiness and the inability to maintain concentration. Often, the client's family members will state the client snores loudly and stops breathing while sleeping. Swelling in the lower extremities and shortness of breath when lying supine (orthopnea) are related to heart failure, not OSA.

A client with major depression is prescribed the extended release form of venlafaxine. Which statement by the client indicates a need for additional teaching?

"I can stop taking the drug when I start feeling better." rationale Venlafaxine is a serotonin/norepinephrine reuptake inhibitor (SNRI) used for major depression, panic disorders and social phobias. It blocks neuronal uptake of serotonin and norepinephrine with minimal effects on other transmitters or receptors. Pharmacologic effects are similar to those of SSRIs. The most common side effect is nausea (37% to 58%). Sexual dysfunction may occur and can cause the client to stop taking the medication. Therefore, the client should contact their provider for a possible alternate prescription. The client is prescribed the extended release form and should not chew or break the pill, but swallow the pill whole. The client is expected to feel less depressed and should not stop taking the medication. Abrupt discontinuation can cause an intense withdrawal syndrome. Symptoms include anxiety, agitation, tremors, headache, vertigo, nausea, tachycardia and tinnitus. Worsening of pretreatment symptoms may also occur.

A client reports feeling upset after electroconvulsive therapy (ECT) because the client is experiencing memory loss and cannot remember important phone numbers for family and friends. What would be the most therapeutic response from the nurse?

"I can understand that forgetfulness is upsetting to you." rationale The most common side effects of ECT are temporary memory loss and confusion.Communicating caring and empathy while acknowledging the client's feelings is the most appropriate and therapeutic response. Developing a plan for dealing with the effects of memory loss can be done later if the client agrees. False reassurance and ignoring the client's concerns are nontherapeutic responses and are not appropriate nursing interventions. Correct!

The nurse is caring for a female client who underwent a left modified radical mastectomy. Which statement indicates the client needs additional support from the nurse?

"I can't bear to look at myself in the mirror." Correct! rationale Concerns about appearance after this type of surgery are common and are often a threat to the client's self-concept as a woman. The statement that she cannot look at herself in the mirror illustrates the client's anxiety. The nurse should not push her to accept this body image change immediately. Much of a person's body image is a reflection of how others respond. Therefore, the response of the client's family or partner to the surgery is crucial in determining the effect on her self-esteem.

A client tells a nurse, "I have something very important to tell you if you promise not to tell anyone." Which statement by the nurse would be the most appropriate response?

"I can't make such a promise." Rationale Secrets are inappropriate in therapeutic relationships and are counterproductive to the therapeutic efforts of the interdisciplinary team. Secrets may be related to a risk for harm to self or others. The nurse should honor and help clients understand the rights, limitations and boundaries of confidentiality.

The nurse is caring for a client admitted with a phosphorus level of 1.5 mg/dL. Which statement by the client should alert the nurse to collect further data about possible causes for the phosphate imbalance? (Select all that apply.)

"I do not eat any meat or dairy products." "I take a calcium supplement with every meal." ratiHypophosphatemia refers to a below-normal concentration of phosphorus in the ECF (serum phosphate less than 2.5 mg/dL). The most common causes of hypophosphatemia are depletion of phosphorus because of insufficient intestinal absorption, hypercalcemia, transcompartmental shifts and increased renal losses. Lack of parathyroid hormone (PTH) after removal of the parathyroid gland leads to decreased blood levels of calcium (hypocalcemia) and increased levels of blood phosphorus (hyperphosphatemia), not hypophosphatemia. Nuts are high in organic phosphorus and considered good snack foods. Meats and dairy products are high in phosphate and a lack of intake of those foods can lead to a low serum phosphorus level.onale

An adolescent client is paralyzed from the waist down after being involved in a motor vehicle accident. Which client statement would indicate to the nurse that the client is using repression as an ego defense mechanism?

"I don't remember anything about what happened to me." An individual experiences psychological responses to stress or a traumatic event. Anna Freud (1953-) identified a number of defense mechanisms commonly employed by the ego. Repression is the unconscious and involuntary forgetting of painful events, ideas and conflicts. In this case, the client has no memory of the catastrophic event. Deflecting attention to what others are feeling, blaming someone else and expressing false hope indicate the client is using other ego defense mechanisms, such as projection, displacement and denial.

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." rationale 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.

The nurse is reinforcing teaching with a client who has recurrent kidney stones. Which statement by the client would indicate that further teaching is needed?

"I will follow a low-calcium diet and avoid dairy products." rationale The client's statement regarding a low-calcium diet and avoiding dairy products would require further teaching from the nurse. Low-calcium diets are not generally recommended as this can lead to osteoporosis. Clients should be drinking fluids, preferably water, at least every 1 to 2 hours throughout the day. This can flush the system and prevent the occurrence of kidney stones. Clinical manifestations of kidney stones include pain, infection and difficulty with urination. Clients should notify their health care providers at the first sign of a urinary tract infection, as this can be caused by a kidney stone obstructing the flow of urine.

The nurse understands that the prescribed levothyroxine is effective when the client with hypothyroidism makes which statement?

"I have been having daily, formed bowel movements." rationale Levothyroxine sodium is utilized to treat hypothyroidism. The nurse must first understand signs and symptoms of hypothyroidism, such as fatigue, lethargy, constipation, hypotension, anorexia and weight gain. In doing so, the nurse can identify that reports of having regular bowel movements is indicative of the levothyroxine working as intended, as constipation is a common symptom of hypothyroidism.Additionally, the nurse must also recognize symptoms of hyperthyroidism, as some clients on levothyroxine sodium may be receiving too high a dose, resulting in excess thyroid hormone and symptoms of hyperthyroidism, such as diaphoresis, irritability, heart palpitations, weight loss and diarrhea. The nurse should recognize that a client who sweats through the night or who is irritable and angry at work may be displaying symptoms of hyperthyroidism.

The home health nurse is reviewing the medical record of a client with closed-angle glaucoma in both eyes. Which statement by the client would support this diagnosis?

"I have to turn my head to see around the room." rationale As intraocular pressure rises in glaucoma, there is a slow, progressive loss of the peripheral visual field in the affected eye(s). If untreated or uncontrolled, it eventually can lead to blindness. The client's statement that they have to turn their head to be able to see indicates a loss of peripheral vision. Tiny, painless particles floating inside the eye are called floaters that can be harmless or signal retinal detachment. Blurred vision can have many causes, including refractive errors, chronic dry eyes, cataracts and macular degeneration. Complete, unilateral loss of vision is typically seen with a stroke or other intracerebral process.

A client is discharged with a prescription for warfarin. A nurse recognizes that additional teaching is needed if the client makes which incorrect comment?

"I know I must avoid crowds." There are no specific reasons for the client on warfarin to avoid crowds. The other options are true statements. Warfarin is used to prevent blood clots from forming and is commonly prescribed postoperatively following a major surgery, after suffering a heart attack, or for certain types of irregular heartbeats.

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 nurse is collecting data on a client believed to be in an abusive relationship. Which client statement is most indicative that this individual is experiencing intimate partner abuse?

"I must have done something to deserve this." rationale Abused individuals stay in abusive relationships for a variety of reasons. They may blame themselves for being abused and often believe they can keep the peace if they stay. They may have reason to fear danger if they try to leave, including threats made by the abuser against the victim's children. All members of the family suffer from effects of the abuse, even if they are not direct victims themselves.

The nurse is reinforcing teaching for a client with genital herpes. Which statement by the client indicates that the teaching was effective?

"I need to inform my sexual partner of my infection." rationale It is critical for the nurse to make sure the client understands that informing their partners of the disease is important to help stop the spread of the infection. Genital herpes is transmittable even when lesions are not visible. Genital herpes is an incurable, life-long infection. Although not a cure, antiviral medications are often used to shorten healing time of lesions and reduce the frequency of outbreaks. Herpes simplex virus (HSV) is typically not required to be reported. However, gonorrhea and syphilis are required to be reported to public health authorities throughout the U.S. In some states, chlamydia infections must also be reported.

The nurse is reinforcing discharge instructions for a client after cataract surgery of the left eye. Which statements by the client indicate an understanding of the instructions? (Select all that apply.)

"I will call the surgeon if the pain is intense." "I will follow the instructions for the eye drops." "I will not rub, press on or scratch my eye." rationale Cataract surgery is generally done in an outpatient environment, with the client being discharged within a few hours of the procedure. There is generally little to no pain, and what pain the client has can be relieved with mild analgesics. The client should not press on, scratch or rub the eye. They will likely be prescribed eye drops with varying instructions and should follow these directions. Intense pain may indicate an increase in intraocular pressure or hemorrhage and the surgeon should be notified immediately. Eyes that are bloodshot or bruised is an expected occurrence and should be resolved within a week. The client should not drive until instructed by the surgeon, generally for 48 hours.

The nurse has given discharge instructions to a client who is diagnosed with alcohol use disorder. Which of the following statements indicate that the client correctly understands the nurse's instructions?

"I should avoid taking acetaminophen while drinking alcohol." "Alcoholism can lead to the development of cardiovascular disease." "Taking antihistamines while drinking alcohol can lead to sleepiness." Chronic alcohol use has been linked to cardiovascular disease, liver disease and digestive problems. Alcohol should not be consumed in combination with some over-the-counter (OTC) medications, including acetaminophen and antihistamines. Consuming alcohol while ingesting acetaminophen can lead to liver damage, and consuming alcohol while taking antihistamines can lead to increased central nervous system (CNS) depressant effects. Alcohol withdrawal can occur when an individual who consumes alcohol chronically suddenly stops drinking alcohol. Death may occur from alcohol withdrawal, typically stemming from sepsis, vascular collapse or aspiration pneumonia. Alcoholics are at risk for malnutrition and vitamin deficiencies (e.g., magnesium, calcium, potassium, folic acid and thiamine).

A client asks the nurse for information about a living will. Which statement made by the client dem onstrates 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." rational 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 client has received education from the nurse about their new diagnosis of systemic lupus erythematosus. Which statement by the client indicates that additional teaching is needed?

"I will avoid foods that contain high levels of vitamin K." rationale Systemic lupus erythematosus (SLE) is a chronic, progressive, inflammatory connective tissue disorder that can cause major body organs and systems to fail. Clients with SLE should avoid prolonged sun exposure. The nurse should instruct clients to wear long sleeves and a large brimmed hat when outdoors. They should use sun blocking agents with a sun protection factor (SPF) of 30 or higher on exposed skin surfaces. It is expected for clients with SLE to experience fatigue, so they should allow time to rest when needed. Clients with SLE should monitor their body temperature carefully because this is typically the first sign of an exacerbation, during which the client can become critically ill. There is no established diet recommendation for clients with SLE, except to eat a well-balanced diet. Avoiding foods that contain vitamin K is not necessary, so this statement should be followed up on.

The nurse is reinforcing teaching regarding the use of methotrexate with a female client who has systemic lupus erythematosus. Which statement by the client indicates an understanding of the teaching?

"I will avoid interacting with people in large crowds." rationale Methotrexate is an immunosuppressant medication that is used to treat systemic lupus erythematosus (SLE). Due to immunosuppression, clients taking methotrexate should avoid large crowds of people to prevent becoming ill. Methotrexate should be taken with folic acid to decrease gastrointestinal and hepatic toxicity. Clients who are taking this medication should have a complete blood count test done regularly to monitor for decreased white blood cells and platelets, which can indicate bone marrow suppression. Methotrexate is teratogenic, therefore, pregnancy should be avoided while taking this medication. Oral contraceptives that contain estrogen are not contraindicated with this medication or disease.

A client who was admitted with viral hepatitis is being discharged home. Which of the following statements by the client indicate an understanding of the discharge instructions? (Select all that apply.)

"I will avoid too much salt in my diet." "I will avoid drinking alcoholic beverages." "I will call my doctor if my skin turns yellow." "I will call my doctor if my belly gets bigger." rationale Hepatitis is an inflammation in the liver that leads to liver cell damage. Clients with hepatitis should avoid drinking alcohol and taking drugs metabolized in the liver, such as acetaminophen. A yellow discoloration of the sclera of the eyes and the skin on the rest of the body is called jaundice. Jaundice is an indication of worsening hepatic function. Clients with impaired hepatic function should also avoid high levels of salt in their diets to prevent fluid retention. Abdominal distention (i.e., the client's belly getting bigger) could be ascites, a condition which occurs as a result of low serum albumin levels that can lead to fluid accumulation in the abdominal cavity. Clients should report these findings to their health care provider.

The nurse is reviewing discharge instructions with a client with a new diagnosis of a seizure disorder. Which statements indicate that the client understood the instructions? (Select all that apply.)

"I will keep a diary of any seizure activity "I will not miss a dose of my seizure medication." "I will make sure to wear a medical alert bracelet." "My family has developed a plan for when I have a seizure." rationale Seizures may involve sudden jerky movements accompanied by a loss of consciousness. Once a seizure has occurred it is important for a client and their family members to be prepared and try to prevent recurrence. It is important to take anticonvulsant medication as ordered. Diaries of seizure activity help to determine if there is a trigger. Wearing a medical alert bracelet and having a plan for the family, such as when to call an ambulance, is a proactive plan to manage the disease. The client does not have to stop attending college and should continue with their normal life and activities. A client experiencing a seizure should not be restrained or held down during the seizure as that can cause injury to the client or family member.

The nurse is teaching the client with chronic pancreatitis about the prevention of an acute attack. Which statement by the client requires additional teaching?

"I will limit my alcohol intake to 1 to 2 glasses a week." rational The focus of community-based, collaborative care for the client with chronic pancreatitis is the prevention of acute attacks. Clients need to avoid irritating substances such as alcohol, caffeine and nicotine. (Alcohol consumption is one of the primary causes of exacerbation of chronic pancreatitis and should be completely avoided, not just limited.) Diet teaching should include low-fat and high-protein meals. (Insufficiency of pancreatic enzymes d/t pancreatitis impairs fat digestion and protein absorption.) Pancreatic enzyme products (e.g., pancrelipase (Creon)) contain amylase, lipase and trypsin and are used to replace deficient pancreatic enzymes.

The nurse is reinforcing education for a client with type 2 diabetes mellitus who is being discharged home. Which statement by the client would require clarification from the nurse?

"I will make sure to have an eye exam every five years." rationale For diabetic clients, it is imperative they protect and monitor the function of their eyes and kidneys due to the vascular damage associated with diabetes mellitus. Eye exams should be performed annually for diabetic clients due to the risk of diabetic retinopathy. Clients should increase physical activity slowly to prevent injury. Additionally, before meals and at bedtime is an appropriate time for checking blood sugar. Rotating injection sites helps prevent lipodystrophy and increase absorption of insulin.

Which of the following statements by a client taking lithium for bipolar disorder indicates the need for additional teaching?

"I will need to have my blood drawn once a year to check the lithium level." Lithium levels should be checked more frequently than once per year, with some sources recommending routine monitoring as often as every 1 to 2 months. The nurse would need to inform the client that it will be necessary to monitor lithium levels more often than once per year and coordinate with the HCP to identify the appropriate monitoring schedule for this client.Blurred vision, tinnitus, slurred speech and confusion could indicate a dangerous condition called lithium toxicity and the HCP would need to be notified immediately. Similarly, vomiting or diarrhea could increase the risk of dangerous levels of lithium in the blood. It is appropriate for clients taking lithium to drink 6 to 8 glasses of water each day.

Which of the following statements by a client taking lithium for bipolar disorder indicates the need for additional teaching?

"I will need to have my blood drawn once a year to check the lithium level." Correct! rational Lithium levels should be checked more frequently than once per year, with some sources recommending routine monitoring as often as every 1 to 2 months. The nurse would need to inform the client that it will be necessary to monitor lithium levels more often than once per year and coordinate with the HCP to identify the appropriate monitoring schedule for this client.Blurred vision, tinnitus, slurred speech and confusion could indicate a dangerous condition called lithium toxicity and the HCP would need to be notified immediately. Similarly, vomiting or diarrhea could increase the risk of dangerous levels of lithium in the blood. It is appropriate for clients taking lithium to drink 6 to 8 glasses of water each day.

The nurse in an outpatient surgery center is caring for a client after cataract surgery. Which statement by the client indicates an understanding of the discharge instructions?

"I will not drive until I have permission from my doctor." rationale After cataract surgery to the eyes, the client will experience changes in their vision. The teaching priority after cataract surgery pertains to safety due to impaired vision. The client should be advised to refrain from driving, operating machinery and participating in certain sports until given specific permission from the ophthalmologist. Clients should wear sunglasses to protect their eyes when outdoors and in brightly-lit rooms. Eating a modified diet or refraining from tub baths isn't necessary following this type of surgery.

The nurse is reviewing discharge instructions with a client who has been prescribed ciprofloxacin following a minor burn injury. Which statement by the client requires additional teaching?

"I will not take ciprofloxacin prior to sun exposure." rationale Ciprofloxacin is an antibiotic that is associated with causing photosensitivity. Clients should be instructed to protect their skin from sun exposure while taking this medication. Appropriate methods to protect the skin are to limit sun exposure and to wear sunscreen and protective clothing. For a superficial-thickness burn, no scarring will occur and healing should take 3 to 6 days. The client may take a nonsteroidal anti-inflammatory drug (NSAID), such as ibuprofen, to alleviate the pain associated with the burn. It is inappropriate for the client to stop taking their antibiotic. However, if the client cannot avoid sun exposure, the nurse may contact the health care provider and request that the antibiotic be changed to one that does not cause photosensitivity.

The home health nurse is visiting an older adult client who recently moved to this community from a much colder climate. The nurse provides the client with instructions on how to prevent a heat stroke. Which statement by the client indicates that additional teaching is needed?

"I will not take my diuretic on days that I exercise." rationale It is important to exercise outside when the temperature is low as exposure to high temperature increases the likelihood of heat-induced injury. Increasing fluid intake before, during and after exercise will decrease the likelihood of muscle cramping. Loose clothing and a hat to provide shade will keep the body temperature down. While taking a medication such as a diuretic is a risk factor for non-exertional heat stroke, clients should always take medications as prescribed. If the client takes a diuretic, increasing fluid intake while exercising and being exposed to high temperatures will aid in maintaining adequate hydration status.

A client has been prescribed alendronate for osteoporosis. Which of the following statements indicate the client understands how to safely take this medication? (Select all that apply.)

"I will notify my doctor if I experience worsening heartburn." "I will swallow the pill with a full glass of water." "I will stand or sit quietly for 30 minutes after taking the pill." rationale Alendronate is a bisphosphonate used to treat osteoporosis. It can cause esophagitis or esophageal ulcers unless precautions are followed. The client must sit upright or stand for at least 30 minutes after taking the medication. The client should take the medication with a full glass of water, at least 30 minutes before eating or drinking anything or taking any other medication. Antacids will interfere with absorption and should not be taken at the same tim

The nurse in the urgent care clinic is reinforcing teaching for a client who is being discharged with a new cast on the left arm due to a spiral fracture. Which statement indicates that the client correctly understands how to care for the cast?

"I will notify my health care provider if my hand becomes pale." rationale Clients being discharged with a cast on their arm should be instructed to elevate their arm above the level of the heart, to apply ice to their cast to help decrease swelling and to monitor for signs and symptoms of decreased perfusion. A pale hand can signal a decrease in perfusion and the client should report this to their health care provider. The client with a cast should not expect drainage and any drainage should be reported. The nurse should explain that the gap between the cast and skin should not be greater than one finger width.

The nurse is evaluating the effectiveness of a bowel training program for a client with chronic constipation. Which statements made by the client should the LPN/VN report to the RN for additional teaching? (Select all that apply.)

"I will push as hard as I can to push out my stool." Correct Response "l will drink no more than 1.5 liters each day." Correct Response "I will make sure to insert my suppository just before bedtime." Correct Response "I will make sure that my foods do not have much fiber and are soft." Correct! rationaleBowel training programs are designed to return defecation to normal. Fluid intake should be 2.5 to 3 liters per day. The client should increase fiber in their diet, and intake hot drinks just prior to their normal bowel elimination time to facilitate normal bowel function. A suppository treatment should be administered about half an hour before the client's normal bowel elimination time—inserting it just prior to bedtime will disturb the client's sleep pattern. The client should be provided with privacy for about 30 to 40 minutes and should sit on a commode or bedpan whenever they have the urge to defecate. Straining at stool should be avoided due to risk for hemorrhoids.

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." rationale 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.

The nurse is reinforcing teaching for a client with Bell's palsy. Which statement by the client indicates that additional teaching is needed?

"I will rest my facial muscles because they are recovering." rationale Bell's palsy is a form of acute facial paralysis. The disorder is characterized by a drawing sensation and the paralysis of all facial muscles on the affected side. The client cannot close the eye, wrinkle the forehead, smile, whistle or grimace. Nursing care is directed toward managing the major neurologic deficits and providing psychosocial support. Because the eye does not close, the client should wear an eyepatch or tape their eye closed at bedtime to protect their cornea from drying and developing subsequent ulceration or abrasion. The client should eat and drink using the unaffected side of their mouth. Simple massage techniques, the application of warm, moist heat and facial exercises should be explained to the client. The client's statement about resting their facial muscles is incorrect because they should be taught to exercise their facial muscles to aid in the recovery.

The nurse is meeting a client for the first time. The client has told the nurse that he does not take his medication as prescribed. Which is the best response:

"Tell me more about why you are not taking the medication as prescribed." rational The nurse must explore the reasons for non-compliance before it can be addressed. Asking why is the starting point. Shaming a client is not therapeutic nor does it show a genuine concern for the client's well-being. The nurse also should not assume they know the reason a client is noncompliant.

The nurse is reinforcing teaching with a client regarding their diagnosis of hepatic encephalopathy. Which statement by the client indicates that additional teaching is needed?

"I will stop taking my lactulose when I have more than one loose stool." rationale Hepatic encephalopathy is a life-threatening complication of liver failure. The functions of the liver include generating proteins for clotting, preventing bleeding, metabolizing waste products such as ammonia and producing albumin to maintain oncotic pressure. Lactulose is a common medication prescribed to a client with hepatic encephalopathy. Lactulose will bind to ammonia and is excreted from the body by stool. Without this medication, the ammonia level will build because the damaged liver is unable to metabolize it, increasing the severity of the disease. While taking lactulose the client may have loose bowel movements, but this should not stop them from taking the medication. The client needs to ensure they are eating enough protein to meet their body's energy demands. With a higher risk of bleeding, clients should use a soft toothbrush and avoid any type of NSAID medications.

The nurse at the outpatient clinic is reviewing after-visit instructions with a client diagnosed with Staphylococcus aureus cellulitis to the right thigh area. Which statement by the client indicates understanding of the instructions?

"I will take all of the antibiotic pills until they are gone." rationale Cellulitis is an inflammation of the subcutaneous tissue. Staphylococcus aureus and group A beta-hemolytic streptococci are common organisms responsible for causing bacterial skin infections such as cellulitis. It is important to complete the entire course of the prescribed antibiotic to prevent recurrence or drug-resistance. Cellulitis of this type is not typically contagious. Although being a diabetic predisposes the client for developing an infection in general, cellulitis tends to occur following a break in the skin that becomes infected. The client should apply moist heat, not cold, to the area.

The nurse in the primary care office is following up with a client who has been experiencing frequent constipation. Which statement by the client about using psyllium (Metamucil) indicates that additional teaching is needed?

"I will take it together with my other medications." raWhen using psyllium to manage constipation, it needs to be taken with at least 240 mL of water. The client may experience abdominal discomfort or bloating while taking psyllium. When using psyllium to treat constipation, it should not be used long-term and be discontinued when the constipation has resolved. Bulk laxatives can interfere with the absorption of some medications, so it should be taken two hours before or two hours after other medications. The client's statement about taking the psyllium with other medications requires additional teaching.tionale

The nurse is evaluating a client post kidney transplant about the client's understanding of mycophenolate mofetil. Which statement by the client indicates a need for further teaching?

"I will take milk of magnesia with it to prevent heartburn." rationale Mycophenolate mofetil is a medication used to prevent transplant organ rejection. Absorption of this medication can be decreased by antacids that contain magnesium and aluminum hydroxides such as milk of magnesia. Accordingly, mycophenolate mofetil should not be given simultaneously with these drugs. Taking acetaminophen (Tylenol) for minor pain is acceptable, as long as the client remains within the FDA-recommended maximum daily dose of 3,900 mg. A sore throat and chills can be early symptoms of an infection in immunosuppressed clients, so the client should notify their HCP. Taking the drug on an empty stomach will facilitate complete absorption and is recommended.

A nurse is caring for a client recently diagnosed with Addison's disease. While the nurse is reinforcing education, which statement by the client indicates the need for additional teaching?

"I will take my methylprednisolone when I start to feel sick." rationale A person with Addison's disease suffers from low levels of circulating cortisol. The client will be required to take exogenous corticosteroids. A commonly prescribed medication is methylprednisolone, which the client should take every day, not only when they feel sick. This medication suppresses the immune system, so the client should wash their hands often to prevent infection. As their condition progresses, clients may experience anorexia, nausea, vomiting and diarrhea. To ease gastrointenstinal discomfort, the client should eat small meals throughout the day and drink sufficient amounts of fluids. Low-dose, long-term therapy with steroids can cause depression or other psychologic disturbances. The client should be educated about potential psychologic reactions and when to notify their health care provider.

The nurse is reinforcing teaching for a client diagnosed with asthma. Which statement indicates that the client understands the use of the prescribed long-acting beta2 agonist medication?

"I will take this medication daily to prevent an acute attack." rationale Long-acting beta2 agonists (LABA) such as salmeterol cause bronchodilation by relaxing bronchiolar smooth muscle, binding to and activating pulmonary beta2 receptors. Their onset of action is slow with a long duration. They are primarily used for the prevention of an asthma attack. The client will take this medication every day for best effect. This is not the medication the client will use during an acute asthma attack because it does not have an immediate onset of action. The client will be required to take this medication long-term.

The nurse is reinforcing foot care instructions for a client with a history of arterial insufficiency in the legs. Which client statement should the nurse identify as incorrect?

"I will use Epsom salt to remove any corns and calluses." rationale Clients who have peripheral arterial vascular disease suffer from decreased circulation and sensation to the lower legs and feet. Appropriate and regular foot care is very important to prevent integumentary complications. The client should not use commercial preparations or home remedies such as magnesium sulfate, the active ingredient in Epsom salt, to remove calluses or corns. Whenever possible, the client should have a professional inspect and remove any calluses or corns.

The nurse is reinforcing teaching about preventing episodes of agitation in a client with dementia. Which statement by the caregiver would indicate a correct understanding of the teaching?

"I will use a consistent routine for our activities each day." rationale Dementia is a syndrome that is characterized by a slow, progressive decline in cognitive function. Two important actions that are necessary for a client with dementia are preventing overstimulation and providing a structured and orderly environment to reduce and prevent episodes of anxiety and agitation. Environmental distractions and noise should be kept to a minimum. Raising one's voice should be avoided, since it may make the client more agitated. Clients with dementia may have sleep disturbances, thus caffeinated beverages or having a TV on at night should be avoided because those actions are likely to further disrupt the client's ability to sleep.

The nurse working in a dermatology office is reinforcing teaching with a client about skin cancer prevention. Which statement by the client requires follow up by the nurse?

"I will use a tanning bed to get a tan so I avoid the harmful rays from the sun." rationale The major cause of skin cancer is overexposure to the sun's harmful ultraviolet (UV) rays. Sunscreen should be worn at all times when outdoors. It is also recommended to wear a wide-brimmed hat, long sleeves and sunglasses when outside. The sun's UV rays are the strongest between 11 am and 3 pm and should be avoided if possible. Sunless tanning creams can safely produce a tan coloring of the skin without harmful exposure to the sun. The nurse should follow up on the statement about using a tanning bed because tanning beds emit the same harmful UV rays as the sun and should be avoided.

The nurse is assisting with discharging a client from the hospital who was admitted for acute exacerbation of chronic obstructive pulmonary disease. Which statement by the client indicates that teaching was effective?

"I will use my spacer each time I use my inhaler." rationale Clients with chronic obstructive pulmonary disease (COPD) should abstain from smoking any type of cigarettes, including e-cigarettes. E-cigarettes often contain nicotine, which will worsen the client's COPD and can cause exacerbations. The pneumonia vaccination is typically given every five years, not annually. Clients with COPD tend to be undernourished and should eat foods that are high in protein and calories. When using a spacer with an inhaler, more medication reaches its site of action in the lungs, and less is deposited in the mouth and throat.

After the death of a client, the family approaches the nurse and requests that a family member be allowed to perform a ritual bath on the deceased client prior to moving the body. What would be the most appropriate response by the nurse?

"Is there anything you need from me to perform the bath?" Rituals are processes that allow the bereaved to acknowledge the reality of death. Religious rituals, specifically, offer meaning and provide hope within the context of the particular faith tradition. The nurse should inquire about the family's wishes for rituals or observances following death and respect the family's request. The other options are inappropriate and culturally insensitive.

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." rationale 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 nurse is reinforcing teaching for a client with chronic kidney disease about the prescribed aluminum hydroxide. Which is the best statement by the nurse about this medication?

"It decreases phosphate levels." rationale Phosphates tend to accumulate in the client with chronic kidney disease due to decreased filtration capacity of the kidneys. Antacids that contain aluminum such as aluminum hydroxide (Amphojel) are commonly used to lower phosphate levels. Aluminum binds phosphates in the gastrointestinal tract and prevents their absorption. Aluminum hydroxide neutralizes stomach acid already present, but does not control gastric acid production or secretion. It does not affect potassium absorption or levels.

The daughter of a client with Alzheimer's disease asks the nurse, "Will the medication my mother is taking cure her dementia?" What is the best response by the nurse?

"It will not improve dementia but can help control emotional responses." rationale Drug therapy for Alzheimer's disease such as memantine and donepezil produce modest improvements in cognition, behavior, and function, and slightly delayed disease progression. They do not reverse the dementia or halt the progression of Alzheimer's disease. At best, drugs currently in use may slow loss of memory and improve cognitive functions (e.g., memory, thought, reasoning) and emotional lability. However, these improvements are modest and last a short time and for many clients, even these modest goals are elusive.

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." rationale 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 nurse at the outpatient surgery center is speaking with a client who is scheduled for a colonoscopy the next morning. Which information about the procedure should the nurse make sure to include? (Select all that apply.)

"Make sure to drink the entire bowel preparation liquid." "You will have an intravenous catheter inserted prior to the procedure." "Remember to stop eating any food six hours before you come to the center." "You should only consume clear liquids for the next 12 to 24 hours." A colonoscopy is used to visualize the large bowel. It is used to detect sources of bleeding, colon cancer, polyps or other abnormalities. To help cleanse the bowel, the client should be on a clear liquid diet for 12 to 24 hours prior to the procedure. In addition, the client will be required to drink an oral liquid preparation (e.g., sodium phosphate, Phospho-Soda or GoLYTELY). Watery diarrhea usually begins in about an hour after starting the bowel preparation process. Intravenous access is necessary for the administration of moderate sedation during the procedure. The client should be NPO 4 to 6 hours before the procedure. The client will not be required to lay still for 6 to 8 hours after the colonoscopy.

Which discharge instruction should the nurse make sure to include for a client with chronic pancreatitis?

