NCLEX STUDY 1

A nurse observes that decerebrate posturing is a comatose client's response to painful stimuli. Decerebrate posturing as a response to pain indicates A. dysfunction in the cerebrum. B. risk for increased intracranial pressure. C. dysfunction in the brain stem. D. dysfunction in the spinal column.

C. dysfunction in the brain stem. Decerebrate posturing indicates damage of the upper brain stem. Decorticate posturing indicates cerebral dysfunction. Increased intracranial pressure is a cause of decortication and decerebration. Alterations in sensation or paralysis indicate dysfunction in the spinal column.

A client with type 1 diabetes mellitus is admitted to the emergency department. Which respiratory pattern in a client with diabetes mellitus requires immediate action? A. deep, rapid respirations with long expirations B. shallow respirations alternating with long expirations C. regular depth of respirations with frequent pauses D. short expirations and inspirations

A. deep, rapid respirations with long expirations. Deep, rapid respirations with long expirations are indicative of Kussmaul respirations, which occur in metabolic acidosis. The respirations increase in rate and depth, and the breath has a "fruity" or acetone-like odor. This breathing pattern is the body's attempt to blow off carbon dioxide and acetone, thus compensating for the acidosis. The other breathing patterns listed are not related to ketoacidosis and would not compensate for the acidosis.

A nurse has inserted a peripheral intravenous catheter. Which type of dressing is most appropriate to use to cover the insertion site? A. transparent B. adhesive C. hydrocolloid D. gauze

A. transparent A transparent dressing is optimal since it allows assessment of the insertion site. A sterile gauze dressing must be changed every 48 hours or more often if needed according to agency protocol. Adhesive bandages are not occlusive, cover a small surface area, and often irritate the skin. Hydrocolloid and foam dressings are used on pressure ulcers and not peripheral intravenous sites.

The nurse is assessing a neonate at 5 minutes after birth. The nurse records the Apgar score based on the findings in the accompanying chart (see third column). The nurse compares these findings to the Apgar score determined by the findings recorded at birth (see second column). What should the nurse do next? A. Notify the neonatologist on call. B. Continue to assess the neonate. C. Apply an oxygen mask. D. Rub the neonate's extremities.

B. Continue to assess the neonate. The neonate's Apgar score has been improving since birth. (The birth score is 6; the current score is 9.) The nurse should continue to assess the neonate. There is no indication that oxygen is needed since the color is improving, and stimulating the baby is not necessary as the baby is now flexing the extremities.

A nurse is caring for a client recovering from cocaine use. Which is the priority intervention for this client? A. skin care B. suicide precautions C. frequent orientation D. nutrition consultation

B. suicide precautions Clients recovering from cocaine use are prone to post-coke depression, and have a likelihood of becoming suicidal if they can't take the drug. Frequent orientation and skin care are routine nursing interventions but aren't the most immediate considerations for this client. Nutrition consultation isn't the most pressing intervention for this client.

The nurse should plan to use an abduction pillow (or splint) after a total hip replacement to: A. prevent hip flexion. B. decrease formation of sacral pressure ulcers. C. prevent dislocation of the prosthesis. D. increase peripheral circulation.

C. prevent dislocation of the prosthesis. After a total hip replacement, it is important to maintain the hip in a state of abduction to prevent dislocation of the prosthesis.Use of an abduction pillow or splint will not prevent hip flexion or the formation of sacral pressure ulcers, nor will it increase peripheral circulation.

During a home visit the nurse observed a mother giving her infant a bath. The nurse documents "Risk for injury (fall) related to parent's knowledge deficit." Which instruction by the nurse best addresses this nursing diagnosis? A. "Hold the neonate loosely and gently." B. "Support the neonate's head and back with the forearm." C. "Use one hand to support the neonate's head." D. "Strap the neonate into the bath basin."

B. "Support the neonate's head and back with the forearm." To maintain a secure grip while bathing the neonate, the nurse should support the neonate's head and back with the forearm. A loose hold may increase the risk of dropping the neonate. The nurse must support the neonate's back and head. Strapping the neonate into the bath basin is inappropriate and confining and precludes optimal physical contact.

What information should the nurse include in the discharge teaching for an adolescent client who's taking metronidazole to treat trichomoniasis? A. Sexual intercourse should be avoided until the medication is completed. B. Alcohol shouldn't be consumed while taking this medication. C. Milk products should be avoided since they reduce the effectiveness of the medicine. D. Exposure to sunlight should be limited to 1 hour per day.

B. Alcohol shouldn't be consumed while taking this medication. Clients should not consume alcohol for 48 hours following the last dose of metronidazole. The other choices have no effect on the client taking this medication.

The client with a cervical spinal cord injury is admitted to the rehabilitation unit with skeletal traction (Gardner-Wells Traction). What nursing actions are a priority when caring for the client? Select all that apply. A. Adjust the amount of traction weight. B. Assess the client's skin integrity. C. Maintain proper body alignment. D. Assess client's neurological function. E. Maintain active range of motion.

B. Assess the client's skin integrity. C. Maintain proper body alignment. D. Assess client's neurological function. The nurse will assess the client's skin integrity, maintain proper body alignment, and assess client's neurological function. The Gardner Wells traction does not have weights and clients are limited with active range of motion.

The nurse is caring for a client with juvenile idiopathic arthritis. What will the nurse include in the client's plan of care? Select all that apply. A. keep the client on bed rest B. administer ibuprofen for pain C. encourage a well-balanced diet D. measure growth and development E. assess joints for swelling and deformity

B. administer ibuprofen for pain C. encourage a well-balanced diet D. measure growth and development E. assess joints for swelling and deformity Juvenile idiopathic arthritis affects the joints. Ibuprofen is a drug of choice, and eating a well-balanced diet helps in weight management. The joints can become deformed and swollen. Growth and development can be affected due to the changes in the joints.

A client with severe shortness of breath comes to the emergency department. The client tells the emergency department staff that they recently traveled to China for business. Based on the client's travel history and presentation, the staff suspects severe acute respiratory syndrome (SARS). Which isolation precautions should the staff institute? A. droplet precautions B. airborne and contact precautions C. contact and droplet precautions D. contact precautions

B. airborne and contact precautions Explanation: SARS, a highly contagious viral respiratory illness, is spread by close person-to-person contact. The client should be placed on airborne and contact precautions to prevent the spread of infection. Droplet precautions don't require a negative air pressure room and wouldn't protect the nurse who touches contaminated items in the client's room. Contact precautions alone don't provide adequate protection from airborne particles.

