NCLEX SET 2

A 72 year-old client calls the clinic hotline and reports generalized muscle aches and pains. In response, which question should the nurse ask first?

"Can you tell me more about the severity and location of the pain?" rationale Most older adults have one or more chronic painful illnesses, and in fact, they often must be asked about discomfort (rather than "pain") to reveal the presence of pain. Application of the nursing process directs a nurse to first collect data about the pain. The nurse should also ask about any medications the person normally takes (prescribed and over-the-counter), not only pain medications. Recall that many older adults may be taking a statin for high cholesterol and that a common side effect of statins is leg pain. It would also be appropriate to ask about exercise, but this isn't the nurse's first concern.

A client diagnosed with depression and who has recently been acting suicidal, suddenly becomes more social and energetic than usual. During a clinic visit the client smiles and says to a nurse, "I have made some decisions about my life." What should be the nurse's initial response?

"Do those decisions include thoughts about killing yourself?" rationale Sudden mood elevation and energy may signal increased risk of imminent suicide. The nurse must validate suicide ideation as a beginning step in evaluating the seriousness of the risk. Asking clients to talk about any decision they have made would be the initial response if clients have not had the sudden change in energetic behavior. When clients exhibit sudden changes in behavior and verbal expressions they are at greatest risk for suicide.

A client is receiving an intravenous piggyback infusion of penicillin. Which client statement would require the nurse's immediate attention?

"I am itching all over my chest and belly" rationale Complaints of itching, feeling hot all over and/or the appearance of raised, red welts on the skin are findings of an severe allergic reaction to the penicillin infusion. Therefore, the medication administration should be stopped immediately and the LPN should immediately notify the registered nurse (RN). Notice that only one option focuses on the entire body ("All over my chest and belly"), which indicates a more generalized response. The other options are more specific areas of the body and are less likely to be of an "immediate" concern.

A nurse talks with a 27 year-old client diagnosed with asthma to reinforce information about the management of the therapeutic regimen. Which statement by the client is incorrect and indicates a need for additional reinforcement of information?

"I need to limit my exercise, especially activities such as walking and running." rationale Limiting physical activity in an otherwise healthy, young client should not be necessary if asthma is properly treated. If exercise intolerance exists (wheezing or coughing with exercise, and needing to stop prematurely because of getting short of breath), the asthma management plan should include specific medications to treat the problem such as using an inhaled short-acting beta-agonist (SABA) such as albuterol a few minutes before exercise. The goal is always to resume a normal, active lifestyle. The key here is to notice that this is an exception question so you will look for the odd answer, meaning three of the answers will relate to the management of asthma and one will not. You will also notice that only option speaks to what should not be done, making it the odd answer. In exception questions, the odd answer is the correct answer.

A client expresses anger when the call light is not answered promptly. How should the nurse respond?

"I see this is frustrating for you." This is the most appropriate answer because the response gives credence to the client's concerns. The nurse is validating the client's feelings to provide feedback that the nurse has listened.

A teenage client with a history of sickle cell disease is admitted to the hospital with a diagnosis of sickle cell crisis. Which statement by the client indicates the most likely cause of this event?

"I went to the health care provider last week for a cold and I have gotten worse." Any condition that increases the body's need for oxygen or alters the transport of oxygen, such as infection, trauma, acute dehydration or even cold weather, may cause a sickle cell crisis.

The nurse is reinforcing how to use a short-acting beta agonist inhaler with a client. Which statement made by the client indicates an understanding of what to do after pressing on the canister and administering the medication?

"I will hold my breath for at least 10 seconds." rationale The client should breathe in slowly and hold the breath for at least 10 seconds to allow the medication to reach the airways of the lung. If the client is using a spacer and hears a horn-like sound, then breathing is too rapid and needs to slow down. It is usually only necessary to rinse one's mouth after using a corticosteroid inhaler, not a beta agonist inhaler.

A client is admitted for the placement of a suprapubic catheter. Which statement by the client is incorrect and indicates a misunderstanding of care?

"I will put the tube in every four hours to drain my bladder." In a client with suprapubic catheter, the catheter is surgically placed and remains in place at all times. The client may have been doing self-urinary catheterization before this procedure, and thus may be remembering what was done before. Information about care of the new tube is needed so that the client can properly provide self-care at home. In clients with a suprapubic catheter, antibiotics are given for signs of an active infection. Sitting up or moving enhances the drainage of urine to prevent stasis in the kidney and bladder. Adequate fluid intake will prevent crystallization of the urine and stone formation. Routine changes of the urine bag, as needed, is appropriate because the care is similar to the drainage bag of a urethral catheter.

A client states to the nursing assistant, "I have pressure in the center of my chest." The nursing assistant reports this to the nurse. As the nurse is collecting additional data, which of these statements made by the client would require immediate attention?

"It feels like an elephant is sitting on my chest." A feeling like an elephant is sitting on the chest is a classic finding of myocardial ischemia or myocardial infarction. This would require immediate attention. A stabbing sensation associated with deep breathing is indicative of pleurisy, not angina. In another option, postprandial pain is associated with indigestion. To have pain with reaching or movement is indicative of muscular strain or sprain.

A client tells the nurse, "I have decided to stop taking sertraline because I don't like the nightmares, sex dreams and obsessions I have experienced since I started on the medication." Which response by the nurse would be the most appropriate in this situation?

"It is unsafe to abruptly stop taking any prescribed medication." rationale It is generally unsafe to stop taking many different medications, including the short-acting selective serotonin reuptake inhibitor (SSRI) sertraline (Zoloft). Abrupt discontinuation can cause SSRI Discontinuation Syndrome. A slow tapering of the medication will be prescribed to avoid the symptoms associated with this syndrome, which may include insomnia, headache, dizziness, nausea, vomiting and diarrhea.

Which statement by a parent would alert the nurse to check with the registered nurse (RN) about a risk for iron-deficiency anemia in a 14 month-old toddler?

"My child doesn't like many fruits and vegetables, but really loves milk." rationale Two to three cups of milk a day are sufficient for the young child's needs. Sometimes excess milk intake, a habit carried over from infancy, may exclude many solid foods from the diet. As a result, the child may lack iron and develop a so-called milk anemia. Although the majority of infants with iron deficiency are underweight, many are overweight because of excessive milk ingestion.

A nurse has reinforced discharge instructions to the parents of a child on phenytoin. Which statement by a parent suggests that the teaching was effective?

"Our child should brush after every meal and floss daily." rationale Phenytoin (Dilantin) causes lymphoid hyperplasia that is most noticeable in the gums (as an overgrowth of the gums). Frequent gum massage and careful attention to good oral hygiene may reduce the gingival hyperplasia. More frequent dental checkups may be required.

A client diagnosed with delusional behaviors refuses to eat, stating that the food is poisoned. What should be the initial nursing response to the client's statement?

"The food is not poisoned. You think that someone wants to poison you?" rationale A client with delusions is out of touch with reality and cannot respond to reason. This response acknowledges perception through a reflective question, which presents the opportunity for discussion, clarification of meaning and expressing doubt. These actions present reality. The other options are either inappropriate attempts to reason with the client or affirm the client's delusion.

The nurse prepares to give a 5 month-old infant an intramuscular injection into the vastus lateralis muscle. The parent is concerned about causing the child too much pain. What should be the nurse's initial response to the parent?

"The pain is minimal because the muscle is not located near a nerve." The preferred injection site for an infant is the vastus lateralis (or anterolateral thigh) muscle, which lies along the lateral aspect of the thigh. It is the most developed muscle in children who are not yet walking and, therefore, is able to tolerate large volumes. It is not located near any nerves or blood vessels. To help answer this question, be sure to focus on the question being asked: The parent's concern about the pain. Notice that you can eliminate two of the responses because they bring in a new subject: the needle. Although the injection may be necessary to make the child feel better, this does not address the parent's concern.

A client in alcoholic recovery asks a nurse, "Will it be alright for me to just drink at special family gatherings?" Which response by the nurse would be best?

"The recovering person can never return to drinking." Recovery from addiction of any substance involves total abstinence from all alcohol or other drugs. Notice that three of the (incorrect) options imply that it might be okay for the client to drink again.

The nurse in the emergency department is caring for a child who experienced a seizure at school. The parent comments that this is the first occurrence and denies any family history of epilepsy. What is the best response by the nurse?

"The seizure your child had today may or may not mean your child has epilepsy." rationale Many different factors can cause childhood seizures. These include fever, central nervous system conditions, trauma, metabolic alterations and idiopathic etiologies (unknown). Telling the parent to not worry is dismissive and therefore inappropriate. The comment about no recurrence is false. The long-term treatment comment is premature, given that there is no confirmed medical diagnosis. You should also note that the correct response is the only one that contains the key words found in the question.

The parents of a 4 year-old hospitalized child tell the nurse they will leave for a time and return at 6 pm. When the child asks when the parents will come again, the nurse should respond by making which statement?