"Make sure to eat a low-fat, high-fiber diet." rationale Chronic pancreatitis is a progressive, destructive disease of the pancreas that has remissions and exacerbations (i.e., flare-ups). Inflammation and fibrosis of the tissue contribute to pancreatic insufficiency and diminished function of the organ. Acute episodes can be lessened by dietary management and lifestyle changes. These include eating bland, low-fat, frequent meals and avoiding rich, fatty foods. Alcohol consumption should be avoided completely as alcohol can precipitate an acute episode. The client should avoid nicotine. The pancreatic enzymes should be taken with food to replace enzymes lacking due to the pancreatitis and aid in digestion.

The parent of a 5-year-old child is concerned about an outbreak of measles in the community. The nurse understands that additional education about immunizations is needed when the parent makes which of the following statements? (Select all that apply.)

"My child should have passive immunity from the vaccine I had as a child." "If a child develops a rash, the risk of spreading measles is gone." rationale Measles is a preventable communicable disease that was well controlled in the United States until recently. There have been outbreaks of measles in communities where children did not receive the vaccines. The Centers for Disease Control and Prevention (CDC) recommends immunization at around age one, with a booster between ages four and six. The child should be protected from the disease after the first vaccine. The period of time measles is communicable is from 3 to 5 days before the rash appears until about four days after the rash appears. In the first year of life, the child may have passive immunity from the mother. It is important to avoid being in confined spaces with any individual with a high fever.

The nurse has given discharge instructions to a client who suffers from sensory neuropathy due to diabetes. The client was prescribed gabapentin. Which of the following statements indicates that the client understands the nurse's instructions regarding the medication?

"My doctor prescribed it for the pain in my legs rationale Gabapentin is an anticonvulsant that can also be used for off-labeled purposes, such as for neuropathic pain syndromes (e.g., sensory neuropathy, postherpetic neuralgia). Taking gabapentin can lead to drowsiness and dizziness, not excitability and insomnia. Gabapentin should not be suddenly discontinued because that could lead to a seizure. Gabapentin is considered a first-line medication to treat neuropathic pain in people who suffer from sensory neuropathy and postherpetic neuralgia. Although uncommon, it is possible to overdose on gabapentin.

The nurse is caring for a client receiving chemotherapy for breast cancer. Which client statement indicates that additional teaching is required?

"My neighbor is bringing me fresh flowers from her garden." rationale Clients receiving chemotherapeutic treatment are at-risk for neutropenia and associated infections. Chemotherapy can suppress, or weaken, the immune system, otherwise known as immunosuppression. Fresh flowers and plants introduce the potential for the client to be exposed to fungi or bacteria, and thus should be avoided in immunosuppressed patients on chemotherapeutic agents. Nausea and impaired sleep are common side effects of chemotherapy, and although they should be addressed by the nurse, they are not a priority concern. Clients who drink water throughout the day are likely to stay hydrated despite potential nausea and vomiting, so this is also not a concerning statement.

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." rationale 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 discharging a client who is at risk for venous thromboembolism (VTE). The client is prescribed enoxaparin. Which instruction should the nurse provide to this client?

"Notify your health care provider if your stools appear tarry or black." rationale As with any anticoagulant, enoxaparin carries the risk of bleeding. Clients should be instructed to report the presence of tarry stools, bleeding gums, hematuria, ecchymosis or petechiae to their HCP. PTT monitoring is not required for this medication. This type of heparin is administered subcutaneously, not intravenously. Massaging the site will cause bruising and decrease effectiveness of the drug.

The nurse is caring for a client recently diagnosed with hypothyroidism. Which client statement indicates that additional teaching is needed?

"Once I feel better, I won't need to take this medication every day." rationale Clients with hypothyroidism often need lifelong thyroid hormone replacement therapy (HRT). Therefore, a client who plans on stopping medications once symptoms have improved is likely to have a re-emergence of symptoms, demonstrating the need for additional teaching. Clients can expect symptoms of hypothyroidism to improve within a few weeks after starting HRT. HRT with such drugs as levothyroxine may cause such side effects as anxiety, nervousness or insomnia. The client should be taught that these are often temporary but to notify their health care provider (HCP) if they worsen. Clients on HRT will have their thyroid stimulating hormone (TSH) levels checked regularly to monitor the effectiveness of their medication therapy.

A 15-year-old high school student comes to the school nurse's office and asks the nurse for permission to miss their physical education class. The nurse notes the presence of large, open comedones (blackheads), papules and pustules on the student's forehead, cheeks and chin. Which is the best response by the nurse?

"Please tell me more about your reason for not wanting to go to physical education class." rationale Adolescence is a time of transitions and many adolescents will deal with issues that relate to self-esteem and body image in a body that is undergoing rapid changes. An individual's body image is based on the subjective interpretation of one's physical appearance. A disturbance in one's body image may occur with physical changes, such as severe facial acne that can cause comedones and inflammatory lesions on the face, neck and upper back. Nursing interventions for adolescents should focus on providing support and empathy to ease the difficult transitions they are undergoing. The best response by the nurse is an open-ended statement that invites the student to talk about the reason for not wanting to attend the physical education class. The other responses are nontherapeutic and indicate that the nurse is making assumptions about the student based on their physical appearance.

A client is placed on a high-protein diet and asks the nurse to describe the role of protein in the body. Which responses by the nurse describe the role of protein? (Select all that apply.)

"Protein plays a role in the body's immunity." Correct! "Wound healing is poor with decreased levels of protein." Correct Response "Protein is necessary for the formation of body structures, including bone, muscle and red blood cells." "You can determine your protein needs according to your body weight." rationale Protein is a vital component of every living cell and is required for the formation of all body structures, including genes, enzymes, muscle, bone matrix, skin and blood. Protein is critical for the structure, function and regulation of the body's tissues and organs. The Acceptable Macronutrient Distribution Range (AMDR) is a recommended percentage of energy intake for carbohydrates, proteins and fats. The AMDR for protein is 10 to 35%;With decreased levels of protein there is a decrease in immune cells. Wound healing is poor and the body is unable to fight off infection because of multiple immunologic malfunctions throughout the body.Protein needs can be determined according to body weight or by using the value of grams per day, which is reliable for most healthy people. As a general guideline, the recommended daily intake of protein is .04 to .06 ounces (1 to 1.8 grams) per 2.2 pounds (.1 kg) of body weight.

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." rationale 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.

The nurse is working with a client who is diagnosed with multiple sclerosis on how to reduce muscle spasticity. Which statement by the client indicates the need for further teaching?

"Taking a long hot bath may relieve the muscle spasms." rationale The client with multiple sclerosis (MS) should not use hot water for a bath because of the risk of thermal injury (e.g., burns) due to sensory deficits with MS. Instead, warm compresses may be used to relieve muscle spasms. The other actions can help with muscle spasms and are appropriate for the client to use.

The nurse is caring for a client who has expressed some anxiety about their upcoming surgery. The most appropriate therapeutic response would be:

"Tell me more about how you are feeling." Therapeutic communication includes using silence, open-ended questions, clarification statements and reflection. In this question, the nurse is clarifying the client's feelings for better understanding. Avoid using responses such as closed-ended questions, advice-giving, reassuring statements, arguing, asking why in a disapproving way and judgmental responses.

The nurse is caring for a client who has expressed some anxiety about their upcoming surgery. The most appropriate therapeutic response would be:

"Tell me more about how you are feeling." rational Therapeutic communication includes using silence, open-ended questions, clarification statements and reflection. In this question, the nurse is clarifying the client's feelings for better understanding. Avoid using responses such as closed-ended questions, advice-giving, reassuring statements, arguing, asking why in a disapproving way and judgmental responses.

The nurse is meeting a client for the first time. The client has told the nurse that he does not take his medication as prescribed. Which is the best response:

"Tell me more about why you are not taking the medication as prescribed." The nurse must explore the reasons for non-compliance before it can be addressed. Asking why is the starting point. Shaming a client is not therapeutic nor does it show a genuine concern for the client's well-being. The nurse also should not assume they know the reason a client is noncompliant.

A client with stage I, non-small cell lung cancer is scheduled for a lobe resection. The client tells the nurse, "I would rather have chemotherapy than surgery." Which response by the nurse is most appropriate?

"Tell me what you know about the treatment options available." rationale The client's statement indicates that the client seems to have concerns about the surgery. In this situation, it is most appropriate to further explore the client's understanding with an open-ended response by the nurse that will elicit the most information from the client. Although the answer "Surgery is the treatment of choice..." is accurate, it is a closed-ended response that will discourage the client from sharing their concerns about surgery. The remaining two answers indicate that the nurse has jumped to conclusions about the client's reasons for not wanting surgery and are not therapeutic or appropriate.

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." rationale 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 is caring for a client who has an alcohol use disorder (AUD). The client states that the client's dysfunctional family caused the addiction. Which response by the nurse would best help the client accept responsibility for their own behavior?

"The lab report showed a high blood alcohol level when you were admitted." rationale Denial is a common response with substance use disorders. The nurse should divert the client's attention away from external issues and focus instead on behavioral outcomes associated with substance use. Presenting information in a matter-of-fact, nonjudgmental way and explaining what behaviors constitute substance-related disorders encourage the client to view substance abuse as an illness that requires help.

The nurse is preparing a client with rheumatoid arthritis (RA) for discharge to an assisted living facility. Which statement about the prescribed oral glucocorticoid is correct?

"The medication will be gradually tapered off over 5 to 7 days." Correct Response rationale RA is an autoimmune, inflammatory disease that affects the joints. It is a progressive disease that causes joint deterioration and destruction, joint deformities and functional limitations for affected clients. The main goal of pharmacotherapy for RA is symptom relief. Glucocorticoids are anti-inflammatory drugs, which can relieve symptoms of RA and may also delay disease progression. For generalized symptoms related to RA, oral glucocorticoids are indicated. The most commonly employed oral glucocorticoids are prednisone and prednisolone.Glucocorticoids can slow disease progression, but will not reverse it. Treatment with glucocorticoids for RA is usually limited to short courses. Adverse psychological reactions such as hallucinations, memory loss or other psychoses must be reported to the provider and may require discontinuation of the glucocorticoid. To minimize adrenal insufficiency when glucocorticoids are discontinued, doses should be tapered very gradually. Incorrect

A client who has been newly diagnosed with carpal tunnel syndrome asks the nurse why they are having pain and tingling in their fingers. Which is the best response from the nurse?

"The pain and tingling is caused by compression of the median nerve in your wrist." rationale Carpal tunnel syndrome (CTS) is a common, repetitive motion-related condition in the wrist. The carpal tunnel is a rigid canal lying between the carpal bones and a fibrous tissue sheet called the flexor retinaculum. A group of nine tendons, enveloped by synovium, share space with the median nerve in the carpal tunnel. When the synovium becomes swollen or thickened, the median nerve is compressed. This causes pain, numbness and painful tingling in the client's fingers and hand. CTS typically does not cause soft tissue fluid build-up. Uric acid crystals collecting in small joints is seen with gout. Sclerotic plaques along nerve fibers tend to occur with multiple sclerosis (MS). Therefore, the best response includes information about the median nerve in the wrist being compressed.

A client scheduled for a mammogram asks the nurse about the risks from radiation exposure. How should the nurse respond?

"The radiation from today's mammograms is very low." The nurse should explain that mammograms do expose the breasts to small amounts of radiation. Modern machines use low radiation doses to get breast X-rays that are high in image quality. To put the dose into perspective, the radiation used for a screening mammogram of both breasts is about the same amount that a woman would receive from her natural surroundings over about seven weeks. In addition, the benefits of mammography outweigh any possible harm from the radiation exposure. The other responses are nontherapeutic and do not address the client's question.

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." rationale 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).

A client tells a nurse about an Internet site that claims bupropion was taken off the market because it caused seizures. What would be an appropriate response by the nurse?

"There were problems and the recommended dose was changed." rationale 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.

A client with benign prostatic hypertrophy has been prescribed tamsulosin. Which statement by the nurse describes how this medication works?

"This medication will improve the flow of urine." rationale Tamsulosin is an alpha-adrenergic blocker that is prescribed to promote bladder and prostate gland relaxation for clients with benign prostatic hypertropy or hyperplasia (BPH). Common clinical manifestations of BPH include urine obstruction, urinary retention, decrease urine flow, hesitancy and nocturia. Tamsulosin will relax the smooth muscle of the bladder neck and prostate, allowing urine to flow more easily and decreasing bladder neck contractions that can cause hesitancy. Tamsulosin does not shrink the prostate, nor does it increase libido or sexual desire. Finasteride, an androgen inhibitor also commonly prescribed for BPH, reduces the prostate size, thus helping to alleviate the urinary symptoms of BPH. Although tamsulosin may reduce episodes of having to void during the night (nocturia), it might not eliminate them.

The nurse is caring for a 20-year-old male client who has not been previously vaccinated for human papilloma virus (HPV). The client states: "I thought the HPV vaccine is only given to women." What would be the best response by the nurse?

"Vaccination for HPV is recommended for both males and females and helps prevent cancer." The best response is to inform the client that the HPV vaccine is recommended for both males and females and is believed to protect against the development of certain types of cancer (oral, anal, cervical). Vaccination for HPV should occur before sexual activity and is recommended to be initially offered at ages 11 to 12. While it is true that HPV vaccination is administered in separate IM injections, this is not the best response because it does not address the client's misconception about who should be vaccinated. It is true that there are different types of vaccinations that offer protection against different types of HPV, but that statement also does not address the client's misconception about who should be vaccinated.

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.

A home health nurse is caring for a client diagnosed with late-stage, Lewy body dementia (LBD). The nurse is meeting with the client's family to discuss options for care of the client. What is the initial question the nurse should ask to assist the family with their decision-making process?

"What type of assistance does your parent require?" rationale Lewy body dementia (LBD) is a disease associated with abnormal protein deposits (Lewy bodies) in the brain, leading to problems with thinking, movement, behavior and mood. LBD is one of the most common causes of dementia. As the disease advances, people with LBD require help due to a decline in their ability to think and move. In the later stages of the disease, they often depend entirely on others for assistance and care.The nurse's initial question should focus on the family's understanding of the client's needs. Because the client is cognitively impaired, the client is not a reliable source of information. The sequence of questioning after this would be to ask if the family is able to care for the client, determine what medications the client is taking and then explore the family's opinion of other living arrangements, such as an assisted living facility, memory/dementia adult day care center or nursing home.

A male client who is diagnosed with gonococcal urethritis tells the nurse he had recent sexual contact with a woman who did not appear to have any disease. What is the best response by the nurse?

"Women might not realize that they have gonorrhea because they are often asymptomatic." rationale Men and women who are sexually active are equally at risk for contracting gonorrhea. Many women with gonorrhea are asymptomatic or have minor symptoms that are easily overlooked. The disease may affect both the genitals and the other reproductive organs and cause complications such as pelvic inflammatory disease. Only persons with an active infection of gonorrhea can transmit the disease. A person does not become a carrier of gonorrhea.

A client diagnosed with tuberculosis is prescribed rifampin and isoniazid. Which information should the nurse include when reinforcing information about these medications?

"You may notice an orange-red color to your urine." rationale Rifampin can cause reddish-orange discoloration of the urine and other body fluids, including tears and sweat. This is harmless, but the client needs to be made aware of it. The nurse should caution the client not to wear soft contacts while taking this medication because they can become discolored. The other information does not apply to those two medications.

A client at risk for a stroke has been prescribed clopidogrel. Which information is most important for the nurse to reinforce with the client?

"You must stop the medication a week before your surgery." rationale Clopidogrel is an oral antiplatelet drug with similar effects to aspirin. The drug is taken for secondary prevention of myocardial infarction, ischemic stroke and other vascular events. Clopidogrel prevents platelet aggregation. Like all other antiplatelet drugs, clopidogrel poses a risk of serious bleeding. Clopidogrel should be discontinued 5 to 7 days before elective surgery.The drug's effects begin two hours after the first dose and plateau after 3 to 7 days of treatment. Platelet function and bleeding time return to baseline 7 to 10 days after the last dose. It can be taken with or without food. No weekly lab tests are required with clopidogrel. Clients should not be instructed to double up when missing a dose.

The nurse is caring for a client recently diagnosed with cancer. The client is quietly crying and states, "I am not sure if I should tell my daughter." Which statement by the nurse would be most appropriat

"You seem unsure about telling your daughter." rationa Reflection is one of the techniques used in therapeutic communication. By directing the context back to the client, the nurse allows them to explore their own ideas and feelings. It would not be appropriate to leave the client alone in this situation, unless they request privacy. The nurse should not offer false reassurance. It is inappropriate to redirect the conversation to focus on the nurse's experience.

The nurse is caring for a client recently diagnosed with cancer. The client is quietly crying and states, "I am not sure if I should tell my daughter." Which statement by the nurse would be most appropriate?

"You seem unsure about telling your daughter." Reflection is one of the techniques used in therapeutic communication. By directing the context back to the client, the nurse allows them to explore their own ideas and feelings. It would not be appropriate to leave the client alone in this situation, unless they request privacy. The nurse should not offer false reassurance. It is inappropriate to redirect the conversation to focus on the nurse's experience.

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"? rationale 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.

The home health nurse is reviewing information with a client who is being treated for pulmonary tuberculosis. Which statement by the nurse is correct?

"You should avoid public transportation and crowds in enclosed areas." rationale Tuberculosis (TB) is an infectious disease that usually involves the lungs but can affect other organs. Treatment involves drug therapy and the prevention of transmission. Drug therapy typically consists of several medications that must be taken for several months, even if symptoms have subsided. Clients with pulmonary TB are not required to remain indoors, but should avoid travel on public transportation and trips to public places. Currently, there is no recommended vaccine for TB in the U.S.

A woman who is 15 weeks pregnant verbalizes concern to the nurse about weight gain during pregnancy. Which statement indicates a correct understanding of weight changes for a woman during the second trimester?

"You should gain about one pound each week." Women with a normal body mass index (BMI) should expect to gain between 25 to 35 pounds (11.34 to 15.88 kg) during pregnancy. Women who are underweight will need to gain more (up to 40 pounds (18.14 kg)) while women who are obese should gain less (between 10 to 20 pounds (4.54 to 9.07 kg)). During the first trimester, women should gain between 3 to 5 pounds (1.36 to 2.27 kg). In the second and third trimesters, women should gain a pound a week. Weight gain should be steady and gradual, with a focus on healthy eating habits. Dieting and binge eating should be discouraged.

A client with eczematous dermatitis (eczema) of the hands asks the nurse how to treat the excoriation and scaling of the palmar surface of both hands. What is the best response by the nurse?

"You should soak both hands in lukewarm water twice a day." rationale Soaking the hands in lukewarm water, ideally with colloidal oatmeal added to it, is the best response. Soaking the hands will debride crust and scales, and soften the skin. Diphenhydramine is an antihistamine that can reduce itching, but will not help with the scaly, excoriated skin. In addition, the sedative effects of the medication can be dangerous and the drug should be taken only as needed, preferably at bedtime. Wearing gloves is not appropriate because it will trap moisture and warmth, most likely aggravating the eczema. An antibacterial cream is not indicated at this time, unless the client develops a localized infection.

"A client diagnosed with iron deficiency anemia is prescribed ferrous sulfate suspension orally. Which instruction would be most appropriate for the nurse to give to the client regarding this medication?

"You should use a straw when taking this medication. rationale Iron deficiency anemia is the most common type of anemia. Treatment includes nutritional therapy, oral iron supplementation and blood transfusions. Although diarrhea is a potential side effect of iron supplementation, the more common side effect of iron supplementation is constipation. Clients should take iron on an empty stomach for better absorption. Only in rare circumstances should clients take iron with food. Because liquid iron can stain the teeth, the most appropriate instruction is to use a straw. Iron medications do not cause discoloration of urine, but they can cause stool to turn black.

A client with paranoid delusions stares at the nurse over a period of several days. The client suddenly walks up to the nurse and shouts, "You think you're so perfect, pure and good." How should the nurse respond?

"You sound angry right now." The nurse recognizes and identifies the underlying emotion with a matter-of-fact attitude. In similar situations of emotional outbursts, the action by the nurse should be to focus on the client's feelings before the client's behavior.

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." rationale 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.

A 25-year-old client is scheduled for a gynecological exam and calls the office nurse for instructions prior to the appointment. It has been five years since her last exam. Which of the following instructions are appropriate for the nurse to provide?

"You will need to have a Papanicolaou test (PAP test)." "You should avoid sexual intercourse for 24 hours prior to your appointment." "Your exam should be scheduled between your menstrual periods." The American Cancer Society (ACS) recommends PAP tests every three years for women between ages 21 and 29. They will also need a human papilloma virus (HPV) test every five years. The HPV test is done from the same sample as the PAP test. It is better if the client schedules a PAP test between menstrual periods, because blood in the sample can interfere with the results. The client should avoid intercourse, douching, vaginal medications and vaginal deodorants for 24 hours or more before the examination because these can interfere with the results.

The nurse is providing care for an elderly client who was just admitted to the facility. During the admission process, the client's family reports that the client has been having increasing episodes of forgetting things and misplacing important items. Which of the following statements should the nurse include each time they check on the client?

"Your call light is in your hand and I will check on you every hour." In the early stages of cognitive decline, it is important to provide reality orientation by informing the client where their call light is and establishing a routine of hourly checks. Both of these will help to reassure the client and family about the client's safety. It would be important to reduce external noise and light stimuli. The nurse might be able to leave a night light if that makes the client feel safe—but not leave on all the lights in the room. The bed alarm would need to be activated, but leaving all four siderails up is a restraint, which is not appropriate for this client.

The nurse is providing care for an elderly client who was just admitted to the facility. During the admission process, the client's family reports that the client has been having increasing episodes of forgetting things and misplacing important items. Which of the following statements should the nurse include each time they check on the client?

"Your call light is in your hand and I will check on you every hour." rational In the early stages of cognitive decline, it is important to provide reality orientation by informing the client where their call light is and establishing a routine of hourly checks. Both of these will help to reassure the client and family about the client's safety. It would be important to reduce external noise and light stimuli. The nurse might be able to leave a night light if that makes the client feel safe—but not leave on all the lights in the room. The bed alarm would need to be activated, but leaving all four siderails up is a restraint, which is not appropriate for this client.

The nurse is planning care for a client admitted to the hospital with influenza. Which interventions should the nurse include in the client's plan of care? (Select all that apply.)

.Limit visitors who show signs of a respiratory infection. Instruct the client on proper cough etiquette. Maintain droplet precautions. Administer the prescribed oseltamivir. rationale Antiviral agents, such as oseltamivir, are used to shorten the course and reduce symptoms of the flu. Droplet transmission-based precautions are indicated to prevent the spread of the flu. To avoid further transmission of the illness, visitors with signs/symptoms of a respiratory illness should not be permitted on the unit. It is important to ensure that clients understand how to prevent transmission of infections such as the flu through proper hand hygiene and cough etiquette. The flu vaccine should not be given while the client is acutely ill.

The nurse should monitor which clients who may be at-risk for the development of acute kidney injury? (Select all that apply.)

A client admitted with an acute myocardial infarction A client recovering from septic shock A client who received multiple blood transfusions rationale Reduced renal perfusion is a risk factor for acute kidney injury (AKI). A client with significant blood or fluid loss, such as one who was recently in a motor vehicle accident would be at-risk for the development of AKI due to poor perfusion. Myocardial infarction is another risk factor for AKI due to reduced cardiac output and subsequent hypoperfusion. Finally, septic shock is associated with significant hypotension, which can cause poor blood flow and hypoperfusion to the kidneys. All of these factors predispose a client to developing AKI. Clients with a history of syndrome of inappropriate antidiuretic hormone secretion (SIADH) or cirrhosis, on the other hand, may present with volume overload, and thus are not at increased risk for the development of AKI.

The nurse is reviewing vital signs documented in the electronic health record for a group of clients. Based on this data, which client should the nurse see first?

A client diagnosed with heart failure who has a SpO2 of 82%. rationale The nurse should see the client with heart failure and a SpO2 of 82% first. The client with heart failure could be experiencing life-threatening pulmonary edema, and the SpO2 of 82% indicates dangerously low oxygenation.An elevated temperature in a client with infective endocarditis is a clinically significant but not unexpected finding. A heart rate of 110 beats per minute in a client with atrial fibrillation is concerning, but it does not reflect the same life-threatening clinical finding as the low SpO2 in the client with heart failure. While elevated and of concern, a blood pressure of 152/88 is not as high of a priority for the nurse to address as a dangerously low oxygen level.

The nurse is caring for child diagnosed with celiac disease. Which of the following foods would be an appropriate snack choice for this child?

A cup of yogurt rationale Celiac disease is an autoimmune disease that occurs in genetically predisposed people, where the ingestion of gluten leads to damage in the small intestine. Gluten is a general name for the proteins found in wheat, rye, barley and triticale (a cross between wheat and rye). Gluten helps foods maintain their shape, acting as a glue that holds food together. Gluten can be found in many types of foods, even ones that would not be expected. Children or adults with celiac disease should eat a gluten-free diet. An oatmeal cookie, wheat bread and cereal contain gluten and should be avoided. Dairy products are generally considered gluten-free and are an appropriate snack choice for the child.

The nurse is caring for a client who is experiencing an acute gout attack. Which action should the nurse implement?

Administer indomethacin. rationale Gout is a disease where uric acid crystals form and accumulate in joints and other tissues. During an acute gout attack, the client experiences pain and inflammation in the joints. The nurse should administer a non-steroidal anti-inflammatory medication such as indomethacin to help decrease pain and inflammation. Restricting sodium would not benefit the client and providing a high-protein diet may make the situation worse. There is no need to monitor liver enzymes with an acute gout attack.

The nurse in the primary health care provider's office is reviewing the medical record of a client with idiopathic pulmonary arterial hypertension. The nurse should expect which potential clinical manifestations with this disease? (Select all that apply.)

Abnormal heart sounds Dyspnea on exertion Exertional chest pain Cor pulmonale rationale Idiopathic pulmonary arterial hypertension (IPAH) has no apparent cause and is characterized by an elevated pressure in the pulmonary arterial circulation. The disease is incurable but drug therapy will greatly help. Classic symptoms include: exertional dyspnea and chest pain, fatigue, right-sided heart failure (cor pulmonale) due to the increased workload of the right ventricle and abnormal heart sounds, such as an S3. An elevated creatinine level would indicate renal dysfunction, not pulmonary hypertension.

The client is grimacing, crying and reports having pain. What is the first step the nurse should take when collecting data about the client's pain?

Accept the client's report of pain. rationale Although all of the actions are correct, the first and most important aspect of pain management is for the nurse to accept that the client is in pain and the pain is as severe as the client reports it to be. Pain is a subjective phenomenon and only the person experiencing it can confirm its presence and severity. Pain can exist even if no physical cause is apparent.

A postoperative client following a thyroidectomy suddenly develops difficulty breathing, stridor and an increase in swelling of the anterior neck area. What should the nurse do first?

Activate the hospital's emergency or rapid response system. rationale The client is demonstrating clinical manifestations of an airway obstruction related to bleeding and/or swelling following the thyroidectomy. This is a life-threatening, medical emergency and the nurse's first action should be to activate the hospital's emergency or rapid response system. It is possible that the client will need an emergency surgical airway intervention, such as a tracheostomy, to maintain a patent airway.

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 rationale 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 nurse is asking two unlicensed assistive persons (UAPs) to help with repositioning a client in bed. Which actions by the nursing staff best support correct ergonomics and safe client handling? (Select all that apply.)

Adjust the height of the bed to hip level. Lower the head of the bed into a flat position. Use a friction-reducing device/sheet underneath the client. Coordinate lifting together by counting to three. rationale Adhering to ergonomic principles will help prevent injuries to the nursing staff and/or the client. Raising the bed to hip level, lowering the head of the bed, using a friction-reducing device and coordinating moving at the same time will help with repositioning the client in a safe manner and reducing the risk of injury, such as straining the lower back. Asking a visitor to help and asking the client to hold their breath are not appropriate.

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 rationale 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.

The nurse is preparing a client for an intravenous pyelogram (IVP) test. Which intervention should the nurse plan to implement?

Administer a laxative the evening before the test. rationale Intravenous pyelography refers to a series of X-rays taken of the kidneys, their collection or drainage system (the ureters) and the bladder to locate a suspected obstruction in the flow of urine. It is important for the large intestine to be clear of stool to allow full visualization of the kidney, bladder and ureters. Clients are often given a laxative the night before and an enema the morning of the test. In addition, the client should eat a clear liquid diet the day before the test and remain NPO after midnight. The other interventions are incorrect.

An older adult client, diagnosed with active pulmonary tuberculosis, has difficulty in coughing up secretions for a sputum specimen. Which nursing intervention would be most helpful for this client?

Administer a nebulizer treatment rationale Spraying the throat with saline may cause irritation and coughing and could reduce oxygenation. The specimen needs to come from deep in the lungs, not from the nose or mouth. Increasing fluid intake for eight hours will not be sufficient in liquefying secretions. Although ambulation will help with mucociliary action and ability to expectorate secretion, the most helpful intervention is to administer a nebulizer treatment with sterile water or hypertonic saline that will thin secretions and facilitate expectoration.

A client is admitted to the telemetry unit with syncope due to sinus bradycardia. Which intervention should the nurse include in the client's plan of care?

Administer a stool softener daily. rationale Sinus bradycardia is defined as a heart rate of less than 60 beats per minutes with a regular rhythm that originates from the sinoatrial (SA) node. Typically, clients who develop sinus bradycardia are asymptomatic. If a client develops symptomatic bradycardia, they can present with hypotension, shortness of breath, chest pain, syncope or syncopal episodes and altered mentation. To avoid a vasovagal response (i.e., the slowing of the heart rate caused by bearing down when trying to defecate) and the risk for another syncopal episode, it is important to ensure that the client's bowel movements are soft and easily expelled. The client should also be instructed to avoid holding their breath or bearing down (Valsalva maneuver). The other interventions are not appropriate or required for this client.

An adult client arrives at the clinic after being stung by a bee. The nurse notes that the client is having difficulty breathing, is audibly wheezing and has swollen lips. What is the nurse's highest priority?

Administer epinephrine. rationale The client's condition indicates the high likelihood of a life-threatening anaphylactic reaction to a bee sting, with an obstructed airway due to bronchoconstriction and a high potential for hypoxemia. While obtaining a home medication list and obtaining arterial blood gases may be part of the care provided to the client, the highest priority is to administer epinephrine. Epinephrine is a critical drug in the treatment of anaphylaxis. Relieving the vasoconstriction effects on bronchial muscles with epinephrine could be life-saving in this situation. A bronchodilator may also be prescribed, but not before epinephrine has been administered.

The nurse is caring for a client with diabetes who was admitted for intractable vomiting. The nurse notes that the client's skin is cool to the touch, and the fingerstick blood sugar result is 55 mg/dL. What intervention should the nurse implement first?

Administer glucagon. rationale A client with diabetes receiving anti-hyperglycemic agents or insulin who is unable to eat or digest food is at risk for hypoglycemia (blood sugar level greater than 70 mg/dL). Cool, clammy skin and a decreased level of consciousness are additional signs of hypoglycemia. To treat the hypoglycemia, the client requires glucose in the form of glucagon or another carbohydrate to increase the blood glucose to an acceptable level, typically greater than 70 mg/dL. After addressing the hypoglycemia first, the nurse should implement the other interventions.

An adult client who has been experiencing a seizure for approximately 15 minutes is brought to the emergency department by private vehicle. Which intervention should the nurse implement first?

