NCLEX/SAUNDERS Pre-Test

A primary health care provider prescribes morphine sulfate, 2.5mg intravenously stat, for a client with terminal cancer. The medication ampule reads, "morphine sulfate 10mg/mL." how many mL of medication does the nurse prepare to administer the correct dose?

0.25mL Rational: 2.5 mg * xmL = 10 mg * 1 mL 10x = 2.50.25 mL To calculate the dosage, set up a ratio and proportion formula. The correct dose is 0.25 mL.

A nurse on the day shift receives the client assignment for the day. In which order will the nurse assess the assigned clients? 1. A client who has been fitted with a closed chest tube drainage system 2. A client on nothing-by-mouth (NPO) status who is scheduled for a barium enema at 10 a.m. 3. A client who was admitted during the night because of congestive heart failure 4. A client with a nasogastric tube who underwent bowel resection 2 days ago

3, 1, 4, 2 Rational: The nurse would first assess the client who was admitted during the night because of congestive heart failure. This client's problem is directly related to airway, breathing, and circulation, and the nurse would need to determine that the interventions administered on admission and during the night were effective. The nurse would next assess the client who has been fitted with a closed chest tube drainage system. This client's problem also involves oxygenation; however, there is no indication that this client is experiencing any acute problems. The nurse would next assess the client with a nasogastric tube who underwent bowel resection 2 days ago to ensure that the client is comfortable and that the nasogastric tube is functioning. The nurse would then assess the client scheduled for a barium enema to ensure that this client understands the reason for the diagnostic test.

A nurse on the day shift is assigned to care for four clients. In which order will the nurse assess the clients after receiving report from the night shift. A. A client scheduled for an electrocardiogram (ECG) at 11 a.m. B. A client on nothing-by-mouth (NPO) status who is for bronchoscopy at 9 a.m. C. A client who has undergone above-the-knee amputation who is scheduled for discharge home D. A client who had a seizure at 2 a.m. and was treated with intravenous (IV) diazepam and phenytoin

A client who had a seizure at 2 a.m. and was treated with intravenous (IV) diazepam and phenytoin Rational: Airway is always a high priority, and the nurse must first assess the client who had a seizure during the night and was treated with IV diazepam and phenytoin. The nurse would next assess the client scheduled for bronchoscopy to ensure that the client understands the test. The client scheduled for discharge would be assessed third for discharge needs, followed by the client scheduled for an ECG.

A nurse provides instruction to a client with chronic obstructive pulmonary disease (COPD) about home oxygen therapy. Which statement by the client indicates a need for further instruction? Select all that apply. A. "I should limit activity as much as I possibly can." B. "If I have trouble breathing, I need to call the doctor." C. "I need to drink lots of fluids to keep my mucus thin." D. "I can apply petroleum jelly to my nose if the oxygen dries it out." E. "I should wear a scarf over my nose and mouth in cold weather." F. "If I get a flu shot, I don't have to worry about being around people with colds."

A. "I should limit activity as much as I possibly can." D. "I can apply petroleum jelly to my nose if the oxygen dries it out." F. "If I get a flu shot, I don't have to worry about being around people with colds." Rational: Clients with COPD should be encouraged to keep up their daily activities as much as possible to help prevent muscle wasting and maintain activity tolerance. An occupational therapy consult may be useful in helping the client learn how to perform activities in ways that conserve energy. Oxygen is drying to the membranes of the nose, but the client should apply a water-soluble lubricant to the inside of the nose to reduce dryness and cracking rather than petroleum jelly, which could be inhaled. Every client with COPD should be encouraged to get a yearly flu vaccination, but because of the increased risk of infection, the client must still avoid crowds and people with infections. The remaining options are appropriate home care measures.

A woman whose husband died 2 months ago says to the visiting nurse, "My daughter came over yesterday to help me move my husband's things out of our bedroom, and I was so angry with her for moving his belongings from where he always kept them. She doesn't know how much I'm hurting." Which statement by the nurse would be therapeutic? A. "I know just how you feel, because I lost my husband last summer." B. "It's OK to grieve and be angry with your daughter and anyone else for a time." C. "You need to focus on the many good years you enjoyed together and move on." D. "I know it's a troubling time for you, but try to focus on your children and grandchildren."

A. "It's OK to grieve and be angry with your daughter and anyone else for a time." Rational: The therapeutic statement is the one that gives the client permission to grieve and acknowledges that anger is part of loss and that it may be aimed at the people who are trying most to help and are closest. "I know just how you feel, because I lost my husband last summer," "I know it's a troubling time for you, but try to focus on your children and grandchildren," and "You need to focus on the many good years you enjoyed together and move on" are all nontherapeutic and do not encourage the client to express her feelings.

The mother of 6-year-old twins says to the nurse, "My mother-in-law doesn't think that the twins should come to the funeral service for their grandfather. What do you advise?" Which response by the nurse would be therapeutic? A. "What do you and your husband believe is the right thing for your children?" B. "By all means have them attend. Keeping them home will only prolong their grief." C. "I agree with your mother-in-law. Just tell your children that their grandfather is in heaven." D. "It's a difficult decision, but given their young age, maybe it would be best to keep them home from the wake and just let them attend the funeral."

A. "What do you and your husband believe is the right thing for your children?" Rational: The therapeutic response is the one that encourages open expression of feelings and empowers the grieving relative. Values, beliefs, and practices will differ with the client's ethnic and spiritual background, and the nurse should not push a decision based on his or her own belief system. The remaining options are nontherapeutic responses because the nurse is agreeing with or advising the mother.

A nurse is caring for a client who has just undergone cardioversion. Which intervention is the nurse's priority after this procedure? A. Administering oxygen B. Monitoring the blood pressure C. Administering antidysrhythmic medications D. Monitoring the client's level of consciousness

A. Administering oxygen Rational: Nursing responsibilities after cardioversion include maintenance of a patent airway, oxygen administration, assessment of vital signs and level of consciousness, and detection of dysrhythmias. The priority nursing intervention here is administering oxygen.

A child who is HIV-positive is scheduled to receive a mumps, measles, and rubella (MMR) vaccine. The laboratory results show the CD4+ as 1000 cells/mm3. Which nursing action is appropriate? A. Administering the vaccine B. Contacting the primary health care provider C. Asking the laboratory to repeat the CD4+ test D. Informing the child's mother that the vaccine must not be administered at this time

A. Administering the vaccine Rational: The normal CD4+ count is 500 to 1600 cells/mm3. Because this child's CD4+ count is 1000 cells/mm3, the nurse would administer the vaccine. Contacting the primary health care provider, asking the laboratory to repeat the CD4+ test, and telling the mother that the vaccine should not be administered at this time are all incorrect in light of the results of the CD4+ count.