"They will be back right after supper." rationale A 4 year-old or preschooler may not completely understand the concept of time. Children at this age interpret time within their own frame of reference, which is why it's best to explain time in relationship to routine events, such as a meal.

A toddler diagnosed with acquired immune deficiency syndrome (AIDS) was given intravenous gamma globulin. The parents ask, "Why is this medication being given?" The best response by a nurse should include which comment?

"This medication is used to prevent bacterial infections." Intravenous gamma globulin is given to help prevent, as well as to fight, bacterial infections in young children with AIDS or in any immunosuppressed client. To help answer this question, you will note that two of the options address both "medication" and an 18 month-old child. The fact that these two options include the entire content of the question make these the ones to focus on. You'll also note that one option addresses "overall general health," which is probably too general of an answer to be the correct answer; the correct option is about a specific type of infection.

A client, with an infected leg wound from a motorcycle accident, has returned home from the hospital. The client was ordered to keep the affected leg elevated and is on contact precautions. The client asks the home health nurse, "Can my friends come to visit me?" Which response by the nurse is the most appropriate?

"Visitors should wash their hands before and after touching you anywhere." rationale Gown and gloves are worn by persons coming in contact with the wounds or infected equipment. Visitors should wash their hands before and after touching the client.

A client calls the evening health clinic to state, "I know I have severely low sugar since the Lantus insulin I took three hours ago is now at its peak." What should be the nurse's initial question to the client?

"What are you physically feeling at this moment?" The correct response focuses on the here and now, which would be the priority. It is also the most patient-centered that gathers assessment data about the client. Two responses are focused on an earlier time. These should be asked next. The other response draws attention to the client's knowledge about the insulin and should be asked last.

A client is being discharged seven days after myocardial infarction (MI). The client asks, "Why do I have to wait six weeks before having sexual intercourse?" Which statement is the best response by the nurse?

"When you can climb two flights of stairs without problems, it is generally safe here is a risk of cardiac rupture at the point of the MI for about six weeks. Associate this time frame with most surgical procedures where activity is limited for 6 to 8 weeks. Scar tissue should form about that time. Waiting until the client can tolerate climbing two flights of stairs without shortness of breath or other findings is the usual advice given by health care providers.

A nurse who works at an extended care facility has just reviewed a new medication order which is not legible. Which statement best reflects assertive communication to the health care provider who wrote the order?

"Would you please clarify what you have written so I am sure I am reading the order correctly?" Assertive communication respects the rights and responsibilities of both parties. This statement is an honest expression of concern for safe practice and a request for clarification without self-depreciation. It reflects the right of the professional to give and receive information. During the reading of each answer option, compare the content for the subjectivity or objectivity and then ask, does the comment contain emotion, negative correction or belittling? If yes, then it is neither an objective or assertive comment.

A nurse is collecting data about a 4 year-old child diagnosed with possible rheumatic fever. Which finding should the nurse suspect is related to this diagnosis?

A sore throat two weeks ago that was treated with an herbal remedy Evidence supports a strong relationship between an infection with Group A beta-hemolytic streptococci without adequate antibiotic treatment, and subsequent rheumatic fever (usually within two to six weeks). Therefore, the history of a sore throat in the child with rheumatic fever indicates that this was most likely strep throat, and the use of herbal remedies would not prevent rheumatic fever from occurring.

A client is being maintained on heparin therapy. The nurse caring for this client must closely monitor which laboratory value?

Activated partial thromboplastin time rationale Heparin is used to prevent further clots from being formed and to prevent the present clot from enlarging. The activated partial thromboplastin time (aPTT) test is a highly sensitive test used to monitor the effects to clients on heparin.

A nurse is making a home visit to a client diagnosed with chronic obstructive pulmonary disease (COPD). The client tells the nurse, "I used to be able to walk from the house to the mailbox without difficulty. Now, I have to pause to catch my breath halfway through the trip." Which nursing diagnosis would the nurse expect on the plan of care for this client?

Activity intolerance related to chronic tissue hypoxia rationale Activity intolerance describes a condition in which the client's physiological capacity for activities is compromised. Remember, the words in quotations are the content of the question and the question is asking for a nursing diagnosis related to this person's "chronic" condition. Begin by reading the first part of each option ("activity intolerance," "impaired mobility," "self-care deficit" and "ineffective airway"). Next, try to match these options with the symptoms in the client's statement. The diagnosis in the second part of each response will confirm the correct answer.

The client is diagnosed with rheumatoid arthritis. Which nursing diagnosis should the nurse anticipate to be a priority in the plan of care for this client?

Alteration in comfort Relieving pain is the priority for this client. The other options are appropriate nursing diagnoses for the disease, but because there is no additional information about the client, you don't know if alteration in mobility or risk for injury is appropriate. Because the question is of a more general nature, the option associated with pain is the best choice. Arthritis is painful in all instances.

A nurse is assigned to care for a 76 year-old client. Which nursing diagnosis would indicate that an older adult client is at greatest risk for falls?

Altered patterns of urinary elimination related to nocturia Nocturia is especially problematic because many older adult clients fall when they rush to reach the bathroom at night. They may be confused or not fully alert upon waking during the night. Inadequate lighting can increase their chances of stumbling and they often fall over furniture, carpets or shoes.

A nurse is providing care for a child diagnosed with sickle cell anemia. During a discussion with the parents of the child, the nurse is asked about the the cause of the illness. Which piece of information should be addressed in this discussion?

An imbalance occurs between red cell destruction and production rationale Anemia results when the rate of red cell destruction exceeds the rate of production through stimulated erythropoiesis in bone marrow (life span shortened from 120 days to 12 to 20 days). Notice that "red blood cells" appears in two options. Think, is anemia a red or white blood cell condition? It is a red cell condition. Sickle cell anemia is not caused by an iron problem. Another option follows a similar pattern; the second half of the statement is true, but the first part is not.

Which is the appropriate injection site to give an influenza vaccine to an adult? Use your cursor to select an area on the image below.

An influenza (or flu) vaccine is less than 1 mL of fluid, so it is acceptable to administer this injection in the deltoid muscle. The deltoid muscle of the upper arm is a site that is easily accessible in public settings where mass vaccinations are administered.

A client is admitted for first- and second-degree burns on the face, neck, anterior chest and hands. Which nursing action is most important at this time?

Assess for dyspnea or stridor Due to the location of the burns on the upper body, face and neck, the client likely has smoke inhalation injuries and is at risk for the development of upper airway edema and subsequent respiratory distress. This is the most important priority at this time - remember ABCs. Although pain control is very important, it is not the correct answer given the location and extent of the burned areas. The remaining two options are incorrect actions at this time. In the emergent phase, burns are not routinely covered and fluid resuscitation a priority. It is in the next acute phase, after the initial 48 to 72 hours, that fluid overload is of concern. In the initial phase of the burn injury, fluid depletion is a concern due to the leaking of fluid from injured tissues. Intravenous fluid is replaced rapidly based on the extent of the burn injury with a goal of maintaining adequate urine output.

The nurse is making a follow-up home visit for a client diagnosed with urinary incontinence. What information should the nurse reinforce with the client?

Avoid taking antihistamines rationale Antihistamines, antidepressants and tranquilizers can aggravate urinary incontinence and should be avoided in clients with urinary incontinence. Holding the urine, avoiding high-sodium foods and restricting fluids have not been shown to reduce urinary incontinence.

The client is seeking medical care in a clinic for an outbreak of herpes simplex virus (HSV) type 2. The client reports having only one other outbreak six months ago. The client is given a new prescription for acyclovir. The nurse should be sure to reinforce which information about the medication?

Begin treatment with acyclovir at the onset of findings of recurrence rationale Episodic treatment is most effective if started when the client is aware of the early findings of a breakout such as pain, itching or tingling. Although most health care providers will suggest not to take medications during pregnancy, acyclovir (Zovirax) is considered safe and has been assigned to pregnancy category B. Unless a client has six or more outbreaks a year, ongoing suppressive treatment may not necessary.

The nurse is reinforcing instructions to a client with moderate persistent asthma on the proper method for using a dry powder inhaler (DPI). Which medication should be administered first?

Beta-agonist rationale The beta-agonist is taken first to open the airway (bronchodilator). The client should wait about five minutes before using another inhalant medication. A dry powder inhaler is similar to a metered dose inhaler in that both are hand-held devices that deliver a precisely measured dose of asthma medicine into the lungs. The advantage of using a dry powder inhaler is that it is breath-activated, so the client doesn't have to coordinate activating the inhaler (spraying the medicine) while at the same time inhaling the medication; the client simply breathes in quickly to activate the flow of medication. To help remember the action of beta-agonists, associate the "B" in beta with the "B" in bronchodilator.

A client is admitted to the hospital with a diagnosis of deep vein thrombosis (DVT). During the admission process, the client reports sudden shortness of breath. The oxygen saturation is 87%. What should be the priority focus of the nurse at this time?