Administer lorazepam intravenously. rationale This client is experiencing status epilepticus and is in immediate need of medication to stop the seizure. Of the provided options, the highest priority would be to administer the intravenous (IV) lorazepam to stop the seizure. While levetiracetam, an anticonvulsant, may be indicated for the client, lorazepam, a benzodiazepine, would be administered first in an attempt to stop the seizure quickly. An electroencephalogram (EEG) is an important test when evaluating for seizures, but it would not be highest priority at this time. A 12-lead electrocardiogram (ECG) may be part of a more general diagnostic work-up for many clients, but it would be a lower priority than stopping the seizures.

The home health nurse is assisting a client who is scheduled for a chemotherapy infusion the next day. The client's medical record indicates frequent episodes of nausea and vomiting after previous chemotherapy treatments. Which action would be most helpful in preventing nausea and vomiting in this client?

Administrate metoclopramide prior to start of the infusion. rationale Chemotherapy-induced nausea and vomiting (CINV) arises from a variety of local and central nervous system mechanisms. Most chemotherapy drugs are emetogenic to some degree. The most helpful way to prevent CINV is by premedicating the client with an antiemetic drug, such as metoclopramide, before the infusion. The client may need to take antiemetics for a couple days after the infusion, but the need for them can be decreased if the client has been premedicated with antiemetics. Although education is important, it will not prevent CINV.

The nurse is in the process of inserting a urinary catheter in an adult female client. The nurse advances the catheter approximately 2 to 3 inches (5 to 7 cm), but no urine return is seen. What should the nurse do next?

Advance the catheter a few more inches. rationale For an adult female, a urinary catheter should be inserted about 2 to 3 inches (5 to 7 cm) in the urinary meatus until the urine flow begins. If urine does not flow, the catheter can be carefully inserted a bit further. When a catheter is inserted about 4 to 5 inches (10 to 12 cm) with no urine return, the catheter is probably in the vaginal canal. The nurse should not inflate the balloon until proper placement is confirmed (i.e., urine is draining) to avoid damaging the urethra. If the nurse decides to withdraw the catheter, a new, sterile catheterization kit must be obtained first. The nurse should never use the same catheter because the risk of bacterial contamination with withdrawal is too great. The HCP should be notified after troubleshooting and a second unsuccessful attempt.

The nurse is caring for a 30-year-old female client scheduled for a hypophysectomy due to a pituitary tumor. The client asks how removal of the pituitary gland will affect her Which is the best response by the nurse?

After the procedure, you might have difficulties getting pregnant." rationale Surgical removal of the pituitary gland, or hypophysectomy, is a common treatment strategy for patients with pituitary tumors. Unfortunately, because the pituitary gland is responsible for fertility-related hormones such as luteinizing hormone (LH) and follicle-stimulating hormone (FSH), complications of this surgery include problems with fertility and the cessation of menses in women of childbearing age. Removal of the pituitary gland will not affect glucose metabolism and the immune system or create a risk for seizures.

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 rationale 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.

The nurse is reviewing the medical record of a client with a new prescription for lovastatin for hyperlipidemia. Which finding requires the nurse to notify the health care provider immediately?

Alanine aminotransferase level of 90 U/L rationale Lovastatin is an HMG-CoA reductase inhibitor, commonly called a "statin," which is used for the treatment of hyperlipidemia and other cardiovascular diseases. Statins can be hepatotoxic and liver injury, as evidenced by elevations in serum transaminase levels, can develop. Normal alanine aminotransferase (ALT) levels range from 10 to 40 U/L. An ALT level of 90 is above normal and the nurse should notify the prescriber immediately. An elevated cholesterol level is an indication for treatment with lovastatin. The hemoglobin A1c level is also high but pertains to diabetes management, not the medication prescribed in this scenario. The creatinine level is normal.

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 rationale 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.

The nurse is collecting data from a college student who comes to the health clinic with symptoms of meningitis. The student resides in the school dormitory. What is the priority action the nurse should take?

Alert the college's administration and dormitory staff. rationale Although all of the actions are appropriate for this client, the priority is to notify school officials and the dormitory staff. If the client turns out to have bacterial meningitis, it is important to identify other students who might have been exposed.

The nurse is caring for a 75 year-old client with type 2 diabetes mellitus. The client should be instructed to contact the outpatient clinic immediately if which findings are present?

An open wound on the heel with minimal discomfort rationale 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. Foot wounds in diabetics can take months or even years to heal, even with appropriate treatment. Without treatment, serious infection, gangrene, limb loss and even death from septic shock may result. Peripheral neuropathy is common in prolonged diabetes with diminished sensation in the feet and legs in these clients and increased risk of injury. Even though perineal area complaints would need to have further evaluation, the problem is not the highest priority. Insomnia is not a manifestation of type 2 diabetes. The other option is a distractor that is unrelated to the diabetes.

The nurse is providing care for a client who has been diagnosed with terminal cancer. The nurse notes that the client's wife is not visiting very often. When she does visit the client, she only stays for a brief time, stands in the corner and does not approach the client during interactions. Which of the grieving processes is the client's wife most likely experiencing?

Anticipatory grief In cases of terminal illness, family members may begin the grieving process before the client has passed away. This is known as anticipatory grief. The result of anticipatory grief is the family member becomes distant and detached from the client and the client feels isolated and alone. Death anxiety is worry or fear related to dying that may be seen with a grieving child. Disenfranchised grief is when the individual cannot acknowledge the loss, perhaps because of an unrecognized loss, such as an abortion or a suicide. Perceived loss is a loss that cannot be verified by others such as a loss of self-esteem or a loss of control.

Which action should the nurse take before communicating with a client diagnosed with presbycusis?

Ask for permission to turn off the television. rationale Presbycusis is a sensorineural type of hearing loss, especially of high-pitched sounds, that occurs with aging. It is caused by degeneration of cochlear nerve cells, loss of elasticity of the basilar membrane or a decreased blood supply to the inner ear. When planning to communicate with a client with presbycusis, it is important to eliminate surrounding noise that could further interfere with the client's ability to hear and understand the nurse, such as turning off the television. The other actions are not appropriate for this client.

While interviewing a client admitted to the behavioral health unit, the nurse notices that the client is shifting positions, moving and constantly twisting their hands, and avoiding eye contact. What initial action should the nurse take?

Ask the client about their current feelings or thoughts. Correct Response rationale Active listening is an important component of therapeutic communication. To listen actively, be attentive, hear and understand what the client is saying, both verbally and nonverbally. The client's nonverbal behaviors suggest that the client may be anxious or nervous about the interview or questions being asked. Giving broad openings or offering general leads, using phrases such as "tell me what you are thinking..." are therapeutic communication techniques the nurse should use to emphasize the importance of the client's role in the interview and encourage the client to respond.

The nurse is caring for a postpartum Latina client who keeps declining the hospital food because it is "cold." What action should the nurse take initially?

Ask the client what foods are acceptable. A traditional health belief and practice seen in clients from a Latin American cultural background includes the concept of humoral imbalance. Humoral imbalance describes the belief that physical and mental illness result from an imbalance between a person and their environment, described as either "hot" and "cold" or "wet" and "dry." To correct an imbalance, people consume foods or herbs with the opposite quality. After giving birth, a woman is considered to be in a "cold" state due to blood loss. Therefore, she needs to restore her humoral balance by eating "hot" food. The nurse is practicing culturally-sensitive care by asking the client what foods she prefers. The other actions do not consider the client's cultural background and personal preferences.

A client diagnosed with renal calculi is admitted to the unit. Which intervention should the nurse implement first?

Assess the client's pain. rationale The nurse should use the nursing process to prioritize and plan which intervention to implement first. The first step in the process is assessment/data collection and should be taken before formulating a plan of care and implementing interventions. All of the interventions in the scenario are appropriate for a client with renal calculi, but asking the client about their pain level should be done first. Based on the data obtained (i.e., the client's pain level) the nurse should then decide how to proceed.

A male client underwent a hernia repair in an outpatient surgery clinic. He is awake and alert, but has not been able to void since he returned from surgery six hours ago. He received 1000 mL of intravenous (IV) fluids. Which action should the nurse implement to help this client urinate?

Assist the client to stand to void. rationale Clients can experience difficulty urinating after surgery due to the anticholinergic medications commonly administered during surgery. Lying down can make voiding/urinating into a urinal or bedpan difficult. The nurse should implement the least invasive intervention first. Standing up can help the client with urination. If that action fails, the nurse should contact the health care provider (HCP). Inserting a catheter should be the last option due to the risk of causing a urinary tract infection. Although obtaining a bladder ultrasound can confirm that the bladder contains urine, it will not by itself promote urination. The client received an adequate amount of IV fluids and should not be drinking additional oral fluids, which will further aggravate any bladder distention.

A client with dyspnea due to exacerbation of COPD is becoming very anxious. An arterial blood gas shows a PaO2 of 93 mm Hg. What action by the nurse is best?

Assist the client with relaxation techniques. rationale A normal partial pressure of arterial oxygen (PaO2) level ranges from 80 to 100 mm Hg. A level of 93 is normal and therefore it is not necessary to increase the oxygen or administer a bronchodilator. However, both of these interventions would be appropriate if the client were hypoxic. A client with respiratory problems should not take an antianxiety medication as a first-line intervention, because this may decrease their respiratory rate and/or alertness. The best intervention at this time is to assist the client with relaxation techniques.

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.

Propranolol is prescribed for a client with coronary artery disease (CAD). The nurse should consult with the health care provider (HCP) before giving this medication when the client reports a history of which condition?

Asthma rationale Non-cardioselective beta-blockers such as propranolol block b1- and b2-adrenergic receptors and can cause bronchospasm, especially in clients with a history of asthma. Beta-blockers will have no effect on the client's peptic ulcer disease or risk for DVT. Beta-blocker therapy is recommended after an MI.

At 9 am, the nurse administers 10 units of insulin aspart subcutaneously to a client with a blood sugar of 322 mg/dL. At approximately what time should the nurse expect the insulin to peak?

At noon rationale Insulin aspart is an analog of human insulin with a rapid onset (10 to 20 minutes) and short duration (3 to 5 hours). The drug is structurally identical to human insulin. Insulin aspart (100 units/ mL) is supplied in 10 mL vials and 3 mL pre-filled pens and cartridges. Dosing is almost always done by subcutaneous injection or subcutaneous infusion with an insulin pump. Because insulin aspart acts rapidly, it is often used for sliding scale coverage and injections should be given 5 to 15 minutes before meals.

The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) and a significant family history of coronary artery disease. Which of the following prescriptions by the health care provider would treat a major modifiable risk factor of coronary artery disease?

Atorvastatin Atorvastatin is an HMG-CoA reductase inhibitor, more widely known as a statin, and it is a medication used to treat hyperlipidemia. Statins reduce LDL levels, reduce triglycerides and increase HDL levels. Hyperlipidemia is a major modifiable risk factor of coronary artery disease. Prednisone is a corticosteroid that may be used to treat a COPD exacerbation. Albuterol is a short acting B2-adrenergic agonist that may be used in treatment of COPD. Fluticasone/salmeterol is a combination medication of an inhaled corticosteroid (ICS) and long-acting beta agonist (LABA) used in the treatment of COPD.

A client has herpes simplex I with visible cold sores on the lips. Which intervention is most important for the client to implement to prevent spreading the infection?

Avoid sharing towels. rationale Sharing any items (towels, lipstick, toothbrush, utensils, cups, etc.) that may touch the mouth has the highest risk of spreading infection from one individual to another. Washing hands and not touching/scratching the affected area are proactive measures to prevent spreading the infection, but are not the priority. Taking antiviral medication as prescribed will promote healing.

The nurse is reviewing the plan of care for a client with thrombocytopenia. What should be the priority interventions for tUse a soft-bristle toothbrush.his client? (Select all that apply.)

Avoid using medications that prolong bleeding. Do not engage in contact sports. Shave only with an electric razor. Use a soft-bristle toothbrush. rationale Thrombocytopenia is a reduction of platelets below 150,000/uL, resulting in prolonged bleeding from minor trauma or spontaneous bleeding without injury. The overall goals for the client with thrombocytopenia is the prevention of gross or occult bleeding. Medications such as aspirin further inhibit platelet aggregation, increasing the risk of bleeding. Shaving with a blade can lead to cuts that may bleed for extended periods of time. Contact sports such as football can cause internal bleeding due to external blows to the abdomen. The flu vaccine or higher calcium intake would not help prevent bleeding in this client.

The nurse is reinforcing teaching for a client who was newly diagnosed with asthma. Clients with asthma should demonstrate understanding of which of the following? (Select all that apply.)

Avoiding triggers for asthma attacks Use of peak flow monitoring When to seek medical assistance Action and purpose of medications rationale Clients must understand the use of medications including quick-relief (rescue) and long-acting (maintenance) therapies. Clients use the peak flow meter to assess effectiveness of medication or breathing status. An acute attack can be a medical emergency and knowing where and how to seek medical care is important. Certain conditions (triggers) can exacerbate an attack and should be avoided. Consumption of large meals can distend the abdomen, which can add to respiratory distress. Smaller, frequent meals are better tolerated. Clients should increase, not limit, fluid intake to help liquefy secretions for easier expectoration. Incorrect

A client is prescribed furosemide and digoxin for heart failure. The nurse should monitor the client for which potential adverse drug effect?

Cardiac dysrhythmias rationale Digoxin is a cardiac glycoside, or positive inotrope that increases myocardial contractility. By increasing contractile force, digoxin can increase cardiac output in clients with heart failure (HF). Furosemide is a potassium-wasting (loop) diuretic, prescribed to prevent fluid overload in clients with HF. Clients who take furosemide are at risk for developing hypokalemia. Potassium ions compete with digoxin and a low potassium level can cause digoxin toxicity, leading to lethal cardiac dysrhythmias. Therefore, it is imperative that potassium levels be kept within normal range (3.5 to 5 mEq/L) while taking digoxin.

The nurse in the outpatient clinic is following up on a client with a fractured arm. The client's arm was placed in a cast four hours ago. The client states, "my fingers are tingling and feel cold." Which action should the nurse take first?

Check the capillary refill in the client's fingers. rationale The client with a cast on an extremity is at risk for development of compartment syndrome. Compartment syndrome occurs when the swelling underneath the cast becomes so great that it will decrease circulation and tissue perfusion to the extremity, distal to the cast. This is a medical emergency. Using the nursing process, the nurse should first collect more data by checking the client's capillary refill, which can support the possibility of compartment syndrome. After obtaining the additional information, the nurse can make the best decision about what to do next.

The nurse is caring for a client who has type I diabetes mellitus. Upon entering the room, the nurse notes the client has rapid, deep respirations, and is lethargic and difficult to arouse. What should the nurse do first?

Check the client's blood sugar. rationale Rapid, deep respirations and a decreased level of consciousness are signs that the client may be in diabetic ketoacidosis (DKA). Onset of DKA can be rapid with precipitating factors associated with infection, surgery or stress. Due to the acidotic state within the body, the respiratory system attempts to "blow off" CO2 to correct the metabolic acidosis, hence the rapid, deep respirations. Glucagon is given in cases of hypoglycemia and should not be given until the blood sugar level has been verified. While reviewing the last dose of insulin and verifying that the insulin pump is working correctly are important, it is essential to check the blood sugar first. Collecting data is the first step in the nursing process and will help the nurse decide what to do next.

The nurse is caring for a client with a medical history of peripheral artery disease, hypertension and smoking. The client reports severe pain in the right lower leg that started very suddenly and did not get better after receiving an analgesic. What action should the nurse take first?

Check the client's pedal pulse. rationale Peripheral artery disease (PAD) refers to excessive plaque buildup in the arterial walls. Excessive plaque buildup, due to atherosclerosis, can have an impact on perfusion to limbs and is associated with high levels of morbidity and mortality. The client is exhibiting symptoms of an acute arterial obstruction. This obstruction usually causes severe pain, loss of pulses and skin color changes. The nurse should follow the nursing process and first collect more data. Based on the data collected (e.g., an absent pulse) the nurse should notify health care provider right away because this would signal a medical emergency. Ice would be contraindicated as that would further reduce tissue perfusion to the leg.

A client is admitted to the orthopedic nursing unit with a fractured right tibia. The client is complaining of pain. Which action should the nurse take first?

Check the pulse and capillary refill in the right foot. rationale The nurse should first collect more data about the client's pain. Compartment syndrome is a potential complication with an acute fracture and the nurse should evaluate tissue perfusion in the affected extremity to make sure that the pain is solely related to the acute fracture. Signs of compartment syndrome include worsening pain, weak peripheral pulses, edema, slow capillary refill and paresthesia (i.e., numbness, tingling). If the nurse suspects that compartment syndrome is occurring, the health care provider (HCP) must be notified immediately. After ruling out compartment syndrome, the nurse can proceed with administering an analgesic and applying ice.

The nurse in a long-term care facility is observing the certified nursing assistant (CNA) change a soiled incontinence brief on a client with incontinence-associated dermatitis (IAD). Which actions by the CNA would require the nurse to intervene?

Cleanses the perineal area with toilet tissue. rationale Incontinence associated dermatitis (IAD) is a common perineal skin injury caused by excessive exposure to urine and stool. Perineal wound care for clients with IAD should include use of pre-moistened soft wipes, gentle cleansing with a mild soap and warm water, application of a thin layer of a skin-protectant barrier cream and application of an absorbent dressing or pad. The client should be positioned in a side-lying position to avoid pressure on the buttocks and perineum. Toilet tissue should be avoided because it can be abrasive to the injured perineal skin. The nurse should intervene and advise the CNA to use pre-moistened, soft wipes instead of toilet tissue.

The nurse will plan to include information about prophylactic antibiotics before dental procedures for which client?

Client admitted for mitral valve replacement with a mechanical valve rationale The use of prophylactic antibiotics before dental procedures is indicated for clients at risk for infective endocarditis (IE). IE occurs primarily in clients who abuse IV drugs, have had valve replacements, have experienced systemic alterations in immunity or have structural cardiac defects. Possible ports of entry for infecting organisms include: the oral cavity (especially if dental procedures have been performed), skin rashes, lesions or abscesses, infections (cutaneous, genitourinary, gastrointestinal or systemic) and surgery or invasive procedures, including intravenous line placement. Therefore, current guidelines recommend the use of prophylactic antibiotics before dental procedures for clients with prosthetic heart valves to prevent IE.

A client diagnosed with schizophrenia first speaks animatedly to another client, with exaggerated clarity of pronunciation. The nurse then observes the client turning abruptly away, mumbling to themselves and speaking to the wall. Which priority goal/outcome should the nurse select for the client's plan of care?

Client will engage in meaningful and understandable verbal communication. The client is exhibiting behaviors that show disturbed sensory perception, thought processes and impaired verbal communication. The nurse should focus first on goals and outcomes that improve the client's ability to communicate appropriately with the Interdisciplinary Team (IDT). Although the other goals should also be included in the client's plan of care, the priority for the nurse and IDT is being able to communicate effectively to establish trust with the client, since suspiciousness is a common symptom in this disorder.

The nurse is preparing to speak at a community center about strategies on how to prevent the transmission of human immunodeficiency virus (HIV). Which of the following statements would be appropriate for the nurse to include?

Condom use during all sexual activity significantly decreases the risk of contracting HIV. Antiviral medications started immediately after exposure can reduce the risk of developing HIV. Pre-exposure prophylaxis (PrEP) with antiviral drugs will significantly reduce the risk of contracting HIV. Testing for HIV is recommended for individuals with an increased risk. Pre-exposure prophylaxis (PrEP) reduces the risk of contracting HIV through a medication regimen taken prior to potential exposure to the virus, and postexposure prophylaxis decreases the risk of HIV infection after exposure to HIV. HIV testing is recommended as part of regular medical care. Condom use during oral, vaginal and anal sexual activity decreases the risk of contracting HIV. HIV is not transmitted by mosquitoes.

The off-duty nurse witnesses a motor vehicle accident and is concerned that the driver of the automobile may be injured. What should the nurse do first?

Consider scene safety to prevent further injury. rationale When attempting to render aid after a motor vehicle collision, it is critically important that the responder first consider scene safety. Responders should assess the scene for risks to safety to prevent further injury to themselves, the victim and other motorists on the road. Minimizing the movement of the driver's cervical spine, checking the driver's pulse and checking the driver's respiratory rate may all be indicated in the scenario, but scene safety should be considered first.

The nurse in the dialysis center suspects that a client receiving hemodialysis is infected with scabies. Which transmission-based precautions should the nurse implement immediately?

Contact precautions rationale Contact precautions reduce the risk of transmission by direct or indirect contact. Indirect transmission involves contact with a contaminated object. Scabies is a parasitic skin infection that is transmitted by direct, physical contact with infected individuals or by sharing clothing or bedding with an infected individual. The other precautions are not appropriate for preventing the transmission of scabies. Bloodborne precautions are not transmission-based precautions. Those precautions fall under standard precautions, which are taken for every client when the possibility of exposure to blood and/or bodily fluids exists, regardless of the presence of a communicable infection.

A 2-year-old child is brought to the pediatrician's office by the parents, who report that the child has been having diarrhea for two days. What nutritional information should the nurse provide to the parents?

Continue a regular diet and add electrolyte replacement drinks. rationale Current recommendations for mild to moderate diarrhea are to maintain an age-appropriate diet and include rehydration fluids that contain electrolytes. Some providers now recommend a diet of cereal, rice and milk (the C.R.A.M. diet) because milk provides fat and protein and the C.R.A.M. foods are shown to ease diarrhea quickly. The B.R.A.T. diet, consisting of bananas, rice, applesauce and toast or tea, should be avoided for children with acute gastroenteritis because it is low in energy foods, protein and fat. Both the C.R.A.M. and B.R.A.T. diets require oral hydration therapy. The other recommendations are incorrect.

A nurse is caring for a client who had a cholecystectomy with common bile duct exploration and placement of a T-tube 24 hours ago. The nurse observes large amounts of bilious drainage from the T-tube. Which action should the nurse take?

Continue to monitor the drainage. rationale A T-tube drains bile after a cholecystectomy. It should be kept in a dependent position and secured to the client. Several hundred milliliters of drainage is expected from a T-tube in the initial 24 to 48 hours after this type of surgery. The nurse's responsibility is to monitor the drainage and notify the health care provider (HCP) if the findings indicate leakage of bile into the peritoneum or a blocked duct. The tube should not be clamped unless there is a specific order to do so. Keeping the head of the bed elevated will help to facilitate drainage. Administering pain medication does not address the main problem in this situation.

The nurse is reviewing the medical record of a client admitted with acute kidney injury. Which findings would support this diagnosis? (Select all that apply.)

Decreased glomerular filtration rate Proteinuria Elevated creatinine level Hematuria rationale Acute kidney injury (AKI) is the rapid loss of kidney function due to some form of damage. A clinical manifestation of AKI includes an elevated blood urea nitrogen level due to the breakdown of protein. Protein is then released into the bloodstream and is filtered through the kidneys. Through a urine analysis protein can be found, which is not typically present. Increased levels of protein can damage the kidney, causing an elevated creatinine level, a decreased glomerular filtration rate and hematuria and can cause the release of cellular potassium into body fluids. This can cause hyperkalemia, not hypokalemia.

The nurse is caring for a client with meningitis. Which observation by the nurse would indicate that the client's condition is worsening?

Decreased level of consciousness rationale Meningitis is an inflammation of the arachnoid and pia matter of the brain and spinal cord. Expected findings for a client with meningitis include photophobia, headache, fever and chills. The most important nursing intervention for clients with meningitis is the accurate monitoring and recording of their neurologic status, vital signs and vascular assessment. Increased Intracranial Pressure (ICP) is a life-threatening complication of meningitis. A decrease in the client's level of consciousness is typically the first sign of an increasing ICP.

A school nurse is talking with a teen who comes into the health office complaining about not feeling well. The nurse notices that the teen is breathing rapidly, has fruity-smelling breath and is clenching their abdomen. The teen's medical records indicate that they have diabetes mellitus type 1. What is the most likely cause of the teen's symptoms?

Diabetic ketoacidosis rationale Diabetic ketoacidosis (DKA) is a serious complication related to the deficiency of insulin in individuals with type 1 diabetes mellitus. The most common cause for DKA is poor adherence to insulin treatment or not taking insulin altogether. Manifestations include hyperglycemia, abdominal pain, nausea, vomiting, fruity-smelling breath (due to the build-up of ketones), frequent urination and deep, rapid respirations (Kussmaul's) due to the metabolic acidosis. Respiratory failure, kidney failure and pancreatitis would not cause DKA or the symptoms the teen is exhibiting.

A nurse notes an abrupt onset of confusion in an 85-year-old client. Which newly prescribed medication most likely caused this change in the client's mental status?

Diphenhydramine r4ationale Older adults are susceptible to the side effect of anticholinergic medications, such as antihistamines. Diphenhydramine is a first-generation histamine blocker. Older antihistamines often cause confusion, especially at higher doses. In fact, first-generation antihistamines are included in the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. Metoprolol (a beta blocker), pantoprazole (a proton pump inhibitor) and warfarin (an anticoagulant) are not known to cause mental status changes.

The nurse in a long-term care facility is reviewing the plan of care for a female client diagnosed with a urinary tract infection. To reduce the risk of recurrence, which interventions should the nurse include in the plan of care? (Select all that apply.)

Discourage the client from drinking coffee or tea. Assist the client with wiping the perineum front to back. Have the client void every 2 to 3 hours. Appropriate interventions include having the client void every 2 to 3 hours during the day to prevent retention and ensure frequent emptying of the bladder. Drinking caffeinate beverages can cause irritation to the bladder, increasing the risk for an infection. To help reduce pathogens from entering the urethral opening, the nurse should assist the client in wiping the perineum from front to back. The client should take a shower, rather than bathe, as the bacteria in the tub water may enter the urethra. The client should drink at least 2 to 3 liters of water a day, if not contraindicated, to help flush out bacteria in the urinary tract.

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.

A client is admitted to the hospital after falling at home and is given an opioid analgesic for pain. Two days later, the client develops delirium. What clinical manifestation(s) should the nurse monitor the client for? (Select all that apply.)

Disturbances in sleep-wake patter Fluctuating emotions Correct Response Rambling, incoherent speech Correct! Delirium is an acute disorder that is characterized by a change in cognition, which develops quickly over a short period of time. Predisposing risk factors for delirium include anesthesia, dehydration, electrolyte disturbances, sleep deprivation and opioid pain medications. Disturbances in the sleep-wake cycle can occur in clients with delirium. The symptoms of delirium typically last for days or weeks, but not months. The client with delirium thinks in a disorganized pattern and thus speaks randomly and incoherently. The client with delirium can develop emotional instability that is manifested by fear, anxiety and apathy. The client with delirium is easily distracted and has difficulties focusing on tasks. Memory loss, especially long-term, is not associated with acute delirium, but is often seen in clients with dementia.

A client is admitted to the hospital after falling at home and is given an opioid analgesic for pain. Two days later, the client develops delirium. What clinical manifestation(s) should the nurse monitor the client for? (Select all that apply.)

Disturbances in sleep-wake pattern Fluctuating emotions Rambling, incoherent speech Delirium is an acute disorder that is characterized by a change in cognition, which develops quickly over a short period of time. Predisposing risk factors for delirium include anesthesia, dehydration, electrolyte disturbances, sleep deprivation and opioid pain medications. Disturbances in the sleep-wake cycle can occur in clients with delirium. The symptoms of delirium typically last for days or weeks, but not months. The client with delirium thinks in a disorganized pattern and thus speaks randomly and incoherently. The client with delirium can develop emotional instability that is manifested by fear, anxiety and apathy. The client with delirium is easily distracted and has difficulties focusing on tasks. Memory loss, especially long-term, is not associated with acute delirium, but is often seen in clients with dementia.

The nurse is reviewing the plan of care for a client with acute adrenocortical insufficiency. Which intervention should be a priority for this client?

Electrocardiogram monitoring Adrenocortical insufficiency is caused by an insufficiency of both cortisol and aldosterone. Reduced aldosterone secretion causes a reduction in potassium excretion and an increase in sodium and fluid excretion, ultimately resulting in hyperkalemia and subsequent hyponatremia. Hyperkalemia can result in cardiac arrhythmias which can be fatal. Therefore, the priority intervention is to complete electrocardiogram monitoring to assess for the presence of dangerous arrhythmias. Additionally, the other interventions are clearly inappropriate. Implementation of sodium restriction is inappropriate, as patients may be experiencing hyponatremia. Additionally, administration of potassium supplements is also inappropriate, as patients with adrenocortical insufficiency are likely to experience hyperkalemia. Some patients with adrenocortical insufficiency present with hypoglycemia, so the administration of insulin may worsen their condition.

The nursing care plan for a client in the diuresis stage of acute kidney injury (AKI) should include monitoring for which complication?

Electrolyte imbalance rationale During the diuresis stage of AKI, the client will be losing an excessive amount of urine (3 to 6 liters per day) and will be at risk for fluid volume deficiency and electrolyte imbalance. The nurse must monitor the client's electrolyte levels, especially potassium (hypokalemia).

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) rationale 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.

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 rationale 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. Correct!

The nurse is reviewing the plan of care for a 30-year-old client newly diagnosed with multiple sclerosis. Which interventions should the nurse include for this client? (Select all that apply.)

Encourage independence in personal care and bathing. Review methods to prevent and treat constipation .Encourage participation in vocational rehabilitation. Encourage participation in physical and occupational therapy. rationale Multiple sclerosis (MS) is a debilitating disorder affecting the myelin sheaths of the nervous system. Symptoms will vary depending on the extent and area of damage. Clients with MS are encouraged to maintain as high a level as possible of independence. They are encouraged to participate in physical and occupational therapy (PT/OT), as well as exercise therapies. They should be taught about methods to prevent and treat constipation. They should be taught how to manage cases of bladder incontinence, but it is not necessary to self-catheterize. The client should be encouraged to maintain independence in personal care. Depending on the level and severity of the disease, the client may need to participate in vocational rehabilitation (VR). VR is a federal-state program that helps people who have physical disabilities maintain or return to employment.

A client who was recently diagnosed with colorectal cancer is crying in their hospital room. The client is scheduled to have surgery tomorrow for placement of a new colostomy. Which action by the nurse would be most effective in helping this client cope?

Encourage the client to verbalize their feelings or fears about the upcoming surgery. rationale The diagnosis of cancer can have a significant, emotional impact on a client. It would be most effective for the nurse to first explore the client's feelings and thoughts about the illness and planned interventions by encouraging the client to verbalize and actively listening to what the client says. The nurse should not assume that the reason the client is upset is because of the surgery and/or colostomy itself. Making statements about managing the colostomy post-surgery and recommending cancer support groups are premature and provide false reassurance that ignores the client's current emotional needs.

The nurse is reviewing the medical history of a client who is receiving weekly erythropoietin injections. Which medical condition requires the use of this medication?

End-stage kidney disease (ESKD) rationale Erythropoietin is a hormone that stimulates production of red blood cells (RBCs) in the bone marrow. The hormone is produced by cells in the proximal tubules of the kidneys. Erythropoietin can partially reverse anemia associated with chronic or end-stage renal failure. Initial effects can be seen within 1 to 2 weeks. Hemoglobin usually reaches acceptable levels (10 to 11 gm/dL) in 2 to 3 months. Erythropoietin is not used for iron-deficiency anemia, sickle cell disease or Ebola.

The caregiver of an older client with dementia asks the nurse to insert an indwelling urinary catheter to prevent incontinence-associated dermatitis. What should the nurse do next?