A nurse is assigned to care for a client with chronic renal failure who is undergoing hemodialysis through an internal arteriovenous (AV) fistula in the right arm. Which intervention should the nurse implement in caring for the client? Select all that apply. A. Assessing the radial pulse in the right extremity B. Using the left arm to take blood pressure readings C. Drawing predialysis blood specimens from the left arm D. Assessing the area over the AV fistula for a bruit and thrill each shift E. Placing a pressure dressing over the site after each dialysis treatment F. Administering intravenous (IV) fluids through the venous site of the AV fistula as needed

A. Assessing the radial pulse in the right extremity B. Using the left arm to take blood pressure readings C. Drawing predialysis blood specimens from the left arm D. Assessing the area over the AV fistula for a bruit and thrill each shift Rational: Several precautions must be observed to ensure the function of an internal AV fistula. The nurse assesses the fistula, and the distal portion of the extremity, for adequate circulation; checks for a bruit and a thrill by means of auscultation or palpation over the access site; monitors the radial pulse in the extremity; and avoids taking blood pressure readings or drawing blood from the arm with the AV fistula. Venipuncture is avoided in the extremity bearing the AV fistula. Blood is never drawn from the AV fistula, and the AV fistula is not used for the administration of IV fluids. The AV fistula site is not covered with a pressure dressing after dialysis.

A nurse on the telemetry unit is caring for a client who has had a myocardial infarction and is now attached to a cardiac monitor. The nurse, monitoring the client's cardiac rhythm, notes the rhythm depicted in the image. Which nursing action should the nurse take first? A. Calling the rapid response team B. Preparing the client for cardioversion C. Asking the client to bear down and cough D. Preparing to administer diltiazem

A. Calling the rapid response team Rational: This pattern indicates ventricular fibrillation (VF). Clients who have sustained a myocardial infarction are at great risk for VF. With the onset of VF the client feels faint, then immediately loses consciousness and becomes pulseless and apneic. There is no blood pressure, and heart sounds are absent. The goals of treatment are to terminate VF promptly and convert it to an organized rhythm. Because defibrillation is the immediate treatment, the nurse must call the rapid response team and initiate cardiopulmonary resuscitation. The client would not be able to bear down or cough. Cardioversion is a synchronized countershock that may be performed in emergencies for unstable ventricular or supraventricular tachydysrhythmias or electively for stable tachydysrhythmias that are resistant to medical therapies such as the administration of diltiazem.

A nurse stops at the scene of an automobile accident. One of the victims is sitting in the driver's seat, complaining of severe muscle spasms in the neck area. The nurse must take which action first? A. Stabilize the neck area B. Firmly massage the neck area C. Assist the victim out of the automobile and lay the victim on the ground D. Tell the victim that the nurse is leaving to call an ambulance but will be right back

A. Stabilize the neck area Rational: The presence of muscle spasms after a spinal or head injury may indicate cervical fracture or dislocation. The rescuer must stabilize the affected area and help the client remain still. The client should not be moved. The nurse should remain with the victim and have someone else call for emergency help.

A nurse provides instructions to a pregnant woman about foods that contain calcium. The nurse realizes the client understands instructions if the client selects which products? Select all that apply. A. Cheese B. Yogurt C. Spinach D. Sardines E. Shellfish

A. Cheese B. Yogurt D. Sardines Rational: Calcium is essential for fetal skeleton and tooth formation. The body also uses calcium to maintain maternal bone and tooth mineralization during pregnancy. Therefore adequate intake of calcium is of utmost importance for the bone health of both mother and fetus. Cheese, sardines (and other fish eaten with bones left in), and yogurt are good sources of calcium. Shellfish are a good source of zinc and green leafy vegetables (except spinach and Swiss chard) are good sources of calcium. Spinach is a good source of iron and many vitamins.

A nurse is performing an initial assessment of a pregnant adolescent client with diabetes mellitus. The client says to the nurse, "I've stopped my insulin and cut back on my food." Which client concern does the nurse recognize as the priority? A. Concern about nutritional deficiency B. Concern about getting stretch marks C. Concern about being able to care for the infant D. Concern about what her friends might think about her wearing maternity clothes

A. Concern about nutritional deficiency Rational: The decrease in nutritional intake during the pregnancy will place the mother and fetus at risk. Because she is diabetic, the mother is at risk for ketoacidosis, which can be harmful to the fetus. Also, deficiencies of specific nutrients, such as folic acid, may produce fetal anomalies. Body image disturbance is a problem for this client; however, nutrition is a higher priority. Most adolescent mothers are not developmentally, emotionally, psychologically, or financially prepared for the responsibilities of parenthood, but this is a concern that may be addressed as a later time, for it does not put the fetus or the mother at immediate risk.

A client has recently been diagnosed with deep vein thrombosis (DVT) of the right leg. Which of intervention does the nurse immediately implement? A. Elevating the foot of the bed 6 inches (15 cm) B. Placing ice packs on and under the right leg C. Documenting the need for hourly calf measurements D. Performing passive range-of-motion exercises of the right leg

A. Elevating the foot of the bed 6 inches (15 cm) Rational: Standard therapy for DVT consists of bed rest, leg elevation, and application of warm, moist heat to the affected leg. Elevation of the legs decreases venous pressure, which in turn relieves edema and pain. The client may have calf measurements prescribed once per shift or once per day, but they would not be obtained hourly. Placing ice packs on and under the right leg is incorrect, because heat, not cold, is usually prescribed. Passive range-of-motion exercises of the right leg would be dangerous to the client because activity after clot formation can cause pulmonary embolus.

A nurse is caring for the client who is in bed and begins to exhibit seizure activity. Which actions does the nurse implement to care for the client? Select all that apply. A. Observing and timing the seizure B. Loosening any restrictive clothing C. Turning the client's head to the side D. emoving the pads on the side rails E. Inserting an airway into the client's mouth F. Removing objects that might injure the client from the vicinity

A. Observing and timing the seizure B. Loosening any restrictive clothing C. Turning the client's head to the side F. Removing objects that might injure the client from the vicinity Rational: Client safety is a priority for the client experiencing a seizure. Nursing actions during a seizure include providing privacy, loosening restrictive clothing, removing the pillow, raising the padded side rails on the bed, removing objects that might cause injury to the client, and placing the client on the side with the head flexed forward, if possible, to allow the tongue to fall forward and facilitate drainage. (The nurse should not insert anything into the client's mouth.) The nurse also observes, documents, and times the seizure. If the client is not in bed when seizure activity begins, the nurse lowers the client to the floor, if possible; protects the head against injury; and moves furniture that may injure the client if he or she were to come in contact with it during the seizure.

A man calls the clinic and tells the nurse that he sustained a bee sting on his leg while working in his yard. The client states that he is not allergic to bees and wants to know how to treat the sting. The nurse tells the client to first take which action? A. Place a cool compress on the sting site B. Apply an antipruritic lotion to the sting site C. Apply a topical corticosteroid to the sting site D. Take an oral antihistamine such as diphenhydramine (Benadryl)

A. Place a cool compress on the sting site Rational: Treatment for a bee sting depends on the severity of the reaction. Mild reactions are treated with elevation, cool compresses, antipruritic lotions, and oral antihistamines. Rings, watches, and restrictive clothing are removed. In this situation, there is no information to indicate that the client is experiencing a severe reaction, so the nurse would first tell the client to apply a cool compress to the sting site. More severe reactions are treated with intravenous antihistamines such as diphenhydramine, subcutaneous epinephrine, and corticosteroids.