Blood pressure rationale Blood pressure is a critical focus at this point. A pulmonary embolism may cause a sudden decrease in the heart's cardiac output if a clot is lodged in large pulmonary blood vessel. This decrease in cardiac output would result in a sudden decrease in blood pressure, signaling that the client is at risk for cardiac arrest. Pulmonary embolism is associated with the classic finding of sudden onset of difficulty breathing. The other findings are important to assess, but the nurse should first check the blood pressure. Normal oxygen saturation is greater than 95% in younger adults, and greater than 92% in older adults.

The nurse is caring for a client newly diagnosed with supraventricular tachycardia (SVT). Which of these identified findings should be a priority concern?

Blood pressure 90/50 rationale A client with SVT will experience tachycardia, where the heart rate increases to about 140-200 beats/minute. When the pulse rate increases, blood pressure falls. The client may report a "thumping heart" sensation and dizziness. If a client has low blood pressure or chest pain, the condition is considered unstable and the client may need immediate medical intervention (including cardioversion). The client may experience nausea due to SVT; the nausea is unrelated to food. SVT leads to decreased cardiac output and decreased (not increased) urine output. Skin may be cool to the touch, but this would not be the priority.

A client is receiving digoxin 0.25 mg daily. The health care provider has written a new order to also give metoprolol 25 mg twice a day. In checking the client prior to administering the medications, which finding should the nurse report immediately to the registered nurse (RN) charge nurse?

Blood pressure 94/60 mm Hg Both medications decrease the heart rate. Metoprolol (Lopressor) affects blood pressure. Therefore, the heart rate and blood pressure must be within normal range (HR 60-100; systolic BP over 100) in order to safely administer both medications.

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

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

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

Burning mouth and throat pain rationale

The client, who started attending a geriatric day care program a few weeks ago, is crying and repeating, "I want to go home. Call my daddy to come for me." Which action should the nurse initiate?

Call the client by name and invite the client to join the exercise group rationale Engaging clients by using their name and inviting them to a concrete activity, in the here and now, will redirect them and increase their sense of security and belonging. The exercise will also provide an outlet for the emotional distress. The other options are not therapeutic interventions for either the client or the client's family.

The licensed practice nurse (LPN), who is working in a centralized telemetry monitoring area, has identified what appears to be ventricular tachycardia on a client. What action should the nurse take next?

Call the emergency phone on the client's unit and request any available nurse to assess the client's status When there is ventricular tachycardia, ventricular fibrillation, asystole, extreme tachycardia or extreme bradycardia, the person working in the centralized telemetry monitoring area must place an emergency call to the unit and request that any available nurse go assess the client. This nurse will then determine whether to call a Code Blue. Remember, it is best to gather information before taking action, and the client should be treated, not the monitor. If it was another type of rhythm change not listed above, centralized telemetry could call the unit, request to speak to the nurse caring for the client, and then follow up with a facsimile of the rhythm strip.

The client returned from the cardiac catheterization lab four hours ago. The groin was used as the insertion site. Which of the assessment findings would the nurse immediately report to the health care provider? (Select all that apply.)

Capillary refill 6 seconds on the affected toes Pale color of the affected limb Nonpalpable pedal pulse on the affected limb rationale A trace of serosanguineous drainage on the dressing is common. Some bruising or a small lump is expected at the insertion site. Reportable conditions include significant reports of pain; abnormal lab values; abnormal ECG strip; post-procedure bleeding or swelling; color, temperature or pulse changes, especially to the affected limb. Capillary refill should be about 3 seconds.

A female client has a hemoglobin level of 14 g/dL and a hematocrit of 42% following a dilation and curettage (D and C). Which finding should a nurse expect when collecting data on this client?

Capillary refill less than three seconds Because the hemoglobin and hematocrit are normal for an adult female, any related assessments should also be normal. Capillary refill is the only stated "normal" data.

A nurse is assigned to a child after corrective surgery for Tetralogy of Fallot. The change of shift report includes that the child had a seizure during the night of the first day postop. The nurse recognizes this problem may be associated with what factor?

Cerebrovascular accident (CVA) rationale Polycythemia occurs as a physiological reaction to chronic hypoxemia, which commonly occurs in clients with Tetralogy of Fallot. Polycythemia and the resultant increased viscosity of the blood increase the risk of thromboembolic events, such as CVA. The content of this question is neurological and postsurgical, which eliminates two options immediately. Go back to the stem of the question and notice there is nothing that would lead us to an "infection answer," eliminating another option. By process of elimination, only the correct response is left.

The client is prescribed isoniazid to treat pulmonary tuberculosis (TB). The client reports feeling nauseated and begins to vomit. What action should the nurse take?

Check for changes in skin color rationale Although holding a medication until a client stops vomiting is usually indicated, in this case, the nurse will need to collect data to help determine the cause of the nausea. The nurse should also know that clients receiving isoniazid are at increased risk for developing hepatotoxicity. In addition to nausea and vomiting, the client may show signs of jaundice, dark urine, weakness, fatigue and anorexia. Any change in skin color (jaundice), especially when the other findings are present, should be reported to the health care provider.

The LPN is assisting with the care of a client three days after an intramedullary nailing of a proximal right femur fracture. What types of tasks will the charge nurse assign to the LPN? (Select all that apply.)

Check pulse, color, temperature of affected leg Assist client to turn onto let side with legs abducted Assess skin for signs of breakdown rationale The LPN would check pedal pulses, capillary refill, color, temperature of the affected leg. The client will have physical therapy for passive and active range-of-motion exercises but the client will be either non-weight-bearing or partial-weight-bearing at first. If the client is not in traction, s/he can be turned using a pillow between the legs. The indwelling catheter should be removed 12-24 hours after surgery.

A child, injured on the school playground, appears to have a fractured leg. What is the first action a school nurse should take?

Check the child and the extent of the injury When applying the nursing process, a general assessment of the child should be the first step in caring for a child. Even though the other options (which are all interventions) are correct and should be performed, the nurse should gather information and assess the client first. The six "Ps" of vascular impairment can be used as a guide (pain, pulselessness, pallor, paresthesia, paralysis, poikilothermia or coolness).

The client with cancer is being treated with a biological response modifier. Which of the following side effects does the nurse anticipate with biologic therapy?

Chills and fever Biological response modifier cancer therapy agents (for example, interferons and interleukins) are drugs that stimulate the body's own defense mechanisms to fight cancer cells. Flu-like findings such as chills, fever and nausea, are common side effects of this type of therapy. The other assessment findings are not what you would expect when the body is fighting pathogens.

A client with a fractured lower right leg is medicated for pain with meperidine (Demerol) 100 mg and hydroxyzine hydrochloride (Vistaril) 50 mg IM. One hour later the client reports the pain is getting worse. What should the nurse recognize as a potential reason for the unrelieved pain?

Compartment syndrome rationale Increasing pain that is not relieved by narcotic analgesics may be an indication of compartment syndrome. The nurse should immediately inform the charge nurse and emergency intervention will be required. Thromboembolic complications include deep vein thrombosis and pulmonary embolism, which are not characterized by increasing pain at the site of injury. Both pulmonary embolism and fat embolism present with sudden respiratory findings. Osteomyelitis is a bone infection that could occur some time after the initial injury, usually after at least 48-72 hours.

Which factor accounts for the primary reason why domestic violence may remain undetected for many years?

Complaints of the abused person may be vague rationale Signs of abuse may not be clearly manifested and a series of vague complaints such as headache, abdominal pain, insomnia, back pain, and dizziness may be covert indications of undetected abuse. Barriers to diagnosing and treating domestic violence include a lack of knowledge or inquiry and lack of confidence to intervene. Notice that only two of the options focus on the content of this question: "domestic violence" and "undetected." The incorrect option doesn't make sense (how is it known "how few" battered individuals seek medical care?).

The nurse is caring for a child who receives chest physiotherapy (CPT). Which action by the nurse would be appropriate?

Confine the percussion to the rib cage area Percussion (clapping) should be only done in the area of the rib cage. The most common procedures used are postural drainage and chest percussion. The client is rotated through a variety of positions to facilitate drainage of secretions from a specific lobe or segment of the lung. The exercises are done two to three times a day, before meals and at bedtime.

A 2 year-old child is diagnosed with cystic fibrosis. The nurse is reinforcing aspects of home care with the parents. Which information is appropriate for the nurse to include?

Continue with the child's normal activities Physical activity is important in a 2 year-old who is developing autonomy. Physical activity is a valuable adjunct to chest physical therapy. Exercise tends to stimulate mucous secretion and help develop normal breathing patterns. You will notice that two of the options are direct opposites of each other - one states to "restrict" activity and the other states "continue" with normal activities. Ask yourself which would be more realistic for a 2 year-old.

The nurse is caring for a client who is receiving intravenous procainamide. The nurse should include which intervention while this medication is infusing?