Explain that the risk of a catheter-associated infection outweighs the benefits. rationale Incontinence episodes are not a valid reason for inserting a urinary catheter. The risk of a catheter-associated urinary tract infection (CAUTI) is too great. The nurse should advocate for the client by educating the client's caregiver on better alternatives to prevent incontinence-associated dermatitis (IAD). Interventions to prevent incontinence and IAD include: setting up a toileting schedule for the client, offering to take the client to the bathroom after administration of diuretics, applying barrier cream to the perineum and changing soiled or wet undergarments and clothing promptly. The nurse should not hold the prescribed diuretic or place the client in an adult diaper since those actions can be construed as dignity issues and will not help prevent IAD.

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 rationale 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.

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 rationale 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?

The nurse is caring for a client who is suffering from an exacerbation of ulcerative colitis. Which manifestations would the nurse expect to see with this client? (Select all that apply.)

Frequent bloody stools Abdominal pain relieved by defecation Mucous noted in the stool Due to the inflammatory nature of ulcerative colitis (UC), clients suffering from this illness will experience frequent, bloody stools that often contains mucous. Clients will often report lower abdominal pain that is relieved by defecation. Anemia can be associated with prolonged intestinal bleeding and dehydration may occur related to decreased absorption. Clients with UC may have a low-grade fever, but a high fever such as 104° (40° C), would be more likely to be associated with an infection or peritonitis.

The nurse is caring for a client with end-stage renal disease (ESRD). Which manifestations would the nurse expect to see with this client? (Select all that apply).

Frequent fractures Pruritus Conjunctivitis rationale Clients with chronic kidney disease (CKD) and ESRD will present with calcium and phosphorous imbalance, low calcium levels and high phosphorous levels. Bone mineral loss as a result of low calcium levels can result in frequent fractures. Additionally, excessive phosphorous, called metastatic calcifications, can become deposited in various body tissues and systems, including the optic area, which can result in conjunctivitis. Pruritus is a common side effect of excessive serum phosphate. Both diabetes mellitus and hypertension are risk factors for CKD/ESRD, but a HbA1c of 5.9% shows that the diabetes is well-controlled, so does the blood pressure of 119/78 for hypertension.

The nurse is caring for a client who fell two hours ago while alone in their room. The client appears tired and disoriented. What should the nurse do first?

Gather data about the client's baseline neurologic status. rThe nurse should follow the nursing process and collect data first. Based on the data collected, the nurse will then be able to identify and make a clinical decision about which interventions are the priority to implement. The client in this scenario suffered an unwitnessed fall and may have hit their head. A decrease or change in the level of consciousness is typically the first sign of deterioration in neurologic status. By establishing the client's baseline data, the nurse can detect subtle changes in the client's neurologic status. This enables the health care team to prevent or treat the potentially life-threatening complications of a head injury. Reorientation, fall precautions and use of a gait belt would be beneficial for a client with a history of falling, but obtaining a neurological baseline is the priority in this scenario.ationale

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 rationale he 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.

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 rationale 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 (LPN) is caring for a client with an order that reads, "morphine sulfate 2 mg IV push every 3 to 4 hours as needed for pain." There are no other licensed persons working that shift. Which action should the nurse take?

Hold the medication and contact the health care provider. rational LPN/VNs cannot administer medications using intravenous push or bolus route. The nurse will need to contact the health care provider and ask to have the order changed so the medication can be administered by another route.

The nurse is developing a plan of care for a client with chronic obstructive pulmonary disease (COPD). Which interventions should the nurse include in the plan? (Select all that apply.)

Instruct the client on the pursed-lip breathing technique to reduce carbon dioxide (CO2) retention. Schedule the client for an annual influenza vaccination. Provide high-protein, high-calorie meals to help maintain adequate nutrition. Educate the client about relaxation techniques to help with their anxiety. rationale Diaphragmatic (abdominal) and pursed-lip breathing help manage dyspneic episodes that occur with COPD. Breathing through pursed lips creates mild resistance, which prolongs exhalation and increases airway pressure. This technique delays airway compression and reduces air trapping prevalent with COPD. Clients with COPD tend to become anxious during acute dyspneic episodes. The nurse will help the client manage dyspneic episodes and panic attacks through the use of progressive relaxation, hypnosis therapy and biofeedback. For some clients, anxiolytics may be needed. Pneumonia is a common complication of COPD and the client should receive the yearly influenza vaccine. Clients with COPD tend to feel too full to eat, and have poor appetite and meal-related dyspnea. The work of breathing raises the client's calorie and protein needs, which can lead to protein-calorie malnutrition. It is important to urge the client to eat small, frequent meals of high-calorie, high-protein foods. Exercise for conditioning and pulmonary rehabilitation can improve function and activity tolerance in clients with COPD. Each client's exercise program should be personalized to the client's limitations. The simplest plan is to have the client walk daily at a self-paced rate, until symptoms limit further walking. High-intensity aerobic exercise would not be appropriate for the client with COPD.

The nurse is assisting in the preoperative plan of care for an older adult client who will be undergoing a total hip arthroplasty. To improve the client's postoperative course, which interventions should the nurse plan for? (Select all that apply.)

Instruction on plantar and dorsiflexion exercises The use of assistive devices for ambulation Application of sequential compression devices rationale Due to the client's age and the surgical procedure, the client is at risk for a venous thromboembolism. The nurse should include the use of sequential compression devices to decrease venous stasis along with providing instruction on plantar and dorsiflexion exercises. Warfarin is administered orally; it does not come in an injectable form. The client will most likely need assistive devices initially for safe ambulation postoperatively. Preoperatively, the nurse should not use naproxen to control pain because it is a nonsteroidal anti-inflammatory drug (NSAID) and can increase the risk of bleeding during surgery.

The nurse is providing care to an older adult client diagnosed with bilateral pneumonia. Which intervention should the nurse implement to best promote the client's comfort?

Keep conversations short. rationale Keeping conversations short will promote the older adult client's comfort by decreasing the demands on the client's breathing and energy. Increased intake of fluids is not related to the client's comfort. While the presence of family is supportive, demands on the client to interact with the visitors may interfere with the client's need for rest. Monitoring vital signs is an important assessment but not related to promoting the client's comfort.

The clinic nurse is following up with a client who was seen a few days ago for trigeminal neuralgia. Which action by the client indicates an understanding of how to manage the condition?

Keeps the environment at a moderate temperature and free from drafts. rationale Trigeminal neuralgia is a disruption in the cranial nerve and causes sudden, severe, brief stabbing pain. Keeping the environment at a moderate temperature and free from drafts can reduce the risk of triggering an acute attack. The client will often avoid oral care because of the potential for pain, but should be instructed to use a soft-bristles toothbrush and gently brush their teeth. Meals should be warm-to-cool, not hot, to avoid pain exacerbation. Analgesics should be taken before performing activities that can increase feelings of discomfort.

The nurse is caring for a client who has suspected Cushing's disease. The nurse should monitor for which potential symptoms? (Select all that apply.)

Large fat pads on the back and shoulders History of pathologic fractures rationale Cushing's disease occurs when there is an excess amount of cortisol. The nurse must understand that glucocorticoids, including cortisol, regulate metabolism and immune function, and play a role in the regulation and distribution of serum calcium levels. Therefore, deposition of fat pads on the back and shoulders, as well as fractures secondary to osteoporosis, are signs and symptoms of Cushing's disease that the nurse should be able to recognize. The nurse should understand that tachycardia and panic attacks, as well as to polyuria, are not often associated with Cushing's disease, but are instead associated with other endocrine conditions. Tachycardia and panic attacks are sometimes seen with adrenal tumors, such as pheochromocytoma. Polyuria and polydipsia may be associated with both diabetes insipidus and diabetes mellitus, and changes in vision can be associated with advanced diabetes mellitus.

The nurse in a long-term care facility is assigned to the dementia unit. What type of functions should the nurse expect to see impaired in these clients?

Learning, creativity and judgment Correct! rationale Dementia is not a single disease but a general term used to describe symptoms such as impairments to memory, communication and thinking. There are many causes of dementia and although we generally associate dementia with aging, we know that it is due to degenerative changes to the brain. The other options include other expected changes due to aging, but do not necessarily indicate cognitive impairment related to dementia.

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 rationale 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 nurse is caring for a client who was recently admitted following an episode of status epilepticus. Which of the following data is most important to collect?

Level of consciousness (LOC) rationale Cerebral blood flow undergoes a significant increase during seizure activity with a depletion of oxygen at the neuronal level. Cerebral anoxia may result in progressive brain tissue injury and destruction. The nurse should monitor the client's level of consciousness (LOC) after a seizure. Although the other information is also important, LOC is the priority data for the nurse to collect after a seizure.

A client with diabetes is starting on insulin therapy. Which type of short-acting insulin will the nurse discuss using for mealtime coverage?

Lispro rationale When classified according to time course, insulin preparations fall into three major groups: short duration, intermediate duration and long duration. Lispro is a rapid-acting insulin with an onset of 15 to 30 minutes, a peak of 0.5 to 2.5 hours and duration of 3 to 6 hours. Rapid- or short-acting insulin is commonly used for mealtime coverage for clients receiving insulin therapy. NPH insulin, glargine or detemir will be used as the basal insulin for intermediate- and long-duration blood sugar control.

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 rationale 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.

A client has been taking isoniazid (INH) and rifampin for several months. Which laboratory test should the nurse monitor with this client?

Liver enzymes rationale INH and rifampin are used to treat tuberculosis and both are hepatotoxic. Isoniazid can cause hepatocellular injury and multilobular necrosis and is believed to result from the production of a toxic isoniazid metabolite. Rifampin is also toxic to the liver, posing a risk of jaundice and even hepatitis. Asymptomatic elevation of liver enzymes occurs in about 14% of patients. Hepatotoxicity is most likely in people who abuse alcohol and in clients with pre-existing liver disease. These individuals should be monitored closely for signs of liver dysfunction. Tests of liver function (serum aminotransferase levels) should be made before treatment and every 2 to 4 weeks thereafter. The other lab tests are not specific to the medications the client is taking.

While caring for a client after lumbar spine surgery, which action can the nurse on the ortho-spine unit delegate to the unlicensed assistive person (UAP)?

Log roll the client from side to side every two ho rationale Repositioning a client is included in the training of UAPs. UAPs working on a specialty unit, such as ortho-spine, will be familiar with how to maintain alignment for a postoperative spinal surgery client. Evaluating the effectiveness of pain management, assessing neurologic function such as plantar and dorsiflexion and evaluating a client's readiness to ambulate after surgery require higher level nursing education and scope of practice and, therefore, cannot be delegated to UAPs.

A nurse is caring for a client diagnosed with Cushing's syndrome. While reviewing the client's medical record, which risk factor most likely caused the client to have this syndrome?

Long-term use of steriods rationale Cushing's syndrome is different from Cushing's disease and most commonly develops as a side effect of long-term use of corticosteroids. This syndrome refers to the clinical manifestations caused by excessive levels of cortisol, including hyperglycemia and fluid retention, which can subsequently cause edema, hypertension, weight gain, glucose intolerance and protein wasting. Chronic kidney disease is not a risk factor for Cushing's syndrome.

The home health care nurse is caring for a client who has epilepsy. While the nurse is providing care, the client has a seizure. Which intervention would be most appropriate to prevent an injury to the client?

Lowering the client to the ground rationale Epilepsy is a disorder that involves two or more unprovoked seizures. A seizure is an abnormal discharge of electrical activity in the brain which can cause alterations in motor function, sensation, consciousness, behavior and autonomic function. During a seizure, clients may suddenly lose consciousness and fall to the ground, increasing their risk of breaking a bone or suffering a head injury. The most appropriate intervention at this time is to prevent further injury by lowering the client to the ground and placing them in the recovery position to prevent aspiration. Clothing should be loosened around the neck, not the waist, to ensure a patent airway. Once the client is more awake, the nurse can reoriented them to their surroundings.

The nurse is preparing to administer medications to her assigned clients. In order to reduce medication errors, which of the following rights of medication administration should the nurse adhere to? (Select all that apply.)

Maintain a distraction-free environment while administering medication. Check the medication against the medication administration record (MAR). Verify the client's full name and date of birth in the medication administration record (MAR). Ensure the medication is in the right form as ordered by the health care provider (HCP). rationale Medication safety includes maintaining a culture of safety and ensuring rigorous verification prior to administration. Distraction-free medication administration is recommended, as well as checking three times to ensure the correct medication and the rights of medication. The rights of medication include the right medication, client, dosage, form, route, timing and indication. Medication should be prepared at the time of administration and never left unattended by the nurse. These safeguards help reduce medication errors.

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 rationale 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.

The nurse is caring for a client when the client begins to have a seizure. Which is the priority action for the nurse to take?

Maintain the client's airway. rationale During a seizure, the client may not be able to maintain an open airway and is at risk for aspirating their own secretions. In order to maintain an open airway, the nurse should turn the client to their side and have suction equipment available. During a seizure, restricting the client's movements and/or inserting an object into the client's mouth is contraindicated and cause injury or further airway obstruction. After addressing the client's airway and breathing needs, the nurse should administer any prescribed antiepileptics.

The most important action for the nurse caring for a client with bronchiolitis is:

Maintaining a patent airway rationale Bronchiolitis (tracheobronchitis) is the swelling and mucus buildup in the bronchioles, usually due to a viral infection. The nurse needs to ensure a patent airway for this client. Administering CPR would not be indicated unless no pulse or respirations were present. Antiviral medications are indicated, but would be used as supportive care. Maintaining the airway is the most important intervention.

The nurse is caring for a client who is receiving bolus enteral tube feedings. Which of the following actions by the nurse demonstrate safe practice for this client? (Select all that apply.)

Maintaining the head of the bed at 30 to 45° during feedings Aspirating and measuring the residual gastric contents before each feeding Verifying the initial placement of the tube by radiographic assessment Correct! raSafe care of clients receiving enteral feedings focuses on preventing regurgitation and aspiration. This is done by verifying the initial placement of the tube via radiographic assessment, maintaining the head of bed above 30° during and for 30 minutes following the feeding and ensuring the patient is able to tolerate the volume and speed of the nutrition by measuring residual volumes prior to feeding. Flushing the tube every hour is not indicated and could lead to fluid overload. Placing the client in a supine position is contraindicated after just having received a bolus of tube feeding, because it increases the risk of regurgitation and aspiration. Oral care should be provided regularly and at least every shift. Connecting the tube to suction is incorrect.tionale

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

A nurse is caring for a client with a personality disorder. He comments to the nurse that she "doesn't know what she is doing because all the other nurses let him take his coffee into his room. Most of them will even bring me coffee in my room!" The nurse recognizes that this is what type of behavior?

Manipulative behavior Many clients with personality disorders have self-esteem issues related to dependency. Because of this, clients may manipulate staff in this way. Attempts to manipulate are attempts to show superiority and deny one's own feelings.

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 rationale 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 presents with a small, elevated and ulcerated skin lesion on the upper back. The lesion has irregular edges that vary in color. The nurse knows that this finding could be associated with which type of skin cancer?

Melanoma rationale Melanomas tend to appear as lesions with irregular edges, which are small in size, flat or elevated, eroded or ulcerated. They can be black, brown, gray or white in color. Most common sites of melanoma include the back, chest or legs. Squamous cell carcinoma is more commonly found on sun-exposed areas, such as the face and hands. Basal cell carcinoma lesions tend to look like sharply defined, pearly, flat to barely elevated plaques.

A nurse administers cimetidine to a 75-year-old client diagnosed with a gastric ulcer. The nurse should monitor the client for which adverse reaction?

Mental status change rationale Cimetidine is a histamine H2-receptor antagonist used to treat gastric ulcers. It has been found to cause confusion in susceptible clients, such as the elderly and debilitated clients. Clients over age 50 or who are severely ill may become temporarily confused while taking H2 blockers, especially cimetidine.

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 rationale 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 home health nurse is visiting a client with sickle cell disease. What are the priority interventions for this client? (Select all that apply.)

Minimizing end-organ damage. Managing pain effectively. Receiving annual influenza vaccination. Preventing sickle cell crisis. Maintaining fluid intake of 2 to 3 liters per day. rationale Care for the client with sickle cell disease (SCD) focuses on prevention of crises and sequelae from the disease. Because an acute infection can precipitate a sickle cell crisis, the client should receive the influenza vaccine annually. Increased intake of fluids is recommended to reduce blood viscosity and maintain renal function. SCD is a genetic disease and currently incurable. SCD can be very painful, especially during a crisis. Clients will require increasing doses of analgesics in order to achieve pain control. Morphine and hydromorphone are the drugs of choice.

The nurse is assisting with developing a plan of care for a client with benign prostatic hyperplasia. Which nursing interventions should the nurse include for this client? (Select all that apply.)

Monitor for bladder distention. Limit caffeinated and alcoholic beverages. Catheterize as needed for post-void residual urine. rationale Benign prostatic hyperplasia (BPH) is a benign enlargement of the prostate gland. This is common among aging men and can cause urinary difficulties including obstruction, retention, infection and incontinence. Nursing management includes assessing/monitoring for bladder distention. With urinary retention, this can cause pain and increased risk of an acute kidney injury. If the client is retaining urine, the nurse might need to perform straight catheterization to empty the bladder. The client should attempt to void every 4 to 6 hours to prevent retention. The client should avoid or limit the use of caffeinated and alcoholic beverages as these can cause irritation to the bladder and worsen symptoms. Monitoring intake and output would be appropriate to evaluate a client's fluid balance and kidney function, not BPH.

A client presents with elevations in triiodothyronine (T3) and thyroxine (T4) and with normal thyroid-stimulating hormone (TSH) levels. Which is the nurse's priority intervention?

Monitor the apical pulse. rationale The client's laboratory findings suggest that the client is experiencing hyperthyroidism. The increased metabolic rate can cause an increase in the client's heart rate, and the client should be monitored for the development of dysrhythmias. Placing the client on a telemetry monitor might also be an appropriate precaution. Synthroid is given for hypothyroidism. Propranolol is a beta blocker often used to lower sympathetic nervous system activity in hyperthyroidism. Hyperthyroidism can cause a mild to moderate elevation in serum calcium levels but Trousseau's sign is indicative of hypocalcemia not hypercalcemia.

The nurse is caring for a client with severe iron deficiency anemia. Which interventions should the nurse include in the client's plan of care? (Select all that apply.)

Monitor the client for palpitations and orthostatic hypotension. Encourage the client to eat more green leafy vegetables and beans. Instruct assistive personnel to allow the client to rest during care activities. Review the client's medical record for NSAID use. Monitor the client's stool for color, consistency and frequency. rationale Iron deficiency anemia is the most common type of anemia. Lower levels of iron in the body fail to produce red blood cells (RBCs). Without sufficient RBCs, the client's body and tissues will not receive enough oxygen. Risk factors for iron deficiency anemia include pregnancy, gastric bypass, blood loss, gastric ulcer, gastrectomy and menstruation. Because iron deficiency anemia can be caused by gastrointestinal (GI) bleeding, it is recommended to check the color of the client's stool. Dark, tarry stools could indicate upper GI bleeding. Manifestations of anemia include palpitations, tachycardia, hypotension, pallor and shortness of breath. Clients should take iron on an empty stomach for better absorption. Taking iron with milk will block the medication's absorption. Clients should be encouraged to eat foods that contain iron, such as green leafy vegetables, beans, legumes and muscle meats. NSAID use has the potential to cause gastric ulcer development and GI bleeding. Clients with anemia will be fatigued and tire easily and should be allowed to rest during care activities. The scenario does not indicate that the client needs a blood transfusion at this time.

The nurse is caring for a client who was admitted to the hospital for syndrome of inappropriate antidiuretic hormone. Which interventions are appropriate for this client's plan of care? (Select all that apply.)

Monitor the client's serum sodium level. Document the client's weight daily. Document changes in the client's neurologic status. Monitor the client for pulmonary edema and orthopnea. rationale Syndrome of inappropriate antidiuretic hormone (SIADH) is caused by excessive antidiuretic hormone leading to fluid volume overload and dilutional hyponatremia. Associated clinical manifestations are related to fluid overload (pulmonary edema, orthopnea and crackles/rales in the lungs) and dilutional hyponatremia (confusion, headache, decreased muscle strength and decreased neuromuscular excitability). Appropriate interventions include monitoring the response to treatment, preventing complications, maintaining a safe environment and reinforcing education regarding fluid restriction. Vasopressin, an antidiuretic analogue, is contraindicated in clients with SIADH. While this client is at increased risk for seizures, padded tongue blades are not appropriate seizure precautions. Monitoring and documenting sodium levels, daily weight, pulmonary status and neurologic status are appropriate for this client.

The client is discharged from the hospital with a new prescription for furosemide. During a follow-up visit one week later, the nurse notes the following findings. Which finding is most important to report to the health care provider?

Muscle cramps rational Furosemide is a loop (potassium-wasting) diuretic. It can cause dehydration and hypokalemia, which can result in muscle cramps. This is the most important finding. Dizziness or lightheadedness may occur as the body adjusts to the medication. The nurse should reinforce to the client that they should get up slowly when rising from a sitting or lying position. The client should tell the HCP if these findings persist or become worse. Increased urine production is an expected action of the medication. Some people experience constipation when taking this medication, but it is not as important to report that finding as the possibility of hypokalemia.

The nurse is reinforcing medication interactions with a client who is taking warfarin. Which over-the-counter (OTC) medication should the nurse remind the client to avoid?

Naproxen rationale Warfarin is an anticoagulant. OTC medications that interact with warfarin should be avoided. Naproxen, a nonsteroidal anti-inflammatory drug (NSAID), is a commonly used OTC analgesic. Naproxen can prolong bleeding time and should therefore be avoided by clients who take anticoagulants. The other medications are not contraindicated when taking warfarin.

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 rationale 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.

A client presents to the emergency department with a prolonged asthma attack that did not resolve after the client used a metered-dosed inhaler at home. Which medication should the nurse plan to administer first for this client?

Nebulized albuterol rationale The nurse would anticipate that nebulized albuterol would be given first in this situation to address the acute asthma attack through bronchodilation. While oral prednisone may be used in the treatment of this client, it would be given after administration of an inhaled B2-adrenergic agonist like albuterol. There is no information provided that would indicate antibiotic therapy is needed for the client. A fluticasone inhaler may be part of long-term asthma management for this client, but is not recommended as a rescue treatment for acute asthma attacks.

The nurse is caring for a client who received thrombolytic therapy for an acute myocardial infarction (MI). Which information is most important for the nurse to communicate to the health care provider (HCP)?

No change in the client's reported level of chest pain rationale Continued chest pain suggests myocardial ischemia and that the thrombolytic therapy is not effective. Other coronary interventions may be needed, such as a stent. Bruising is a possible side effect of thrombolytic therapy and should be monitored, but it is not more important to report than the unrelieved chest pain. The decrease of the ST-segment elevation indicates that perfusion is returning to the injured myocardium. An increase in troponin levels is expected with reperfusion and is related to the release of cardiac biomarkers into the circulation as the blocked vessel reopens.

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 rationale 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.

The nurse is preparing a client diagnosed with a deep vein thrombosis (DVT) for a venous Doppler ultrasound study. Which nursing intervention is necessary to prepare the client for this test?

No special preparation is necessary for the client. raionale This is a noninvasive procedure. Because this is an ultrasound test for the venous circulation of the affected extremity, it does not require any special preparation (as compared to an ultrasound of the uterus, for example, which requires a full bladder). Stopping anticoagulants is contraindicated since it could lead to development of another thrombosis. Giving a sedative medication or keeping the client NPO are not needed for this test.

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 rationale 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%.

The nurse suspects cardiac tamponade in a client who has acute pericarditis. How should the nurse determine the presence of pulsus paradoxus?

Note when Korotkoff sounds are auscultated during inspiration and expiration. rationale Pulsus paradoxus is a decrease in systolic blood pressure (SBP) during inspiration that is exaggerated in cardiac tamponade. Pulsus paradoxus exists when there is a difference greater than 10 mm Hg between when Korotkoff sounds are heard during expiration and when they are heard throughout the respiratory cycle. The other methods described would not be useful in determining the presence of pulsus paradoxus.

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 rationale 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.

The nurse on a postpartum nursing unit is receiving report about a client who had a normal spontaneous vaginal delivery the night before. The client has been passing golf ball-sized clots on her peri-pad for the last few hours. The client's most recent blood pressure is 88/56, and her heart rate is 118. The nurse enters the client's room and notices blood oozing from her intravenous insertion site. Which action should the nurse take first?

Notify the client's health care provider. rationale After a normal spontaneous vaginal delivery (NSVD), it is normal for a client to have vaginal bleeding on their peri-pad. Postpartum hemorrhage (PPH) is defined as blood loss greater than or equal to 500 mL after birth. If a patient is saturating more than one peri-pad in an hour or passing several large clots, the patient could be experiencing PPH. This is an obstetric emergency. Signs and symptoms of PPH include dizziness, hypotension, tachycardia, large clots passed vaginally and heavy bleeding on the peri-pad. PPH can progress to a life-threatening condition called disseminated intravascular coagulation (DIC). This can occur after an injury or childbirth. Proteins in the blood that form blood clots travel to the injury site to help stop bleeding. If these proteins become abnormally overactive throughout the body, DIC can ensue. Small blood clots form in blood vessels throughout the body, and can clog the vessels and cut off the normal blood supply to the organs. Signs and symptoms of DIC include severe bleeding, oozing from puncture sites, hypotension, tachycardia, dizziness and hypoxia. The nurse should suspect DIC and should notify the primary health care provider (HCP) immediately. Nursing measures to monitor and control normal postpartum uterine bleeding can include uterine massage, breastfeeding and peri-care. The client in this scenario may be experiencing a medical emergency (e.g., DIC), therefore the nurse should first notify the HCP. Correct! LESSON

The nurse on a postpartum nursing unit is receiving report about a client who had a normal spontaneous vaginal delivery the night before. The client has been passing golf ball-sized clots on her peri-pad for the last few hours. The client's most recent blood pressure is 88/56, and her heart rate is 118. The nurse enters the client's room and notices blood oozing from her intravenous insertion site. Which action should the nurse take first? Palpate and massage the client's uterus

Notify the client's health care provider. rationale After a normal spontaneous vaginal delivery (NSVD), it is normal for a client to have vaginal bleeding on their peri-pad. Postpartum hemorrhage (PPH) is defined as blood loss greater than or equal to 500 mL after birth. If a patient is saturating more than one peri-pad in an hour or passing several large clots, the patient could be experiencing PPH. This is an obstetric emergency. Signs and symptoms of PPH include dizziness, hypotension, tachycardia, large clots passed vaginally and heavy bleeding on the peri-pad. PPH can progress to a life-threatening condition called disseminated intravascular coagulation (DIC). This can occur after an injury or childbirth. Proteins in the blood that form blood clots travel to the injury site to help stop bleeding. If these proteins become abnormally overactive throughout the body, DIC can ensue. Small blood clots form in blood vessels throughout the body, and can clog the vessels and cut off the normal blood supply to the organs. Signs and symptoms of DIC include severe bleeding, oozing from puncture sites, hypotension, tachycardia, dizziness and hypoxia. The nurse should suspect DIC and should notify the primary health care provider (HCP) immediately. Nursing measures to monitor and control normal postpartum uterine bleeding can include uterine massage, breastfeeding and peri-care. The client in this scenario may be experiencing a medical emergency (e.g., DIC), therefore the nurse should first notify the HCP. Correct!

The nurse administers a medication to the wrong client. Which action(s) should the nurse take when the medication error is identified? (Select all that apply.)

Notify the health care provider (HCP). Monitor the client for adverse effects. Complete an incident report. Document the error in the medical record. rationale When a medication error occurs, the nurse should notify the HCP immediately. Giving the wrong medication to a client may cause adverse effects and the nurse should monitor the client closely for the appropriate length of time. The administration of ipecac syrup to induce vomiting is not recommended after the occurrence of a medication error. The nurse is required to document the medication error and follow-up interventions in the client's medical record. An incident report regarding the medication error needs to be completed as well. The report allows the nurse and health care facility to investigate the root cause for the medication error and put measures in place to prevent future errors. Reporting the error to the BON is not required.

A client is receiving heparin and warfarin after total hip replacement surgery. Lab results show an international normalized ratio (INR) of 5.5. Which priority action should the nurse take?

Notify the health care provider (HCP). rationale The INR lab test is used to evaluate the therapeutic effectiveness of warfarin, an anticoagulant. The therapeutic range for INR is 2 to 3, therefore a client with a 5.5 INR is at a high risk for bleeding and the nurse should notify the HCP immediately. The nurse should also monitor the client closely and hold the warfarin until the nurse has communicated with the HCP. Protamine sulfate is the antidote for heparin, not warfarin, and the therapeutic range for heparin is measured with a partial thromboplastin time (PTT), not an INR.

The nurse is caring for a client with osteoporosis who has been prescribed alendronate. When providing care, which intervention would be a priority?

Notify the health care provider if the client reports jaw pain. rationale Alendronate is a bisphosphonate that helps slow down bone resorption, decreasing osteoporosis. Osteonecrosis of the jaw is a rare, adverse reaction to alendronate, and jaw pain can be a symptom of this. Therefore, notifying the health care provider of the jaw pain is the priority. The other interventions are also correct for a client with osteoporosis, but are not as important as reporting the potential adverse drug effect.

The nurse is caring for a client who has a history of peptic ulcer disease. The nurse notes the abdomen is rigid and the client complains of severe pain with palpation. What is the priority action by the nurse?

Notify the health care provider of the findings. rationale A complication of peptic ulcer disease (PUD) is perforation. When perforation occurs, gastrointestinal contents will leak into the peritoneal cavity, causing peritonitis. This is a surgical emergency. While the client with PUD may complain of epigastric pain or tenderness, severe pain and a rigid abdomen are not expected finding. Past medication use and dietary habits are important to note, but alerting the HCP is the priority.

A client who has a wet chest drainage system following a thoracotomy develops continuous bubbling in the water seal chamber of the collection device. What action should the nurse take?

Notify the health care provider of the presence of an air leak. rationale Continuous bubbling in the water seal chamber is indicative of an air leak. Clamping the chest tube is contraindicated and can cause a pneumothorax. Increasing or decreasing the vacuum source will not adjust the suction pressure. The amount of suction applied is regulated by the amount of water in this chamber and not by the amount of suction applied to the system. Instructing the client to deep breathe and cough is not an appropriate intervention in this situation.

The nurse is caring for a client with a diagnosis of pericarditis. The unlicensed assistive person reports to the nurse that the client's last set of vital signs were blood pressure of 84/40 mm Hg, respiratory rate of 28 breaths/minute, heart rate of 112 and the client seemed short of breath. The nurse examines the client and also notes the presence of jugular vein distention. What should the nurse do next?

Notify the health care provider. rationale Clients with pericarditis are at risk for developing cardiac tamponade. Cardiac tamponade means the fluid buildup within the pericardial sac, compressing the heart and making it difficult to pump, thus reducing cardiac output. The client is showing signs and symptoms of cardiac tamponade and reduced cardiac output: hypotension, tachycardia, tachypnea, shortness of breath and jugular vein distention. The nurse should immediately notify the health care provider (HCP), because cardiac tamponade is a life-threatening emergency that requires immediate intervention. The nurse should not give the metoprolol, a beta blocker, since the drug will further lower the client's blood pressure and may cause the client to go into shock. The other interventions should be performed after the HCP has been notified.

The nurse is caring for a client who had a closed reduction of a fractured right wrist, followed by the application of a cast about 12 hours ago. Which finding requires the nurse's immediate attention?