A pregnant woman is being admitted to the maternity unit. The woman tells the nurse that she felt a large gush of fluid from her vagina on the way to the hospital. The nurse detects a fetal heart rate of 90 beats/min. On physical examination, the nurse finds that the umbilical cord is protruding from the vagina. Which actions should the nurse perform? Select all that apply. A. Placing the woman in knee-chest position B. Administering oxygen at 2 to 4 L/min by nasal cannula C. Administering terbutaline to stop contractions D. With two gloved fingers, exerting upward pressure, into the vagina, on the presenting part E. Wrapping the cord loosely in a sterile towel saturated with warm sterile normal saline solution

A. Placing the woman in knee-chest position D. With two gloved fingers, exerting upward pressure, into the vagina, on the presenting part E. Wrapping the cord loosely in a sterile towel saturated with warm sterile normal saline solution Rational: When the umbilical cord is protruding, one of the first interventions the nurse should perform is to relieve compression of the cord by exerting upward pressure on the presenting part with two gloved fingers inserted vaginally. The cord must be protected from drying out and from becoming compressed. Therefore it should be wrapped with towels soaked in warm, sterile normal saline solution. The client is placed in an extreme Trendelenburg or modified Sims position or knee-chest position to ease compression. Oxygen should be administered by way of face mask at a rate of 8 to 10 L/min. A primary health care provider's prescription is needed for terbutaline, but this medication is usually not given in these circumstances.

A nurse is caring for a client in labor who is receiving an oxytocin infusion. The nurse notes that the client is experiencing uterine hypertonicity. The nurse should take which action immediately? A. Stop the oxytocin infusion B. Check the client's blood pressure C. Contact the primary health care provider D. Place the client in a side-lying position

A. Stop the oxytocin infusion Rational: If uterine hypertonicity or a nonreassuring fetal heart pattern occurs, the nurse must intervene to increase fetal oxygenation. The oxytocin infusion is stopped immediately and the infusion rate of the nonadditive IV solution is increased. The client is placed in a side-lying position, and oxygen is administered with the use of a snug face mask at 8 to 10 L/min. The primary health care provider is notified of the adverse reactions, the nursing interventions implemented, and the client's response to the interventions. The client's blood pressure is monitored closely.

A nurse assesses the chest tube drainage system of a client who has undergone thoracic surgery and notes intermittent bubbling in the water seal chamber. One hour later, the nurse notes the presence of continuous bubbling in the chamber. On the basis of this finding, which would the nurse check first? A. The chest tube connection sites B. For bubbling in the suction-control chamber C. The amount of drainage in the collection chamber D. The amount of suction being applied to the chest tube system

A. The chest tube connection sites Rational: Continuous bubbling in the water seal chamber indicates that air is leaking into the drainage system or pleural cavity. The nurse must locate the source of the air leak and would first check all of the chest tube connection sites. If a break in the tubing or a loose connection is found, the nurse tightens the connection or seals the break with tape. The remaining options are unrelated to continuous bubbling in the water seal chamber.

A child with osteosarcoma who required amputation of a lower limb is experiencing phantom limb pain. The nurse attempts to comfort the child by providing which explanation? A. The pain is a normal, temporary condition B. The pain occurs because nerves have been cut C. This pain will go away once a prosthesis is used D. Pain medication may be needed for life to alleviate the discomfort

A. The pain is a normal, temporary condition Rational: Phantom limb pain is a temporary condition that some people who undergo amputation experience. This sensation of burning, aching, or cramping in the missing limb is most distressing to the client. The child should be reassured that the condition is normal. Numerous pharmacological agents are available to help ease postoperative neurogenic pain. Pain medication is not needed for life. The incorrect options will not provide comfort to the child.

A client with a basilar skull fracture has clear fluid leaking from the ears. The nurse should take which action first? A. Assess the clear fluid for protein B. Check the clear fluid for the presence of glucose C. Place cotton balls or dry gauze loosely in the ears D. Use an otoscope to assess the tympanic membrane for rupture

B. Check the clear fluid for the presence of glucose Rational: Leakage of cerebrospinal fluid (CSF) from the ears or nose may accompany basilar skull fracture. CSF can be distinguished from other body fluids because it will separate into bloody and yellow concentric rings on dressing material, a phenomenon referred to as the halo sign. It also tests positive for glucose. CSF does not contain protein. The presence of CSF indicates a disruption in the integrity of the cranium. Therefore inserting cotton balls, gauze, or an otoscope into the ear puts the client at risk for infection.

After a nonimmunocompromised client undergoes a Mantoux test for tuberculosis (TB) infection, an area of induration 6 mm wide develops. The client asks the nurse what this result means. Which is the nurse's best response? A. "We'll have to repeat the test, because the result is inconclusive." B. "The swollen area is small, so that means your test result is negative." C. "You've been exposed to tuberculosis, so you'll need to have a chest x-ray." D. "You need to get started on medication right away, because you've got tuberculosis."

B. "The swollen area is small, so that means your test result is negative." Rational: An area of induration of less than 10 mm is considered a negative result. An area of induration (not redness) measuring 10 mm or more in diameter 48 to 72 hours after injection in a client without immunosuppressive disease indicates exposure to and possible infection with TB. A reaction of 5 mm or greater is considered positive in immunocompromised individuals. A positive reaction does not mean that active disease is present but instead indicates exposure to TB or the presence of inactive (dormant) TB. Further testing, including a chest x-ray and sputum culture, would be required if the reaction were positive.

A client who has just received a diagnosis of asthma says to the nurse, "This is just another nail in my coffin." Which response by the nurse is therapeutic? A. "Do you think that having asthma will kill you?" B. "You seem very distressed at learning that you have asthma." C. "I'm not going to work with you if you can't view this as a challenge rather than a 'nail in your coffin." D. "Asthma is a very treatable condition, but it's important to learn how to properly administer your medications. Let's practice with your inhalant."

B. "You seem very distressed at learning that you have asthma." Rational: A clients who has learned that he or she has a chronic illness may exhibit denial, anger, or sarcasm because of the fear associated with such illnesses. It is important for the nurse to convey an accepting attitude as a means of enhancing mutual respect and trust. Stating, "You seem very distressed at learning that you have asthma" paraphrases the client's words and focuses on the client's feelings. "Do you think that having asthma will kill you?" reflects and paraphrases the client's words but is somewhat sarcastic. "Asthma is a very treatable condition, but it's important to learn how to properly administer your medications. Let's practice with your inhalant" lectures the client and does not deal directly with expressed concerns. "I'm not going to work with you if you can't view this as a challenge rather than as a 'nail in your coffin'" is punitive, threatens the client, and sarcastically quotes the client's words.