The nurse develops the plan of care for a child with cystic fibrosis (CF) who is scheduled to receive postural drainage. The nurse should anticipate performing postural drainage at which times? A. after meals B. before meals C. after rest periods D. before inhalation treatments

B. before meals Postural drainage, which aids in mobilizing the thick, tenacious secretions commonly associated with CF, is usually performed before meals to avoid the possibility of vomiting or regurgitating food. Although the child with CF needs frequent rest periods, this is not an important factor in scheduling postural drainage. However, the nurse would not want to interrupt the child's rest period to perform the treatment. Inhalation treatments are usually given before postural drainage to help loosen secretions.

The nurse is caring for a client who is G2, T1, P0, A0, and L1 at term. The client is completely effaced and dilated to 2 cm and has contractions every 3 minutes that last for 45 seconds. The client is asking for an epidural to make them more comfortable. What is the most appropriate response by the nurse? A. "We cannot give epidurals until you are 5 to 6 cm dilated. There is intravenous medication available if you would like it now." B. "You cannot have an epidural until your membranes have ruptured." C. Your contraction pattern is slow at this point and will need to accelerate before you can have your epidural." D. "It is too early in labor for the epidural, but you can have IV medication to keep you comfortable until you have dilated 1 to 2 cm more."

D. "It is too early in labor for the epidural, but you can have IV medication to keep you comfortable until you have dilated 1 to 2 cm more." Epidurals are given when labor is established, usually at 3- to 4-cm dilation. The effect of the epidural should be that labor will continue and not be slowed down by the administration of the epidural. The use of an epidural is not correlated with rupture of membranes. The contraction pattern for this client is adequate, not slow, and considered normal for 2-cm dilation. Epidurals are given at 3- to 4-cm dilation, and if there is medication available, it can be given to make the client comfortable until an epidural can be given.

The nurse provides care to a verbally unresponsive client diagnosed with terminal cancer. The client's family refuses palliation on religious grounds. The nurse experiences great anxiety and distress when caring for the client due to the level of suffering perceived. What action should the nurse take? A. Accept that this is the client's and family's wish. B. File a complaint with the facility's client advocate. C. Discuss the plan of care with the client's healthcare provider. D. Speak to the charge nurse about the nurse's moral conflict.

D. Speak to the charge nurse about the nurse's moral conflict. The nurse is experiencing moral conflict and needs to discuss this with the charge nurse. The nurse is not able to simply ignore the feelings being experienced and accept the family's wish; if that were the case, there would be no issue to begin with. If there is an ethical breach related to the client's care, the nurse's first action is to speak with the healthcare team, not with the client advocate. In this case, a true ethical issue is not established. The goal is to strike a balance between the religious freedom of the client and family, the moral autonomy of the nurse, and the delivery of care that exhibits non-malfeasance. After consulting with the charge nurse, it may be decided to excuse the nurse from working with the client on moral grounds, or that the ethical committee needs to be consulted.

An adolescent with ulcerative colitis who is taking corticosteroids is at risk for which complication? A. jaundice B. decreased bowel sounds C. perianal lesions D. delayed sexual maturation

D. delayed sexual maturation In children and adolescents with ulcerative colitis, frequent diarrhea and poor nutrient absorption from the bowel lead to malnutrition. Nausea, vomiting, and anorexia may further compromise nutritional status. Malnutrition, in turn, may cause growth restriction and delayed sexual maturation. Corticosteroid therapy, which is commonly used to treat ulcerative colitis, may also cause growth retardation and delayed sexual maturation. Jaundice isn't associated with ulcerative colitis. Because this disease causes increased bowel motility, bowel sounds may be hyperactive, not decreased. Perianal lesions are rare in clients with ulcerative colitis.

A nurse is caring for a client with agoraphobia. Which signs and symptoms would the nurse anticipate? Select all that apply. A. hallucinations. B. panic attacks. C. inability to leave home. D. eating disorders. E. alcohol consumption. F. tobacco use.

B. panic attacks. C. inability to leave home. Agoraphobia is characterized by extreme anxiety and a fear of being in open places. Panic attacks and an inability to leave home are symptoms associated with the disorder. No correlation exists between fear of open spaces and hallucinations, eating disorders, alcohol consumption, or tobacco use.

The nurse is caring for a frail, older adult client who is experiencing pain. At the client care meeting, the family asks if it is safe for the client to receive narcotics. The nurse is aware that the client is receiving hydromorphone hydrochloride for pain. What is the nurse's most appropriate response to this family? A. The narcotic is safe because it does not accumulate in the body. B. The drug does not cause any problems with breathing. C. The drug is not as strong as morphine. D. This drug is similar to methamphetamine.

A. The narcotic is safe because it does not accumulate in the body. Hydromorphone is a fast-acting narcotic analgesic drug and is a useful alternative to morphine or meperidine due to its short half-life. Morphine and meperidine can increase the risk of confusion in older adults. Hydromorphone is a synthetic drug similar to morphine with an 8 to 10 times more potent analgesic effect. Respiratory depression may occur, but is less frequent than with some other narcotics.

A nurse is reviewing the shift assignment. Which child should be assessed first? A. a 5-month-old infant with I.V. fluids infusing B. an 11-month-old infant receiving chemotherapy through a central venous catheter C. an 8-year-old child in traction with a femur fracture D. a 14-year-old child who is postoperative and has a nasogastric tube and an indwelling urinary catheter

B. an 11-month-old infant receiving chemotherapy through a central venous catheter The nurse should assess the 11-month-old infant with a central venous catheter first. This child takes priority because of the invasive line and chemotherapy, which may cause toxic effects. Next, the nurse should assess the 5-month-old infant with an I.V. infusion and then the 14-year-old postoperative child. Because the 8-year-old child in traction is the most stable, the nurse can assess this client last.

A nurse is caring for an elderly bedridden adult in the long term care facility. To prevent pressure ulcers, which intervention should the nurse include in the care plan? A. Turn and reposition the client every 4 hours. B. Massage lotion over bony prominences when turning. C. Develop a written, individual turning schedule. D. Use two people when sliding the client up in bed.

C. Develop a written, individual turning schedule. A turning schedule sheet helps ensure that the client gets turned and, thus, helps prevent pressure ulcers. Turning should occur every 1 to 2 hours — not every 4 hours — for clients who are in bed for prolonged periods. The nurse should apply lotion to keep the skin moist, but should avoid vigorous massage, which could damage capillaries. When moving the client, the nurse should lift — rather than slide — the client to avoid shearing, despite the amount of helpers.