Continuous ECG readings rationale Procainamide is used to suppress cardiac arrythmias. When administered intravenously, it must be accompanied by continuous cardiac monitoring by ECG. You will note that the correct response is the only heart-related answer. Urinary output is related to the urinary system, blood pressure is vascular and the remaining option is neurologic. You will also note that the correct option involves continuous monitoring (not hourly) and that this would be best during administration of an IV medication.

A client is admitted with lower abdominal pain, difficulty swallowing, nausea, dizziness, headache and fatigue. During the initial observation the client exhibits agitation, fearfulness and tachycardia. The client remarks, "I am too sick to return to work." The client is diagnosed with somatoform disorder. Following a team discussion about the plan of care, what will the nurse understand about the client's behavior?

Controlled by the subconscious mind rationale People with somatoform disorder do not intend to feign illness; their complaints are not under conscious control. The intent to use illness to avoid work or perform is called "malingering" and is a factitious disorder. To help you answer this question, note that two of the options are opposites: one states that the client has no conscious control of behavior and the other states that the behavior is conscious (manipulative). Because the question is asking about the "big picture," and is not necessarily only focused on "work responsibilities," the most comprehensive option would be the best answer.

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

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

During a routine checkup, a client with a diagnosis of type 1 diabetes has their glycated hemoglobin (A1c) checked. The results indicate a level of 11%. Based on this result, what teaching should be reinforced?

Daily blood sugar monitoring rationale The normal range for HgbA1c (glycosylated hemoglobin) level is 4%-5.9%. The goal for people with diabetes is a hemoglobin A1c less than 7%. Elevation indicates elevated glucose levels over the past two to three months. Keeping the glycosylated hemoglobin at or below 7% has been shown to minimize long-term complications associated with diabetes mellitus. The mean blood glucose level of someone with a HgbA1c of 11% would be 310 mg/dL (17.2 mmol/L); the mean blood glucose for a 6% A1c would be 135 mg/dL (7.5 mmol/L).

The nurse is reviewing the MAR for an 85 year-old client. There is an order for diazepam (Valium). Which of the physical changes associated with aging will have the greatest impact on how this drug is metabolized?

Decreased liver function All of these physiologic changes associated with aging will affect the pharmacokinetics of medications. Decreased lean body mass will have the greatest impact on drug distribution. Decreased kidney function will affect drug elimination. Decreased liver function will have the greatest impact on drug metabolism. Lipid-soluble agents, such as diazepam, will have a prolonged half-life in the elderly and repeated dosing may result in toxic serum levels.

A nurse is collecting data about the growth and development of a toddler diagnosed with acquired immune deficiency syndrome (AIDS). Which finding should the nurse expect?

Delayed achievement of all developmental milestones The majority of children with AIDS have neurological involvement. There is decreased brain growth, as evidenced by microcephaly and abnormal neurologic findings. Developmental delays are common; some children may experience some normal developmental milestones but then experience a reversal or decline of those achievements.

A client was admitted to the eating disorder unit with a diagnosis of bulimia nervosa. When the nurse gathers data about a history of any complications, which of these findings should the nurse expect?

Dental erosion, parotid gland enlargement rationale Dental erosion and parotid gland enlargement are associated with the frequent purging. The acid from the stomach is damaging to the enamel on the teeth. Other findings of bulimia nervosa include swelling of hands and feet, skin changes on the fingers related to the self-induced vomiting (ulceration, callus formation or scarring), irregular menses, and possibly bloody diarrhea (in laxative abusers). Metabolic acidosis, yellowish discoloration of the skin, decreased body temperature are findings associated with anorexia nervosa.

A nurse is reinforcing information about adding table foods to the diet of an 11 month-old infant. What option should the nurse include when reviewing information with the parents about appropriate finger foods?

Diced bananas Finger foods should be bite-size pieces of soft foods, such as bananas or other nibbly foods, like nutritious cereals or crackers. Children should not be given "choking foods" such as hot dogs, grapes, peanuts, popcorn, cherry tomatoes or chewing gum until they are about 4 years old.

A female client who is a former actress enters the day room wearing a sheer nightgown, high heels, numerous bracelets, bright red lipstick and heavily rouged cheeks. Which is the best nursing action in response to the client's attire?

Directly assist client to her room for appropriate apparel selection rationale Assisting the client back to her room allows the client to maintain self-esteem, while modifying her behavior. Discussion with the client about appropriate clothing should be done in a private location.

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

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

At which point should a nurse begin planning for a client's discharge?

During the admission process to an acute care health organization rationale Thoughts about discharge concerns for the plan of care are incorporated after the admission process is completed and during the initial discussion of the client's needs. If guessing, the incorrect responses can be clustered or grouped under the theme of "to wait after admission." Select the correct response as the odd option, which has the time frame of "during the admission process."

A client continually repeats phrases that others have just said. Which term should the nurse use to document this behavior?

Echolalic Echolalic behavior is the immediate and involuntary repetition of words or phrases that other people have just said. It is a common finding in clients diagnosed with autism or in individuals with developmental disabilities. It is also a finding associated with diagnoses such as schizophrenia, Parkinson's disease, and Tourette's syndrome. However, it should be noted that this is a normal and expected finding during the toddler years.

The nurse is reviewing the medication administration record for a newly admitted client. The client is prescribed the beta blocker propranolol, but is not diagnosed with hypertension and does not have a history of heart disease. Which health issue might best explain the reason for prescribing propranolol?

Essential tremors Propranolol is used to help control essential tremors. These tremors are the most common type of tremor; they are usually mild and not associated with any known pathology. Parkinson's tremor usually improves with dopaminergic and anticholinergic medications. Antipsychotic medications can cause tremors and they can be treated with benztropine. Beta blockers can aggravate symptoms of Raynaud's disease.

The nurse is talking with a client. The client abruptly says to the nurse, "The moon is full. Astronauts walk on the moon. Walking is a good health habit." How should the nurse document the client's behavior?

Flight of ideas Flight of ideas is defined as a nearly continuous flow of speech that jumps from one topic to another. As you read the question, notice the client moves from one idea to another, which should help you determine the best answer. Word salad is speech that is unintelligible; even though each words is real, the manner in which they are strung together results in incoherent gibberish. For example, the question "Why do people believe in God?" elicits a response like "Because he makes a twirl in life, my box is broken, I like electrons." A neologism is a new word or combination of words with meaning that is known only by the speaker; it is often used in the speech of schizophrenics.

The nurse arranges for an interpreter to assist with communication between the health care team and a non-English speaking client. In order to promote therapeutic communication in this situation, which action should be the priority for the nurse?

Focus on the client's verbal and nonverbal exchange The nurse should communicate with the client, not with the interpreter. Culturally appropriate eye contact, gestures, and body language toward the client and family are important factors to enhance rapport and understanding. The nurse should elicit feedback and read nonverbal cues of the client. Although all options might be considered, the question being asked is for the "priority." Relate "therapeutic communication" in the stem of the question with "verbal and nonverbal exchange" in the correct response, which is the most client-centered and comprehensive answer.

A client is admitted to the postanesthesia care unit (PACU). The anesthesiologist reports that malignant hyperthermia occurred during surgery. The nurse should recognize that this complication is related to which condition?

Genetic predisposition rationale Malignant hyperthermia is a rare and potentially fatal reaction to inhaled anesthetics. There is a genetic predisposition to this disorder. IV dantrolene is used to treat and prevent malignant hyperthermia.

A client is admitted with the diagnosis of a myocardial infarction (MI). Two days later, the client's temperature is 100.8 F (38.2 C). What is the appropriate nursing intervention?

Give the prescribed PRN acetaminophen (Tylenol) rationale Fever is common starting the second day following MI because of the inflammatory process. Nursing interventions should focus on promoting comfort. Because the client's fever is the result of the MI, the alternative options are less correct. Use of the incentive spirometer, ambulation and increasing fluids can all lower the body temperature. However, when the body temperature reaches 100.5 F (38 C) or higher, the use of the antipyretic acetaminophen is the preferred approach for fever reduction, particularly in recent MI cases, as fever increases the body's need for oxygen.

A woman who is 12-weeks pregnant with her second child comes to the antepartum clinic for a routine prenatal examination. How should the nurse document this information in the progress notes?

Gravida 2, Para 1 rationale Gravida describes a woman who is or has been pregnant, regardless of the outcome of the pregnancy. Para describes the number of babies born past a point of viability. Therefore, a woman pregnant with her second child would be described as Gravida 2, Para 1. In the alphabet, "G" comes before "P," so associate that "G" = the number of pregnancies and "P" = the number of viable births.

After lunch, a client diagnosed with anorexia nervosa states, "I shouldn't have eaten all of that sandwich. I don't know why I ate it. I wasn't hungry." What is this client experiencing?

Guilt rationale When people with anorexia lose control and eat more than they believe to be appropriate, they experience guilt. Self-hate guilt is elevated in adolescents with anorexia nervosa and treatment strategies should take this into consideration when developing treatment options.