During a preoperative assessment, a nurse notices the client is crying. In light of this observation, which statement by the nurse is appropriate? A. "You seem upset. Would you rather be alone?" B. "You're crying. Tell me more about how you are feeling." C. "Your surgeon is the best and has done many of these operations." D. "Crying before a serious operation is common, but everything will be okay."

B. "You're crying. Tell me more about how you are feeling." Rational: Taking time to discuss the client's concerns is as important a nursing action in many instances as any intervention for physical care. Therapeutic communication in this situation involves focusing on the client's nonverbal cues and encouraging the client to express feelings or concerns about surgery. Changing the subject and avoiding the client are techniques that also block communication with the client. False reassurance also blocks communication with the client.

A nurse is preparing client assignments for the day. Which assignments would be appropriate for a registered nurse who is pregnant? Select all that apply. A. A client with active herpes virus lesions in the perianal area B. A client who requires frequent abdominal wound irrigations C. A client with a solid sealed implanted radiation source who is restricted to bed rest D. A client with methicillin-resistant Staphylococcus aureus (MRSA) under contact precautions E. A client undergoing mechanical ventilation through a tracheostomy who requires frequent suctioning

B. A client who requires frequent abdominal wound irrigations D. A client with methicillin-resistant Staphylococcus aureus (MRSA) under contact precautions E. A client undergoing mechanical ventilation through a tracheostomy who requires frequent suctioning Rational: Pregnant nurses should not care for clients with solid sealed implanted radiation sources. The client emits radiation while the implant is in place, and the ionizing radiation could have a damaging effect on the fetus. Likewise, pregnant nurses should not care for any client with herpes lesions, because the virus may damage the fetus. There are no contraindications to assigning the other clients to a pregnant nurse.Test-Taking Strategy: Use the process of elimination. Focus on the subject, a registered nurse who is pregnant. Thinking about the risks associated with each client listed in the options will direct you to the correct options.

A client with diabetes mellitus who is scheduled to have blood drawn for determination of the glycosylated hemoglobin (HbA1C) level asks the nurse why the test is necessary if he is performing blood glucose monitoring at home. Which is the best response for the nurse to provide? A. Detect diabetic complications B. Assess long-term glycemic control C. Determine whether the client is at risk for hypoglycemia D. Determine whether the prescribed insulin dosage is adequate

B. Assess long-term glycemic control Rational: The HbA1C reading provides an indication of glycemic control over the preceding 3 months. An HbA1C value of less than 7% indicates good glycemic control. When increases in the blood glucose occur, some glucose molecules attach themselves to red blood cells (RBCs) and remain there for the life of the RBCs. Therefore a high value on this test is correlated with a high blood glucose level, indicating poor long-term control of blood glucose, which often leads to the development of complications in the client with diabetes mellitus. The other options are not purposes for this test.

A client with skeletal traction applied to the right leg complains of severe pain in the leg. The nurse realigns the client's position, but this intervention does not relieve the pain. Which action would the nurse take next? A. Providing pin care B. Calling the primary health care provider C. Removing some of the traction weights D. Medicating the client with the prescribed analgesic

B. Calling the primary health care provider Rational: A client who complains of severe pain may need realignment, or the prescribed traction weights may be too heavy. The nurse realigns the client and, if this is ineffective, calls the primary health care provider. The nurse never removes traction weights unless this is specifically prescribed by the primary health care provider. Severe leg pain, once traction has been established, indicates a problem. The client should be medicated after an attempt has been made to identify and treat the cause of the pain. Pin care is unrelated to the problem as described.

A primigravida is admitted to the labor unit. During assessment, the client's membranes rupture spontaneously. What is the priority nursing action? A. Checking the amniotic fluid B. Checking the fetal heart rate C. Assessing the contraction pattern D. Preparing for immediate delivery

B. Checking the fetal heart rate Rational: When the membranes rupture in the birth setting, the nurse immediately assesses the fetal heart rate to detect changes associated with prolapse or compression of the umbilical cord. Assessing the contraction pattern and amniotic fluid may also be a part of the assessment, but neither is the priority action. There is no information to indicate that immediate delivery is necessary at this time.

A nurse provides home care instructions to an adolescent with sickle cell disease about measures to prevent vaso-occlusive crisis. The nurse should emphasize which priority instruction? A. Restrict fluid intake B. Contact your primary health care provider if you have a fever. C. Take acetylsalicylic acid (aspirin) immediately if a fever develops D. Be sure to spend plenty of time in the fresh air and sun each day

B. Contact your primary health care provider if you have a fever. Rational: The adolescent with sickle cell disease is advised to contact the primary health care provider if a fever develops since fever can precipitate a vaso-occlusive crisis. The use of aspirin is avoided. The adolescent is instructed to contact the primary health care provider if a fever develops. Dehydration is avoided, and the adolescent is instructed to consume adequate fluids. Cold and heat stress and prolonged exposure to the sun are avoided because they can cause dehydration, which may precipitate a crisis.

The nurse is participating in a facility's planning committee to deal with possible bioterrorism threats. The nurse should recommend implementing which infection control measures to be used for clients in whom smallpox is diagnosed? Select all that apply. A. Enteric B. Droplet C. Contact D. Standard F. Protective isolation

B. Droplet C. Contact D. Standard Rational: Smallpox is transmitted from person to person in infected aerosols and air droplets spread by way of face-to-face contact with an infected person after fever has begun, especially if the infected person is also coughing. The disease can also be transmitted in contaminated clothes and bedding, although the risk of infection from this source is much lower. Therefore droplet and contact precautions are necessary. Standard precautions are implemented for the care of all clients. Enteric precautions are implemented if the infectious agent is transmitted by way of contact with feces. Protective isolation is implemented when the client is neutropenic and needs to be protected from infection.

A nurse is caring for a hospitalized child with newly diagnosed type 1 diabetes mellitus who received NPH and regular humulin insulin at 7:30 a.m. At 11 a.m. the child suddenly complains of dizziness, headache, and a shaky feeling. The nurse immediately takes which action? A. Contacts the physician B. Gives the child milk to drink C. Arranges to have the child's lunch tray delivered early D. Prepares to administer intravenous 5% dextrose solution

B. Gives the child milk to drink Rational: Dizziness, headache, and a shaky feeling are signs of hypoglycemia. A blood glucose reading will confirm the diagnosis and would be the initial action. However, because this is not one of the options, the nurse would give the child milk to drink because of the child's history and current symptoms indicating hypoglycemia. Other items used to treat hypoglycemia include orange juice and hard candy. The nurse would prepare to administer intravenous dextrose solution if the child were not responsive enough to safely take oral fluids, but this is not indicated in the question. Arranging to have the child's lunch tray delivered early is inappropriate because the child should eat meals at basically the same time each day to achieve the best control of the diabetes. Contacting the physician would not be the immediate action.