The nurse is caring for a client who entered the hospital with a diagnosis of dehydration. The client's serum potassium is 5.2 mmol/L this morning and the healthcare provider orders the primary I.V. fluid as D5 1/2 NSS with 20 mEq/KCL (mmol/L). What will the nurse do? Select all that apply. A. Hold the I.V. fluid. B. Hang the I.V. fluid. C. Clarify the order with the healthcare provider. D. Clarify the order with the pharmacy. E. Review the lab results.

A. Hold the I.V. fluid. C. Clarify the order with the healthcare provider. E. Review the lab results. Normal levels of serum potassium are 3.6 to 5.2 mmol/L. The serum level is at the high end, so this client does not need potassium supplement. The client does not need the extra potassium because the serum potassium level is high, the nurse would not administer I.V.F. with potassium added. The nurse already knows the serum potassium level is high so, instead of checking with the pharmacy, the nurse would call the healthcare provider and inform of the high serum potassium level and ask for another I.V.F. order that does not have potassium added.

The nurse reads the new medication prescriptions for a 4-year-old child with nephrotic syndrome (see exhibit). What action should the nurse take? A. Discontinue the prednisolone 40 mg, and give the 30-mg dose today. B. Check the medication record first to see when the last dose of prednisolone was given. C. Start the 30-mg dose tomorrow. D. Contact the prescriber for clarification.

D. Contact the prescriber for clarification. There are many problems with this medication prescription. The abbreviation QOD is ambiguous and open to various interpretations. The abbreviation D/C may be interpreted as "discontinue" or "discharge." The prescriber should have specifically stated when to start the lower dose because the nurse could reason beginning the medication that day, the next, or even the day after that. The only safe thing to do is call for clarification.

The health care provider orders ibuprofen for a client reporting pain. What should the nurse include in the client's teaching concerning ibuprofen? Select all that apply. A. Notify the health care provider immediately of dark tarry stools. B. Do not use over-the-counter medications while on ibuprofen. C. Do not take aspirin concurrently with ibuprofen. D. Notify the health care provider of skin rash or jaundice immediately. E. Avoid exposure to strong sunlight.

A. Notify the health care provider immediately of dark tarry stools. C. Do not take aspirin concurrently with ibuprofen. D. Notify the health care provider of skin rash or jaundice immediately. The nurse should teach the client to notify their health care provider of dark tarry stools, coffee ground emesis, frank blood emesis, or other GI distress, as well as blood or protein in the urine and onset of skin rash, pruritus, and jaundice. The nurse should teach the client not to take aspirin concurrently with ibuprofen and not to drive or engage in potentially dangerous activities until drug response is known. Teaching should not include avoiding exposure to strong sunlight or avoiding over-the-counter medications.

The nurse is caring for a client who is 12 weeks' pregnant and speaks Spanish only. Which intervention(s) should the nurse include in the plan of care at the client's initial visit? Select all that apply. A. Provide brochures in the client's native language. B. Discuss differences with the dominant culture. C. Arrange for an interpreter for their appointments. D. Discuss contraception and options. E. Review nutritional preferences.

A. Provide brochures in the client's native language. C. Arrange for an interpreter for their appointments. E. Review nutritional preferences. Providing culturally sensitive care includes providing printed material in the client's native language. Discussing cultural differences is not a priority or important at the first visit. Clients need to have an interpreter for each prenatal visit to translate and interpret questions. Contraceptive options are not a priority for the first prenatal visit. Reviewing dietary intake and discussing nutrition are important components of early prenatal care.

A student nurse is questioning a nursing instructor about the responsibility to have malpractice insurance. The nursing instructor confirms the safeguard of malpractice insurance by emphasizing which points regarding student liability? Select all that apply. A. The student nurse is responsible for the student nurse's actions. B. The student nurse is held to the same standard of care as a nurse. C. The student can practice as an employee during clinical experiences. D. The student nurse is not responsible for knowing the facility's policy and procedures. E. The nursing instructor can be liable if the assignment is above the student's competency.

A. The student nurse is responsible for the student nurse's actions. B. The student nurse is held to the same standard of care as a nurse. E. The nursing instructor can be liable if the assignment is above the student's competency. Student nurses are responsible for their actions and are held to the same standard of care as a nurse. The nursing instructor can be liable if the student assignment is above the student's competency. Students cannot practice as employees during an educational clinical experience. Students are responsible for being familiar with hospital policy and procedures.

A registered nurse (RN) has been paired with a licensed practical nurse (LPN) for the shift. Whose care should the RN delegate to the LPN? A. a 2-year-old child who nearly drowned 2 days earlier B. a 19-month-old infant who had surgery for a fractured tibia 12 hours ago C. a 6-month-old infant who has gastroenteritis and vomits every 30 minutes D. a 17-month-old infant who lost consciousness 2 hours earlier because of a head injury

A. a 2-year-old child who nearly drowned 2 days earlier The nurse can delegate care of the near-drowning victim to an LPN. Children recover quite quickly from near-drowning experiences; acute care isn't necessary. The infant who has undergone surgery is still under the effects of anesthesia and requires close observation for dehydration, pain, and signs of adverse reactions. The infant with gastroenteritis also requires close monitoring for signs of dehydration. The infant who lost consciousness will need to be monitored most closely. The child's status could quickly become very critical.

How does the nurse on the obstetrics unit assure client safety? Select all that apply. A. reconciliation of medication prescriptions B. communication among staff C. placing culturally similar clients together D. use of two unique identifiers E. staff training

A. reconciliation of medication prescriptions B. communication among staff D. use of two unique identifiers E. staff training Client care safety is enhanced by the process of reconciling all medication prescriptions at least one time each 24 hours of hospitalization. This can rule out duplication of prescriptions, missing medication prescriptions, or alerting the staff to medications that should have been terminated. Communication among all staff members enhances client safety and prevents errors in written or in verbal format. Culturally similar clients are appreciative of being with someone who can speak their language or share thoughts and ideas, but this does not increase the safety of the clients. The use of two identifiers should be consistently used to prevent wrong client and procedure errors. Staff training is an extremely valuable tool to educate and increase communication among staff members concerning existing or potential safety situations.

A 25-year-old client diagnosed with chronic schizophrenia states, "I stopped my medications a week ago. I was just tired of not being able to drink with my friends. Besides, I feel fine without them." Which response by the nurse is most appropriate? A. "It's important for you to go back on your medicines." B. "I hear how difficult it must be to live with the changes caused by your illness." C. "You'll have to talk to your health care provider (HCP) about stopping your medications." D. "Your buddies will understand that you can't drink anymore."