Numbness in the right hand rationale Numbness and tingling, or paresthesia, may be an indication of compartment syndrome and requires immediate action by the nurse. A client with compartment syndrome may also report extreme pain. There may be pallor and an absent or diminished pulse on the affected extremity, distal to the cast. A low calcium level will need to be addressed because it could have contributed to the fracture and will delay healing. The other findings are expected with a client in this situation.

A client comes to the community health clinic with symptoms of gonorrhea. Which intervention should the nurse implement first?

Obtain information about the client's recent sexual encounters. rationale The nurse should first obtain information from the client about their recent sexual encounters. This will provide further insight and assist other health care providers who are coordinating care. The nurse should prepare for a urethral swab, but this should not be the first intervention. The nurse must provide sensitive care because some people are reluctant to seek health care when problems first arise. Sexually transmitted infections can cause emotional distress and may progress without symptoms. It would be important for the client to speak to any sexual partners that may have a risk of contracting the infection, but this should not be the first thing. Discussing the risk of infertility would not be appropriate at this time.

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 rationale 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 caring for a mother who has just delivered a stillborn infant. What would be the most therapeutic nursing intervention?

Offering the mother the opportunity to hold, bathe and dress the infant. Correct! rationale The loss of an infant has special meaning for grieving parents. To help them understand that the death is a reality and to facilitate their grieving, it is important to offer the opportunity to hold the infant while dying or after the delivery and to provide a quiet, private place for the parents with their child. Allow the parents to have as much time with their child as they request. Differences in gender, cultural practices and religious beliefs will affect the parents' grief response and the nurse needs to be alert for verbal and nonverbal cues.Giving false reassurance, pointing out that future pregnancies are possible and arranging for a chaplain's visit are nontherapeutic interventions that are insensitive to the mother's current, emotional needs and are based on cultural bias and assumptions.

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? (Select all that apply.)

Oranges Grilled sirloin steak Marinated cauliflower and broccoli rationale 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.

A nurse is caring for a client who has reported pain at their surgical site. Which statement(s) suggests the nurse understands the pain phenomenon? (Select all that apply.)

Pain exists when and where the client says it exists. Pain can be treated with pharmacologic and/or nonpharmacologic therapies. rationale Assessing/evaluating pain is an important part of the nurse's responsibility in all nursing care circumstances, including postoperative pain. Pain is subjective, highly individualized and sometimes complex to treat. Pain is a physiological process and sensation caused by a specific stimulus that can include inflammation and tissue damage. It is a misconception that clients from Eastern cultures need less pain medication.

The nurse is caring for a client with a femur fracture. Which of the following findings require the nurse's immediate action? (Select all that apply.)

Palpable hard mass near fracture site Blood pressure of 88/54 mm Hg Absent pulse in affected extremity Shortness of breath rationale Complications related to fractures, especially of the long bones such as the femur, can include fat embolism, compartment syndrome and hemorrhage. Findings seen with compartment syndrome will include worsening pain, paresthesia (numbness, tingling), pallor (coolness and loss of color) and weak, diminished or absent pulse. A fat embolism will typically travel to the pulmonary vasculature and cause respiratory symptoms. Hemorrhage near the fracture site will manifest with swelling, bruising/hematoma, hypotension and tachycardia. The other findings are important to note but are not life-threatening and should be addressed at a later time.

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 rationale 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 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 rationale 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.

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.)

Place a soft foam triangular pillow between the client's legs when in bed Provide a seat riser for the toilet or commode Encourage client to perform leg exercises when in bed rationale 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 client is admitted to the hospital with endocarditis. The nurse understands that which risk factors can lead to the development of endocarditis? (Select all that apply.)

Placement of a central venous access device Placement of an arteriovenous fistula for hemodialysis Oral abscess with tooth extraction History of aortic valve replacement rationale Infective endocarditis (IE) is an infection of the inner layer of the heart wall and muscle. The infection is commonly caused by bacteria such as Staphylococcus aureus. The endocardium can become infected when bacteria are carried through the heart by blood flow. IE can occur in individuals with existing cardiac disease or with no cardiac disease. Clients who have poor oral hygiene and a history of dental procedures (i.e., tooth extraction) are at risk for developing IE. Invasive devices (i.e., indwelling catheters, venous access devices, pacemakers and arteriovenous fistulas) and heart valve replacement place clients at risks for IE. One complication of endocarditis includes arrhythmias, but arrhythmias (i.e., atrial fibrillation) do not place the client at risk for developing IE. Individuals who engage in intravenous drug use are at risk for IE. However, individuals who take methadone by mouth for a substance use disorder are not at risk for IE.

A client received hydromorphone orally one hour ago. When the nurse enters the client's room, the client is unresponsive to verbal stimuli and has a respiratory rate of six. Which action should the nurse take next?

Prepare to administer naloxone. rationale Hydromorphone is an opioid analgesic. The client seems to be experiencing central nervous system and respiratory depression related to the medication. The antidote for opioids is naloxone. The nurse should first administer naloxone to reverse the effects of the hydromorphone. The other actions are not appropriate for the client at this time.

The nurse is assisting in the development of a plan of care for a client with acute rheumatoid arthritis. Which priority interventions should the nurse include? (Select all that apply.)

Preventing joint deformity Preserving joint function Relieving pain Pain relief is a high priority during the acute phase of RA because the pain is typically severe and interferes with the client's ability to function. Preserving joint function and preventing joint deformity are high priorities during the acute phase to promote an optimal level of functioning and reduce the risk of contractures. Managing stress and establishing a goal for a healthy weight are also important, but can wait to be addressed until the acute episode has resolved.

The nurse receives an order to give a client iron by deep injection. What does the nurse understand about the reason for using this method of administration?

Prevents the medication from tissue irritation rationale Deep injection, or Z-track, is a special method of giving medications via the intramuscular route. Use of this technique prevents irritating or staining medications from being tracked through tissue. Use of Z-track does not affect dose, absorption, or distribution of the medication. Oil-based or thick medication is commonly given in this manner for the same reason.

The nurse is caring for a client diagnosed with substance use disorder (SUD). The client states, "I just drink occasionally. I don't know why my wife and the judge think that I need to be in an alcohol treatment program." Which of the following behaviors are consistent with SUD?

Prone to act impulsively Craving and inability to abstain from alcohol Insecurity in relationships SUD is a chronic disease where a person persistently uses alcohol or drugs. Individuals with SUD have a craving for the addictive substance and are unable to abstain from it. Despite the negative consequences of abusing drugs or alcohol, they typically are not internally motivated to change. They often demonstrate an inability to identify problem behaviors. They are anxious, insecure and often have family and work problems. They may experience blackouts and cannot remember what happened when they were drinking, but the inability to suppress memories is not an issue with SUD.

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

Protection from harm to self and others rationale 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 rationale 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 nurse is caring for a homeless client recently diagnosed with type 2 diabetes. Which actions demonstrate that the nurse is advocating for the patient? (Select all that apply.)

Provide a list of area pharmacies that offer free or reduced-price medications. Consult a social worker to help the client apply for Medicaid. Arrange for a follow-up appointment at a free clinic. rationale The nurse as an advocate needs to understand the client's current situation. It would not be possible for a homeless individual to receive scheduled meal delivery services. Family members should not be approached. The nurse could arrange appointments at a free clinic and refer the client to area pharmacies that provide free or reduced-price medications. The social worker should be consulted to help the client apply for Medicaid, as well as for other available social services.

The nurse is preparing interventions for a client with major depression who has been showing signs of impaired social interaction. Which of the following nursing interventions is initially appropriate for this client?

Provide activities that require minimal concentration Clients with depression who are struggling to interact with others should be given time to adjust to the therapeutic environment or milieu. The nurse will accomplish this initially by providing the client activities that require minimal concentration. Once the client shows signs of improved mood and concentration, the nurse should implement the other interventions.

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

Provide more frequent feedings Rationale 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 client who has osteoarthritis, affecting both knees, is reporting constant pain at a level of 4 on a 0 to 10 scale. Which nonpharmacological intervention should the nurse implement for this client to help alleviate the pain?

Provide opportunity for the client to participate in hydrotherapy. Osteoarthritis (OA) means the degeneration of cartilage in the joints, primarily the weight-bearing joints. These degenerative changes lead to swelling and pain in the joint. To prevent joint stiffness, it is important to encourage the client to balance activity and rest. Strict bedrest would only increase joint stiffness and further decrease in joint mobility. Paraffin (a type of wax) dips are helpful for clients with OA in the hands, but are not usually used for OA in the knees. The joints should be placed in a neutral, not flexed, position to prevent contractures. Soaking in a hot bathtub or doing hydrotherapy with physical therapy provides warmth that will decrease pain. The buoyancy of the client's body in water decreases weight on the joints, which will also decrease pain.

A client is on NPO status and has a nasogastric (NG) tube in place, connected to low-intermittent suction, to help resolve a small bowel obstruction. Which nursing intervention should the nurse implement for this client?

Provide oral care at least every 2 to 4 hours. rationale Oral hygiene is an important part of basic client care, especially for clients who are older and/or on NPO status. Regular oral care maintains mucous membrane integrity and prevents oral cavity inflammation or infections. Some clients (e.g., clients who've experienced stroke or trauma to their oral cavity, or a client with an endotracheal tube) require oral care as often as every 1 to 2 hours. Effective oral hygiene include brushing their teeth at least twice a day. For clients at increased risk of poor oral hygiene, use an antimicrobial toothpaste and 0.12% chlorhexidine (CHG) oral rinse. Ice chips are contraindicated for a client who is NPO and has a bowel obstruction. Lemon and glycerin swabs will further dry out mucous membranes and erode tooth enamel and should not be used.

The nurse is preparing to suction a client's tracheostomy. What action should the nurse take to prevent hypoxia during the procedure?

Provide preoxygenation to the client. rationale All of the actions are appropriate during suctioning, but their rationales differ. Using sterile technique is important to prevent introducing bacteria into the airway and causing an infection such as pneumonia. Explaining the procedure to the client is important to help the client understand what to expect and minimize fear and apprehension about the procedure. Monitoring the HR is important to evaluate how the client is tolerating the procedure. A transient increase in HR is to be expected, but the HR should return to baseline quickly after suctioning is stopped. A significant decrease in HR can indicate a vasovagal response, and low oxygenation and suctioning should be stopped immediately. Preoxygenation with 100% oxygen prior to suctioning is the best method to prevent hypoxia during suctioning. In addition, each suction pass should be limited to 10 to 15 seconds.

A client with a new tracheostomy is becoming frustrated because of being unable to speak. Which nursing intervention would be the most effective to help the client to communicate

Provide the client with a communication board and check on them frequently. rationale The inability to talk is a major stressor for a client with a new tracheostomy. It is important to maintain communication with the client. The nurse can use a writing tablet, a board with pictures and letters, communication flash cards on a ring, hand signals and smartphones to promote communication and decrease frustration from not being able to speak or be understood. The other interventions, while important, would not be as effective. The nurse should phrase questions to solicit "yes" or "no" answers to help the client respond more easily and place a note at the central call light system intercom to indicate that the client cannot speak

A client diagnosed with hypoparathyroidism would be most likely to display which of the following symptoms?

Pruritus rationale A client with hypoparathyroidism can present with the following laboratory anomalies: hypocalcemia, hyperphosphatemia and hypomagnesemia. Therefore, the nurse should identify signs and symptoms associated with these laboratory changes. Pruritus is often associated with increased levels of serum phosphorous and is common in patients with hypoparathyroidism. Kidney stones and associated flank pain are sometimes seen in clients with hypercalcemia, which is not traditionally seen in clients with hypoparathyroidism. In fact, clients with hypoparathyroidism often have low levels of serum calcium. Clients with hypermagnesemia can present with decreased reflexes. However, serum magnesium is often low in clients with hypoparathyroidism. Polydipsia is often seen in clients with diabetes mellitus secondary to hyperglycemia, and glucose levels are not typically impacted by hypoparathyroidism.

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 rationale 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.

The nurse is caring for a client who presents with polyuria, polydipsia and a urine specific gravity of 1.002. The nurse suspects that the client is experiencing diabetes insipidus. Which risk factors would support this diagnosis? (Select all that apply.)

Recent neurologic injury History of radiation treatment History of recent surgery Current use of lithium rationale Diabetes insipidus is a pathological condition caused by a deficient volume of antidiuretic hormone or an inability of the kidneys to respond to antidiuretic hormone. This results in the excretion of large volumes of dilute urine, accompanied by thirst to maintain homeostasis in the light of dehydration. The nurse should be able to identify that polydipsia and a low urine specific gravity may be indicative of diabetes insipidus, and should be able to assess for the presence of risk factors. A history of recent surgery, radiation treatment or neurologic injury may predispose an individual to poor antidiuretic hormone secretion if the posterior pituitary gland, where antidiuretic hormone is excreted from, was injured. Lithium use can be nephrotoxic and can result in the kidney's failure to respond to antidiuretic hormone. A client's history of pulmonary disease is a risk factor for the development of syndrome of inappropriate antidiuretic hormone (SIADH), a condition that results from excess antidiuretic hormone.

A 20-year-old male client who has a profuse, purulent urethral discharge with painful urination is seen at a community health clinic. Which information will be most important for the nurse to obtain?

Recent sexual contacts The client is exhibiting clinical manifestations of a sexually transmitted infection (STI). Information about the client's sexual contacts is needed to establish whether the client has been exposed to a STI and if confirmed, the client's sexual contacts will also need treatment. The other information may also be gathered but is not as important in determining the plan of care for the client's current symptoms.

A client reports to the nurse that he must check to make sure that the iron is unplugged 10 times before leaving the house. The nurse understands that this is the client's attempt to:

Reduce personal anxiety A client's motivation for the obsessive/compulsive checking of the iron is to decrease their own personal anxiety. The behavior is not motivated by malicious intention or safety awareness.

A client reports to the nurse that he must check to make sure that the iron is unplugged 10 times before leaving the house. The nurse understands that this is the client's attempt to:

Reduce personal anxiety rational A client's motivation for the obsessive/compulsive checking of the iron is to decrease their own personal anxiety. The behavior is not motivated by malicious intention or safety awareness.

The nurse is reviewing the plan of care for a client with peripheral artery disease who has a history of leg pain with walking. Which interventions should the nurse include in the client's plan of care? (Select all that apply).

Reinforce teaching on the importance of not walking without shoes on. Enroll the client in an exercise program that involves low-impact activities. Assist the client in selecting food items that are low in saturated fats and cholesterol. Assist the client in enrolling in a smoking cessation program. rationale Peripheral artery disease (PAD) occurs when atherosclerosis develops in peripheral arteries. As a result, arteries become narrow and blood supply becomes restricted in the affected extremity. Risk factors for PAD include smoking, hypercholesterolemia and diabetes. To prevent the progression of PAD, clients should quit smoking. As PAD progresses, the narrowed vessel can become more occluded. As a result, clients with PAD should not elevate their legs, as that will further diminish blood flow to the area. Low-impact exercise such as riding a stationary bike can improve circulation to the peripheral tissue. Clients should reduce saturated fats and cholesterol in their diet to slow the progression of PAD. Clients with PAD should not walk barefoot due to the risk for injury and wound development. Wounds that develop in clients with PAD are difficult to heal due to the decreased blood supply and tissue perfusion.

The school nurse is called to see a student who is having a nosebleed that will not stop. The student's records show a history of hemophilia. What are the priority interventions for this client? (Select all that apply.)

Remind the student to avoid blowing the nose too forcefully. Notify the student's health care provider. Apply direct pressure by squeezing the nose tightly. Notify the student's parent or guardian(s). rationale Hemophilia is a genetic disorder caused by a defective or deficient coagulation factor. All clinical manifestations relate to bleeding, and any bleeding episode in a person with hemophilia can lead to a life-threatening hemorrhage. The nurse should immediately implement steps to stop the nosebleed and notify the student's next-of-kin and health care provider. The nosebleed could have started by forceful blowing of the nose and the student should be reminded to avoid forceful blowing of the nose in the future. Notifying the principal and not participating in future physical exercises are not priorities at this time.

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 rationale Persistent coughing should be reported to the health care provider because this may indicate bleeding.

The nurse is planning care for a client admitted with uncontrolled hyperglycemia. Which activities can the nurse delegate to the unlicensed assistive person (UAP)? (Select all that apply.)

Report any skin lesions or breakdown to the nurse. After bathing, ensure that the client's skin is completely dry. Check the client's blood sugar before meals and at bedtime. When collaborating with the UAP, it is important to delegate activities that are appropriate for the UAP to perform and appropriate for the client and their condition. In clients who suffer from diabetes, blood sugar monitoring, skin care and foot care are essential. The UAP should check the client's blood sugar before meals and at bedtime. However, the UAP should not administer insulin. While providing hygiene care, the UAP should dry the skin and apply moisturizing lotion. However, lotion should not be applied between the toes due to the risk of macerating injuries. When providing foot care, soaking the feet is contraindicated and nails should be cut straight across to prevent injury.

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 raSerious 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.tionale

The nurse has been reinforcing information about cardiac risks to adult clients when they visit the hypertension clinic. What would be the best way to determine if learning has occurred?

Reported behavioral changes rationale If a client alters any behaviors, such as smoking, drinking alcohol and stress management, this would suggest that learning has occurred.

The home health nurse is discussing safety concerns with a client who has osteoporosis. Which interventions should the nurse recommend to the client? (Select all that apply.)

Request a referral for physical therapy. Increase intake of dairy products. Enroll in a smoking cessation program. Correct! Provide assistive devices, if needed. rationale Clients with osteoporosis have fragile bones and are at risk for fractures. The nurse should encourage coordination with physical therapy to increase muscle strength, balance and decrease the likelihood of a fall. The nurse would also provide assistive devices if the client requires them. Not all clients with osteoporosis will need an assistive device. Due to the impact on joints that occurs with running, the nurse should not recommend jogging or running to a client with osteoporosis. Low-impact activities such as walking would be better. Since smoking decreases tissue perfusion in general and impacts bone development, the client should stop smoking. Dairy products are high in calcium and will help with strengthening bones.

A client's arterial blood gas shows a pH of 7.30, pCO2 of 53 and HCO3 of 24. The nurse recognizes which acid-base imbalance?

Respiratory acidosis rationale A normal pH ranges from 7.35 to 7.45. A pH of 7.30 is low and indicates acidosis. Next, the nurse should look at the partial pressure of carbon dioxide (PCO2) level. Normally, carbon dioxide (CO2) levels range between 35 to 45 mm Hg. A level of 53 is high and since CO2 is an acid, it is causing a respiratory acidosis. The kidneys manage the balance of hydrogen and bicarbonate ions and will attempt to balance the CO2 imbalance by producing more bicarbonate, a base. This renal compensatory response takes time. A normal bicarbonate (HCO3) level ranges from 21 to 28 mmol or mEq/L. Since the HCO3 level for this client is still normal, compensation has not yet occurred. Therefore, the client has an uncompensated, respiratory acidosis.

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 rationale 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.

A client is two days postoperative after surgery to remove an abdominal tumor. The client's current vital signs are blood pressure 160/90, heart rate 110, respiratory rate 30 and temperature 100.4⁰ F (38⁰ C). Which vital sign should be of greatest concern to the nurse?

Respiratory rate rationale The nurse in this situation should follow the A-B-C prioritization strategy. Tachypnea is one of the first clues that the client could be experiencing an airway, breathing or oxygenation problem. The increased BP and HR are most likely compensatory mechanisms for the underlying respiratory problem. The fever is also of concern, but should be addressed after the nurse has determined the cause of the tachypnea.

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 rationale 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 mother asks about expected motor skills for her 3 year-old child. Which activity should the nurse discuss as normal at this age?

Riding a tricycle rationale Coordination is gained through large muscle use. A 3 year-old child has the ability to ride a tricycle, hop and stand on one foot. The other activities would more typically be found in preschoolers.

The nurse in a long-term care facility is caring for an 89-year-old client with atrial fibrillation and a history of multiple falls. The client's medications include amiodarone, atorvastatin, baby aspirin and metoprolol. Which new finding should be of greatest concern to the nurse?

Right-sided facial droop rationale The most concerning finding would be the development of a right-sided facial droop. The client with atrial fibrillation is at increased risk of stroke, and this client's listed medications do not include an anticoagulant, typically prescribed to prevent a stroke. Given the finding of frequent falls, it is possible that the client is not on a stronger anticoagulant, such as warfarin, due to an increased risk of intracranial hemorrhage after a fall. A SpO2 of 89% on room air, a heart rate of 106 and crackles on auscultation are all concerning findings, but the possibility of a stroke should be of the greatest concern to the nurse.

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 rationale 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.

The clinic nurse is evaluating an older male client who reports having trouble urinating. After the client uses the bathroom, which method should the nurse use to check for post-void residual (PVR)?

Scan the bladder, using a portable ultrasound scanner. Urinary retention and incomplete bladder emptying can result from urethral obstruction, as seen in benign prostatic hyperplasia (BPH). The nurse can palpate the area from the umbilicus towards the symphysis pubis. An empty bladder rests behind the symphysis pubis and should not be palpable. The nurse can also percuss this area. A urine-filled bladder produces a dull sound. But a bladder ultrasound is the most effective technique since it will digitally register bladder volume. Routine catheterization to check for PVR is not recommended. Abdominal rebound tenderness will not determine urinary retention.

The nurse is planning care for a client with Alzheimer's disease. The client has episodes of bowel and bladder incontinence. Which intervention should the nurse include in the client's plan of care?

Schedule toileting for the client every two hours during the day. rationale When planning care for a client with Alzheimer's disease the nurse should promote bowel and bladder continence. The client may need prompting from health care personnel to complete the act of toileting. The client may remain continent of bowel and bladder for long periods if taken to the bathroom or given a bedpan or urinal every two hours or more often during the day. The nurse encourages the client to drink adequate fluids to promote optimal voiding. Placing a picture on the bathroom door may help the client identify the bathroom if they have been voiding in inappropriate places like the sink or a wastebasket. Clients with Alzheimer's disease often have difficulty sleeping, so their treatment and medication schedule should be adjusted to provide uninterrupted sleep.

The nurse is caring for a client receiving mechanical ventilation. The nurse understands which are the possible causes for a high-pressure alarm? (Select all that apply.)

Secretions Bronchospasms Kinked tubing rationale High-pressure alarms are usually caused by something preventing or blocking air from being delivered by the ventilator to the lungs. Kinked tubing, secretions and/or bronchospasms cause obstruction to airflow from the ventilator, creating high pressure in the ventilator circuit and setting off the high-pressure alarm. Total or partial extubation would cause a low-pressure alarm due to air escaping from the closed circuit and ventilator malfunction would produce a machine inoperable or similar alarm.

The nurse is preparing to ambulate a client who requires the use of a gait belt. Which of the following actions are appropriate for the nurse to take?

Secure the gait belt to fit around the client's waist. Use an underhand grasp at the center of the client's back to grasp the gait belt. When ambulating a client who requires minimal assistance, a gait belt is important to help support the client's mobility. The gait belt should be secured around the client's waist. The nurse should use the inside arm with an underhand grasp in the center of the client's back to secure the belt providing support for the client. With minimal assistance, the nurse should ambulate at the client's pace and support the client's weaker side. The buckle should be in the front of the client.

The nurse is preparing a client for a pulmonary CT angiogram with contrast to rule out a pulmonary embolism. For which laboratory result should the nurse notify the health care provider immediately?

Serum creatinine level of 2.8 mg/dL rationale Pulmonary embolism means the blockage of a pulmonary artery by a thrombus. A spiral CT scan, i.e., CT angiography, is the test most frequently used to confirm a pulmonary embolism (PE). An intravenous injection of contrast media (dye) is required to visualize the pulmonary vasculature. The dye has the potential to cause renal failure and should be used with caution in clients with impaired renal function. The client's creatinine level is significantly elevated (normal creatinine level is 0.8 to 1.2 mg/dL), placing the client at risk for dye-induced renal failure and the nurse should notify the health care provider of this lab result immediately. The elevated D-dimer level is to be expected. The PaO2 and troponin levels are within normal limits.

The nurse is reviewing the chart of a client who was admitted after having been found lying on the bathroom floor in their home. The client's family reports that the client could have been lying on the floor for over 12 hours. Which laboratory result should be of greatest concern to the nurse?

Serum creatinine level of 4.2 mg/dL rationale When a person falls and lies immobile for an extended period of time, muscle tissue will start to break down. This is called rhabdomyolysis. Rhabdomyolysis leads to the release of myoglobin (muscle protein) into the bloodstream. Myoglobin breaks down into substances that will damage the kidneys, causing acute kidney injury (AKI) as evidenced by the client's severely elevated creatine level. (A normal range would be between 0.5 to 1.2 mg/dL). Although the client's other lab values are also outside of the normal range, the values are not as severely elevated or decreased as the creatinine level which represents the greatest concern to the client's condition at this time.

An 80-year-old client with type 2 diabetes mellitus is admitted to the emergency department with worsening confusion and decreased level of consciousness. Which of these findings is most important for the nurse to report to the health care provider?

Serum osmolarity of 355 mOsm/L rationale The nurse must be able to differentiate between diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar syndrome (HHS) and their correlating laboratory values. HHS occurs more often in type 2 diabetics than type 1 diabetics and is more likely in older adult clients. Many older adults have contributing risk factors such as diuretic use, impaired thirst mechanism, dehydration and inadequate oral fluid intake. HHS is characterized by elevated blood sugar level (often > 600), blood osmolarity > 320 to 350 (normal = 270 to 300), polyuria and normal blood pH (absence of ketosis and acidosis). Hyperosmolarity and severe cellular dehydration will cause central nervous system problems, from worsening mental status to seizures, coma and death. The first priority for this client is fluid replacement to correct the severe dehydration.

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 rationale 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.

The nurse in the long-term care facility is reviewing the plan of care for a client with Parkinson's disease. Which interventions should the nurse make sure to include for this client? (Select all that apply.)

Set-up a bladder training program for the client. Correct! Encourage participation in speech therapy. Use cognitive strategies to enhance the client's memory. Provide assistance with ambulation. rationale Parkinson's disease is a neurological disease that primarily affects movement and can impact cognitive function such as memory. All of the interventions are appropriate for this client with the exception of allowing the client to wander throughout the facility. Clients with Parkinson's disease often suffer from postural instability and are at great risk for falls and injury. The client should have someone with them if they wish to walk throughout the facility. There are other ways to promote the client's independence and the client's safety must come first.

A nurse at a community health clinic is speaking to a group of young adults about preventing HIV infection. Which high risk behaviors to avoid should the nurse include? (Select all that apply.)

Sharing needles Having unprotected sex Risk factors associated with HIV include sharing injection drug equipment, having multiple sexual partners, having sexual relations with infected persons, being born to mothers with HIV infection and not using some form of protection during sex. The nurse should provide preventative education regarding using safer sexual practices to reduce the risk of transmitting HIV and avoid sharing any type of needles, razors, toothbrushes or anything that is potentially contaminated with blood. The other behaviors are not known to increase the risk for contracting HIV.

A 48-year-old male client who is being admitted to the emergency department with an acute myocardial infarction (MI) gives the following list of medications to the nurse. Which medication would the nurse recognize as having the most immediate implications for the client's care?

Sildenafil ratational The nurse will need to avoid giving nitrates to the client because nitrate administration, commonly prescribed for clients experiencing an acute MI, is contraindicated in clients who are using sildenafil (a PDE5 inhibitor) because of the risk of severe hypotension caused by vasodilation. The other medications the client is taking should also be documented and reported to the health care provider (HCP) but do not have as immediate an impact on decisions about the client's treatment.

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 rationale he 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 rationale 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.

The nurse in the pediatric clinic is caring for an acutely ill, 10-year-old child. Which assessment finding would require immediate intervention by the nurse?

Slow, irregular respirations rationale A slow and irregular respiratory rate is a sign of respiratory fatigue and impending acute respiratory failure in the child. Respiratory failure can rapidly lead to respiratory and cardiac arrest. Immediate interventions are required, such as supplemental oxygen, intubation and mechanical ventilation to support the child's respiratory status.

The nurse is discussing modifiable cardiac risk factors with a group of adult clients at a community center. Which topic should the nurse reinforce as the highest priority intervention?

Smoking cessation Stopping smoking is the highest priority for clients at risk for cardiac disease because of the effects of smoking on the arteries, including atherosclerosis and vasoconstriction. The other interventions are also important, modifiable actions to prevent cardiovascular disease (CVD). However, smoking tobacco products is widely considered the greatest risk factor for developing CVD (as well as other diseases).

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 nurse is caring for a client who has hearing loss. Which of the following actions should be implemented by the nurse to improve communication? (Select all that apply.)

Speak to the client at eye level. Use short sentences. Important actions to improve communication between the nurse and a client with hearing loss is for the nurse to be sure they speak to the client at eye level and use short sentences. It is not necessary to turn the lights down, speak at a slower rate or speak loudly. Not all clients with hearing loss understand sign language and nurses are not required to learn it.

A client with a back injury asks the nurse how chiropractic manipulation works. What is the nurse's best response?

Spinal column manipulation The term "chiropractic" derives from the Greek "chir-" referring to the hand, and "prassein," meaning to work with the hands or to manipulate. Chiropractic medicine employs the manipulation of body structures, such as the spinal column, to relieve pressure on nerves that cause pain. Chiropractic medicine does not use energy fields. Mind-body balance refers to forms of exercise that combine body movement, mental focus and controlled breathing to improve strength, balance, flexibility and overall health. Exercising joints is usually done as part of a physical therapy program.

The nurse is caring for a client with late-stage liver cirrhosis. The nurse should monitor the client for which clinical manifestations? (Select all that apply.)

Splenomegaly Spider angiomas Ascites Late clinical manifestations related to cirrhosis are the result of portal hypertension and the inability of the liver to maintain normal functions such as detoxification, blood clotting, bile production, blood filtration and carbohydrate, protein and fat metabolism. Common findings include low serum albumin levels, leading to edema and fluid volume excess, spider angiomas (i.e., telangiectasia or spider nevi), and increased venous pressure in the portal circulation, leading to ascites and an enlarged spleen.

The nurse is preparing to administer an antibiotic intramuscularly (IM) to a 2-year-old child. The total volume of the injection is 2 mL. What is the best approach for the nurse to take when administering this medication?

Split the medication into two separate injections. rationale Recommendations for IM medication administration for an infant/toddler (1 month to 2 years) include using a 1 inch, 22 to 25 gauge needle. The vastus lateralis muscle is preferred. The deltoid muscle should only be used if the muscle mass is adequately developed. IM injections for small children should not exceed a volume of 1 mL. For medication doses that exceed this volume, it is best to split the dose into two separate injections of 1 mL each. The other actions are not appropriate in this situation.

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 Rationale: 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.

An off-duty nurse arrives at a park and is told by a bystander that a child is choking and needs assistance. The bystander has already called 911. The nurse observes an approximately 8-year-old child with cyanosis and an inability to breathe who remains conscious and standing. What should the nurse do next?

Stand behind the child and administer abdominal thrusts. rationale For a conscious choking victim, according to basic life support (BLS) guidelines by the American Heart Association (AHA), the next action by the nurse should be to perform abdominal thrusts (i.e., the Heimlich Maneuver) to attempt to clear the airway obstruction. Attempting to deliver rescue breaths or checking the carotid pulse of a conscious choking victim would not be indicated. If the child were to become unconscious, then chest compressions should be initiated.

The nurse observes an unlicensed assistive person (UAP) providing care to a client who had a total hip arthroplasty 24 hours ago. Which action by the UAP would require the nurse to intervene immediately?