A female client is examined in the clinic, and gonorrhea is diagnosed. The nurse provides information to the client about the disease and provides which information? A. Condoms will not help prevent transmission of the infection B. Healthcare providers are legally responsible for reporting all cases of gonorrhea to the health authorities C. It is not necessary for sexual partners to be examined, because the disease is not highly communicable D. Treatment includes the administration of an antibiotic, but it is not necessary for sexual partners to be treated

B. Healthcare providers are legally responsible for reporting all cases of gonorrhea to the health authorities Rational: Gonorrhea is caused by the aerobic Gram-negative diplococcus Neisseria gonorrheae. It is almost exclusively transmitted by way of sexual contact. Gonorrhea is a reportable communicable disease; healthcare providers are legally responsible for reporting all cases of gonorrhea to the health authorities, usually the local health department of the woman's county of residence. Gonorrhea is highly communicable. Recent sexual partners (past 30 days) should be examined, cultures performed, and treatment with the appropriate regimen provided. Women are counseled to have their partners use condoms.

A nurse performing a fundal assessment after a vaginal birth notes that the fundus is above the umbilicus and displaced from the midline. What should the nurse do first? A. Massage the fundus B. Help the client void C. Document the findings D. Help the client ambulate

B. Help the client void Rational: After a vaginal birth, the fundus should be firmly contracted and at or near the level of the umbilicus. If the uterus is above the expected level or displaced from the midline position (usually to the right), the bladder may be distended. The nurse would help the client void and then reassess the location of the fundus. Fundal massage is indicated if the fundus is difficult to locate or is soft or boggy. Ambulation is not appropriate. Although the nurse would document the findings, the most appropriate initial action would be to help the client void.

A nurse developing a plan of care for a client with a spinal cord injury includes measures to prevent autonomic dysreflexia (hyperreflexia). Which intervention does the nurse incorporate into the plan to prevent this complication? A. Keeping a fan running in the client's room B. Keeping the linens wrinkle-free under the client C. Limiting bladder catheterization to once every 12 hours D. Avoiding the administration of enemas and rectal suppositories

B. Keeping the linens wrinkle-free under the client Rational: The most frequent causes of autonomic dysreflexia are a distended bladder and impacted feces in the rectum. Straight catheterization should be performed every 4 to 6 hours, and the Foley catheter should be checked frequently to prevent kinks in the tubing. Constipation and fecal impaction are other causes, so maintaining bowel regularity is important. Other causes include stimulation of the skin by tactile, thermal, or painful stimuli. The nurse renders care in such a way as to minimize risk in these areas.

A nurse caring for a client with acquired immunodeficiency syndrome (AIDS) is monitoring the client for signs of complications. Which finding would cause the nurse to suspect infection with Pneumocystis jiroveci? Select all that apply. A. Diarrhea B. Tachypnea C. Pedal edema D. Intermittent fever E. Dyspnea when ambulating F. Expectoration of frothy mucus

B. Tachypnea D. Intermittent fever E. Dyspnea when ambulating Rational: Pneumocystis jiroveci pneumonia is a very common and severe opportunistic infection affecting the client with AIDS. Clinical manifestations include dyspnea, nonproductive cough, intermittent fever, fatigue, anorexia, weight loss, and tachypnea. Persons with advanced disease may exhibit crackles, decreased breath sounds, and cyanosis. Diarrhea and pedal edema are not associated with this infection.

A nurse provides information to a pregnant client about foods that are high in iron. Which food, suggested by the client after this discussion, indicates that the client requires further instruction? A. Spinach B. Tomatoes C. Lima beans D. Whole-grain bread

B. Tomatoes Rational: Foods that are high in iron include red meat, whole-grain bread and cereals, lima beans, raisins, spinach, and broccoli. Tomatoes are high in vitamin C.

As a nurse is providing care, the client suddenly experiences a tonic-clonic seizure. The nurse would immediately take which action first? A. Call the physician B. Turn the client to the side C. Restrain the client's limbs D. Insert an airway in the client's mouth

B. Turn the client to the side Rational: When a client experiences a seizure, the nurse must immediately turn the client to the side and protect the client from injury. The nurse would maintain the client's airway and suction the client as needed but would not place an airway in the client's mouth. The physician is also notified, but turning the client to the side is the immediate action. Restrictive clothing is loosened, but restraints are not applied, because this could result in injury to the client.

A client who is delusional says to the nurse, "Terrorists have been sent here to kill me." How should the nurse respond to the client? A. "No one is going to kill you." B. "Your medication is making you feel like this." C. "Are you worried that people are trying to hurt you?" D. "What makes you think that terrorists were sent to hurt you?"

C. "Are you worried that people are trying to hurt you?" Rational: It is most therapeutic for the nurse to empathize with the client's experience. Disagreeing with delusions may make the client more defensive and cause the client to cling to the delusions even more strongly. Medication may be prescribed to reduce the occurrence of delusions, but it does not cause the delusions. Encouraging discussion regarding the delusion is inappropriate.

A nurse provides home care instructions to a client who has been fitted with a halo device to treat a cervical fracture. Which statement by the client indicates the need for further instruction? A. "I need to get more fluids and fiber into my diet." B. "I should cut my food into small pieces before I eat." C. "I need to put powder under the vest twice a day to prevent sweating." D. "I have to check the pin sites every day and watch for signs of infection."

C. "I need to put powder under the vest twice a day to prevent sweating." Rational: The client should cleanse the skin under the lambs-wool liner each day to prevent rashes or sores. Powder or lotions should be used only sparingly or not at all because they may cake, resulting in skin irritation. The client should increase intake of fluid and fiber to help prevent constipation. Food should be cut into small pieces to facilitate chewing and swallowing. The client should also use a straw for drinking. The pin sites should be checked daily for signs of infection.

A nurse provides information to the mother of a child with diarrhea about signs and symptoms that indicate the need to call the primary health care provider. Which statement by the mother indicates the need for further instruction? A. "I'll call the doctor if she gets dizzy and acts sick." B. "I'll call the doctor if she has severe stomach cramps." C. "I'll call the doctor if her temperature is 102°F (38.9°C) or higher." D. "I'll call the physician if she goes longer than 6 hours without urinating."

C. "I'll call the doctor if her temperature is 102°F (38.9°C) or higher." Rational: The mother should call the physician if a fever higher than 100°F (37.8°C), especially one that persists for more than 72 hours, develops. The mother should not wait until the temperature reaches 102°F. The remaining statements are all accurate because the findings indicate possible dehydration and hypovolemia. Additionally, severe abdominal cramps could indicate the presence of an acute problem.

A rubella titer is performed on a woman who has just been told that she is pregnant. The results of the titer indicate that the mother is not immune to rubella. The nurse realizes the patient understands patient teaching if the patient makes which statement? A. "I may need to get a therapeutic abortion." B. "I will need an immunization against rubella immediately." C. "Immunization against rubella is required after delivery." D. "Antibiotics will be prescribed to prevent the infection."