B. "I hear how difficult it must be to live with the changes caused by your illness." By acknowledging the difficulties of living with the illness, the nurse conveys empathy for the client's feelings and opens up the lines of communication. Although it is important for the client to maintain compliance with medication therapy, telling the client that it is important to start taking them again or to talk with the health care provider (HCP) about stopping the medications ignores the underlying feelings of the client's initial statements. Stating that the client's buddies will understand may or may not be true. Additionally, this statement ignores the underlying feelings.

A client complains that they experience pain and numbness in the fingers when typing on a computer keyboard. Which action will help the nurse assess for Phalen's sign? A. Having the client hold both hands above their head with their arms straight for 30 seconds B. Having the client hold both wrists in acute flexion with the dorsal surfaces touching for 60 seconds C. Tapping gently over the median nerve in the wrist D. Having the client extend their wrists while the nurse provides resistance

B. Having the client hold both wrists in acute flexion with the dorsal surfaces touching for 60 seconds Acute wrist flexion places pressure on the inflamed median nerve, causing the pain and numbness of carpal tunnel syndrome (Phalen's sign). Holding the hands above the head with arms straight for 30 seconds isn't an assessment technique. Tapping gently over the median nerve in the wrist tests for Tinel's sign, another sign of carpal tunnel syndrome. Placing the wrists in extension against resistance tests strength.

A home health nurse is educating a client who has been diagnosed with diverticulitis about dietary modifications necessary to prevent future episodes. Which statement by the client indicates effective teaching? A. "I'll increase my intake of protein during exacerbations." B. I should increase my intake of fresh fruits and vegetables during remissions." C. "I'll snack on nuts, olives, and popcorn during flare-ups." D. "I'll incorporate foods rich in omega-3 fatty acids into my diet."

B. I should increase my intake of fresh fruits and vegetables during remissions." A client with diverticulitis needs to modify fiber intake to effectively manage the disease. During episodes of diverticulitis, the client may need to follow a low-fiber diet to help minimize bulk in the stools. During episodes of remission, however, the client should follow a high-fiber diet, and fresh fruits and vegetables are usually an important part of this. Clients with diverticular disease don't need to modify their intake of protein and omega-3 fatty acids. Foods that may become lodged in the diverticula, such as nuts, seeds, and popcorn, should be avoided during flare-ups.

The nurse administers mannitol to the client with increased intracranial pressure (ICP). Which parameter requires close monitoring? A. muscle relaxation B. intake and output C. widening of the pulse pressure D. pupil dilation

B. intake and output After administering mannitol, the nurse closely monitors intake and output because mannitol promotes diuresis and is given primarily to pull water from the extracellular fluid of the edematous brain. Mannitol can cause hypokalemia and may lead to muscle contractions, not muscle relaxation. Signs and symptoms, such as widening pulse pressure and pupil dilation, should not occur because mannitol serves to decrease ICP.

The nurse is performing the initial assessment on a middle age woman recently diagnosed with Cushing's syndrome. The nurse reviews the history and physical (see chart). The nurse should develop a plan with the client to manage which effects? Select all that apply. A. low blood volume B. risk for injury C. slow healing D. in physical appearance E. risk for infection

B. risk for injury C. slow healing D. in physical appearance E. risk for infection Cushing's syndrome results from excessive levels of cortisol. Some effects of excessive adrenocortical activity include musculoskeletal changes, and the client may be at risk for injury and falls. There is excessive protein catabolism causing muscle wasting, decreased inflammatory response, and potential for delayed healing and infection. The increased cortisol levels cause a moon-faced appearance to which clients must adjust. The skin becomes thin and fragile, and the client is also at risk for infection. Increased cortisol levels do not cause deficient fluid volume.

A nurse is caring for a client who is undergoing chemotherapy. Current laboratory values are noted on the medical record. Which action would be most appropriate for the nurse to implement? A. wearing a protective gown and particulate respiratory mask when completing treatments B. washing hands before and after entering the room C. restricting visitors D. contacting the health care provider (HCP) for a prescription for hematopoietic factors such as erythropoietin

B. washing hands before and after entering the room Chemotherapy causes myelosuppression with a decrease in red blood cells (RBCs), WBCs, and platelets. This client's data demonstrate neutropenia, placing the client at risk for infection. An ANC of 500 to 1,000/mm3 (0.5 to 1 × 109/L) indicates a moderate risk of infection; less than 500/mm3 (0.5 × 109/L) indicates severe neutropenia and a high risk of infection. When the WBC count is low and immature WBCs are present, normal phagocytosis is impaired. Precautions to protect the client from life-threatening infections may be instituted when ANC is less than 1,000/mm3 (1 × 109/L). Hand washing is the best way to avoid the spread of infection. It is not necessary to wear a gown and mask to take care of this client. It is also not necessary to restrict visitors; however, visitors should be screened to avoid exposing the client to possible infections. Erythropoietin is used for stimulating RBCs, not WBCs. Granulocyte colony-stimulating factors or granulocyte macrophage colony-stimulating factors are useful for treating neutropenia.

A client who had a Pap test 2 months ago and is now beginning oral contraceptives tells the nurse that her menstrual flow has decreased since taking the oral contraceptives. What should the nurse tell the client to do? A. Ask her primary care provider about having another Pap test. B. Request a consultation with an endocrinologist. C. Continue to take the oral contraceptives because decreased menstrual flow is normal. D. Have her health care provider write a prescription for a lower dosage of oral contraceptives.

C. Continue to take the oral contraceptives because decreased menstrual flow is normal. A common side effect of oral contraceptives is decreased menstrual flow. Other adverse effects include breast tenderness, irritability, nausea, headaches, cyclic weight gain, and increased vaginal yeast infections. More serious adverse effects include hypertension, myocardial infarction, and thrombophlebitis. The nurse should instruct the client that decreased menstrual flow is normal. The client does not need another Pap test because these are usually performed annually. Nothing in the situation suggests the need for another Pap test. The client does not need an endocrine workup or lower dosage of oral contraceptives because the client's change in menstrual flow is a normal and common side effect of the drug therapy.

The family members of a client with mild dementia are asking the nurse about permitting the elderly father to prepare an advance directive. Which information would be essential for the nurse to include in a discussion with this family? A. Discuss how careful the family needs to be if they allow a person with mild dementia to develop an advance directive. B. Facilitate a conversation with the family that addresses if this is the client's way of telling the family that the client wants to die. C. Explain that the client may have some ideas and some ability to make certain decisions about what is wanted at end of life. D. Suggest to the family that the client be evaluated psychiatrically to determine if the client should construct an advance directive.