A young adult male is admitted with a diagnosis of testicular cancer. Which finding would the nurse expect the client to report?

Heaviness in the affected testicle rationale The feeling of heaviness in the scrotum is a classic finding related to testicular cancer. Erectile dysfunction and scrotal discoloration are not expected manifestations of testicular cancer. Notice that only the correct option addresses the testicles - many times the correct response is the one that matches the content in the question.

The nurse is caring for a client who is involved in an abusive relationship. The nurse understands that during the "tension building" phase, the battered client may experience which of these feelings?

Helplessness rationale Intimate partner violence and abuse is all about gaining and maintaining total control over the victim. Victims of abuse often have poor self-esteem. They feel helpless and believe no one can help them. In the tension-building phase, the abuser finds more things to criticize and becomes more cruel. Victims may become more compliant or withdraw; they cannot allow themselves to become angry or fight back. The fear of violence is often as coercive as the violence itself.

A child presents in the emergency department with a documented acetaminophen poisoning event. In order to provide counseling and education for the parents, what information should the nurse understand?

Hepatic problems may occur and may be life-threatening rationale Clinical manifestations associated with acetaminophen poisoning occur in four stages. The third stage is hepatic involvement, which may last up to seven days and be permanent. Clients who do not die in the hepatic stage gradually recover. The antidote for acetaminophen overdose is N-acetylcysteine (NAC). It is most effective when given within eight hours of the event and can prevent liver failure if given early enough.

A nurse is caring for a 4 month-old infant. Which behavior would the nurse expect the child to exhibit?

Hold a rattle rationale The age at which a baby will develop the skill of grasping a toy with help is four to six months. The infant would use a palmar grasp because the pincer grasp does not develop until around nine months of age.

The father of an 8 month-old infant asks the nurse if his infant's vocalizations are normal for this age. Which finding should the nurse expect at this age?

Imitation of sounds rationale Imitation of sounds such as "da-da" is expected at this time. Babbling is done earlier. Laughter starts at about 4 months, and once attained, remains.

The client, diagnosed with an acute myocardial infarction (MI), is admitted to the cardiac care unit. There is an order for oxygen at 4L/min per nasal cannula. What is the best reason for administering oxygen?

Increase oxygen to ischemic cardiac cells rationale Anoxia of the myocardium occurs in MI. Oxygen administration may help relieve dyspnea on exertion and cyanosis associated with the condition. However, the major purpose is to increase the oxygen concentration in the ischemic, damaged myocardial cells.

A 4 year-old child is admitted with a diagnosis of burns to the legs and lower abdomen. When collecting data on the child's hydration status, which findings indicate less-than-adequate fluid replacement?

Increased hematocrit levels and decreased urine output rationale A rising hematocrit indicates a decreased total blood volume, which indirectly reflects dehydration (it is called a hemoconcentration process). The decreased urine volume indicates the kidneys are conserving water, which is common with intravascular dehydration.

A nurse is performing a neurological assessment on a client who has been diagnosed with a right-brain cerebrovascular accident (CVA). Which of these findings, if observed by the nurse on the day after admission, would warrant immediate attention?

Increased lethargy and difficulty rousing to stimuli rationale A further decrease in the level of consciousness, such as increased lethargy and difficulty arousing to stimuli, could signal a further progression of the CVA and associated brain damage. This is a priority question where all answers could be considered correct. Notice that three options would not require as immediate attention as the correct response, the change or decrease in level of consciousness. Also note that the question focuses on a finding that is observed a day after the CVA. The other three options could be expected residual effects from the CVA. Comparison of findings with the baseline data on admission would be important to detect changes in the client's condition.

A home health nurse makes a postpartum home visit to a married client. Upon arrival, the nurse observes that the client has a black eye and numerous bruises on the arms and legs. The partner is not present at this visit. What action should the nurse take next?

Interview the client to determine the origin of the injuries rationale It would be incorrect to assume domestic violence without further data collection. The approach is to separate the suspected victim from her partner until battering has been ruled out.

A nurse suspects domestic violence as the etiology of a client's injuries. What action should the nurse take first?

Interview the client without the companion rationale The initial critical action is to separate clients from their partners or significant others. Nurses should consider the potential for abuse when completing data collection. The other options are correct actions that would be taken afterwards.

A 6 year-old has enuresis. Which of the following statements about this condition should the school nurse understand?

It has no clear etiology rationale Although predictive factors associated with enuresis have been identified, no clear etiology has been determined. You will note that this option is different from all the others, which suggest a cause for enuresis. When you are unsure of the correct answer, select the odd option.

The client develops swelling and an ache in the left lower leg after abdominal surgery. Which is an appropriate nursing intervention?

Keep the client on bed rest until further evaluation by the provider rationale The client is exhibiting evidence of deep vein thrombosis (DVT, unilateral leg swelling)in the left leg. DVT is a clot in the venous circulation that causes unilateral leg swelling, redness, pain and warmth. The priority is to have the client reduce activity, as a serious complication of DVT is pulmonary embolism, in which the clot in the leg breaks loose, traveling through the venous blood stream to lodge in a pulmonary blood vessel. Pulmonary embolism (PE) can cause sudden problems with breathing, chest pain, hypoxemia and potentially cardiac arrest if the PE is very large, preventing blood from traveling through the lungs to the left side of the heart. Keeping the client on bed rest until further evaluation is the most appropriate way to prevent this complication. Because this is a venous problem, the arterial pulses will not be affected. Antiembolism stockings are indicated for the prevention of DVT and since the client has a swollen leg, this action is not indicated or advised at this time. Immobilizing the leg using pillows is not indicated.

The client has a pressure ulcer on the heel that is covered with black hard tissue. What would be the focus of the nurse developing an appropriate plan of care for this client?

Keep tissue intact If the black tissue (eschar) is dry and intact, no treatment is necessary. If the area presents with either cellulitis or pain, suggesting infection, then debridement would be indicated.

The nurse is reviewing a client's history from an earlier admission. Documentation of anhedonia is noted. The nurse should understand that this refers to which issue?

Lack of enjoyment in usual pleasures rationale Anhedonia is the lack of enjoyment in usual pleasures or an inability to experience pleasure from normally pleasurable life events such as eating, exercise and social or sexual interactions. Anhedonia is recognized as one of the key findings of the mood disorder depression and is also found in schizophrenic disorders. It is often experienced by drug addicts following withdrawal, particularly from stimulants like cocaine and amphetamines. Even if you can't remember the definition of this word, think about the prefix "a" or "an," which usually means "without" or "lack of something." In this case, select the option that includes "lack of" in the response.

The nurse is providing assistance with goal-setting to a client diagnosed with anxiety. What would be an appropriate goal for a client with anxiety?

Learn self-help techniques for anxiety reduction rationale Exploration of alternative coping mechanisms will decrease present anxiety to a manageable level. To assist clients with learning self-help techniques will allow them to cope with their anxiety.

The nurse is caring for a client diagnosed with sickle cell crisis. The client is scheduled to receive two units of packed red blood cells. Which action is appropriate for the nurse when monitoring the infusion?

Limit the infusion time of each of the units to a maximum of four hours rationale Whole blood and packed cells should be infused within four hours of being started. Vital signs are measured and recorded before the infusion starts, 15 minutes after the start of the infusion (while the client is observed for any allergic reaction), and then every 30 to 60 minutes during blood transfusion therapy (or per agency policy). If the client develops fever or chills, the infusion should be stopped. Remember to answer the question being asked. How will the nurse "monitor" the infusion?

A client tells the nurse, "I am afraid of this planned surgery because I have evil thoughts about a family member." Which response should be the initial intervention taken by the nurse?

Listen to the client rationale Therapeutic communications are based on attentive listening in order to have clients express feelings. If the nurse is not familiar with the cultural beliefs of a client, acceptance of feelings should be followed by questions about the beliefs. Remember, when the question asks for an "initial" response, another person should not be introduced into the answer (chaplain). This will narrow your options down. Ask yourself what comes first - accepting, reinforcing or listening? Listening is also the only option that is further "data collection," which is the first step in the nursing process.

A 14 year-old adolescent is diagnosed with scoliosis. Which consequence of treatment will be the most challenging for the adolescent?

Looking different from the peers rationale Conformity to peer influences peaks at around age 14. The adolescent will need help in learning how to deal with reactions of others. Treatment of scoliosis is long-term and involves bracing and/or surgery. The key here is to associate "adolescent" with the word "peers" in the correct option.

A client is prescribed lithium, a mood stabilizer for bipolar disorder. Which of the following findings does the nurse recognize as the early signs of toxicity?

Loss of appetite, mild diarrhea, increased thirst rationale Lithium is approved for the treatment of bipolar disorder and acute mania. Some of the possible side effects of this medication include sedation, nausea, loss of appetite, mild diarrhea, dizziness, fine hand tremors, frequent urination and increased thirst. It's important that the client understands that salt and fluid intake can affect the levels of lithium in the blood. The nurse should notify the prescriber when a client experiences these side effects.