C. "Immunization against rubella is required after delivery." Rational: A rubella titer is performed to determine the pregnant client's immunity to rubella. If the titer is less than 1:8, the woman is not immune. The client is then immunized after delivery. Because the vaccine contains live virus, the client should not be immunized during pregnancy. Antibiotics are not prescribed. Counseling the client on therapeutic abortion is incorrect.

A client who is 8 weeks pregnant reads her electronic medical record via a patient portal. She contacts the clinic and asks the nurse to explain a "positive Hegar sign." Which is the best answer for the nurse to provide? A. "You are able to feel fetal movement." B. "A soft blowing sound can be heard with a stethoscope." C. "The lower part of your uterus is softer than when you are not pregnant." D. "You are experiencing irregular painless contractions during the pregnancy."

C. "The lower part of your uterus is softer than when you are not pregnant." Rational: Softening and compressibility of the lower uterine segment, occurring around the sixth week of pregnancy, is called the Hegar sign. Quickening, or fetal movement, is not perceived until the second trimester. Braxton Hicks contractions are irregular painless contractions that occur throughout pregnancy, although many expectant mothers do not notice them until the third trimester. A soft blowing sound, corresponding to the maternal pulse, that is auscultated over the uterus is known as uterine souffle. This sound is the result of blood circulation to the placenta and corresponds to the maternal pulse.

A contraction stress test is scheduled, and the nurse provides instructions to the client regarding the test. Which pieces of information should the nurse give to the client? Select all that apply. A. An internal fetal monitor is attached. B. The client will walk on a treadmill until contractions begin. C. A positive test result indicates a need for further evaluation. D. Special body movements will be performed to stimulate contractions. E. The client may be asked to massage one or both nipples to stimulate uterine contractions.

C. A positive test result indicates a need for further evaluation. E. The client may be asked to massage one or both nipples to stimulate uterine contractions. Rational: A contraction stress test is used to assess placental oxygenation and function, determine the fetus' capacity to tolerate labor, and determine fetal well-being; it is performed if the nonstress test result is abnormal. The fetus is exposed to the stressor of contractions to assess the adequacy of placental perfusion under simulated labor conditions. An external fetal monitor is applied to the mother, and a 20- to 30-minute baseline strip is recorded. The uterus is stimulated to contract either with the administration of a dilute dose of oxytocin (Pitocin) or by having the mother stimulate the nipples until three palpable contractions with a duration of 40 seconds or more in a 10-minute period have been achieved. Frequent maternal blood pressure readings are taken, and the client is monitored closely if increasing doses of oxytocin are given. A positive contraction stress test result indicates that the fetus may be compromised and requires continued monitoring and further evaluation. A negative result indicates fetal well-being.

A nurse responds to an external disaster in a large city involving an explosion at a shopping mall. Numerous victims require treatment. Which victim will the nurse attend to first? A. A victim with multiple bruises who is alert and oriented B. A victim who has sustained multiple lacerations with minor bleeding C. A victim who is alert and wandering around yelling that he cannot see D. A victim with a crush injury to the abdomen who has no pulse or blood pressure

C. A victim who is alert and wandering around yelling that he cannot see Rational: The nurse determines which victim will be attended to first on the basis of the acuity level of the victims involved in the disaster. The victim who must be treated immediately because of the threat to life, limb, or vision is categorized as emergent and is the priority. The victim who requires treatment but whose life, limb, or vision is not threatened if care can be provided within 1 to 2 hours is considered urgent and is the second priority. Victims who require evaluation and possible treatment but for whom time is not a critical factor are categorized as nonurgent and are the third priority. A victim who is deceased after sustaining multiple serious injuries is not the priority.

A nurse reviewing the record of a child with suspected acute poststreptococcal glomerulonephritis notes that the child recently had a streptococcal throat infection that was treated with antibiotics. Which diagnostic test will confirm the presence of acute poststreptococcal glomerulonephritis does the nurse expect to find? A. Throat culture B. Blood urea nitrogen (BUN) C. Antistreptolysin (ASO) titer D. White blood cell (WBC) count

C. Antistreptolysin (ASO) titer Rational: Immunologic studies are important in diagnosing acute poststreptococcal glomerulonephritis. The ASO titer, which indicates the presence of antibodies to streptococcal bacteria, may be increased. Culture of the throat may be helpful in isolating the bacterium, but this test is only useful if the infection is recent and the child has not received antibiotics. The BUN level would be increased if renal insufficiency was present. The WBC count is usually normal. Throat culture, BUN and WBC count would not confirm the presence of acute poststreptococcal glomerulonephritis.

A nurse is preparing to administer digoxin to a client with heart failure. When assessing the client, the nurse notes an apical pulse rate of 58 beats/min. Also, the client complains of anorexia and nausea. Which action should the nurse take first on the basis of these assessment findings? A. Contact the primary health care provider B. Administer an as-needed antiemetic C. Check the most recent digoxin level D. Administer the digoxin with an antacid

C. Check the most recent digoxin level Rational: Anorexia and nausea are two of the symptoms most commonly associated with digoxin toxicity. The nurse should withhold the digoxin until the primary health care provider has been consulted if the pulse rate is slower than 60 beats/min, because bradycardia is also an indication of digoxin toxicity. The nurse then checks the most recent digoxin level, which will provide additional data to report to the primary health care provider — a key follow-up nursing action. The nurse would not administer an antiemetic without further investigating the client's problem.

Zidovudine is prescribed for a client with acquired immunodeficiency syndrome (AIDS). The nurse tells the client that it is important to report back to the clinic as scheduled for which follow-up diagnostic? A. Blood glucose checks B. Blood pressure checks C. Complete blood counts (CBCs) D. Electrocardiographic (ECG) studies

C. Complete blood counts (CBCs) Rational: Zidovudine is an antiviral medication. Common side effects include agranulocytopenia and anemia. The nurse carefully monitors CBC results for these changes. With early infection or in the client who is asymptomatic, a CBC is usually performed monthly for 3 months, then every 3 months thereafter. In clients with advanced disease, a CBC is usually performed every 2 weeks for the first 2 months and then once a month if the medication is tolerated well. This medication does not affect the blood glucose level, blood pressure, or cardiac status.

A nurse is suctioning a client through a tracheostomy tube. During the procedure, the client begins to cough, and the nurse notes an audible wheeze. The nurse tries to remove the suction catheter from the client's trachea but is unable to do so. After immediately disconnecting the suction source from the catheter, which intervention does the nurse implement next? A. Calling a code B. Administering an inhaled bronchodilator C. Connecting oxygen to the suction catheter D. Encouraging the client to take deep breaths

C. Connecting oxygen to the suction catheter Rational: The inability to remove a suction catheter is a critical situation. This finding, along with the client's symptoms presented in the question, indicates bronchospasm and bronchoconstriction. The nurse must immediately disconnect the suction source from the catheter but leave the catheter in the trachea. The nurse then connects the oxygen source to the catheter, because the client is at risk for hypoxia. The health care provider is notified and will most likely prescribe an inhaled bronchodilator. The nurse also prepares for emergency resuscitation if this situation occurs during suctioning. The client will be unable to take deep breaths. There is no information in the question indicating the need to call a code.