C. Explain that the client may have some ideas and some ability to make certain decisions about what is wanted at end of life. A client with mild dementia may have adequate cognitive ability to contribute to discussing and making end-of-life care decisions, as well as identifying the person to serve as the health care proxy decision maker. It is not necessary to have a complete psychiatric evaluation prior to preparing an advance directive, nor is it necessary to be cautious about encouraging the client to discuss end-of-life wishes. Discussions about advance directives are about having wants met and wishes fulfilled.

A nurse is caring for another nurse's clients while that nurse is on break. While making rounds of the other nurse's clients, the nurse found medications left at a client's bedside stand. How should the nurse best address this problem? A. Inform the nurse supervisor right away. B. the problem and submit a written report. C. Speak to the coworker upon return to the unit. D. Ask for a meeting with the coworker and a manager.

C. Speak to the coworker upon return to the unit. When a nurse discovers substandard practice by another nurse, it is always appropriate to address the situation before conveying the information to a manager or supervisor. Informing the nurse supervisor first does not promote goodwill between nurses and can affect nursing care. It may be necessary to correct the problem before the nurse returns, but a written report may not be necessary if the issue can be remedied informally. If the problem persists, it may be necessary to meet jointly with a manager, but initially the problem should be addressed only by those directly involved.

The nurse is making team assignments and is assigning tasks to the unlicensed assistive personnel (UAP). unit. What information should the nurse know before delegating tasks to the UAP? A. All nursing activities performed by the UAP should be directly supervised by a registered nurse. B. Some nursing activities performed by the UAP should be directly supervised by a registered nurse. C. The UAP's level of knowledge and comfort level in performing specific nursing activities should be considered. D. The UAP has previously completed and practiced the delegated activities.

C. The UAP's level of knowledge and comfort level in performing specific nursing activities should be considered. The RN is responsible for providing, delegating, and at times supervising others to ensure safe nursing care. They remain responsible when delegating nursing tasks to other members of the health care team. The nurse should delegate tasks in collaboration with the UAPs, considering their knowledge level and comfort when performing various aspects of care, regardless of whether the UAPs have previously completed these activities.

A young adult female who was admitted to the psychiatric hospital 2 months ago with an eating disorder is being discharged. Which action indicates the client understands discharge instructions? A. The client returns to the same living situation as she had prior to hospitalization. B. client attends a social club at her local church. C. The client returns to the lab for routine lab tests. D. The client enrolls in a health club.

C. The client returns to the lab for routine lab tests. The client with an eating disorder is instructed to receive regular lab tests to monitor nutritional compliance. Frequently, the living situation from before hospitalization was dysfunctional, and returning to the situation can result in recurrent health problems. Attending a social club is not a priority for the client, and enrolling in a health club could result in the client exercising excessively.

The nurse is caring for a group of clients. Which client should the nurse see first? A. a client with a history of sinus tachycardia who is to receive a beta-blocker B. a client with stable angina who took one sublingual nitroglycerine 30 minutes ago C. a client with a placement of a coronary artery stent 30 minutes ago D. a client with new onset of atrial fibrillation who has a heart rate of 95

C. a client with a placement of a coronary artery stent 30 minutes ago The client who has just returned from having a stent placed in a coronary artery should be seen first. The nurse should assess this client to establish a baseline. Risks associated with a stent placement include a reocclusion, cardiac tamponade, dysrhythmias, bleeding, and thrombosis. While a new onset of atrial fibrillation is a concern, this client's heart rate is less than 100 bpm and is not showing signs of being hemodynamically unstable. A client with a history of sinus rhythm who will receive a beta-blocker is not a higher priority. While a client with stable angina who took a sublingual nitroglycerine 30 minutes ago will need to be assessed frequently, there is no evidence to suggest this client is currently experiencing chest pain.

After 6 months of treatment with diet and exercise, an adolescent with type 2 diabetes still has a fasting blood glucose level of 140 mg/dL (7.8 mmol/L). The health care provider (HCP) has decided to begin metformin. The client asks how the medication works. The nurse should tell the client that the medicine decreases the glucose production and performs which other function? A. replaces natural insulin B. helps the body make more insulin C. increases insulin sensitivity D. decreases carbohydrate adsorption

C. increases insulin sensitivity Metformin is currently approved by the Food and Drug Administration and Health Canada to treat type 2 diabetes in children. The medication decreases glucogenesis in the liver and increases insulin sensitivity in the peripheral tissues. Only insulin can actually replace insulin. This treatment is reserved for clients with type 1 diabetes or those with type 2 who do not respond to diet, exercise, and an oral diabetic agent. Other oral medications used to treat diabetes augment insulin production or decrease carbohydrate absorption, but those medications are primarily used in adults.

While in the emergency department, an adolescent who was in a motorcycle accident less than 1 hour earlier remains conscious but is agitated and anxious. The nurse observes that his pulse and respirations are increasing and his blood pressure is decreasing. The nurse should initiate interventions to manage which complication? A. autonomic dysreflexia B. increased intracranial pressure C. metabolic alkalosis D. spinal shock

D. spinal shock Spinal shock occurs 30 to 60 minutes after a spinal cord injury owing to the sudden disruption of central and autonomic pathways. This disruption causes flaccid paralysis, loss of reflexes, vasodilation, hypotension, and increased pulse and respiratory rates.Autonomic dysreflexia occurs only after the return of spinal reflexes and is characterized by hypertension.Increased intracranial pressure is associated with widened pulse pressure and decreased pulse and respiratory rates.Metabolic alkalosis, manifested by vomiting, elevated plasma and urine pH, and elevated plasma bicarbonate levels, does not occur with spinal shock. Rather, hydrogen ion loss leading to metabolic alkalosis would occur with pyloric stenosis, diuretic therapy, and potassium depletion.

"I'm a whale," a client with anorexia nervosa reports. However, the nurse's assessment reveals that the client is 5′ 8″ (1.7 m) tall and weighs only 90 lb (40.8 kg). Considering the client's unrealistic body image, which intervention should be included in the care plan? A. asking the client to make comparisons of self with people in magazines B. assigning the client to group therapy in which participants provide realistic feedback about the client's weight C. confronting the client about actual appearance during one-on-one sessions, scheduled during each shift D. telling the client of the nurse's concern and desire to help the client make decisions to stay healthy

D. telling the client of the nurse's concern and desire to help the client make decisions to stay healthy. A client with anorexia nervosa has an unrealistic body image that causes the client to consume little or no food. Therefore, this client needs assistance with making decisions about health. Instead of protecting the client's health, asking the client to make self comparisons with people in magazines, assigning the client to a group therapy, and confronting the client about actual appearance may make the client defensive and more invested in the unrealistic body image.