Standing by the client's non-operative side during ambulation. rationale When assisting the client during ambulation following a total hip arthroplasty, the UAP should stand on the operative side (i.e., the side of the surgery) to help provide support to the client because that is the client's weaker side. The other actions are appropriate for this client and do not require intervention by the nurse.

The nurse is teaching a class on health promotion to a group of college students living in a university dormitory. Which information should the nurse include? (Select all that apply.)

Students should obtain a flu vaccine annually Students should seek treatment for upper respiratory infections promptly Students should ensure their meningitis vaccines are current. Students should maintain good hand hygiene practices. College students who live closely together in group housing such as a dormitory are at greater risk for the spread of diseases, especially bacterial meningitis. As part of health promotion, it is essential the students' meningitis vaccines are current. The Centers for Disease Control & Prevention (CDC) recommends the meningitis A vaccine booster at about age 16, which protects against the meningitis serogroups A, C, W and Y. The CDC also recommends the meningitis B vaccine between ages 16 and 18, which protects against serogroup B. Bacterial meningitis often presents as an upper airway infection, so these infections should be treated promptly. The CDC recommends a flu shot annually for all adults and children. Good hand hygiene prevents the spread of many diseases. The pneumococcal vaccine is not required or necessary in this age group.

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

Take on an empty stomach rationale 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.

The client is diagnosed with infective endocarditis of the tricuspid valve. Which finding suggests a complication of this condition?

Sudden dyspnea For the client with infective endocarditis, vegetation growing on the infected heart valves on the right side of the heart can break off and travel in the blood to lodge in a blood vessel in the lung. This is known as pulmonary embolism (PE). A significant piece of evidence of this is sudden dyspnea, as well as a sudden decrease in oxygen saturation. The breath sounds associated most with PEs are diminished or absent, not pronounced. A spike in temperature is more commonly from bacterial pneumonia, urinary tract infection, or otitis media than PE. Vegetation from the infected heart valves on the left side of the heart would lead to the complication of cerebral infarction or finding of a stroke, or ischemia of other peripheral blood vessels.

The nurse is caring for a client with anemia of chronic disease. The client's latest hemoglobin level is 7.6 g/dL. Which clinical manifestations would the nurse expect to find? (Select all that apply.)

Tachypnea Fatigue Pallor rationale A hemoglobin level of 7.6 is very low. Normal levels range from 12 to 16 g/dL for females and 14 to 18 g/dL for males. Due to the low level of hemoglobin in the blood, the client will exhibit signs of low tissue oxygenation or hypoxia, such as fatigue, activity intolerance, shortness of breath, tachycardia, tachypnea and skin pallor (i.e., the skin is pale and cool to the touch). The client would not have bradycardia or hypertension with such severe anemia. The opposite is more likely, such as tachycardia.

A nurse is caring for a 2-year-old child who underwent a tonsillectomy at 8:00 am. At 11:00 am, the child has a temperature of 98.2⁰ F (36.7⁰ C). At 1:00 pm, the child's parent reports to the nurse that the child feels very warm to touch. What should the nurse do first?

Take the child's temperature. rationale The parent's report of warm skin is a subjective sign and the nurse should first obtain a temperature reading to confirm that the client's temperature is truly elevated. A low-grade fever (99 to 101⁰ F or 37.2 to 38.3⁰ C) is common after surgery. Usually, the health care provider (HCP) is contacted if the temperature is higher than 101.5⁰ F (38.6⁰ C). After the nurse has validated and evaluated the client's temperature, the nurse should implement the other actions.

A client is transferred from the postanesthesia care unit (PACU) to the medical-surgical unit after an appendectomy. Which action should the nurse on the medical-surgical unit perform first?

Take the client's vital signs. Correct! rational Although all these actions are appropriate, the first assessment or data collected should be the client's vital signs. After surgery, a client may still experience side effects from the surgery and the anesthetic agents used. Therefore, vital signs provide important information about the client's hemodynamic and respiratory status. Then, the nurse should evaluate the client's level of pain and implement interventions to alleviate the client's pain.

The nurse in a long-term care facility is reviewing the plan of care for a client with quadriplegia. Which risk assessment scale should be included for this particular client?

The Braden scale rationale A client who has paralysis of all four limbs (quadriplegia) is at risk of developing a pressure ulcer. A pressure ulcer is tissue damage caused when the skin and underlying soft tissue are compressed between a bony prominence and an external surface for an extended period of time. The Braden scale is used for predicting pressure ulcer risk, and should be included in this client's plan of care. The Hendrich scale is used for fall risk. The Wong-Baker scale uses visual faces to assess pain. The Hamilton scale is used to rate anxiety. This client likely could not participate in the use of these options, nor are they the highest priority.

The nurse is observing an unlicensed assistive person (UAP) on the nursing unit. For which action by the UAP should the nurse intervene immediately?

The UAP uses hand sanitizer upon exiting the room of a client with Clostridium difficile. rationale Clostridium difficile (C. diff) is a gastrointestinal infection that is easily spread in health care settings. It is important for the client with C. diff to be placed on contact precautions, which include wearing a gown and gloves when entering the room. Although using an alcohol-based hand sanitizer is acceptable for many situations, hand sanitizer does not kill the C. diff pathogen. Therefore, the UAP must wash their hands with soap and water after being in contact with the client. The other actions are appropriate and do not require immediate interventions by the nurse.

Nadolol is prescribed for a client with chronic stable angina. To evaluate whether the drug is effective, the nurse will monitor for which finding?

The ability to do daily activities without chest pain rationale Nadolol is a first generation, non-selective beta-adrenergic antagonist (i.e., beta blocker). Because the medication is ordered to improve the client's angina, it is considered effective when the client is able to accomplish daily activities without chest pain. Blood pressure and heart rate may decrease, but these data do not indicate that the goal of decreased angina has been met. Non-cardioselective b-adrenergic blockers can cause peripheral vasoconstriction, so the nurse would not expect an improvement in distal pulse quality or skin temperature

client is admitted to the nursing unit for respiratory distress due to a myasthenia gravis crisis. Which recent treatment may have been a contributing factor to the client's condition?

The administration of morphine sulfate for acute pain management rMyasthenia gravis is a chronic autoimmune disease characterized by fatigue and weakness, primarily in muscles innervated by the cranial nerves, as well as in skeletal and respiratory muscles. As a result, nerve impulses are not transmitted to the skeletal muscle at the neuromuscular junction. The priority for nursing management of the client in myasthenic crisis is maintaining adequate respiratory function. Since this is an autoimmune disease, corticosteroids may be used for immunosuppression as well as intravenous immunoglobulin (IVIg) therapy. Plasmapheresis exchange is performed to remove antibodies from the blood. Drugs containing magnesium and morphine should be avoided because they may increase the client's weakness and respiratory suppression.ational

A client presents with a burn that is painful, pale and waxy with large flat blisters. The client asks the nurse about the severity of the burn. What is the best response by the nurse?

The burn is a partial thickness burn. rationale The wound described is a deep partial thickness burn. A superficial burn or sunburn is bright red and moist, and might appear glistening with blister formation. A full-thickness burn involves all layers of the skin and may extend into the underlying tissue and is usually not painful.

The nurse in an ambulatory clinic is speaking with the parents of a 2-year-old child diagnosed with acute otitis media. Which information is most important for the nurse to include in the instructions to the parents?

The child must complete the entire course of the prescribed antibiotic. rationale Acute otitis media (AOM) is an inflammation of the middle ear space with a rapid onset of the signs and symptoms of acute infection, namely, fever and otalgia (ear pain). It is one of the most prevalent early childhood illnesses. Treatment for AOM is one of the most common reasons for antibiotic use in the ambulatory setting. When antibiotics are necessary, it is most important to complete the entire course to prevent antibiotic resistance. The child should be seen after antibiotic therapy is complete to ensure that the infection has resolved. Supportive care of AOM includes treating the fever and pain. Decongestants or antihistamines are not recommended for children with ear infections.

A client has received instructions about the management of their chronic dermatitis. Which action by the client indicates an understanding of the instructions?

The client avoids itching and scratching the affected area. rationale Excessive itching can cause excoriation of the skin, potentially resulting in inflammation and infection. Cool compresses may cause vasoconstriction and decrease itching. Heat will exacerbate itching. Oral antihistamines are sometimes recommended to provide relief from itching, although they may cause drowsiness. Topical corticosteroids are also sometimes prescribed because they may numb the itch receptors.

A client is admitted to the cardiology unit for treatment for recurrent supraventricular tachycardia. Which observation by the nurse would best indicate that the client's condition can be considered hemodynamically stable?

The client denies any chest pain and capillary refill is less than three seconds. rationale Supraventricular tachycardia (SVT) is an arrhythmia that originates above the atrioventricular (AV) node. Clients with SVT can have a heart rate between 160-250 beats per minute (BPM). Causes of SVT include electrolyte imbalances, cardiac disease, hypoxia and medications. Clients with SVT typically present with palpitations, chest pain and shortness of breath. They can also develop cardiogenic shock if the rhythm goes untreated. Treatment for SVT includes vagal maneuvers, medications (i.e., adenosine) and synchronized cardioversion. Based on the client's blood pressure and heart rate, the client is hemodynamically unstable. Although the client's oxygenation status is within acceptable limits, it is not a good indicator of hemodynamic status. The absence of chest pain and good capillary refill indicate that the client is maintaining an adequate cardiac output and are, therefore, the best indicators that the client is hemodynamically stable.

The nurse in a long-term care facility is reviewing the medical record of a newly admitted client. Which of the following factors put the client at an increased risk for developing a pressure ulcer? (Select all that apply.)

The client has a body mass index (BMI) of 30. The client is receiving an immunosuppressant drug for rheumatoid arthritis. The client has diabetes mellitus. rationalee Obesity or low body weight are risk factors for pressure ulcer injury. A BMI of 30 puts the client in the obese range, causing increased pressure while sitting or lying in bed. Diabetes mellitus may cause sensory altercations, which also is a risk factor. Immunosuppressant drugs may suppress or reduce the strength of the body's immune system. Exercise-induced asthma is not a direct risk factor and there is no indication the client is in respiratory distress. Clients who are confused may not report or sense pain or discomfort, which could decrease their ability to protect skin integrity, relieve pressure, maintain hygiene or report discomfort.

An older adult client is to receive intravenous (IV) gentamicin for urosepsis. Before administering the medication, for which finding should the nurse notify the health care provider (HCP)?

The client has a history of chronic kidney disease. rationale Gentamicin is an aminoglycoside antibiotic. Aminoglycosides are used to treat severe infections, such as septicemia, and are only given for a short period of time due to their toxic effects. They are not metabolized by the liver. Instead they are excreted by glomerular filtration. Aminoglycosides are nephrotoxic and requires close monitoring of renal function. A client with chronic kidney disease should not receive this medication. The other conditions do not represent a contraindication to gentamicin.

A nurse working on the orthopedic unit has just received change-of-shift report. Which client should the nurse evaluate first?

The client who has not voided 10 hours after a laminectomy. rationale Inability to void may indicate damage to the spinal nerves from the laminectomy that is affecting the bladder and causing urinary retention. This presents a medical emergency, which should be evaluated and reported to the surgeon immediately. The nurse should then evaluate the other clients, but the information about them does not indicate a need to be evaluated first.

The health care provider (HCP) of a client with opioid-induced constipation prescribed the administration of a bisphosphate enema. After reviewing the client's medical record, the nurse recognizes which contraindications for giving the enema? (Select all that apply.)

The client has a history of syncopal episodes. The client has a history of hemorrhoidectomy. The client has a history of thrombocytopenia purpura. rationale An enema can cause a vasovagal response and a temporary decrease in heart rate and blood pressure, causing syncope. Because the client already has a history of syncopal episodes, the nurse should clarify the order with the HCP first. The client's history of hemorrhoidectomy implies that hemorrhoids could be present, even if none are externally visible. If internal hemorrhoids are present, inserting the enema may cause bleeding and discomfort. Therefore, the nurse should clarify the order with the HCP first. Clients with thrombocytopenia (low platelet count) may begin bleeding from the rectum due to the mechanical trauma of the enema and should be given stool softeners and laxatives instead. The other conditions do not represent contraindications for receiving an enema.

A client has a new order for an open magnetic resonance imaging (MRI) scan without contrast to evaluate for osteomyelitis. Which information indicates that the nurse should consult with the health care provider (HCP) before scheduling the MRI?

The client has a pacemaker. rationale Clients with a pacemaker, an internal device made of metal, cannot have a MRI scan done because of the force exerted by the magnetic field on metal objects. An open MRI scan is unlikely to cause claustrophobia. The client will be instructed to remove the glasses before the MRI scan, but this does not require consultation with the HCP. Because contrast medium will not be used, a shellfish allergy is not a contraindication to the MRI scan.

The nurse is reviewing the medical record of a client with recurring, nonhealing venous stasis ulcers to the lower extremities. Which findings are most likely contributing to the nonhealing of the client's wounds? (Select all that apply.)

The client is 74-years-old. The client smokes one pack of cigarettes per day. The client's body mass index (BMI) is 16.5. rationale A number of factors can affect the skin's ability to heal once injured. Factors include chronic disease, age, presence of an infection (systemic or local), nutritional status, substance abuse and smoking. The client's medical record shows a number of factors that are affecting healing of the wounds for this client. The client is undernourished or malnourished (BMI less than 18), a smoker (nicotine causes vasoconstriction, increased coagulability and decreased oxygen delivery to tissues) and older (the aging process causes a decrease in collagen synthesis and epithelialization). The client's ethnicity and history of benign prostatic hyperplasia and allergies do not affect wound healing.

A client is in the rehabilitation phase after suffering severe facial burns. Which behavior by the client best indicates that the client is coping effectively with the injury?

The client is looking forward to attending their high school reunion. rationale Looking forward to attending an event is future-oriented. The client will likely see others who they have not seen in some time, indicating acceptance of one's new appearance. Resuming work is a positive sign but working from home may indicate the client does not want to be exposed to others in person. A support group is also a good idea but is not as indicative of self-acceptance as attending a large social event. A cheerful mood with the spouse is a positive sign but this is a one-on-one interaction with someone the client is most likely comfortable with.

The nurse is reviewing the plan of care for a client with a sacral, stage III pressure ulcer who is prescribed continuous negative-pressure wound therapy (NPWT). For which finding should the nurse notify the health care provider (HCP) immediately?

The client is receiving apixaban. rationale Apixaban is an anticoagulant (a direct factor Xa inhibitor) used to reduce the risk of stroke and systemic embolism in clients with atrial fibrillation. Anticoagulant therapy is a contraindication for NPWT due to the increased risk of bleeding in the wound. The other findings do not contraindicate the use of NPWT.

The nurse in a behavioral health inpatient unit is observing a female client who has been diagnosed with obsessive-compulsive disorder (OCD). Which behavior should the nurse expect to see with this diagnosis?

The client is seen washing her hands every 15 minutes. rationale Washing her hands every 15 minutes indicates compulsive behaviors seen with OCD. OCD is characterized by repetitive, unwanted, intrusive thoughts (obsessions) and irrational, excessive urges to perform certain actions (compulsions). Affected individuals are often unable to stop the compulsive behaviors. The other behaviors are not typically seen with OCD. Verbalized suspicions reflect a paranoid thought process seen with delusional disorders, such as schizophrenia or schizoaffective disorder. Repetitive, involuntary movements are side effects seen with certain antipsychotic medications.

The nurse is planning the discharge of an 80-year-old female client. Which of the following indicates the client needs to be discharged to a skilled nursing facility instead of home? (Select all that apply.)

The client needs intensive rehabilitation after hip replacement surgery. The client has a complex surgical dressing change. The client is not able to manage her activities of daily living (ADL). rationale After a hospital stay, the client may not be able to return to self-care at home and referrals to a skilled nursing facility may be necessary. Some of the criteria for admission to a skilled nursing facility include not being able to manage her own ADL and requiring a complex dressing change. Intensive rehabilitation is better accomplished at a skilled nursing facility. Being afraid to go home by herself will need to be addressed prior to discharge but is not a criterion for admission to a skilled nursing facility. If the client is able to prepare her own meals, it is a sign that the client could stay at home.

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

The nurse is reviewing the chart of a client whose spouse died two years ago. What clinical manifestation(s) would indicate that the client is suffering from complicated grieving? (Select all that apply.)

The client refuses to attend church services and social gatherings. Correct Response The client states that they have trouble sleeping and frequent nightmares. The client is unable to talk about their spouse without crying uncontrollably. Correct! rational Grief can occur in response to any significant personal loss (e.g., death or divorce). After an individual suffers a loss, they should go through a mourning process that is characterized by feelings of sadness, anger, guilt and despair. If an individual does not experience mourning after a loss, this is considered a maladaptive grief response. Although individuals move through the stages of grief and mourning at different times, routinely grieving lasts about a year.After the client moves through the phases of mourning, they should be able to look back on the loss of their loved one without crying uncontrollably.Once the client has moved through the phases of mourning and accepted their loss, they will often pursue new experiences and challenges.Support groups facilitate the grieving process and educate individuals about normal grieving patterns.Once the client has moved through the phases of mourning and accepted their loss, they will often pursue new relationships.Clients who suffer from complicated grieving can experience insomnia, nightmares and somatic symptom disorders.

The nurse is reviewing the chart of a client whose spouse died two years ago. What clinical manifestation(s) would indicate that the client is suffering from complicated grieving? (Select all that apply.)

The client refuses to attend church services and social gatherings. The client states that they have trouble sleeping and frequent nightmares. The client is unable to talk about their spouse without crying uncontrollably. Grief can occur in response to any significant personal loss (e.g., death or divorce). After an individual suffers a loss, they should go through a mourning process that is characterized by feelings of sadness, anger, guilt and despair. If an individual does not experience mourning after a loss, this is considered a maladaptive grief response. Although individuals move through the stages of grief and mourning at different times, routinely grieving lasts about a year.After the client moves through the phases of mourning, they should be able to look back on the loss of their loved one without crying uncontrollably.Once the client has moved through the phases of mourning and accepted their loss, they will often pursue new experiences and challenges.Support groups facilitate the grieving process and educate individuals about normal grieving patterns.Once the client has moved through the phases of mourning and accepted their loss, they will often pursue new relationships.Clients who suffer from complicated grieving can experience insomnia, nightmares and somatic symptom disorders.

The nurse administered furosemide to a client with acute pulmonary edema. Which observation by the nurse would indicate that the client is experiencing an adverse side effect of the medication?

The client reports muscle cramps in both legs. rationale Pulmonary edema is a condition that can occur secondary to left-sided heart failure or volume overload. Pulmonary edema can happen very quickly as fluid accumulates in the lung fields (i.e., interstitial area and alveoli) due to an increase in hydrostatic pressure. Manifestations of acute pulmonary edema include dyspnea, tachypnea, cough, tachycardia, jugular venous distention and hypertension. The hallmark treatment for pulmonary edema is diuretic therapy with a loop diuretic (i.e., furosemide). Furosemide, a potassium-wasting diuretic, can significantly decrease intravascular volume, thus leading to hypotension, dehydration and/or hypokalemia. A blood pressure of 104/60 mm Hg is considered a normal value. Weight loss of 2 lbs. in two days is considered normal for a client receiving a diuretic for pulmonary edema. Dyspnea with exertion is not a medication side effect and is to be expected until the pulmonary edema has resolved. Muscle cramps and spasms while receiving diuretic therapy could indicate hypokalemia, an adverse drug effect of furosemide.

A client has been taking alprazolam for three days. For which expected effect of the medication should the nurse evaluate the client?

The client reports sleeping through the night. rationale Antianxiety medications or anxiolytics, such as alprazolam, a benzodiazepine, work quickly. They produce sedative effects and reduce anxiety through effects on the limbic system, a neuronal network associated with emotionality. They also promote sleep through effects on cortical areas and on the brain's sleep-wakefulness "clock." Alprazolam is not used to treat depression or hallucinations.

The nurse is reviewing the medical record of a client who has been diagnosed with osteoporosis. The nurse identifies which risk factors for this condition? (Select all that apply.)

The client takes 10 mg of prednisone daily. The client has a 30 pack per year smoking history. The client is a 75-year-old Caucasian female. Osteoporosis is the loss of bone density that leads to weakness of the bone. Risk factors for osteoporosis include being a postmenopausal woman (lack of estrogen), smoking, thin stature, steroid use, lack of weight-bearing exercise, such as prolonged immobility or a sedentary lifestyle, and ethnicity. Steroid use is associated with osteoporosis because it impacts the body's ability to rebuild new bone. Smoking is also associated with osteoporosis. Performing weight-bearing exercise increases bone strength and promotes bone development. A client who is 5 feet 2 inches (157 cm) in height and weighs 200 lbs. (90.7 kg) is considered obese and obesity is associated with osteoarthritis, not osteoporosis.

The nurse is evaluating whether teaching a client with dysphagia about preventing aspiration was effective. Which action by the client indicates that additional teaching is required?

The client uses a straw to drink. rationale Dysphagia means difficulties with swallowing that can cause food and/or liquids to be aspirated into the lungs. Strategies to reduce the risk of aspiration include: sitting up in a chair while eating, cutting up food into small, bite-size pieces, chewing food thoroughly, drinking liquids separate from solid food, performing a chin tuck while swallowing, dry swallowing several times and avoiding the use of a straw. Drinking through a straw tends to propel fluids into the back of the mouth faster, increasing the risk for aspiration.

The nurse is evaluating a client who was admitted for a small bowel obstruction and dehydration. Which observation by the nurse would indicate that the dehydration is improving?

The client voided 300 mL of urine in the past two hours. rationale Treatment for dehydration typically includes rehydration by increasing oral fluid intake and/or administering intravenous fluids. During dehydration, urine output usually decreases as the kidneys attempt to restore fluid volume by increasing water reabsorption. The fact that the client voided 300 mL in two hours indicates that fluid volume has been restored, the dehydration is resolved and the kidneys are eliminating excess water. The other findings pertain more to functioning of the client's bowel not the client's fluid balance.

The nurse is administering pneumococcal vaccinations at a community health clinic. Which of these clients should not receive the vaccine?

The client who had chemotherapy four days ago Having recently received chemotherapy can mean that the client is immunocompromised. The client should check with their health care provider (HCP) first to see if they should receive the pneumococcal vaccine, due to potential contraindications with immunosuppressed clients. The pneumococcal vaccine can be given at least one week apart from other vaccines. The other two clients do not have contraindications for receiving a pneumococcal vaccination. On the contrary, their history indicates they should receive the vaccination.

The nurse is participating in a disaster simulation that involves a school bus accident. The nurse is assigned to care for the following four clients in a rural hospital's emergency department. Which client should the nurse see first?

The client with a penetrating abdominal wound rationale Part of a nurse's role is being a part of disaster management and assisting in client care throughout all aspects of health care delivery. To better prepare nurses for disaster situations, simulation is a method used to evaluate preparedness. The nurse needs to be able to respond to disasters in the community and keep clients safe. Answering this specific scenario requires the application of survival potential priority setting frameworks. A client with a penetrating abdominal wound should be seen first because a penetrating injury usually causes internal injuries, such as bleeding, which can quickly lead to death.

What information in a client's history would place them at an increased risk for skin cancer? (Select all that apply.)

The client's profession is fisherman. The client is receiving an immunosuppressant drug. The client has blond hair and green eyes. The client is 65-years-old. rationale A client with fair skin tone, blond or red hair and blue or green eyes are at increased risk for skin cancer. People who work outdoors (e.g., fishermen, farmers, bridge construction workers) are exposed to increased sunlight and ultraviolet light. Age risk factors are adults younger than 30 years and older than 50 years old. Risk of squamous cell skin carcinoma is increased for individuals receiving immunosuppressant drug therapy. Other risk factors include a previous history of sunburns, indoor tanning and family history of skin cancer.

The nurse is evaluating a client with status asthmaticus. Which finding best indicates that interventions were effective?

The client's pulse oximeter reads 94%. rationale Status asthmaticus means a severe, acute asthma exacerbation. Management of an acute asthma exacerbation focuses on correcting hypoxemia and improving ventilation. Supplemental oxygen is usually administered to achieve an O2 saturation of greater than 90%. The client's reading of 94% is the best indicator that interventions were effective. Wheezing, the respiratory rate and the client's subjective report are unreliable signs to gauge if the client's oxygenation status is adequate.

The home health nurse is caring for a client who underwent a partial gastrectomy due to gastric cancer several months ago. Which finding would indicate that the client is suffering from pernicious anemia? (Select all that apply.)

The client's sclerae are icteric. The client reports numbness and tingling in the feet. The client's tongue is shiny and beefy-red. rationale Pernicious anemia or B12 deficiency are expected in this client due to the removal of a portion of the stomach. With the absence of intrinsic factor, B12 absorption cannot occur and, if left untreated, will lead to pernicious anemia. Typical symptoms include a smooth, beefy-red tongue (glossitis), fatigue, weight loss and jaundice (yellowing of the skin and sclerae). B12 also plays a key role in nerve function and, when absent, can cause paresthesia in the hands and feet. Urinary retention and alopecia (hair loss) are not usually seen with pernicious anemia.

The child weighs 68.2 pounds. The nurse must administer amoxicillin by mouth at 30 mg/kg/day in divided doses every six hours.How many milligrams of amoxicillin does the nurse administer for each dose?

The correct answer is 233 mg. Ratio and Proportion Method Step one: convert the weight in pound to kilograms (1 kg = 2.2 lbs) Set up equation: Cross multiply, divide and solve: Step two: how much amoxicillin does the nurse administer each day? (Insert weight in kilograms into the dosage equation.) Step three: how much amoxicillin does the nurse administer for each dose? Calculate doses/day: Civide total daily dose by the number of doses: Dimensional Analysis Method Set up equation: The left side of the equation is the unit of measure you are solving for: The right side of the equation is where you set up information so that all factors cancel out except for the unit of measure you are solving for: Cancel out the matching information Complete the calculation: Solution: the nurse administers 233 mg of amoxicillin for each dose Incorrect

The nurse is reviewing medication orders for a client who has requested something for pain. In the process, the nurse finds a new written order for a pain medication. The health care provider (HCP) wrote, "Give APAP every six hours as needed for pain." Which parts of the medication order should the nurse clarify before administering the medication? (Select all that apply.)

The drug name The dosage The dosage Medication orders must include the client, medication, route, dose, time, frequency and indication. Medication abbreviations increase the risk of errors and should be eliminated from written orders. Not every nurse will know that APAP is an abbreviation for acetaminophen, therefore the order should spell out the full, generic drug name. The nurse functions as the client's advocate and should collaborate with HCPs and pharmacists when they identify potential medication concerns. When reviewing a new medication order, the nurse must clarify each concern with the HCP prior to administration. It is not required to include how the drug works and other pharmacokinetic information in the prescription.

The nurse is evaluating a client who is receiving a continuous intravenous infusion through a short peripheral catheter, located in the client's forearm. The client complains of pain at the catheter insertion site and the area is warm to the touch with a red streak visible along the vein. What actions should the nurse take? Drag and drop the nursing actions in the recommended order.

The nurse is evaluating a client who is receiving a continuous intravenous infusion through a short peripheral catheter, located in the client's forearm. The client complains of pain at the catheter insertion site and the area is warm to the touch with a red streak visible along the vein. What actions should the nurse take? Drag and drop the nursing actions in the recommended . Submit Show Solution The client is exhibiting clinical manifestations of phlebitis or inflammation of the vein. The nurse should take actions in the following, recommended order: The first step should be to stop the infusion. Then, the nurse should remove the catheter. Next, the nurse should insert a new peripheral catheter, ideally not in the same extremity. Then the nurse should restart the IV so that the client can continue to receive the prescribed IV infusion. A warm, moist compress will help with the localized inflammation and pain. Lastly, the nurse should document all interventions implemented and care provided. .

The nurse is working in an inpatient psychiatric setting and understands that touching clients should be limited to a quick handshake for which reason?

The nurse is working in an inpatient psychiatric setting and understands that touching clients should be limited to a quick handshake for which reason? rationaleA handshake allows the use of therapeutic touch while maintaining boundaries. rationale The therapeutic use of touch is a basic part of the nurse-client relationship. However, in a psychiatric setting, the extent of physical contact should be limited to handshakes. Some facilities may even have a no-touch policy, especially when working with clients who have a history of sexual trauma. Even reassuring touching can be misinterpreted by the client.

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 rationale 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.

The nurse observes a new nurse administering a rectal suppository to a client. Which actions are appropriate for the new nurse to implement? (Select all that apply.)

The nurse pushes the suppository in, up to the second knuckle The nurse places the client on the left side during insertion The nurse applies water-soluble lubricant to the suppository. After 10 minutes, the nurse turns the client to the right side. rationale Left side-lying position is the optimal position for the client receiving rectal medications. Due to the position of the descending colon, placing the client on their left side allows the medication to be inserted and move along the natural curve of the intestine and facilitates retention of the medication. The suppository should be somewhat melted after 10 to 15 minutes and turning the client to the right side will aid in further absorption. The suppository should be lubricated to ease insertion and reduce discomfort for the client. Bearing down will place pressure on the anal sphincter and may cause the suppository to be expelled. The client should be instructed to breathe slowly and try to relax.

The nurse is caring for a client with an indwelling urinary catheter. Which of the following statements is true? (Select all that apply.)

The nurse should not allow the tip of the catheter outflow tube to touch the urine collection container. The nurse should assure that the urine collection bag is below the level of the bladder. The nurse should perform daily catheter care with soap and water. rationale A major risk of an indwelling urinary catheter is the development of a catheter-associated urinary tract infection (CAUTI). To reduce the risk of a CAUTI, nurses should perform daily catheter care with soap and water and should not allow the tip of the catheter outflow tube to touch the urine collection container, as this can lead to contamination. Additionally, obstruction of the urine flow can also lead to increased risk of infection. Therefore, the nurse should make sure that urine is draining appropriately, and that the urine collection bag is below the level of the bladder so that urine can be eliminated with gravity. The nurse should not apply antibiotic ointment to the perineal area, as this does not reduce the likelihood of developing a CAUTI and can introduce the potential for contamination. The nurse should always utilize sterile technique, as opposed to clean technique, when inserting an indwelling urinary catheter.

The nurse is caring for a client who is receiving regular insulin, supplied in a glass vial. Which step(s) should the nurse take to ensure the correct administration of the insulin? (Select all that apply.)

The nurse should only use an insulin syringe to administer insulin. The nurse should check the strength of the insulin before administering it. The nurse should store opened vials of insulin at room temperature. The nurse should discard the vial 28 days after it was opened. rationale Insulin is a medication that can be used to control blood glucose levels in clients with both type 1 and type 2 diabetes. Although there are many types of insulin, the act of administering insulin is similar, regardless of the type. Unopened vials of insulin should be stored in the refrigerator, not the freezer. The nurse should gently roll the insulin vial back and forth prior to drawing up the medication. Shaking the vial, could lead to the formation of bubbles in the syringe. To prevent a medication error, the nurse should only use an insulin syringe to administer insulin. Another way the nurse can prevent a medication error, is to check the strength and dose of the insulin before administration. The nurse should not rub the injection site after administering the insulin, as it could alter the absorption of the medication. If necessary, lightly wipe the site with a piece of gauze after the injection. The vial in current use can typically be stored at room temperature for up to one month, but must be kept out of direct sunlight and extreme heat.

The nurse is performing a home visit for an older adult client with Alzheimer's disease. Which of the following observations should be a priority for the nurse to address?