A nurse is assessing a client who has undergone radical neck dissection for the treatment of cancer. The nurse hears this sound when auscultating over the trachea. On the basis of this finding, which is the priority nursing action? A. Assess the client's pulse oximetry B. Place the client in a supine position C. Contact the primary health care provider D. Administer a nebulizer treatment with the use of a bronchodilator

C. Contact the primary health care provider Rational: The sound that the nurse hears is stridor. In the immediate postoperative period, the nurse assesses the client for stridor, a high-pitched musical sound heard on inspiration during auscultation over the trachea. This finding is reported immediately because it indicates airway obstruction. The client is placed in the Fowler position to facilitate breathing and promote comfort. Pulse oximetry may be performed, but this is not the priority of the options provided. Administering a nebulizer treatment with a bronchodilator is not indicated at this time.

An emergency department nurse is caring for an older client who may have been physically abused by her caregiver. In planning care for the client, the nurse takes which priority action? A. Notifying the police department B. Obtaining psychiatric help for the caregiver C. Contacting adult protective services to investigate the situation D. Telling the caregiver that he or she is not allowed to care for the client

C. Contacting adult protective services to investigate the situation Rational: If physical abuse or neglect is suspected, the priority nursing actions are to assess the client, treat any physical injuries, and ensure that the client is safe. Once these measures have been taken, referral to adult protective services is appropriate. The nurse also notifies the primary health care provider. Although there are laws requiring healthcare professionals to report suspected elder abuse to local authorities, calling the police at this point is premature. Telling the caregiver that he or she is no longer allowed to care for the client could trigger aggressive behavior on the part of the caregiver. Although the nurse may be involved in obtaining psychiatric assistance for the caregiver, this is not the priority action.

A postpartum nurse is caring for a client who had a placenta previa. Which nursing intervention does the nurse, reviewing the plan of care, identify as the priority for this client? A. Fundal assessment B. Monitoring of urine output C. Frequent assessment of lochia D. Inclusion of iron in every meal

C. Frequent assessment of lochia Rational: The placenta is implanted in the lower uterine segment, which does not contain the same intertwining musculature as the fundus of the uterus, and this site is more prone to bleeding even when the fundus is firm. The nurse may first see an increase in lochia as a sign of hemorrhage. The nurse then must assess the client carefully for signs of deficient fluid volume as a result of postpartum hemorrhage. This assessment includes urine output and fundal assessment however these are not the priority. Dietary intake of iron is not related specifically to placenta previa.

A nurse is assessing a client during her first prenatal visit to the clinic. The nurse takes the client's temperature: 100.8°F (38.2°C). Which of the following actions on the part of the nurse is appropriate? A. Documenting the temperature B. Retaking the temperature rectally C. Notifying the primary health care provider D. Informing the client that a temperature of 100.8°F is normal during pregnancy

C. Notifying the primary health care provider Rational: The normal temperature during pregnancy is 98° to 99.6°F (36.7° to 37.6°C). A higher temperature requires primary health care provider notification, because it may indicate an infection that requires medical management. The temperature would be documented, but this is not the most appropriate action, because the temperature is abnormal. Taking the temperature rectally is an unnecessarily invasive way of reassessing the client's temperature. The nurse could retake the temperature again orally to make sure that the original reading was correct. A temperature of 100.8°F (38.2°C) is not normal during pregnancy. Therefore the most appropriate nursing action is notification of the physician.

A nurse reviewing the medical history of an infant experiencing gastroesophageal reflux (GER) would expect to note documentation of which other issue? A. Refusal to suck B. Frequent diarrhea C. Recurrent otitis media D. Inability to pass stools

C. Recurrent otitis media Rational: GER is regurgitation of gastric contents back into the esophagus. The three types of GER are physiologic, functional, and pathologic. Vomiting or spitting up after a meal, hiccupping, and recurrent otitis media resulting from pooling of secretions in the nasopharynx during sleep are characteristics of all types of GER. Refusal to suck, diarrhea, and inability to pass stools are not associated with GER.

A nurse completes an initial assessment of a client admitted to the mental health unit. Which assessment finding is the priority concern? A. Bruises on the client's neck B. The client's report of not sleeping well C. The client's report of suicidal thoughts D. The spouse's statement "I don't approve of this treatment."

C. The client's report of suicidal thoughts Rational: The client's verbalized thoughts are extremely important. The verbalization of suicidal thoughts must be incorporated by the nurse into the plan of care. The nurse has the legal responsibility to protect the client from harm. The presence of bruises on the client's neck, the client's report of not sleeping well, and the spouse's statement are concerns to be addressed but are not priority concerns.

In caring for a child admitted to the hospital with Kawasaki disease, the nurse should monitor the child most closely for signs which complication? A. Anemia B. Renal failure C. Thrombus formation D. Gastrointestinal disturbances

C. Thrombus formation Rational: Kawasaki disease, also called mucocutaneous lymph node syndrome, is an acute febrile exanthematous illness of children with a generalized vasculitis of unknown origin. A generalized immune response affects the smooth muscle cells of the vascular walls. These vascular changes, along with the increase in platelets that occurs as part of the disease, can cause thrombus formation, myocardial infarction, and death in some children. Anemia, renal failure, and gastrointestinal disturbances are not specifically associated with this disorder.

A client with a diagnosis of preeclampsia suddenly begins to exhibit seizure activity. Which is the first action on the part of the nurse? A. Calling the physician B. Inserting an oral airway C. Turning the client on her side D. Noting the time of the seizure

C. Turning the client on her side Rational: If seizure activity occurs, the nurse remains with the client and presses the emergency bell for assistance. The client is turned on her side because a side-lying position permits greater circulation through the placenta and helps prevent aspiration. The nurse then notes the time and sequence of the seizure. The physician is notified that a seizure has occurred, because this is an obstetric emergency associated with cerebral hemorrhage, abruptio placentae, severe fetal hypoxia, and death. No object should be placed in the client's mouth during a seizure. An airway may be inserted after the seizure, and the client's mouth and nose are suctioned to prevent aspiration. Oxygen may be administered by way of face mask during the seizure to increase oxygenation of the placenta and all maternal organs.

A nurse has provided dietary instructions to a pregnant client with diabetes mellitus. Which patient statement indicates the patient understands the teaching? A. "I should increase my fat intake to ensure that the baby gains weight." B. "I'll need to start a high-protein, high-fat diet to help control the blood glucose level." C. "I should add extra glucose to the diet because additional calories are needed during pregnancy." D. "I will need to increase fiber in the diet to help control the blood glucose level and prevent constipation."