Which nursing intervention has the highest priority during the first hour after the admission of a client with cholecystitis who is experiencing pain, nausea, and vomiting? A. administering pain medication. B. the admission history C. maintaining hydration D. teaching about planned diagnostic tests

A. administering pain medication. Administering pain medication would have the highest priority during the first hour after the client's admission. Completing the admission history can be done after the client's pain is controlled. Maintaining hydration is important but will be accomplished over time. In the first hour after admission, the highest priority is pain relief. It is not appropriate to try to teach while a client is in pain. Teaching about planned diagnostic tests can occur after the client is comfortable.

A client with respiratory acidosis is admitted to the intensive care unit for close observation. The nurse should stay alert for which complication associated with respiratory acidosis? A. shock B. stroke C. seizures D. hyperglycemia

A. shock Complications of respiratory acidosis include shock and cardiac arrest. Stroke and hyperglycemia aren't associated with respiratory acidosis. Seizures may complicate respiratory alkalosis, not respiratory acidosis.

Which respiratory pattern indicates increasing intracranial pressure in the brain stem? A. slow, irregular respirations B. , shallow respirations C. asymmetric chest excursion D. nasal flaring

A. slow, irregular respirations Neural control of respiration takes place in the brain stem. Deterioration and pressure produce slow and irregular respirations. Rapid and shallow respirations, asymmetric chest movements, and nasal flaring are more characteristic of respiratory distress or hypoxia.

Which client has a greater risk for latex allergies? A. a woman who is admitted for her seventh surgery B. a man who works as a sales clerk C. a man with well-controlled type 2 diabetes D. a woman who is having laser surgery

A. a woman who is admitted for her seventh surgery Clients who have had long-term multiple exposures to latex products, such as would occur with six previous surgeries and recoveries, are at increased risk for latex allergies. The nurse should explore what types of surgeries these were, how involved the client's recoveries were, and whether signs of latex allergies have occurred in the past. Working as a sales clerk, having type 2 diabetes, and undergoing laser surgery do not expose a client to latex or increase the risk of latex allergy.

A prenatal client wants to begin a yoga-based exercise class to keep her healthy during pregnancy. What information should the nurse include in the plan of care? Select all that apply. A. Drink plenty of water before, during, and after a workout. B. Take precautions to prevent overheating. C. Avoid jerky, high-impact motions. D. Modify any positions that put a strain on the abdomen. E. Participate only in classes specifically designed for pregnant clients.

A. Drink plenty of water before, during, and after a workout. B. Take precautions to prevent overheating. C. Avoid jerky, high-impact motions. D. Modify any positions that put a strain on the abdomen. Clients should keep well hydrated with any form of exercise. Dehydration can lead to dizziness and put the client at risk for falls. Later in pregnancy, dehydration can contribute to preterm labor. Becoming overheated can lead to dehydration. In the first trimester, heat can act as a teratogen. Ligaments become more relaxed during pregnancy, making joints more mobile. High-impact, quick movements can lead to injury. Many yoga poses put pressure on the abdomen and would need to be modified as the pregnancy progresses. It is unnecessary to restrict participation to a prenatal yoga class only; however, the client should be advised to notify the instructor that they are pregnant and discuss if participating in that particular class is appropriate.

The nurse is caring for a child with an acute exacerbation of asthma. Oral methylprednisolone has been ordered. Which of the following actions is most important for the nurse to take when administering this medication? A. Give the medication with food. B. Give the medication 2 hours before meals. C. Do not give other medications with methylprednisolone. D. the medication at bedtime.

A. Give the medication with food. Giving the medication with food helps reduce gastric irritation. Oral doses of corticosteroids should be given in the morning.

signs of hypoglycemia

1. confusion

findings for a stroke

1. confusion 2. facial droop 3. garbled speech 4. one-sided paralysis 5. elevated blood pressure

findings of transient ischemic attack (tia)

1. confusion 2. facial droop 3. garbled speech 4. one-sided paralysis 5. elevated blood pressure

The nurse is caring for the client recovering from antithrombotic therapy for a stroke. Select the three (3) body areas that would be the focus of care for this client. 1. mobility 2. vital signs 3. urine output 4. neurologic status 5. swallowing ability 6. blood glucose level 7. infection precautions

2. vital signs 4. neurologic status 5. swallowing ability

The nurse was unsuccessful starting a peripheral intravenous line in the right forearm of a client with a history of a left axillary lymph node removal. What should the nurse do next? A. Ask another nurse to attempt to start a peripheral intravenous line. B. Notify the health care provider. C. Set up for placement of a triple-lumen central venous catheter. D. Try to start the peripheral intravenous line in the left forearm.

A. Ask another nurse to attempt to start a peripheral intravenous line. Another nurse needs to attempt to start an intravenous line. That nurse may be successful with starting the intravenous line. The nurse should not begin by notifying the health care provider. This action should only be performed if multiple attempts have been made to insert an intravenous line without success. The nurse will not set up for placement of a triple-lumen central venous catheter without notifying the health care provider and getting an order. The client should not have an intravenous line started in the left forearm because of the lymph node removal. The removal of lymph nodes increases the risk of lymphedema, which can lead to an infection.

A child with Wilms' tumor has had a kidney removed, and is now receiving chemotherapy. What priority information should the nurse share with this child's family at the time of discharge? A. Avoid contact sports. B. fluid intake as ordered. C. Decrease sodium intake. D. Avoid contact with other children.

A. Avoid contact sports. Because the child has only one kidney, certain precautions are recommended to prevent injury to the remaining kidney. Fluid intake is essential for renal function, and should not be decreased. The child's sodium intake shouldn't be reduced. Avoiding other children is unnecessary, may make the child feel self-conscious, and may lead to regressive behavior.

An elderly couple who have just relocated to a long-term care facility have been unable to obtain a shared room. A staff member at the facility states that this should not be a concern and implies that sexual activity between the couple likely ceased many years ago. How should the nurse best respond to this individual's assertion? A. "Actually it's not true that older people always stop having sexual activity when they get older." B. "It's true that they've probably stopped having sexual activity but it's important for them to have companionship." C. "That's true, but it's important for us to give them the teaching they need in order to resume this part of their relationship." D. "Research has shown the nature of sexual activity changes with age but that it actually becomes more frequent."

A. "Actually it's not true that older people always stop having sexual activity when they get older." Sexual activity need not be hindered by age. There is no evidence, however, that it becomes increasingly frequent in late adulthood.