Throw rugs on the kitchen floor rationale Safety and, especially, falls, is a concern for clients with Alzheimer's disease. The home should ensure good lighting, especially in dark areas such as stairwells. There should be handrails on the stairs and in the tub/shower. Showers should have nonskid mats. The client and caregivers should ensure there are no extension cords in use, as they can be a fire and trip hazard. Throw rugs are also a trip hazard and should be removed from the kitchen floor. This is the priority issue the nurse should address.

A couple that recently immigrated to the United States tells the nurse about their concern that hospital staff is giving their child the "evil eye." What should the nurse communicate to the other personnel who are involved in the care of this family?

Touch the child after or while looking at the child. When providing care to clients from a different cultural background, the nurse is responsible for implementing culturally-sensitive interventions to provide client-centered care. In many cultures, an "evil eye" is cast by looking at a person without touching them or while the person is unaware. The evil eye is believed to cause misfortune or injury. The spell is broken by touching the child while looking at them or assessing them. The other instructions are inappropriate, nontherapeutic and culturally insensitive.

The home health nurse is visiting a client who has peripheral artery disease. It is winter time and cold outside. While observing the client getting dressed, which clothing choice by the client should the nurse question?

Two pairs of cotton socks rationale Clients with peripheral artery disease (PAD) are at risk for frostbite or hypothermia. It is therefore important for the nurse to ensure that the client understands how to prevent injury by dressing appropriately for cold weather. When cotton becomes damp or wet, it doesn't insulate well. Non-cotton materials are preferred. Additionally, a double layer of socks may become constricting and further decrease circulation. Instead, the client should carry an extra pair of socks if needed. The other clothing choices are appropriate.

The nurse is reviewing the history of a client with type 2 diabetes mellitus. The client's most recent hemoglobin A1C level was 9.5%. What information about nutritional therapy should the nurse reinforce with the client? (Select all that apply.)

Use carbohydrate counting. Choose foods low in fat content Limit alcohol intake. Use a diabetes exchange list. rationale A glycosolated hemoglobin A1C level of 9.5% corresponds to an average blood glucose level of 226 mg/dL. The American Diabetic Association recommends an A1C of 7% or less for clients with diabetes. The goals for nutrition therapy in type 2 diabetes emphasize achieving glucose, lipid and blood pressure control. Because overweight and obesity are associated with increased insulin resistance, the client should maintain a nutritionally adequate meal plan with appropriate serving sizes. Carbohydrate counting is a recommended meal planning technique to help track the amount of carbohydrates eaten and keep carbohydrates within a healthy range. A diabetes exchange list is another method to track carbohydrates and allows the client to form a list of exchanges for each meal and snack. Alcohol should be consumed in moderation because it prevents gluconeogenesis and can make managing the diabetes more difficult. The recommended daily protein intake for diabetics is the same as for non-diabetics.

The nurse is reviewing the medical record of a client on the medical surgical unit and notes a positive result of the stool for occult blood (OB) test. The nurse recognizes which risk factors for this result? (Select all that apply.)

Use of naproxen sodium for pain relief Eating a steak dinner the night before Recent use of corticosteroids Recent teeth cleaning at the dentist office rationale Occult blood (OB) testing of the stool is used for colorectal cancer screening or to detect occult blood from other causes such as gastric or duodenal ulcers, diverticulosis or gastrointestinal (GI) bleeding. Drugs that can cause GI bleeding include NSAIDs such as ibuprofen and naproxen (Aleve). Corticosteroids can cause gastric irritation, including peptic ulcers that can also lead to GI bleeding. Factors that may cause a false positive result include bleeding gums following a dental procedure and the ingestion of red meats within three days before testing because red meats contain animal hemoglobin.A family history of colon cancer may put the client at an increased risk for developing colon cancer but would not directly affect the OB test. A recent colonoscopy might affect the stool sample but since the colonoscopy was two years ago, it would not affect the current results.

The nurse in a health clinic is reviewing recommended nutritional therapy with a client who has a history of emphysema. Which action should the nurse emphasize to the client?

Use oxygen during meals. Correct! rationale Clients with emphysema often experience shortness of breath or "air hunger" while eating. Giving the client oxygen through a nasal cannula will alleviate the air hunger while eating. Clients should avoid drinking a lot of fluids with meals to prevent gastric distention, which can worsen the shortness of breath as well as make the client feel full too soon. Engaging in exercise before eating is not recommended, since it can worsen the shortness of breath and decrease appetite. A rescue inhaler should not be used routinely but should be reserved for episodes of acute respiratory distress.

The nurse in the outpatient clinic is reviewing discharge instructions with a client being treated for recurring sinusitis. Which statement by the client indicates that additional teaching is needed? (Select all that apply.)

Use probiotics daily to reduce recurrence. Control asthma symptoms with prescribed medications. Wash hands and change clothing after outdoor activities. rationale The use of nasal decongestant sprays for more than three days often leads to increased rebound congestion when use is discontinued. Instead, the client may opt for saline nasal sprays, which relieve congestion without rebound effects. Probiotics have shown to be effective in reducing acute sinusitis and other upper respiratory tract infections. Sinusitis is much more common in clients with asthma, with up to half of those with moderate-to-severe asthma experiencing chronic sinus inflammation. Allergies often precipitate sinusitis, and handwashing and removing allergens from clothing can reduce allergy symptoms and the risk of sinusitis. Smoking is a risk factor for sinusitis and should be entirely avoided. The client should drink 6 to 8 glasses of water daily to thin secretions and reduce the risk of infection. The client should sleep with the head upright, not flat, in order to allow sinus drainage.

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 rationale 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.

The nurse in the primary care office is speaking with a client who has contact dermatitis on both hands. The client wants to know how to manage the condition. Which interventions should the nurse recommend to the client? (Select all that apply.)

Using soap without fragrance is recommended. Avoid heat that can exacerbate symptoms. Corticosteroid cream is acceptable to use. rationale Exposure to heat or cold may cause or exacerbate contact dermatitis. Rubbing the area may also exacerbate or spread symptoms. While washing hands after exposure to possible irritants is recommended, frequent handwashing is not. Soap with fragrance is an external irritant and may exacerbate symptoms, so fragrance-free soap is recommended. A barrier cream containing a corticosteroid is the most frequently prescribed topical ointment.

A nurse is taking a health history from parents of a child admitted with possible Reye's syndrome. Which recent illness should the nurse recognize as being associated with an increased the risk for the development of Reye's syndrome?

Varicella rationale 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 used. Rubeola, meningitis, and hepatitis are not recognized as precursors to Reye's syndrome. 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.

An obese client tells the nurse, "I just started a diet and I am eating no more than 800 calories a day." What information should the nurse reinforce with the client?

Very low-calorie diets are intended for short-term use only. rationale A very low-calorie diet (VLCD), less than 1,000 calories a day, is a short-term weight loss method for obese people (BMI greater than 30) and can result in a loss of about 3 to 5 pounds per week. Anyone considering this type of diet should be under the care and supervision of a health care provider (HCP). VLCDs are generally considered safe and common side effects, such as fatigue, constipation or diarrhea, are usually minor and improve within a few weeks. The best way to maintain weight loss though, is through a combination of behavioral therapy, exercise and more modest caloric restrictions of around 1,200 calories per day. Every diet should contain fruits and vegetables, but those foods are low in calories and would not make a VLCD more balanced.

The nurse is evaluating the plan of care for a client with osteoporosis. What type of activity should the nurse reinforce for this client?

Walk for 30 minutes, 3 to 5 times a week. rational Weight-bearing exercises are beneficial in the prevention and treatment of osteoporosis. Although bone loss cannot be substantially reversed, further loss can be greatly reduced and prevented if the client includes weight-bearing exercises, and vitamin D and calcium supplements in their treatment protocol. In addition to adopting exercises for muscle strengthening, a general weight-bearing exercise program should be implemented. Teach the client (or reinforce teaching) that walking for 30 minutes, 3 to 5 times a week, is the single most effective exercise for osteoporosis prevention. Remind the client to avoid any activity that would jar the body, such as jogging and horseback riding. These activities can cause compression fractures of the vertebral column. Although swimming can help develop overall muscle strength, it is not as effective in promoting bone density since it is not a weight-bearing activity.

The nurse observes another nurse walking away from their computer with a client's electronic medical record (EMR) still visible on the screen. What should the nurse do first?

Walk over to the computer and close the client's medical record. rational All of the nurse's actions are appropriate, but in order to prevent unauthorized personnel from seeing any of the client's protected health information, the nurse should first close the client's EMR, which is still visible on the screen.

The 4-year-old child is newly diagnosed with hepatitis A. Which instructions should the nurse reinforce with the child's parents?

Wash hands thoroughly with soap and warm water after contact with the child. The hepatitis A virus spreads through contaminated food or water, as well as unsanitary conditions in childcare facilities or schools. The infection resolves spontaneously and symptom relief is usually the only treatment. The child does not have to be confined to bed and they can safely return to daycare or school one week after symptoms begin. In children under 6-years-old, who represent approximately 1/3 of all cases of hepatitis A, the disease may be asymptomatic and jaundice is rarely evident.

A client is seen at the primary care clinic for allergic rhinitis. Which clinical manifestations should the nurse expect with this diagnosis? (Select all that apply.)

Watery, itchy, reddened eyes Alteration in sense of smell Alteration in sense of smell Increase in serum eosinophil count rationale Common symptoms of allergic rhinitis are due primarily to the release of immune mediators such as histamine, prostaglandins, eosinophils and cytokines. This leads to sneezing, runny nose with clear discharge, nasal congestion and an increased eosinophil counts. Symptoms may appear similar to a cold. Due to drainage, the client's sense of smell can be altered. However, purulent green nasal discharge is not consistent with this diagnosis and would be more expected in the case of a sinus infection. Exposure to mold, pets, dust and pollens, especially during spring and fall, can exacerbate allergic rhinitis.

The nurse in the urgent care center is caring for a 20-year-old client who sustained a sprained ankle while playing sports. Which instructions should the nurse give the client to prevent a future sprain injury? (Select all that apply.)

Wear snug, well-fitting shoes that go up to the ankle. Warm up for several minutes before starting the activity. Encourage stretching before and after any sports activity. Use appropriate protective equipment with the activity. rationale A sprain occurs when there is a sudden, abnormal movement around the joint that can lead to stretching and/or tearing of the ligaments attached to the joint. Stretching before and after exercising increases the ligaments pliability and decreases the risk for injury. Gradually warming up prior to engaging in physical activity provides the muscles with increased circulation and loosens up joints; both will decrease the risk for strains or sprains. Wearing proper fitting shoes enhances stability and wearing appropriate protective gear provides protection and decreases the likelihood of sprains. Taking ibuprofen, a nonsteroidal anti-inflammatory drug (NSAID), to decrease inflammation would be appropriate after a musculoskeletal injury, but will not help to prevent one.

The nurse on the surgical unit is caring for a client who underwent a thyroidectomy eight hours ago. Which finding requires immediate action?

Wheezing rationale Following a thyroidectomy, it is critical that the nurse monitors the client closely for hemorrhage or airway obstruction, such as tracheal compression, which can lead to respiratory arrest. Signs of hemorrhage or tracheal compression include wheezing, frequent swallowing or choking and bleeding noted from the incision site. The elevated respiratory rate is related to the tracheal compression/airway obstruction and should return to normal once the compression has been addressed. Voice hoarseness frequently occurs following a thyroidectomy due to edema at the site of incision and diaphoresis may be a symptom of hyperthyroidism. Both should be monitored, but do not require immediate action.

The nurse observes a client using crutches. Which of the following actions by the client would require the nurse to intervene? (Select all that apply.)

While using a three-point gait, the client is bearing weight on both legs. The client is resting their axillae or armpits on top of the crutches. The client is using crutches that have a broken rubber tip. rationale When clients use crutches, their hands should rest on the handgrips of the crutches. The client's weight should not be resting on their axillae, as this could lead to damage of the axillary nerve.Clients should check the integrity of their crutches, including the rubber tips. The crutches should be in good working order and not broken or worn down.Clients should have a spare pair of crutches, including rubber tips.A three-point crutch gait is used for people who only have one weight-bearing leg. Correct!

The nurse is evaluating a pre-admission questionnaire completed by a sexually active female client. Which of the following indicate the client may be demonstrating high-risk behaviors for acquiring a sexually transmitted infection (STI)? (Select all that apply.)

Works as a sex worker several times per week Has recently had sexual intercourse without a condom Uses oral contraceptives as the only birth control method The transmission of STIs can be prevented. The Centers for Disease Control and Prevention (CDC) recommend the use of condoms during sexual intercourse to prevent the transmission of STIs. Sex workers are at a higher risk for getting sexually transmitted diseases. Use of barriers during oral sex reduces the risk of transmission of STIs. Oral contraceptives will prevent pregnancy, but not STIs. The human papilloma virus (HPV) vaccine prevents infection with HPV, which is a sexually-transmitted virus that can lead to genital warts and cervical cancer.

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

A client who had a wrist cast applied three days ago calls from home, reporting that the cast is loose enough to slide off. How should the nurse respond?

You need a new cast now that the swelling is decreased." rationale After a new fracture, the surrounding soft tissue may be significantly swollen when the cast is initially applied. After the swelling has resolved, the cast may become loose. If the cast is loose enough to permit more than one finger between the cast and the skin, the cast probably needs to be replaced. The client should never place anything inside the cast. The client's muscles should not have atrophied while in a cast for just three days. Keeping the arm immobile does not solve the problem and therefore would not be appropriate. On the contrary, immobilizing the arm above the casted fracture is not necessary and can cause contractures of the upper extremity proximal to the fracture.

The nurse is interviewing a client to verify pregnancy. What information from the client will provide presumptive findings?

Amenorrhea Breast sensitivity Nausea A client typically will report breast sensitivity, missed period, nausea and fatigue (this is not a complete list of symptoms pregnant women could report). Uterine and/or cervical changes cannot be reported by the client but will be a finding of the health care provider.

A client who recently experienced a stroke has an order to ambulate with assistance. Which statement by the nurse provides the best instructions to the unlicensed assistive person (UAP) who will assist the client to ambulate?

"Have the client lift and move the walker out to arm's length, then walk into the walker." rationale The nurse should give clear and concise information to the UAP about what is expected to safely complete any task, which is why the option about using the walker is correct. The person assisting the client to ambulate should walk on the client's weak, not strong, side. The nurse should not instruct the UAP to assess or evaluate a client (e.g., "let me know if the client uses the quad cane correctly"). Only nurses can perform those steps of the nursing process. If the client feels dizzy, the UAP should assist them to sit (or ease the client to the floor if they begin to fall.)

The nurse is providing care for a client who was recently diagnosed with end-stage heart failure. The client does not have advance directives in place. Which of the following statements by the nurse would be appropriate? (Select all that apply.)

"Have you thought about what you want done as your disease progresses?" "Have you discussed your wishes regarding resuscitation with your health care provider?" Correct! "What does your family know about your condition and prognosis?" Correct! Approximately half of all deaths from heart failure are sudden and without warning. It is important to assist the client and family in planning for the possibility of sudden cardiac death at home. The nurse should discuss advance directives with the family and encourage them to develop a plan of action that addresses the client wishes. Although heart transplants are an option for clients with heart failure, discussions about treatment options (including a transplant) are the responsibility of the health care provider, not the nurse. Asking the client about their current understanding of the disease will help the nurse determine what additional education might be needed. Although it might be helpful for family members to know how to perform CPR, it is not appropriate for the nurse to request CPR certification.

During a discussion about a living will, the client's son states, "I do not understand the need for a living will." What is the best response by the nurse?

"Health care decisions can be made based on the client's wishes." rationale Health wishes are written in a legal document such as a living will or advanced directives. These wishes are obtained when clients are medically and cognitively able to do so. Such instructions are to be followed if clients are no longer able to make decisions because of cognitive impairment or unconsciousness. One incorrect response defines a health care surrogate or a durable power of attorney. Another incorrect response defines medical directives and not part of a living will. The final incorrect response is associated with the DNR, which may be predetermined by the client as written in a legal document.

The nurse in a primary care provider's office is collecting data on lifestyle choices and activities of daily living (ADLs) from an older adult client. Which of the following statements by the nurse would be appropriate?

"How do you spend your time on a typical day?" "Tell me what you eat on a typical day." "How many glasses of alcohol do you drink per day or per week?" Data collection on ADLs and lifestyle choices measures a client's ability to provide self-care and maintain their health and should be done in a way that positively reinforces what the client is doing correctly. It also collects general information on the client's overall health status. It should be done in a clear, non-judgmental manner. Asking if someone feels unsafe can be unclear. The nurse should use open-ended questions to obtain as much information as possible.

The nurse is providing education to a client in her first trimester of pregnancy. Which statement indicates the client needs further education?

"I will schedule visits with my health care provider only as needed." A pregnant client must adhere to a strict health care visit protocol. The nurse must provide this information and set up an appointment schedule for the client. Adhering to the appointment schedule with the health care provider can help ensure a healthy pregnancy and can identify and prevent complications.Fatigue is normal for a pregnant client to experience along with other symptoms such as, but not limited to, nausea, frequent urination and breast sensitivity. Pregnant clients should continue to take their prenatal vitamins to help prevent complications and may remain on an exercise schedule as discussed with their health care provider.

A client has received a prescription for nitrofurantoin to treat a urinary tract infection. Which of the following statements made by the client indicates the need for additional teaching about the medication?

"I will spend extra time in the sun to get plenty of vitamin D." Clients taking nitrofurantoin should avoid exposure to sunlight while taking the medication. Exposure to sunlight while taking this medication can lead to damage to the skin. A client planning to spend extra time in the sun while taking nitrofurantoin should be informed of the dangers of sun exposure and counseled to avoid sun exposure while taking the medication.Client statements reflecting the importance of taking the complete course of antibiotics, notifying the health care provider if a rash develops and taking the medication with food demonstrate correct understanding of important considerations while taking this antimicrobial therapy.

How should Michael respond?

"Mr. Evans, thank you for coming and letting me know the situation. I'm sorry your partner has waited so long for someone to help him. I can understand your frustration. The CNA or I will be right over." It is important that the nurse manage the conflict by acknowledging the family member's concern and frustration. Give a timeframe regarding when the client's needs will be addressed (e.g., "a few minutes"). The next steps might involve the nurse offering to help the client and family discuss their concerns with the manager or charge nurse to make sure they feel as though their concerns were addressed appropriately.It is important not to respond defensively or take the family member's comments personally. An aggressive response will only escalate the problem. Using hospital policy as a justification or blaming others will not solve the problem and may contribute to the family member's sense that no one cares about the client.

A woman comes to a clinic to discuss contraceptive options. Which statement by the client indicates to the nurse a need for additional teaching?

"My diaphragm will work no matter how much weight I gain." "If my etonogestrel vaginal ring (NuvaRing) falls out, I still will be protected from a potential pregnancy." "I will return every month for a medroxyprogesterone acetate (Depo-Provera) injection." Women who smoke while taking oral contraceptives have an increased risk for a myocardial infarction, stroke and hypertension, so smoking cessation should be encouraged. Diaphragms should be refitted after pregnancy and pelvic surgery and whenever the client's weight changes. Medroxyprogesterone acetate (Depo-Provera) injections are effective for three months. Cervical caps, sponges and IUDs increase the risk for pelvic infections. Vaginal rings may fall out and alternative contraceptive methods should be used. Abstinence is the only method that provides complete protection from pregnancy.

The nurse is preparing a client for a colonoscopy and notes that the consent form has not been signed. Which of the following statements by the nurse are appropriate to make to the client?

"Please tell me your full name and date of birth." "Do you have any questions about the colonoscopy?" "Describe what the health care provider told you about a colonoscopy." Rationale The nurse first verifies the identity of the client using two identifiers to ensure the correct client is consenting to the procedure. The health care provider is responsible for providing the information necessary for the client to make an informed decision regarding the procedure, including the alternatives. The role of the nurse in the informed consent process includes ensuring the person is understands the procedure and is capable consenting to the procedure. Impediments to informed consent include language barriers, temporary or permanent disorientation, confusion and anxiety. Having the client describe the procedure allows the nurse to determine if the client understands the information they received from the health care provider. The nurse should also watch the client sign the form to ensure it is signed by the client and not by another person.

When walking past a client's room, the nurse hears an unlicensed assistive person (UAP) talking to another UAP. Which of these statements requires further intervention by the nurse?

"Since I am late for lunch, would you perform my client's blood glucose test?" rationale Only registered nurses (RNs) and licensed practical or vocational nurses (LPN/VNs) can assign tasks and activities. UAPs cannot re-assign tasks or activities to other UAPs. Nurses are accountable for all nursing care; if UAPs cannot complete assignments, they should notify the nurse, who will reassign the task.

The parents of a toddler ask, "How long will our child have to sit in a car seat when riding in a car?" What would be the best response by the nurse?

"Until the child outgrows the car seat." The American Academy of Pediatrics (Nov. 2018) provides four evidence-based recommendations for best practices in the choice of a car safety seat (CSS) to optimize safety in passenger vehicles for children from birth through adolescence: Use rear-facing car safety seats for as long as the child fits in the seat. Most children should use forward-facing car safety seats from the time the child outgrows rear-facing seats until at least age 4. Most children should use belt-positioning booster seats from the time the child outgrows forward-facing seats until age 8. Use lap and shoulder seat belts for all children who have outgrown booster seats.

A home health nurse is providing care for a client. Which client statement should the nurse report immediately to the client's health care provider?

"When I emptied my urine catheter drainage bag it looked like rusty-colored water." The change in the color of urine to "rusty" suggests blood, a potential sign of an infection or other urinary-renal complication. This requires immediate reporting, documentation and further assessment. The other statements do not require immediate interventions, but should also be addressed as they could indicate depression, social isolation or an underlying, undiagnosed physical problem.

The nurse is preparing to administer regular insulin subcutaneously to a client at 0800. What information from the client's electronic health record should the nurse review in order to safely administer the medication? (Select all that apply.)

1. Name and date of birth. 2. 0700 blood glucose. 3.Medication administration record (MAR). The nurse must review the appropriate information in order to safely administer medications. The use of two client identifiers is to ensure the identity of the correct client. The nurse must review the medication administration record (MAR) to verify the correct medication, dose, and time. The nurse should review the client's most recent blood sugar value before administering the insulin to prevent hypoglycemia.

The automated external defibrillator (AED) has been applied to a client receiving cardiopulmonary resuscitation (CPR). Indicate how the nurse will proceed by placing the following actions in the correct order.

1. Press the analyze button when the AED prompts the nurse to do so. 2. Wait for the AED to analyze the client's heart rhythm. 3. Call out a ''stand clear'' when the AED prompts the nurse to administer a shock. 4. Press the shock button on the AED. 5. Allow for time on the AED to administer a shock. 6. Immediately resume CPR. The American Heath Association (AHA) guidelines for CPR recommend rapid CPR implementation including use of an AED. AEDs provide early interpretation of the client's cardiac rhythm. It provides step-by-step instructions on how to proceed with defibrillation if indicated.

The hospital is under a severe weather warning. The nurse is prioritizing clients for discharge to make beds available for possible emergency admissions. Which of the following adult clients would be most appropriate to discharge?

A client who is ambulatory with the support of crutches. A client who can manage their self-care. A client who requires the administration of enoxaparin. In preparing for a weather emergency, it may be necessary to discharge clients to ensure hospital beds are available for emergency admissions. Ambulatory clients who can manage their self-care should be discharged first. Those requiring minimal care can also be considered for discharge. Clients with complex dressing changes, or who require mechanical ventilation cannot be considered for discharge. Clients or family members can be taught how to self-administer subcutaneous medications such as the anticoagulant enoxaparin (Lovenox) at home.

The client is in her first trimester of pregnancy. What major developmental task should the client accomplish during this stage of pregnancy?

Accepting physical changes related to pregnancy. During the first trimester, the developmental focus is directed toward accepting the pregnancy and adjusting to pregnancy-related physical changes and discomforts. It is expected that the client will have some ambivalence during the first trimester, but the client can maintain physical intimacy with her partner if she wishes, including sexual intercourse. Looking at the fetus as a separate being and overcoming fears related to giving birth will occur in the third trimester, closer to the due date.

The LPN/VN assists the RN in evaluating the plan of care for clients. What action does the LPN focus on during the evaluation phase?

Achievement or status of progress related to prior goals Correct Response Evaluation process of the clinical problem-solving process (the nursing process) should focus on the clients' status, progress toward goal achievement and ongoing re-evaluation of the plan of care. LPN/VN's gather, observe, record and communicate client responses to nursing interventions.

A client diagnosed with schizophrenia insists that the nurse explain the use and side effects of the medications prescribed for the client. What should the nurse understand before responding to the client?

All clients have a right to be informed about their prescribed medications Clients have the right to be informed about the use and side effects of their medications, regardless of their diagnosis. Clients have the right to refuse treatment, including taking prescribed medications, even if the client has a psychiatric diagnosis such as schizophrenia.

Which of these are examples of primary prevention activities?

An exercise class Car seat installation education Vaccination Engaging in an exercise class, correctly installing a child safety or car seat and getting vaccinations are considered primary prevention activities. Rehabilitation falls under tertiary prevention. Cholesterol screening and breast self-exam are secondary prevention interventions.

The licensed practical nurse (LPN) is reassigned to work on an acute care unit. Which of these clients would be most appropriate for the LPN to accept?

An older adult client diagnosed with cystitis who has an indwelling urethral catheter. Rationale: LPNs who are reassigned to work on a different unit should be assigned to clients who are stable. The older adult diagnosed with cystitis is the most stable and the outcomes for care are fairly predictable. The other clients have more complex problems, as well as a higher risk for instability. LPNs should not accept an assignment that is beyond their knowledge or skills.

Which of the following interventions should the nurse include in the plan of care for a client who recently experienced a fall at home?

Apply nonslip strips to the bottom surface of the shower. Ensure the room lighting is adequate and remove clutter in the room. Monitor blood pressure when lying down, sitting and standing. The nurse should ensure that the client's home environment is safe (i.e., has appropriate lighting, is free of clutter and unnecessary furniture and throw rugs). There is no indication for an indwelling catheter for this client, and unnecessary urinary catheterization is a risk factor for catheter-associated urinary tract infections (CAUTIs). Chairs with armrests can reduce the risk of falls, since the armrests provide support and help prevent client from sliding off the chair. Monitoring blood pressure for orthostatic hypotension can reduce the risks of falls. Nonslip strips and grab bars can improve safety in the bathroom and reduce the risk of falls.

A client with a musculoskeletal disorder has been newly fitted with a lower limb orthotic. Which activity can the nurse delegate to the certified nursing assistant (CNA)?

Assist with transferring the client from the bed to the chair. The CNA (i.e., UAP) can assist with routine activities of daily living, including transferring clients from a bed to a chair or wheelchair. When performed correctly, these routine tasks usually have a predictable outcome. Checking the client's skin involves assessment and monitoring the client's response requires evaluation, both of which are nurse-only activities. A physical therapist would teach the client how to ambulate with an orthotic

During the physical inspection of a client, the nurse notes a pulsating mass in the client's periumbilical area. Which action should the nurse take next?

Auscultate the area. A pulsating mass at the periumbilical area is indicative of an abdominal aortic aneurysm (AAA). Auscultation of the abdomen should be done next to check for a bruit, which will further confirm the possible presence of an AAA. The other actions are contraindicated because causing pressure to the area through palpation or percussion may cause the aneurysm to leak or rupture. Measuring the area would not provide any useful data.

The nurse is reviewing the client's medical record and notes that the client has been taking an oral contraceptive for several years. For which potential complications should the nurse monitor the client?

Breast cancer Deep Vein Thrombosis (DVT) Depression Oral contraceptives contain both advantages and disadvantages for clients. Advantages include shortening menstrual cycles, decreasing anemia and protecting against bone loss. Clients have decreased risks for ovarian, colorectal and endometrial cancers. Potential complications include increased risks for breast cancer, depression and a DVT. Women who smoke may have an increased risk for myocardial infarction, stroke and hypertension.

A client is forgetful and experiencing short-term memory loss. While collecting data about short-term memory loss, which action should the nurse take first?

Confirm that the client's hearing is intact. A baseline evaluation of a client's neuro-sensory status should include checking for hearing loss. The client's inability to hear may cause them to answer questions incorrectly, which can be misinterpreted by the nurse as short-term memory loss or confusion. The other actions should then also be implemented to further evaluate the client's cognitive and mobility status.

A community health clinic nurse is interviewing a client who is experiencing lightheadedness. The client reports a history of arthritis and is taking naproxen sodium for the pain. The client is pale, the blood pressure is 88/40, pulse is 114, respiratory rate is 22 and temperature is 98.2° F (36.7 C°). What additional information should the nurse solicit from the client?

Color of bowel movements Frequency and amount of naproxen used Bruising Nonsteroidal anti-inflammatory drugs (NSAIDs) such as naproxen can cause gastrointestinal (GI) irritation and bleeding. The client's vital signs and pale skin color indicate possible hypovolemia (tachycardia and hypotension) secondary to blood loss. The nurse should inquire about other findings that may indicate bleeding, e.g., black tarry stools and bruising. The nurse should also determine the amount of naproxen the client has been taking. Tingling, numbness or photophobia are not side effects seen with naproxen use or overuse.

The nurse is setting up a client's dinner tray. When the nurse turns her back to the client, the client grabs the nurse's buttocks and states he is hungry for much more than dinner. Which of the following responses by the nurse is indicated?

Complete an incident report To keep the therapeutic relationship intact, a nurse needs to set limits on appropriate behavior and not ignore bad behavior. Sexual harassment is a form of violence and is never part of the job. The nurse should report the incident to her supervisor and complete an incident report. The nurse has the right to ask not to be assigned to this client.

A nurse is named in a lawsuit. Which of these factors will offer the best protection for that nurse in a court of law?

Complete and accurate documentation of assessments and interventions The medical record is a legal document. Documentation should include all steps of the nursing process; it must be complete, accurate, concise and in chronological order. Inaccurate or incomplete documentation will raise red flags and may indicate the nurse failed to meet the standards of care. The attorney will review the medical record with the nurse before giving a deposition (sworn pretrial testimony). Above-average performance reviews could be considered supporting information. Certification is an "extra" based on the nurse's initiative; it is, however, unrelated to accurate charting.

The nurse hears a health care provider (HCP) loudly criticizing one of the unlicensed assistive persons (UAP) within the earshot of others. The UAP does not react or respond to the HCP's complaints. What is the best action by the nurse?

Encourage the UAP to directly confront the HCP about the unprofessional behavior. The QSEN competency Teamwork and Collaboration requires the nurse to function effectively within nursing, working with inter-professional teams, and fostering open communication and mutual respect. The nurse should first approach the HCP to stop the behavior and then attempt to discuss communication styles that diminish the risks associated with authority gradients among team members. Notifying the chief of the medical staff might be necessary in the future if the HCP continues to act unprofessionally toward the staff. Directly confronting the HCP would most likely cause the HCP to become defensive and should be avoided. Completing an incident report is not necessary at this time. Correct!

The nurse hears a health care provider (HCP) loudly criticizing one of the unlicensed assistive persons (UAP) within the earshot of others. The UAP does not react or respond to the HCP's complaints. What is the best action by the nurse?