The nurse is caring for a victim of domestic abuse. Which characteristic is commonly associated with the abuser?

Low self-esteem rationale Abusers are often charming, jealous, manipulative, controlling, narcissistic, inconsistent, critical, hypersensitive, vicious and cruel. Even though a lot of abusers seem "tough" and "confident," they often suffer from low self-esteem. Alcohol can make someone who is easily frustrated and angry more violent, but alcoholism does not cause abuse.

The home health nurse observes the client change an ileostomy pouch. Which action is best to help prevent skin breakdown?

Make sure the skin around the stoma is wrinkle-free rationale The ileostomy pouch should be changed approximately every 5 to 7 days; the bag should be emptied about every 4 to 6 hours. Before applying a pouch, the stoma and skin around the stoma should be gently cleaned using mild soap and water and allowed to dry. A skin barrier powder or other skin prep can be applied to intact skin around the stoma - but not to the stoma. The skin around the stoma should be dry and wrinkle-free before applying a new pouch or wafer to ensure a tight, leak-free seal.

During the care of a client in the fourth stage of labor, the nurse determines that the uterus is boggy and there is vaginal bleeding. Which action should the nurse take first?

Massage the fundus rationale The nurse's first action should be to massage the fundus until it is firm because uterine atony is the primary cause of bleeding in the first hour after delivery.

The newborn is admitted with a tentative diagnosis of pyloric stenosis. A nursing history would most likely reveal which finding?

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

The nurse is teaching the client scheduled for a thyroidectomy about taking potassium iodide (SSKI, ThyroShield) drops. What information shall the nurse include?

Mix the medication with juice or milk. This medication is used preoperatively, 10-14 days before surgery, to reduce the size and vascularity of the thyroid gland, not enlarge it. Potassium iodide drops should be mixed with water, fruit juice, milk, broth or even formula. The client can use a straw to drink the mixture. To minimize gastrointestinal irritation, it can be given after meals or with food. It should be stored at room temperature.

A nurse is administering albuterol inhaled to a child diagnosed with asthma. Which intervention should be included in the plan of care?

Monitor heart rate rationale One of the most common adverse effects of beta-adrenergic medications is an increase in heart rate. To help answer this question, you should note that two of the options contain data collection words ("observe" and "monitor"). Ask yourself if monitoring heart rate or observing for lethargy would be more important.

The caregiver of a client with Alzheimer's disease asks the nurse for information about different treatment options that can help with memory or behavior problems. Which of the following responses by the nurse are correct? (Select all that apply.)

Music therapy has been found to help some clients." "Ginkgo biloba may help with memory." "Donepezil (Aricept) may help slow cognitive decline." rationale Some complementary and integrative health therapies may help with the symptoms of Alzheimer's disease. Music, art and dance therapies can help with behavior issues. Ginkgo biloba may be used to improve memory. Acupuncture may be a frightening experience for someone with Alzheimer's disease. Garlic is not a treatment for Alzheimer's disease. Donepezil (Aricept) is used to ease the symptoms associated with Alzheimer's disease.

The nurse is caring for a client several days after being diagnosed with a cerebral vascular accident (CVA). Warfarin has been prescribed. Today's prothrombin level is elevated to three times greater than the normal range. Which focus is the priority for further data collection?

Neurological status rationale An abnormally elevated prothrombin time indicates a high risk for bleeding. Neurological data collection is a priority in clients with a history of an acute CVA. Two options would not be considerations since they would be associated with clotting, which is not the current risk. The option of bleeding gum would be a concern, but would not be a priority over cerebral function.

The nurse recognizes that obtaining accurate post anesthesia vital signs is extremely important. Which of the following client conditions are not appropriate for electronic blood pressure measurement? (Select all that apply.)

Peripheral vascular obstruction Irregular heart rate Shivering rationale Clients with irregular heart rates, peripheral vascular disease, seizures, tremors, and shivering are not candidates for using an electronic blood pressure machine.

A client has returned from having a cardiac catheterization. Within the first few hours, which finding would indicate the client is having a complication from the procedure?

Persistent absent pedal pulse in the affected extremity rationale Persistently absent pulse in the extremity would indicate severely impaired circulation, possibly cause by a femoral artery thrombosis. This is a medical emergency. The other items, which may be more common changes, may be present without indicating a complication.

A nurse is assisting in the discharge of a child who was admitted with a diagnosis of acute spasmodic croup. What topic for home care should be reinforced with the parents?

Provide humidified air with increased oral fluids rationale The most important aspect of home care for a child with acute spasmodic croup is to provide humidified air and increase oral fluids. Moisture soothes inflamed membranes, making it easier to breathe. Cool evening air can also help alleviate respiratory symptoms. Adequate systemic hydration aids in mucociliary clearance and keeps secretions thin, white and watery so that they can be easily coughed up. Croup is a viral respiratory illness. Corticosteriods may be beneficial to decrease inflammation, but sedatives or antihistamines would not be indicated.

The nursing student assigns an unlicensed assistive person (UAP) to complete several tasks. After reviewing the assignments with a preceptor, it is determined that one of the tasks cannot be performed by an UAP. Which task must be reassigned to a registered nurse (RN)?

Provide information about a low-sodium diet prior to discharge rationale The focus of this question is to select the incorrectly assigned task. UAP are typically assigned tasks with predictable outcomes. They assist with activities of daily living, collect specimens, measure weight and can assist with ambulation. It is the registered nurse (RN), and not the UAP, who can teach, initiate referrals or conduct evaluations, as in the case of the client who is being prepared for discharge.

The nurse is caring for a young adult who was in an accident. Which neurological finding would be the priority to report?

Pupils fixed and dilated rationale Fixed and dilated pupils would be the priority to report. The finding of unilaterally or bilaterally fixed and dilated pupils indicates an emergency situation and treatment decisions need to be made quickly. Typically, clients with fixed and dilated pupils have a poor prognosis.

A certified nursing assistant (CNA) reports to the nurse that another CNA is eating food from the client's trays before serving the trays to the clients. What action should the nurse take?

Quietly pull the CNA aside, address the situation and make plans for a follow up meeting rationale Nurses must promote, advocate for and protect the health, safety and rights of the client. It is never acceptable for a staff member to eat food from a client's food tray. In this situation, the nurse must intervene quietly and address the immediate concern; the nurse must also schedule a time to discuss the behavior in a more private setting. It is not appropriate to wait until the next mealtime to try and observe the behavior, delay addressing the behavior or document the behavior (and place a report in a personnel file) without first talking to the CNA.

A client diagnosed with type 2 diabetes mellitus asks the nurse, "Why did the health care provider order a glycosylated hemoglobin (HgbA1c) measurement, since a blood glucose reading was just performed?" Which information will provide the client with the best reason why the HgbA1c test was ordered?

Reflects an average blood sugar level for several months prior to the test rationale Glycosylated hemoglobin values reflect the average blood glucose (hemoglobin-bound) for the previous three to four months. It is used to monitor client adherence to a therapeutic regimen. Usually, the normal range is around 4 to 5.9% (the goal is 7% or less in clients with well-controlled diabetes.) The HgbA1c may also be used with screening for prediabetes in combination with a fasting glucose.

The nurse is caring for a newly admitted 80-year-old client diagnosed with severe dehydration. The client has intravenous fluids infusing and an indwelling urinary catheter. When the nurse is planning care for this client, which task should be a priority to review with an unlicensed assistive person (UAP) who is assigned these tasks?

Report a urine output of less than 30 mL/hr rationale When directing a UAP, the nurse must communicate clearly about each assigned task and give specific instructions about what must be reported. Only implementation or routine tasks should be assigned because they do not require independent nursing judgment or evaluation. With the client's medical diagnosis, fluid loss is a priority and therefore urine output must be monitored.

The nurse is participating in the development of a plan of care for a school-age child diagnosed with acute glomerulonephritis. Which nursing intervention is a priority?

Report changes in blood pressure rationale All of these are appropriate in caring for this client. The task is to decide which action should be done first: an issue related to edema, urine output, rest or blood pressure? Regular and frequent monitoring of blood pressure and other vital signs are essential in order to monitor the progress of this disease. Acute hypertension must be anticipated, identified and treated early. The other actions are a lower priority.

A client is receiving an IV antibiotic infusion and is scheduled to have blood drawn at 1:00 pm for a "peak" antibiotic level measurement. A nurse notes that the IV infusion is running behind schedule and will not be completed by 1:00 pm. The nurse should take which action?

Reschedule the laboratory test rationale If the antibiotic infusion will not be completed at the time the peak blood level is due to be drawn, the nurse should ask that the blood sampling time be adjusted to when the infusion is complete. The range for peak levels to be drawn are from 30 minutes to one hour after infusion of a dose. Trough levels are drawn immediately or up to 30 minutes prior to when the next dose is hung. A general rule is that three doses of a medication is given before peaks and troughs levels are drawn.