The nurse is providing care for a client who is a Muslim. The client has recently received a diagnosis of type 1 diabetes and is receiving health education. What statement by the nurse best addresses this client's religious beliefs? A. "Insulin used to be derived from pigs, but now it is produced synthetically." B. "Diabetes likely will not have any bearing on the practices of fasting that you have followed in the past." C. "You might have to begin eating some foods that are contrary to Islam in order to maintain stable blood glucose." D. "You will be able to manage your diabetes while maintaining a vegetarian diet, but it requires careful management."

A. "Insulin used to be derived from pigs, but now it is produced synthetically." A client who adheres to Islam may be concerned that insulin is porcine derived, since pork products are proscribed. Fasting produces special challenges that must be carefully addressed. There is no need to discard dietary restrictions to maintain glucose levels. Islam does not dictate a vegetarian diet.

Which nursing instructions help parents of a child with hemophilia provide a safe home environment for their child? Select all that apply. A. "Pad the corners of coffee tables when your child is a toddler." B. "Establish a written emergency plan including what to do in specific situations and the names and phone numbers of emergency contacts." C. "Be sure your child wears a helmet when riding a bike." D. "Talk with your child about home safety and problem-solve hypothetical situations about your child's health." E. "Do not worry about visiting the dentist as your child''s teeth are not affected."

A. "Pad the corners of coffee tables when your child is a toddler." B. "Establish a written emergency plan including what to do in specific situations and the names and phone numbers of emergency contacts." C. "Be sure your child wears a helmet when riding a bike." D. "Talk with your child about home safety and problem-solve hypothetical situations about your child's health." All suggestions are good ones with the exception of the instruction to avoid the dentist. With the risk of bleeding during dental procedures, it is important for the child's teeth to be carefully cared for and cavities prevented if possible.

Which fetal presentation is most favorable for birth? A. vertex presentation B. transverse lie C. frank breech presentation D. posterior position of the fetal head

A. vertex presentation Vertex presentation (flexion of the fetal head) is the optimal presentation for passage through the birth canal. Transverse lie presentation (when the neonate is in a horizontal position across the birth canal) requires a cesarean birth. Frank breech presentation, in which the buttocks present first, can make for a difficult vaginal delivery. Posterior positioning of the fetal head can make it difficult for the fetal head to pass under the maternal symphysis pubis bone.

After teaching a new mother about the neonate's fontanels and when they close, which age, when cited by the client for closure of the posterior fontanel, would indicate effective teaching? A. 2 to 3 months B. 6 to 8 months C. 10 to 12 months D. 14 to 16 months

A. 2 to 3 months Normally, the posterior fontanel closes by age 2 to 3 months. The anterior fontanelle typically closes by 18 months.

After 2 days on a psychiatric unit, a client is still isolating himself in his room, except for meals. The client says he is uncomfortable around crowds of people. Which nursing intervention is the most appropriate initially? A. Play a game of checkers with the client in his room. B. Ask the client to attend a group session with the nurse. C. Invite the client to go for a walk with the nurse and one other client. D. Talk with the client in a corner of the crafts room.

C. Invite the client to go for a walk with the nurse and one other client. Going for a walk with the nurse and another client is a more gradual introduction to being with others. The goal is to gradually encourage interaction with others; playing games in the client's room promotes continued isolation. Going to a group session and participating in crafts is exposing the client to large groups too rapidly.

A nurse is assessing a client who's 29 weeks pregnant. What is the most cost-effective method for assessing fetal well-being? A. maternal fetal activity count B. chorionic villi sampling C. ultrasonography D. nonstress test

A. maternal fetal activity count Maternal fetal activity count is the least invasive and demanding method for assessing fetal well-being. To use this method, the client simply counts, records, and reports the number of times the fetus kicks during a designated period each day. Chorionic villi sampling is invasive and expensive and should be reserved for pregnant clients at risk for genetic defects. Ultrasonography and nonstress testing, although noninvasive, are expensive and require the use of medical facilities, which may place extra demands on the client's finances.

Which type of medication order might read "Vitamin K 10 mg I.M. daily × 3 days?" A. one-time order B. stat order C. standing order D. as-needed order

C. standing order This example is a standing order. Prescribers write a one-time order for medications given only once. A stat order is written for medications given immediately for an urgent client problem. An as-needed order doesn't indicate a specific administration time; it gives guidelines for when to administer the medication. Many pain medication orders are as-needed orders.

The nurse develops the discharge plan for a child who had a nephrectomy for a Wilms tumor. The nurse identifies outcomes to prevent damage to the child's remaining kidney and to accomplish which goal? A. Minimize pain. B. Prevent dependent edema. C. urinary tract infection. D. Minimize sodium intake.

C. urinary tract infection. Because the child has only one kidney, measures should be recommended to prevent urinary tract infection and injury to the remaining kidney. Severe pain and dependent edema are not associated with surgery for Wilms tumor. Dietary sodium is not restricted because the function of the remaining kidney is not impaired.

The nurse conducts the discharge teaching with a family of a child recovering from sickle cell crisis. Which condition does the nurse tell the family to report immediately to the health care provider? A. headaches and nausea B. fatigue and lassitude C. skin rash and itching D. sore throat and fever

Children with sickle cell disease are prone to develop infections as a result of necrosis of areas within the body and a generalized less-than-optimal health status. If the child with sickle cell anemia develops signs of infection, such as sore throat and fever, prompt evaluation is necessary because an infection can precipitate a crisis. Fatigue, lassitude, headaches, and nausea could be prodromal signs of infection. However, they also could be signs of other illnesses. Skin rash and itching usually do not indicate an infection but rather a possible contact dermatitis. The exception would be varicella.

A client with acute mania is to receive lithium carbonate 600 mg PO three times daily and 2 mg of haloperidol PO at bedtime. Which action should the nurse take? A. Refuse to give the medications as prescribed. B. Give the lithium only. C. Request a decreased dosage of lithium. D. Give the medications as prescribed.

D. Give the medications as prescribed. Lithium commonly is combined with an antipsychotic agent, such as haloperidol, or a benzodiazepine such as lorazepam. Antipsychotic agents, such as haloperidol, are prescribed to produce a neuroleptic effect until the lithium, produces a clinical response. After a clinical response is achieved, the antipsychotic agent usually is discontinued. Additionally, the dosages of each drug listed are appropriate. Therefore, the nurse would administer the drugs as prescribed.

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

D. the client who had an aortic valve replacement 5 years ago A heart valve prosthesis such as an aortic valve replacement is a major risk factor for the development of infective endocarditis. Preventative measures include antibiotic prophylaxis prior to dental work. Other implanted devices (hip, knee, ICD) can increase the risk of infection, but the client with the greatest risk is the one with the valve replacement.