Encourage the UAP to directly confront the HCP about the unprofessional behavior. rational The QSEN competency Teamwork and Collaboration requires the nurse to function effectively within nursing, working with inter-professional teams, and fostering open communication and mutual respect. The nurse should first approach the HCP to stop the behavior and then attempt to discuss communication styles that diminish the risks associated with authority gradients among team members. Notifying the chief of the medical staff might be necessary in the future if the HCP continues to act unprofessionally toward the staff. Directly confronting the HCP would most likely cause the HCP to become defensive and should be avoided. Completing an incident report is not necessary at this time.

The parent of a 7-year-old child calls the clinic nurse because their child was sent home from school due to a rash. The child was diagnosed with fifth disease (erythema infectiosum) the day before and is otherwise in good health. What would be the appropriate action by the nurse?

Explain that the rash is no longer contagious and does not require isolation. Fifth disease is a viral illness with an uncertain period of communicability (perhaps one week prior to and one week after the onset). Children are not contagious after the appearance of the rash, which gives a "slapped cheek" appearance. Isolation of children with fifth disease is not necessary except in cases of hospitalized children who are immunosuppressed or having aplastic crises. The parents may need written confirmation of this from the health care provider to give to the school. Treatment is symptomatic and supportive. Antibiotics are not indicated for this viral infection.

The nurse recognizes that client identification in accordance with agency policy must occur immediately prior to which of the following actions?

Insertion of an indwelling urinary catheter Administration of oral acetaminophen Discontinuation of an intravenous normal saline infusion Collection of a point of care blood glucose test As part of safe nursing care, the nurse must collect client identification with at least two approved identifiers according to agency policy immediately prior to medication administration, implementation of health care provider prescriptions, collection of laboratory samples, discontinuation of intravenous infusions and many additional situations. It would not be required to confirm the client's identification immediately prior to placing the call light activation device within reach.

The nurse observes a nursing assistant using antiseptic hand sanitizer and rubbing their hands vigorously after leaving the room of a client diagnosed with Clostridium difficile (C-Diff). Which action by the nurse is appropriate?

Instruct the nursing assistant to wash their hands again with soap and water. Anyone who is hospitalized should be encouraged to ask caregivers if they washed their hands and to remind visitors to wash their hands. However, it is the nurse's responsibility to supervise the nurse assistant and to correct practice errors as needed. C. diff is one of the few pathogens that require soap and water for cleansing the hands. Since antiseptic hand rub is ineffective against the hardy spores produced by this bacterium, the nurse should require the nursing assistant to wash their hands with soap and water, especially after providing care for this client.

The nurse is caring for a patient who has just experienced a spontaneous abortion (miscarriage). What action should the nurse implement first?

Monitor the client for bleeding and medicate for pain The nurse's priority is to address the client's physical needs (A-B-C) according to Maslow's hierarchy of needs. The nurse must assess and monitor bleeding and be prepared to act if there is a complication such as a hemorrhage. The other actions are also part of the nurse's plan/implementation but are not the initial priority.

The nurse is assigned to care for several clients on the day shift. Which client should the nurse see first after receiving shift report? pt. 2

The client with peptic ulcer disease who has been vomiting most of the night A client with a peptic ulcer who has been vomiting a lot might be experiencing perforation of the ulcer, which is a life-threatening situation that requires emergency surgery. The client with the peptic ulcer should be checked first and findings reported to the charge nurse and/or health care provider.

The nurse is assigned to care for several clients on the day shift. Which client should the nurse see first after receiving shift report?

The client with peptic ulcer disease who has been vomiting most of the night rational A client with a peptic ulcer who has been vomiting a lot might be experiencing perforation of the ulcer, which is a life-threatening situation that requires emergency surgery. The client with the peptic ulcer should be checked first and findings reported to the charge nurse and/or health care provider.

A nurse must use an interpreter to collect data from a client. Which action should the nurse take to help communicate with the client?

Face the client while asking questions as the interpreter translates the information rationale: Communication is important, especially when the nurse and client do not share the same cultural heritage. Even if the nurse uses an interpreter, it is critical that the nurse use conversational style and spacing, personal space, eye contact, touch, and orientation to time strategies that are acceptable to the client. Therefore, the nurse should face the client and allow the interpreter to translate the content. Facing the client allows nonverbal communication to take place between the client and nurse. Notice that only one option includes the content of this question (collecting data from a client). The other options focus on the "interpreter or the family." Usually, the client-centered option is the best choice.

The licensed practical nurse (LPN) is caring for a client with an order that reads, "morphine sulfate 2 mg IV push every 3 to 4 hours as needed for pain." There are no other licensed persons working that shift. Which action should the nurse take?

Hold the medication and contact the health care provider. LPN/VNs cannot administer medications using intravenous push or bolus route. The nurse will need to contact the health care provider and ask to have the order changed so the medication can be administered by another route.

A LPN complains to the charge nurse that an unlicensed assistive person (UAP) consistently leaves the work area untidy and does not restock supplies. What is the best initial response by the charge nurse?

Explore for further identification about the nature of the problem Helping staff manage conflict is part of the charge nurse's role. It is appropriate to work with the LPN in order to work out problems with minimal intervention from administration when possible. Further definition of the problem and associated issues would be a first step. The nursing process can be used to collect more data before plans or interventions are made.

The nurse is handing-off the care of a client admitted with pneumonia to the nurse for the next shift. What client information should the nurse include in the hand-off report, using the S.B.A.R. method?

IV access, admitting diagnosis, allergies and antibiotics given rational S.B.A.R. stands for situation, background, assessment and recommendation. Situation in the model refers to the client's main problem. Background refers to the client's basic information, such as admitting diagnosis, allergies, etc. Assessment refers to objective and subjective data the nurse collects that helps to define the client's problem. Recommendation is the nurse's suggested solution(s) to the problem. Insurance information, marital status and religious affiliation are not shared when using the S.B.A.R. model of communication.

A home health nurse is making an initial visit to a new client. What action should the nurse take first to meet the client's health needs?

Identify the client's learning needs. With a focus on health promotion, the nurse should first identify any learning needs. This also represents the first step in the nursing process. Once the client's learning needs are identified, the nurse will be able to develop or assist with developing a plan of care that meets the client's individual needs. Then the nurse should perform a home safety check, identify community resources for the client and, if needed, assist with meal planning.

A child is admitted with a suspected diagnosis of meningococcal meningitis. Which admission order should the nurse implement first?

Implement droplet precautions. Meningococcal meningitis is a contagious infection caused by the bacteria Neisseria meningitis. The first action the nurse should take is to implement droplet precautions to prevent transmission of meningitis. Then the nurse will focus on the therapeutic management of acute bacterial meningitis which includes anti-infective therapy (a cephalosporin or penicillin) and monitoring of the client's neurological status along with vital signs. The nurse should institute seizure precautions and maintain adequate hydration of the client.

The nurse is reviewing information about the health care organization's efforts to improve quality of care. Which of these statements best describes the goal of continuous quality improvement (CQI) in a health care setting?

Improve the quality of care in a proactive manner. Rationale: Continuous quality improvement (CQI) is used to identify ways to correctly do the right thing at the right time. It involves proactive problem-solving. Proactive means implementing steps to prevent something from happening rather than responding to it after it has happened (being reactive). The overall goal of CQI is to improve the quality and safety of health care services.

Upon completing a review of a 27-year-old client's admission documents, the nurse identifies that the client does not have an advance directives. What action should the nurse take?

Inform the charge nurse to offer information about advance directives. For every admission, the nurse should check if the client has advance directives and if yes, that a copy of the current advance directive is in the medical record. If there are none, the nurse should inform the appropriate interdisciplinary team member to provide information to the client. In most health care settings, nurses, social services, case managers or the spiritual support team can educate clients on advance directives, including helping them complete an advance directive. Every adult client should have advance directives. The client is 27-years-old and is therefore considered an adult.

The home health nurse is seeing a client diagnosed with type 2 diabetes. The client has a small foot ulcer that was debrided and requires daily dressing changes. Which intervention is most important for the nurse to implement to meet the goal of uncomplicated wound closure?

Involve the client in making decisions. Although all these interventions may benefit the client, the involvement of the client in making health care decisions is the most important intervention to improve meeting desired goals and outcomes. The client will be more motivated to adhere to the nurse's recommendations if they are involved in the process of setting priorities and making decisions.

A newly licensed nurse is concerned about time management. Which action should be most effective in the initial development of a time management plan?

Keep a time log for what was done during the hours worked The first step in planning for time management is to establish what tasks were done and when they were completed. This provides a baseline for needed changes in any activities and time use log. The key words in this question are "time management," "most effective," and "initial development." Remember the first step in the nursing process is data collection - this applies to both caring for clients and developing management skills. Correct!

The nurse is reviewing the documentation of a client's care in their electronic health record and realizes that one of the entries was completed on the wrong client. Which of the following actions are appropriate for the nurse to take?

Mark the entry as "mistaken entry-wrong patient." Enter the time the error was discovered. The entry should be identified as being a mistake. Records should not be deleted. It is not necessary to notify the health care provider, complete an incident report or notify the nurse manager as long as the nurse follows the appropriate policy for correcting documentation errors. The nurse needs to enter the time the error was discovered in order to have a record of the change.

The client is admitted with a diagnosis of hyperglycemia and poor glycemic control. Which task can the nurse assign to an unlicensed assistive person (UAP)?

Measure blood pressure, pulse and respirations rationale UAP can perform standard tasks with predictable outcomes, such as measuring vital signs. They are trained to assist the client with activities of daily living. UAPs cannot assess, plan, teach or evaluate clients

The client requests not to be interrupted before 10 am because it interferes with the client's time to meditate. What action shall the nurse take first?

Meet with the client to formulate a mutually agreeable schedule. rationale The nurse should communicate with the client to help determine how their meditation practice can be incorporated into the morning schedule. This is the first step in the nursing process and will help the nurse develop an individualized plan of care that incorporates respect for the client's personal choices and preferences.

The nurse observes two unlicensed assistive personnel (UAPs) transferring a client using a mechanical lift. Which observations would require the nurse to intervene immediately?

No support is provided for the client's head The client is lowered as quickly as possible to the chair. The safe use of a mechanical lift includes ensuring the equipment and sling are fully functional, and confirming the appropriate weight limit prior to use. The client should be raised just enough to clear their bottom off of the bed. The client should be lowered slowly to the chair. The nursing staff will need to provide support for the client's head during the lift.

A client is being prepped for a surgical procedure and the nurse is reviewing the consent form with the client. The client asks, "Is there any other way to take care of this without having surgery?" What should the nurse do next?

Notify the surgeon that the client has additional questions about the surgery. rational The client should only sign the consent form after all their questions are answered. Notify the appropriate health care provider if the client needs additional information about the surgery. Once the client has all the necessary information, they can then decide not to sign the informed consent form and the surgery can be cancelled. Offering false reassurance violates the client's right to autonomy. Cancelling the surgery is premature at this time.

The nurse hears a scream coming from a client's room. When entering the room, the nurse finds the client lying on the floor beside the bed. Which of the following actions should the nurse take?

Observe the client for abnormal leg rotation. Notify the client's provider about the incident. Take the client's vital signs. Determine the client's level of consciousness. Fall prevention is a national patient safety goal and is monitored closely in all health care settings. It is important for the nurse to assess and evaluate the client to determine if the client experienced a loss of consciousness or a change in vital signs that contributed to the fall. It is important to determine if there are visible injuries and note any areas of pain or abnormal leg rotation. The nurse will notify the provider and complete an incident report. Risk management will receive notification through the completion of an incident report; the nurse should not notify the legal department by themselves. Physical restraints are not indicated and may, in fact, make the client more prone for future falls.

The home health nurse is visiting a client diagnosed with type 1 diabetes and osteoarthritis. The client has difficulty holding and using the prescribed insulin pen. The nurse should refer the client to which community resource person?

Occupational therapist Holding and using an insulin pen requires fine motor skills and good vision. A client with osteoarthritis (OA) might experience limited movement and pain in the joints of the fingers and hand. An occupational therapist can help a client improve the fine motor skills needed to prepare an insulin injection. An occupational therapist works with clients to perform tasks that are needed for smaller movements to maintain activities of daily living or for work. A physical therapist works with general movement problems, mobility stability, range of motion and/or strength training exercises. It would not be appropriate to refer the client to chiropractor and a pharmacist in this situation.

A newly admitted client has a skin ulcer that tested positive for MRSA (methicillin-resistant Staphylococcus aureus). What precautions should the nurse take when caring for this client?

Place personal protective equipment (PPE) at the door to the room. Place the client in a private room. Keep all equipment in the client's room for their sole use. Perform hand hygiene after contact with the client and before leaving the room. Contact precautions are recommended in acute care settings for MRSA when there is a risk for transmission or wounds that cannot be contained by dressings. The client should be in a single room. All equipment, such as stethoscopes and blood pressure devices, should be for the client's sole use and kept in the room. Health care workers must perform hand hygiene (wash hands with soap and water) after direct contact with the client and their environment and before leaving the isolation room. Contact precautions require health care workers to wear PPE such as gloves and a gown, which should be readily available. It is not required to keep the door closed at all times.

The nurse is attending an in-service about health care-acquired infections (HAIs). Which factor is considered a common cause of HAIs for clients in the acute care hospital setting?

Presence of an indwelling urinary catheter Catheter-associated urinary tract infections (CAUTI) is one of the more common HAIs in the acute care hospital setting. Surgical site infections, bloodstream infections and pneumonia are other types of HAIs, but are less common than CAUTIs.

Which of these activities can the nurse assign to an unlicensed assistive person (UAP)?

Provide basic care to the client. rationale UAPs' limited scope includes (but may not be limited to) assisting with ADLs such as bathing, feeding, toileting, obtaining vital signs, input and output (I/O), performing point of care (POC) tests, such as a blood sugar check or 12-lead electrocardiogram, and recording height and weight. UAPs cannot reinforce teaching, create a plan of care or assume nursing care for a client - even if the client is stable.

Which action shall the nurse take to preserve the client's right to autonomy?

Providing the client with requested information to make an informed decision. Autonomy can be defined as the personal freedom and the right of competent people to make choices. Autonomy, the principle of respect for a person, is sometimes called the primary moral principle. This concept holds that humans have incalculable worth or moral dignity not possessed by other objects or creatures. If an autonomous person's actions do not infringe on the autonomous actions of others, that person should be free to decide whatever they wish. This freedom should be applied even if the decision creates risk to their health and even if the decision seems unwise to others. Concepts of freedom and informed consent are grounded in the principle of autonomy.

Which of the following defines the Quality and Safety Education for Nurses (QSEN) competency of Patient-Centered Care?

Recognize the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for patient's preferences, values, and needs. The definition of the Quality and Safety Education for Nurses (QSEN) competency of Patient-Centered Care is: Recognize the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for patient's preferences, values, and needs. The other answers pertain to the competencies of Teamwork and Collaboration, Evidence-Based Practice (EBP) and Quality Improvement.

The new graduate nurse understands that patient-centered care, according to QSEN should include which of the following nursing actions? (Select all that apply.)

Recognizing the boundaries of therapeutic relationships. 2.Respecting and encouraging individual expression of client values. 3.Communicating what care was provided and is needed at each transition in care. rational The QSEN project defines the knowledge, skills and attitudes for six key areas or required competencies for new nurses. Designing systems that support effective teamwork fits under the Teamwork and Collaboration category. Adherence to IRB guidelines is found under the Evidence-based Practice (EBP) competency.

The nurse notices flames and smoke in the garbage can in a client's room. Which action should the nurse take first?

Remove the client from the area. The nurse's first action in an active fire should be to remove the client from imminent harm. The other actions should occur after the client is taken to safety.

The nurse asks another staff nurse to sign for wasting a partial-dose opioid injection, although the wasting was not witnessed by anyone. This type of request seems to be a pattern of behavior for this nurse. What is the most appropriate action for the second staff nurse to take?

Report this request immediately to the nurse manager. rational The incident must be reported to the appropriate supervisor, either the charge nurse or the nurse manager, for both ethical and legal reasons. This is not an incident that a nurse can resolve without referring to an appropriate authority. The second nurse should only sign as a witness to the wasting of a controlled substance if the nurse actually observed the wasting. Signing as a witness without having actually witnessed the wasting action can be considered falsification of records and result in disciplinary action by the nurse's employer and the state board of nursing

The nurse is caring for a client with bilateral wrist restraints. Which intervention(s) should the nurse include in the client's plan of care?

Routinely assess if the client is ready for restraint discontinuation. Monitor the client's emotional response to the restraints. Remove restraints every two hours to allow for movement of involved extremity. Ongoing assessment of clients who require restraints is essential. Restraints should be removed every two hours to allow the nurse to assess the neurovascular status of the restrained extremity, skin integrity under and around the restraint, the client's response to the restraint and the client's emotional state. A new restraint order must be obtained every 24 hours. Assessment of the client with restraints should be documented in the client's medical record at least every 2 to 4 hours. Nurses should frequently assess clients to determine readiness for restraint discontinuation. Restraints should remain in place when client has visitors to ensure client and visitor safety.

A client is admitted to an inpatient crisis unit with the diagnosis of acute mania and has been placed in seclusion. The nurse is assigned to observe the client at all times. It is now time for the client's dinner. What action should the nurse take next?

Serve the dinner in the seclusion room, maintaining observation Seclusion is ordered by a physician and requires continuous observation, unless the order is discontinued or amended. It is incorrect to amend the seclusion or mealtime. Meals can be eaten in the seclusion room with the nurse continuing the 1:1 observation. Meals must be offered on time and should not be withheld. Contracts for safe behavior are meaningless in the presence of psychotic behavior (mania).

During a well-baby visit, the nurse is evaluating developmental milestones for the 7-month-old child. Which of these developmental activities should the child be able to perform?

Sits without support The age at which a child typically develops the ability to sit steadily without support is around 7 to 8 months. Saying several words, drinking from a cup and using a neat pincer grasp are developmental milestones that most children do not reach until age 11 to 12 months.

A client's wound has tested positive for methicillin-resistant Staphylococcus aureus (MRSA). Which transmission-based precautions should the nurse implement for the client?

Standard precaution and contact precautions Standard precautions are used for all clients, regardless of their diagnosis or presumed infection status. Transmission-based precautions provide additional precautions beyond standard precautions to prevent transmissions of pathogens. Contact precautions are used for infections such as MRSA that spread by skin-to-skin contact or contact with other surfaces.

Where can the nurse find the most reliable guidelines regarding the appropriate delegation of tasks to unlicensed assistive personnel (UAP)?

That state's nurse practice act (NPA). rationale When questions arise regarding who can delegate what activities to which unlicensed provider groups, it is the nurse practice acts (NPAs) of individual states that establish the legal definitions of appropriate delegation practices. Because regulations differ among states, each nurse must identify and understand the regulations for the state in which they practice.

The nurse observes an unlicensed assistive personnel (UAP) about to take a client's temperature with a tympanic thermometer. Which observation would require the nurse to intervene immediately?

The UAP applies lubricant to the thermometer probe. The UAP uses the client's room number and name to identify client. The UAP cleans the thermometer by running it under hot water. The correct procedure for using a tympanic thermometer includes cleaning it with approved anti-bacterial wipes. Lubricant is never applied to the probe and put in the client's ear canal. Using the client's room number as a client identifier is not considered a best practice; the client's date of birth and full first and last name are acceptable.Hand hygiene should be performed before and after using any equipment. It is not possible to use a tympanic thermometer with a hearing aid in place.

The nurse and UAP are preparing to reposition a client in bed. Which of the following actions indicate that the UAP requires additional training on correct body mechanics?

The UAP lifts the client, using their upper arm and shoulder strength. It is important to use proper body mechanics when transferring, lifting or repositioning clients. To apply proper mechanics, the health care worker should stand with their feet shoulder width apart and their knees slightly bent and avoid twisting when repositioning the client. Elevate the bed so the working surface is at waist level, which is the health care worker's center of gravity. The nurse or UAP should bend from the knees to aid in the lift, rather than using their arms and shoulders to reposition the client.

A client with Parkinson's disease is prescribed benztropine (Cogentin). For which of the following should the nurse call the health care provider immediately?

The client has a history of primary angle-closure glaucoma. rational The nurse must be able to recognize adverse drug effects and contraindications of medications commonly prescribed for the client with Parkinson's disease. Common clinical manifestations of Parkinson's disease include bradykinesia (slow movement), dysarthria (slurred speech) and orthostatic hypotension, caused by the loss of the neurotransmitter dopamine. The goal of pharmacotherapy is to restore the functional balance of dopamine and acetylcholine. This is achieved by giving dopaminergic drugs and cholinergic blockers.Benztropine is an anticholinergic medication used in the treatment of Parkinson's disease that blocks excess cholinergic stimulation in the brain and reduces muscular tremors and rigidity. Tachycardia is a potential adverse drug event, but a heart rate increase of 15 bpm is within acceptable limits. Due to their blocking actions of the parasympathetic nervous system, anticholinergics are contraindicated with glaucoma, where they can cause an increase in intraocular pressure (IOP), which can lead to vision loss and blindness.

The nurse has administered haloperidol 5 mg orally (PO) as needed (PRN) to a client with a diagnosis of schizophrenia. Which of the following behaviors justify use of this chemical restraint?

The client is experiencing command hallucinations. The client is verbalizing a plan to harm another client. The client is expressing paranoid delusions. Command hallucinations and paranoid delusions can be frightening or dangerous, potentially causing a client to act aggressively. It is important to intervene before a client acts on a plan to harm another person. An antipsychotic medication, such as haloperidol, will help control and manage symptoms and behaviors associated with schizophrenia. A chemical restraint should be used in an extreme or emergent situation. A client has the right to refuse to participate in activities. Verbal intervention, such as offering to speak with the client 1:1, would be appropriate if the client is upset and crying.

The nurse is caring for an 80-year-old client who requires wrist restraints. What client behaviors would support the need to continue to use restraints?

The client is resisting care and attempting to hit the staff. The client is confused and trying to pull out an IV catheter. Physical restraints should only be used as a last resort. If restraints are indicated, the least restrictive device available should be used to restrain the client. The restraint should protect the individual, but also allow for freedom of movement. Circumstances that require the use of physical restraints include when clients attempt to remove life-support equipment, when clients interfere with therapy or treatment (e.g., enteral feedings, intravenous infusions, tracheostomy tubes, etc.) and when clients are combative and a risk to others. Restraints are not indicated for the convenience of hospital staff. Examples of physical restraints include hand mitts, arm sleeves, lap belts and limb restraints.

The nurse enters the room while a student nurse is taking a manual blood pressure on a client sitting in the chair. For which of the following observations should the nurse reinforce teaching with the student nurse?

The client is talking on the telephone and laughing The client is crossing his legs The client is drinking a cup of black tea The air is released rapidly while auscultating for Korotkoff sounds Systolic and diastolic blood pressure increase when talking. If the artery is below heart level, you may get a false-high reading. Caffeine can increase blood pressure if ingested up to 30 minutes prior to taking the reading. The client should not be crossing his legs during BP measurement as that can artificially increase the blood pressure.The air should be released gradually/slowly while auscultating for sound. The cuff positioned at 2 to 3 cm above the antecubital fossa is correct.

The nurse has been assigned to four clients. Which client should the nurse see first?

The client with a history of coronary artery disease (CAD) reporting dyspnea, nausea and unusual discomfort in the upper back rationale Dyspnea, nausea and unusual discomfort in the upper back can suggest an acute myocardial infarction (AMI) and therefore this client should be seen first. The client with the elevated BP should be seen next. Increased urinary output is an expected finding after taking a diuretic and intermittent claudication is a common and expected finding in PAD.

Four clients are admitted to an adult medical unit on the same shift. The nurse should implement airborne precautions for which client?

The client with a productive cough who just returned from vacation in India India has the greatest incidence of tuberculosis (TB) in the world and a client who develops a cough after spending time in India should be tested for TB or other contagious respiratory infections. Until the testing is complete, the client should be placed in airborne transmission-based precautions, which require a private, negative-pressure room. Health care workers would have to use a N-95 mask when in the room providing care for the client. The CMV virus is not highly contagious, but it can be transmitted by close, direct contact with infectious body fluids. Contact transmission-based precautions might be indicated. Clients with VAP and lung cancer are not considered contagious and do not require airborne precautions.

During the management of a client's pain, the nurse should adhere to the code of ethics for nurses. Which of these actions should the nurse consider first when treating the client's pain?

The client's self-report of pain is the most important consideration. .Pain is a complex phenomenon that is perceived differently by each individual. A client's self-reported pain serves as the foundation for the nurse's approach to pain management. The nurse shall keep in mind that pain is subjective and accept the client's report of pain in a nonjudgmental and objective manner. Client-centered and ethical nursing care requires that the nurse recognizes their personally held values and beliefs about the management of pain and that the client's expectations, values and beliefs influence outcomes in the management of their pain. Correct! LESSON Management of Care or Coordinated Care Ethical Practice COURSE RN & PN Review KEYWORDS code of ethicspatient-centeredclient-centeredpain management CONFIDENCE Need Help Fair Strong

A client has been placed in physical restraints due to aggressive behavior. Which of the following demonstrates that the nurse has appropriately implemented the restraints?

The client's status is documented every 15 minutes. The appropriate client advocate or relative has been notified. The radial and pedal pulses are palpable and strong. To avoid injury, restraints should never be fastened to a moving part of a bed or stretcher. A physical restraint order is never "as needed." An order must be written by a provider for each restraint episode. Using profanity and cursing is not cause for physical restraints. To justify physical restraints, the client must be an imminent threat to themselves or others. Strong radial and pedal pulses indicate that the restraints are not occluding circulation. Documentation must be done every 15 minutes on the restraint flow sheet, which is part of the client's permanent medical record. It is a legal requirement to notify the client's advocate or a relative if requested by the client.

An outpatient client is scheduled to receive an oral solution of radioactive iodine. In order to reduce radiation exposure to others, which information should the nurse reinforce?

Urine and saliva will be radioactive for 24 hours after ingestion. The client's urine and saliva will be radioactive for 24 hours after ingestion. The nurse should teach or reinforce teaching to double flush the commode after use, use disposable utensils and avoid close contact with children and pregnant women for seven days after therapy. Because the treatment may cause nausea, it is best that the client does not eat two hours before or after iodine administration. It is not necessary to wash laundry separately or in hot water.

While working a 12-hour night shift, the nurse has a "near miss" and catches an error before administering a new medication to the client. Which factors could have contributed to the near miss?

The nurse has worked four 12-hour night shifts in a row The nurse was interrupted when preparing the medication The nurse is assigned more clients than usual due to staffing issues The nurse works in the intensive care unit (ICU) There are a number of reasons for near misses and making medication errors, including heavy workload and inadequate staffing, distractions, interruptions and inexperience. Fatigue and sleep loss are also factors, especially for nurses working in units with high acuity clients such as the ICU.

The nurse is collecting baseline data on a 14-month-old child during a wellness visit in the primary care provider's office. Which of the following measurement methods are correct?

The nurse measures the child's chest circumference by placing the measurement tape around their chest at the nipple line. The nurse places the tape measure around the child's head at the widest part of the frontal and occipital bones. The nurse places the child on an infant platform scale in either a sitting or supine position. Data collection methods should be correct for the age of the client. Data collection methods for children under the age of two are different than those for older children. A healthy 14-month-old child who is developing normally may prefer to sit on the scale than to be laid on the scale but their height should still be measured while laying down. A toddler's head and chest circumference are measured with a tape measure. The head circumference is measured at the widest point of the frontal and occipital bones, while the chest circumference is measured at the nipple line. An infant or toddler's pulse is counted apically, not radially.

The nurse is preparing to enter a disaster scene to assist with triaging victims. What assessment priorities should the nurse adhere to?

The nurse will allocate resources to those victims with the strongest probability of survival. The nurse will assess clients by considering their airway, breathing, circulation and neurological function. The goal of disaster triage is to use resources for clients with the strongest probability of survival. Age is not a consideration when allocating treatment resources and the nurse does not need to consult a physician prior to making decisions about allocating resources. Furthermore, a nurse does not need special training to assist in a disaster. However, there are certifications available for nurses who are interested. Finally, the nurse will make decisions based on a client's airway, breathing, circulation and neurological function.

The client is diagnosed with active tuberculosis (TB) and the case has been reported to the local health department. The nurse understands that the most important reason for notifying the health department is:

To trace and screen recent contacts the client had Active tuberculosis is a reportable disease because people who had contact with the client must be traced, evaluated for the disease and possibly treated prophylactically. Statistics are kept and trends documented, but that is not the primary or most important reason for required reporting.

The nurse is planning care for a client who is receiving radiation therapy for breast cancer. The client has a nursing diagnosis of risk for impaired skin integrity. Which of the following interventions should the nurse include in the client's plan of care?

Use a mild soap and tepid water to clean the affected area. Radiation can lead to skin changes or skin reactions in the treatment area. Skin changes are commonly seen between the gluteal folds, perineum, collar line and breast. The goal of skin care is to prevent skin breakdown and infection. Clients should be instructed to avoid wearing tight-fitting bras or belts over the treatment areas. During treatment, clients should avoid exposing their treatment areas to direct sunlight, and should also avoid swimming in saltwater and chlorinated pools. Clients should also avoid exposing their treatment area to extremes in temperature (hot or cold). To keep the affected area clean, use a mild soap and tepid water.

The nurse is admitting a client who does not speak English. Which of the following interventions should the nurse include when caring for the client?

Use a trained medical interpreter provided through the facility's interpreter services. Make a note of the client's preferred language in their medical record. Pay attention to any effort by the client to communicate. Plan on taking twice as long as usual to complete nursing interventions. Providing culturally competent care requires the nurse to advocate for clients who do not speak English or whose English proficiency is limited. Advocating for those clients can be accomplished by noting the client's preferred language in their medical record and using an agency interpreter or interpreter services. The nurse should only use a trained medical interpreter, especially for sensitive tasks such as obtaining informed consent. Using an interpreter will require more time than usual, and therefore the nurse should plan to take extra time when caring for the client. Not all interactions with the client will require a qualified interpreter. Show respect for the client by paying close attention to the client's attempts to communicate with the health care team. It is recommended to speak in a low, moderate voice and avoid excessive hand gestures, because they can give the impression that the nurse is angry and yelling at the client. The nurse should avoid using children as interpreters.

A client diagnosed with bipolar disorder has been referred to social services for possible placement in a community halfway house after discharge. The social worker telephones the nurse and asks for information about the client's mental status and adjustment. What should the nurse do next to respond to this request?

Verify that the client's medical record includes the client's written consent to release information. rational HIPAA guidelines are very strict about who has access to and can relay information. In order to release written, verbal or electronic information about a client the medical record must include a signed consent form (unless the client is a threat of harm to themselves or others). In addition, a written request for information is commonly asked for prior to the release of any client information. The nurse must also establish proof of the caller's identity before releasing information over the phone. The nurse can accomplish this by asking the social worker for a phone number, then hanging up and returning the call. This allows the nurse to verify the caller's legitimacy before providing the requested information.

The nurse is caring for a client with a chest tube. The client is confused and keeps attempting to pull out the chest tube. The nurse applies soft restraints on both of the client's wrists. Is the nurse acting appropriately?

Yes, the nurse should apply a restraint to protect the client from self-injury, and then must contact the HCP. Clients have the right to be free from physical or chemical restraints used for the purpose of discipline or staff convenience. A soft wrist restraint can be applied before a doctor's order is given, but the nurse must contact the HCP immediately after the restraint is applied to obtain the order. Sedatives are not appropriate for this client because they can make the client's confusion worse and cause central nervous system and respiratory depression. Asking a family member to stay with the client is not an appropriate intervention.