The nurse checks a client who is on a ventilator for respiratory failure in pneumonia. Which finding indicates that the client may need suctioning?

Restlessness rationale Restlessness, increased heart and respiratory rates, and noisy breath sounds suggest hypoxia and are indications for suctioning to clear the airway of secretions that obstructing air flow and gas exchange.

The client has just returned from surgery for insertion of a permanent pacemaker. Which of the following actions is a priority for the nurse caring for this client?

Restrict movement of the affected arm arm and shoulder area It is important to restrict movement of the client's affected arm and shoulder for 24 to 48 hours following insertion of a permanent pacemaker. This prevents dislodgement of the pacemaker equipment while the scar tissue is being formed over the tip of the wire. because the client just had surgery, it is too early in the postoperative period for infection to develop (unless it was a "dirty" case, and that data is not in the stem.) There is no need for the client to remain NPO after this procedure or to apply a pressure dressing.

The nurse caring for a premature newborn carefully monitors oxygen concentration. The most important reason for this is to prevent which complication?

Retinopathy of prematurity While there are other causes for retinal damage in the premature infant, maintaining the oxygen concentration below 40% reduces the risk for retrolental fibroplasia (also called retinopathy of prematurity). When answering this question you will note that both the correct response and the question contain the word "premature." Although the other conditions may also develop in the premature infant, the most compelling reason for monitoring the oxygen concentration is retrolental fibroplasia.

A school nurse is called to the playground for a child who has experienced mouth trauma. The nurse finds that the front tooth of a 9 year-old child has been avulsed (knocked out). After recovering the tooth, what is the correct initial action by the nurse?

Rinse the tooth in water and then place it into the socket Following avulsion of a permanent tooth, it is important to rinse the dirty tooth in water, saline solution or milk to clean it, then to replace it in the socket as soon as possible, ideally within 30 minutes. Those handling it should avoid contact with the root. The child should be taken to the dentist or the emergency room within 30 minutes. By following these interventions, the child's tooth is likely to be successfully reimplanted. Look at the options that indicate "placing" the tooth back into the socket and then ask which action should come first - rinsing it or simply putting it back in the mouth.

The nurse is discussing dietary habits with a client who takes warfarin. During the course of the discussion, the nurse should reinforce the need to avoid eating which food?

Romaine lettuce rationale Green leafy vegetables, such as romaine lettuce, parsley and spinach, contain vitamin K, which may interfere with the anticoagulant effects of warfarin and may predispose the client to develop blood clots. Cranberry juice and alcohol can increase the effect of warfarin, leading to bleeding problems.

The nurse is assisting with an admission of a client diagnosed with hypertensive crisis. The client reports feeling dizzy after taking diltiazem at home. Which data is most important for the nurse to collect?

Schedule for taking medicine rationale Diltiazem (Cardizem) is a calcium-channel blocker that is used to treat hypertension and to control angina. A common side effect of the medication is dizziness. Asking about diet and activity and obtaining baseline vital signs are part of the admission process. But if the client reports dizziness, the most important question to ask the client taking diltiazem is when s/he takes the medication. Diltiazem should be taken about the same time(s) every day; the regular table is usually taken 3 to 4 times a day and the extended-release capsule or tablet is usually taken 1 to 2 times a day.

A client calls a triage nurse to discuss a recent diagnosis of a panic disorder. Which characteristic identified during the discussion is most significant for this client?

Sense of impending doom rationale The feelings of being overwhelmed and experiencing uncontrollable doom are characteristics of a panic attack. The other options given could also be associated with panic attacks, although they are not the most characteristic findings. The question being asked is about the "most significant characteristic" of "panic disorder." You should be able to narrow the options down to the two that are similar but dissimilar; the one that focuses on specific fears or the one that suggests a generalized sense of danger ("sense of impending doom").

While participating in the planning of care for a 2 year-old hospitalized child, a nurse expects that the toddler's behavior will be most affected by which situation?

Separation from parents rationale Separation anxiety is most evident and at its peak from 6 months to 30 months of age. It is the greatest stress imposed on a toddler by hospitalization. If separation is avoided, young children have a tremendous capacity to withstand other stressors. Open visitation and/or providing parents or primary caregivers the opportunity to stay with the hospitalized toddler will help decrease separation anxiety.

The nurse is collecting data as a general guide for emergency management of acute alcohol intoxication. What data is important for the nurse to obtain about the client?

Serum alcohol level rationale Blood alcohol levels are generally obtained to determine the degree or intensity of intoxication. The amount of alcohol consumed determines how much medication the client needs for treatment and is also a predictor for the risk of complications. In the United States, typically a blood alcohol level greater than 0.08% (80 mg/dL or 17.4 mmol/L) is considered impaired when driving noncommercial vehicles.

A 78 year-old client is prescribed digoxin and bumetanide. The client reports nausea and abdominal cramps and begins to vomit. Which lab result should the nurse check first?

Serum potassium rationale The most common cause of digoxin toxicity is low serum potassium. Clients must be taught that it is important to include dietary sources of potassium while taking diuretics. Thiazide and loop diuretics cause potassium loss. Bumetanide is a loop diuretic.

The nurse is caring for a client in the late stages of amyotrophic lateral sclerosis (ALS). Which finding would the nurse expect?

Shallow respirations rationale ALS is a chronic progressive neurodegenerative disease that affects nerve cells in the brain and spinal cord. In ALS, upper and lower motor neurons degenerate (die) and stop sending messages to muscles; all muscles under voluntary control eventually weaken and atrophy. People eventually lose their ability to speak, eat, move and breathe. However, ALS does not impair a person's mind or intelligence. ALS does not affect a person's ability to see, smell, taste, hear or recognize touch.

An 80 year-old client was admitted with a diagnosis of a cerebral vascular accident (CVA). The nurse has noted increasing lethargy over the past few hours since admission. Which finding should the nurse report immediately to the registered nurse (RN)?

Slurred speech rationale Changes in speech patterns and level of consciousness from baseline can be indicators of extension of the CVA. Sonorous breathing is not indicative of a CVA complication. Muscle weakness, usually unilateral, is expected in the client with CVA, but would be a priority if it is new since admission. Bladder or bowel incontinence also occurs in some cases.

The nurse is handing out information about infant feeding to families visiting a health clinic. Which information should be reinforced by the nurse?

Solid foods are introduced one at a time beginning with cereal rationale Between the ages of 4 and 6 months, solid foods should be added one at a time, one week apart, to detect allergies or intolerance. If the infant is able to tolerate the food, another food may be added in a week. Iron-fortified cereal (usually rice) is the recommended first food. Babies can be given egg yolks, but never egg whites because the whites are highly allergenic. Although many people think that mixing cereal and formula in a bottle helps infants sleep through the night, the American Academy of Pediatrics and dietitians and nutritionists recommend against this practice.

The nurse discusses nutrition with a pregnant woman who has been diagnosed with iron deficiency. The client follows a vegetarian diet. The selection of which food items would indicate that the woman knows appropriate sources of iron?

Spinach and dried fruits rationale Both of these foods would be a good source of iron. Other sources of iron include (highest levels of iron) organ meat, spinach, oysters, peas, legumes and beef; (moderate levels of iron), tofu, seafood, whole grains, enriched grains, wheat germ and oatmeal; and (low levels of iron) peaches, prune juice, dried apricots, potatoes, green beans and broccoli. The client should avoid fluoride, antacids, tetracycline, coffee, tea, dairy products, eggs, or whole grain breads within one hour before or two hours after taking an oral iron supplement as these items interfere with iron absorption. However, taking vitamin C with iron enhances its absorption.

A client is admitted to a mental health unit with the diagnosis of delusional thinking. The nurse should expect to observe which findings in this client?

Suspiciousness and resistance to therapy Clinical features of delusional disorder include extreme suspiciousness, jealousy, distrust and belief that others intend to harm. Flight of ideas and hyperactivity is more commonly associated with the manic state of bipolar disorder. Panic and physical complaints might be more appropriate findings for anxiety disorders. Individuals who are anorexic and have feelings of hopelessness may be suffering from depression.

The nurse is preparing a client for a kidney, ureter, bladder (KUB) radiographic test. Which action should the nurse implement?

Take no special interventions for this examination No special preparation is necessary for this examination. If you are not sure about the correct response, you will note that two of the options address GI information, which differs from the renal content in the stem of the question. Also note that there is usually no need to medicate someone with a narcotic for an x-ray.

The nurse is reinforcing information about an oral hypoglycemic medication to a client. Which issue should the nurse be sure to emphasize?

Take the medication at the specified times rationale Diabetics must be able to self-monitor blood glucose levels and be able to recognize the findings associated with hypoglycemia. But reinforcing information about how and when to take the medication is the best response for this question. Oral hypoglycemics should be taken at the same time each day, before meals. Clients should not change how many pills they take without first consulting with their health care provider.