A nurse is caring for a client with obsessive-compulsive disorder (OCD) with rituals of washing hands, folding and unfolding towels, and switching the bathroom light on and off multiple times prior to meals. What action should the nurse take? A. Interrupt the client's ability to complete the rituals. B. Assist the client in completing the rituals. C. Allow ample time for the client to complete the rituals. D. Gradually limit the time allowed for the client to complete the rituals.

D. Gradually limit the time allowed for the client to complete the rituals. When caring for a client with OCD, the long-term goal is to systematically decrease the undesirable behavior. This is done by helping the client gradually decrease the anxiety that drives the behaviors and, in concert, gradually limiting the time available to perform the rituals. Interrupting the client's rituals will create more anxiety. Getting involved in the client's rituals will make it worse because it reinforces the importance of the ritual. Allowing unlimited time for the client to perform the rituals is appropriate in the early stages of treatment while medications are first begun, but it will not help extinguish the behavior.

A nurse is assisting the health care provider (HCP) with the removal of a central venous access device (CVAD). What should the nurse do to prepare the client? A. Turn the client to the left side. B. Have the client exhale slowly and evenly. C. Elevate the head of the bed. D. Instruct the client to take a deep breath and hold it.

D. Instruct the client to take a deep breath and hold it. The client should be asked to perform the Valsalva maneuver (take a deep breath and hold it) during the insertion and removal of a CVAD. This increases central venous pressure during the procedure and prevents air embolism. Trendelenburg is the preferred position for CVAD insertion and removal. If not possible, a supine position is sufficient for CVAD removal. The client should hold their breath, not exhale.

When developing a discharge plan with a client with chronic obstructive pulmonary disease (COPD), what information should the nurse include in the plan? People with COPD: A. develop respiratory infections easily. B. usually maintain their current status. C. less supplemental oxygen. D. show permanent improvement.

A. develop respiratory infections easily. A client with COPD is at high risk for development of respiratory infections. COPD is slowly progressive; therefore, maintaining current status and establishing a goal that the client will require less supplemental oxygen are unrealistic expectations. Treatment may slow progression of the disease, but permanent improvement is highly unlikely.

A client is admitted for treatment of glomerulonephritis. On initial assessment, the nurse detects one of the classic signs of acute glomerulonephritis of sudden onset. Such signs include: A. periorbital edema. B. green-tinged urine. C. moderate to severe hypotension. D. polyuria.

A. periorbital edema. Periorbital edema is a classic sign of acute glomerulonephritis of sudden onset. Other classic signs and symptoms of this disorder include hematuria (not green-tinged urine), proteinuria, fever, chills, weakness, pallor, anorexia, nausea, and vomiting. The client also may have moderate to severe hypertension (not hypotension), oliguria or anuria (not polyuria), headache, reduced visual acuity, and abdominal or flank pain.

A nurse is helping a client move up in the bed. Which action maintains good body mechanics? A. always keeping the bed in a low position B. having the client fold the arms across the chest C. raising the head of the bed D. having the client help as much as possible

D. having the client help as much as possible When moving up in bed, the client's assistance will reduce strain on the nurse. The nurse may have to adjust the bed to a higher position, so it isn't possible to always keep the bed in a low position. However, the low position is preferred unless the client's medical condition contraindicates it. With folded arms, the client can't help pull or push up in the bed.

A client with a history of chronic cystitis comes to an outpatient clinic with signs and symptoms of this disorder. To prevent cystitis from recurring, the nurse recommends maintaining an acid-ash diet to acidify the urine, thereby decreasing the rate of bacterial multiplication. On an acid-ash diet, the client must restrict which beverage? A. cranberry juice B. coffee C. juice D. milk

D. milk A client on an acid-ash diet must avoid milk and milk products because these make the urine more alkaline, encouraging bacterial growth. Other foods to avoid on this diet include all vegetables except corn and lentils; all fruits except cranberries, plums, and prunes; and any food containing large amounts of potassium, sodium, calcium, or magnesium. Cranberry and prune juice are encouraged because they acidify the urine. Coffee and tea are considered neutral because they don't alter the urine pH.

The nurse at the clinic is assessing a toddler and notices retractions while the child is breathing. The parents state that they began to notice the retractions a few days ago and wondered if it was significant. What is the best response by the nurse? A. "Retractions occur normally when children are very active." B. "This is very serious; you should have brought your child in sooner." C. "Your child is having difficulty breathing and we need to determine why." D. "This is an indication that your child has a respiratory infection."

C. "Your child is having difficulty breathing and we need to determine why." Retractions will initially indicate a degree of respiratory compromise and increased respiratory effort. Continued assessment will determine the degree of that compromise. Retractions are not noted in general situations such as actively playing or appearing out of breath.

A client comes to the emergency department with complaints of a suspected wound infection. The client had major surgery 5 days ago. Which would be the nurse's priority action? A. Ask the client to rate the pain on a scale of 1 to 10. B. Assess the client's white blood cell (WBC) count. C. Assess the wound's drainage. D. Take the client's oral temperature.

C. Assess the wound's drainage. Thick, yellow drainage is most indicative of a wound infection. Drainage is typically serosanguinous. An elevated temperature, WBC count, and pain at the incision site are less specific indicators of infection than drainage. The first three signs could be related to other conditions, such as expected postoperative pain, poor wound healing, or pneumonia.

A nurse notices that a newborn has a swelling in the scrotal area. The nurse interprets this swelling as indicative of hydrocele if what else occurs? A. The swollen bulge can be reduced. B. The increase in scrotal size is bilateral. C. The scrotal sac can be transilluminated. D. The bulge appears during crying.

C. The scrotal sac can be transilluminated. A hydrocele, defined as fluid in the processus vaginalis, is determined when the scrotal sac can be transilluminated. A swelling in the scrotal area that can be reduced indicates an inguinal hernia. Both hydroceles and hernias can enlarge the scrotal sac, and both can be either unilateral or bilateral. A hernia typically is more obvious during crying.

A client undergoing long-term peritoneal dialysis at home is currently experiencing a reduced outflow from the dialysis catheter. To determine if the catheter is obstructed, what should the nurse ask the client about experiencing recently? A. diarrhea B. vomiting C. flatulence D. constipation

D. constipation Constipation may contribute to reduced urine outflow in part because peristalsis facilitates drainage outflow. For this reason, bisacodyl suppositories can be used prophylactically, even without a history of constipation. Diarrhea, vomiting, and flatulence typically do not cause decreased outflow in a peritoneal dialysis catheter.