The child diagnosed with central diabetes insipidus (DI) is being treated with desmopressin nasal. What information is important to reinforce with the family? (Select all that apply.)

The child should wear MedicAlert® identification It is important to decrease intake of water and other fluids while taking this medication Using the nasal preparation may cause a stuffy nose A parent or other responsible adult should supervise and help the child use the medication rationale DI results from reduced secretion of the antidiuretic hormone, vasopressin. Desmopressin (DDAVP) is a synthetic analogue of the natural pituitary hormone vasopressin that will help prevent the loss of water from the body by reducing urine output and helping the kidneys reabsorb water. All clients taking desmopressin must limit drinking of water and other fluids; drinking too much water can result in hyponatremia, which can cause muscle weakness, spasms or cramping as well as loss of appetite, severe headaches, confusion, loss of consciousness and seizures. Anyone with central DI should wear a MedicAlert® ID and carry an emergency medical information card.

The charge nurse is making assignments to the health care team. Which of these clients should the charge nurse assign to the LPN/VN?

The client diagnosed with peripheral vascular disease and an ulceration of the lower leg LPN/VNs can be assigned to clients whose care is not too complex or variable, with a low likelihood of an emergency. The client with peripheral vascular disease is the most stable when compared to the other clients; this client has a chronic condition and needs supportive care.

A nurse is discussing an autograft with a client scheduled for excision of a skin tumor. The nurse recognizes that the client understands the procedure when the client identifies the tissue received will be from what source?

The client's thigh Autografts are done with tissue transplanted from the client's own skin. The others are from nonhuman sources.

A nurse is caring for a client after a spontaneous pneumothorax. Twenty-four hours after a chest tube insertion, the nurse notices that when the client breathes in and out, there is no bubbling in the water seal chamber. Which is the most accurate interpretation by the nurse?

The lung has re-expanded and there is no air leak in the lung rationale When the lung re-expands after a pneumothorax, there is no excess air in the pleural space to be removed and the bubbling stops if the air leak in the lung has healed. You will notice that two of the options involve abnormal findings (an air leak and a kink in the system); these can be eliminated. A spontaneous pneumothorax means the lung has simply collapsed; there would be no anticipated drainage with a pneumothorax. By process of elimination, the odd response or "normal" finding should be selected as the correct response.

The nurse is making rounds with the pediatrician on the postpartum unit. Which of the following newborns should the pediatrician see first?

The newborn with widely spaced cranial suture lines Part of the examination of a newborn is to palpate suture lines; they should be palpable and separated. In cases where there is molding present, they may overlap. If suture lines are widely spaced it may be an indication of hydrocephaly or growth restriction. All the other findings are within normal limits for newborns at term: they usually pass their first meconium stool within 12 to 24 hours after birth; normal blood glucose is 40-60 mg/dL (after the first 24 hours of life, hypoglycemia is blood glucose levels < 45 mg/dL or 2.5 mmol/L) and umbilical cords have two arteries and one vein (only one artery can be indicative of a renal anomaly in the newborn.)

After successful alcohol detoxification, a client remarks to a friend in the visiting area, "I've tried to stop drinking but I just can't. I can't even work without having a drink." What should the nurse understand about this client's confession?

There is a psychological dependence on the drug rationale With psychological dependence, the client's thoughts and attitudes toward alcohol produces the craving and compulsive use. Although addictions typically have both physical and psychological components, the client is expressing a psychological dependence on the drug in this question. Successful treatment of any addiction requires both physical and psychological treatment and support.

A client is taking isoniazide for tuberculosis and asks the nurse about side effects of the medication. The nurse should emphasize the need to report which findings immediately?

Tingling and numbness of the extremities rationale Peripheral neuropathy is the most common side effect of isoniazide and should be reported to the health care provider. It can be reversed or minimized with B6 vitamin or adequate amounts of foods with B6.

The client with iron-deficiency anemia is experiencing extreme fatigue, weakness, headache and dizziness. What does the nurse recognize as the reason for these findings?

Tissue hypoxia rationale Iron-deficiency anemia occurs when there is not enough iron to produce hemoglobin (recall that hemoglobin enables red blood cells to carry oxygen). In anemia, the client's complaints of fatigue and other findings are associated with tissue hypoxia. Causes of iron-deficiency anemia usually include blood loss, lack of iron in the diet or inability to absorb iron. Decreased cardiac output, cerebral edema and reduced hematocrit are unrelated to iron-deficiency anemia.

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

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

A client is admitted with the diagnosis of myocardial infarction (MI). Which laboratory values, if all are elevated, should the nurse anticipate to be most specific to this diagnosis?

Troponin An elevated troponin is the most specific to myocardial damage. CPK is a general test that reflects muscle damage somewhere in the body. When homocysteine levels and C-reactive protein are elevated, they indicate a risk for cardiovascular and coronary artery disease.

A school-aged child is hospitalized diagnosed with nephrotic syndrome. A nurse is assisting the child with lunch selections. Which choice of foods would be the best choice?

Tuna sandwich, corn on the cob, 1% milk rationale Nephrotic syndrome causes the body to excrete too much protein in the urine. It causes edema in the face, arms, legs and even abdomen. Therefore, the menu should include low sodium choices (2000-3000 mg/day), as well as low protein choices (0.8 g/kg/day). The tuna sandwich, corn on the cob and 1% milk are the best choices from those given. The other options, bologna (sandwich meat), frankfurter (hot dog) and the cheese (grilled cheese) have higher sodium content and should be avoided. You will note that the three incorrect options list either 2% or whole milk; clients should also avoid foods with high fat content.

The nurse is caring for an 8 month-old infant diagnosed with cerebral palsy. Which finding should the nurse expect to observe when collecting data about the infant?

Unable to roll from back to stomach rationale Cerebral palsy is a group of disorders that can involve brain and nervous system functions, such as movement, learning, hearing, seeing and thinking. Symptoms can range from mild to severe and may involve only one side or both sides of the body. An inability to roll over by eight months of age would illustrate one delay in the infant's attainment of developmental milestones. The other options listed are not associated with this condition.

The registered nurse (RN) is preparing to administer a high-dose potassium intravenous bolus over a 30-minute period. Which focus is a priority for the licensed practical nurse (LPN) to check before the RN can give this medication?

Urine output rationale Potassium chloride should only be administered after adequate urine output has been established (greater than 20 mL for two consecutive hours). Impaired ability to excrete potassium via the kidneys can result in hyperkalemia. The minimum urine output In children should be 1 to 2 mL/kg/hr.

The nurse working in a long term care facility reads the list of diagnoses for a newly admitted client: Parkinson's disease, hypertension and hepatitis A (HAV). What type of precautions are needed for this client?

Use gloves when toileting the client rationale HAV is usually transmitted via the fecal-oral route. Only standard precautions are needed for this client. If the client was incontinent of feces and/or diapered, then contact precautions would be needed, but there is nothing to indicate that this client is incontinent. The combination of hot water and detergents used in dishwashers is sufficient to decontaminate dishware and utensils; no special precautions are needed for dishware.

A nurse is caring for a child diagnosed with acute severe airway obstruction. Which finding should the nurse monitor for to detect complications of this diagnosis?

Use of accessory muscles of breathing Use of accessory muscles of respiration is a sign of respiratory distress. Accessory muscle use includes intercostal retractions that are exaggerated and deep as well as lifting of the chest and shoulders to assist in expanding the chest to pull air into the lungs. Because this is a respiratory question, it requires a respiratory response. Of the two respiratory responses, decide which would be the most severe - accessory muscle use or rapid, shallow breathing.

Parents call the emergency department to report that their toddler has swallowed a granular drain cleaner. The triage nurse instructs them to call for emergency transport to the hospital. The practical nurse anticipates that the triage nurse suggested giving the toddler sips of which substance while waiting for an ambulance?

Water rationale Small amounts of water (or milk) will dilute a granular material if performed within 30 minutes after ingestion. The other substances have the potential to cause a reaction with the drain cleaner, which would result in more damage.

A nurse is giving instructions to the parents of a child with cystic fibrosis. What information should the nurse emphasize about administration of pancreatic enzymes?

With each meal or snack Pancreatic enzymes are necessary for digesting fat, starch and protein. They should be taken with each meal and most snacks to allow for the proper digestion of the food. If taken on an empty stomach, they may cause gastric irritation and possibly ulcers. Enzyme capsules should be swallowed whole, not crushed or chewed, and the microspheres should not be sprinkled on or mixed with the whole meal.

The home health nurse is reviewing medications to administer to a client through a gastrostomy tube. Which medication would require the nurse to contact the health care provider?

diltiazem SR (Cardizem SR) tablet rationale Diltiazem SR is a "sustained-release" medication form. Sustained release (controlled-release; long-acting) medication formulations are designed to release the medication over an extended period of time. If crushed, as would be required for gastrostomy tube administration, sustained-release properties and blood levels of the medication will be altered. The health care provider must be contacted to order a substitute medication.