D. "I will need to increase fiber in the diet to help control the blood glucose level and prevent constipation." Rational: An increase in calories is needed with pregnancy, but additional glucose should be avoided because it may cause hyperglycemia. Approximately 50% to 60% of the total calories should be carbohydrate, at least 250 g/day. Protein intake should constitute 12% to 20% of the total kilocalories. Twenty percent to 30% of the daily caloric intake should come from fat, with no more than 10% saturated fats. High-fiber foods will cause the blood glucose level to rise more slowly by delaying gastrointestinal absorption. High-fiber foods also aid in the prevention of constipation.

A client with a manic disorder monopolizes group therapy. What should the nurse leading the group say to the client? A. "Leave the room." B. "Go to the nurses' station until our group therapy session is finished." C. "I will recommend that group therapy be eliminated from your treatment plan." D. "Thank you for your comments. Now, try to stop talking and listen to the others."

D. "Thank you for your comments. Now, try to stop talking and listen to the others." Rational: When a client is monopolizing the group, it is important for the nurse to be direct and decisive and set constructive limits. The best action is to acknowledge the client's input and then suggest that the client stop talking and try listening to others. Having the client leave the room, sending the client to the nurses' station until the group therapy session is finished, and eliminating group therapy from the client's treatment plan are all inappropriate interventions.

A nurse is providing care to a client with a closed chest tube drainage system. When the nurse assists the client in turning onto his side, the chest tube is accidentally dislodged from the insertion site. The nurse must immediately take which action? A. Reinsert the chest tube B. Turn the client onto his back C. Contact the primary health care provider D. Apply pressure over the chest tube insertion site

D. Apply pressure over the chest tube insertion site Rational: If a chest tube is dislodged from the insertion site, the nurse immediately applies pressure over the insertion site and covers the site with sterile gauze. The nurse then performs a respiratory assessment and contacts the primary health care provider. The nurse does not reinsert a chest tube, because this is outside the nurse's scope of practice. The physician will reinsert the chest tube if this is necessary. The head of the client's bed should be elevated to facilitate breathing.

A nurse performs a bedside glucose test on a newborn infant whose mother has diabetes mellitus and obtains a reading of (2.164 mmol/L)35 mg/dL. The nurse would take which action first? A. Ask the mother to breastfeed the newborn B. Bottle-feed the newborn with diluted glucose C. Start an intravenous line for the administration of glucose D. Ask the laboratory to perform a blood glucose test immediately

D. Ask the laboratory to perform a blood glucose test immediately Rational: The normal blood glucose level in a newborn is (2.22 mmol/L) 40 mg/dL or higher. Glucose levels of less than (2.22-2.298 mmol/L) 40 to 45 mg/dL measured with bedside glucose screening should be reported and verified in the laboratory. Although feeding is an intervention, the result of a bedside glucose must be verified by the laboratory. Some infants need IV glucose to maintain glucose balance and prevent damage to the brain.

A nurse is assigned to conduct an admission assessment of a client who was treated in the emergency department after attempting suicide by cutting her wrists with a razor blade. When the client arrives at the nursing unit, the nurse should take which action first? A. Ask the client to sign a no-harm contract B. Ask the client to report any suicidal thoughts immediately C. Place the client under suicide precautions with 15-minute checks D. Check the dressings that were placed over the client's wrists in the emergency department

D. Check the dressings that were placed over the client's wrists in the emergency department Rational: The nurse would first assess the physical status of the client. Therefore, the first nursing intervention is to check the dressings that have been placed over the client's wrists. The nurse would also immediately implement one-to-one suicide precautions (not 15-minute checks) for the client who has attempted suicide. The client would be asked to sign a no-harm contract, but this would not be the first action. Asking the client to report any suicidal thoughts immediately is a component of a no-harm contract.

A nurse is evaluating outcomes for a client with Guillain-Barre Syndrome. Which outcome does the nurse recognize as optimal respiratory outcomes for the client? Select all that apply A. Normal deep tendon flexes B. Improved skeletal muscle tone C. Absence of paresthesias in the lower extremities D. Clear sounds in the low lung fields bilaterally E. pO2 88mgHg and pCO2 of 40mmHg

D. Clear sounds in the low lung fields bilaterally E. pO2 88mgHg and pCO2 of 40mmHg Rational: Satisfactory respiratory outcomes include clear breath sounds on auscultation, clear mentation, spontaneous breathing, normal vital capacity, and normal arterial blood gases. The ABG results listed here — a Po2 of 85% and a Pco2 of 40 mm Hg — are normal. The presence of normal deep tendon reflexes, improved skeletal muscle tone, and absence of paresthesias in the lower extremities reflect improvement in the symptoms associated with Guillain-Barré but are not specific to a respiratory outcome.

A nurse provides dietary instructions to the mother of a child with iron-deficiency anemia. The nurse realizes the mother understands the instructions if the mother states she will increase which food in the child's diet? A. Milk B. Cheese C. Orange juice D. Cream of Wheat

D. Cream of Wheat Rational: Foods high in iron include liver, dried beans, Cream of Wheat, iron-fortified cereal, apricots and prunes (and other dried fruits), egg yolks, and dark-green leafy vegetables. Milk and cheese are high in calcium. Orange juice is high in vitamin C.

A nurse is caring for client with increased intracranial pressure (ICP). In which position should the nurse maintain the client? A. Supine, with the head extended B. Side-lying, with the neck flexed C. Supine, with the head turned to the side D. Head midline and elevated 30 to 45 degrees

D. Head midline and elevated 30 to 45 degrees Rational: The client with increased ICP should be positioned with the head in a neutral midline position. It is the responsibility of the nurse to ensure that all those delivering care to the client maintain the proper positioning. The client should avoid flexing or extending the neck or turning the neck side to side. The head of the bed should be raised to 30 to 45 degrees. Use of proper positioning promotes venous drainage from the cranium to keep ICP down.

A client who was sexually assaulted a year ago is self-contained and calm while discussing the assault. The client says to the nurse, "It still doesn't seem real." The nurse is considering requesting a referral to a mental health professional because which defense mechanism has been used for an extensive period of time? A. Denial B. Projection C. Rationalization D. Intellectualization

D. Intellectualization Rational: Denial is a common reaction by a victim of sexual assault. This defense mechanism is an adaptive and protective reaction. Projection is blaming or scapegoating. Rationalization is justifying unacceptable attributes. Intellectualization is the excessive use of abstract thinking or generalizations to decrease painful thinking.

A nurse is monitoring the neurological status of a client who underwent craniotomy 3 days ago. Which signs or symptoms would prompt the nurse to notify the primary health care provider immediately? A. Disorientation to date B. Pupils equal and reactive at 4 mm C. Mild headache relieved by acetaminophen with codeine D. Pain with forward flexion of the neck onto the chest

D. Pain with forward flexion of the neck onto the chest Rational: One of the complications of cranial surgery is meningitis. Signs of meningeal irritation include nuchal rigidity, which is characterized by a stiff neck and soreness and is especially noticeable when the neck is flexed. Pupils that are equal and reactive at 4 mm are normal. Mild headache relieved by acetaminophen with codeine is an expected finding at this point after craniotomy. Disorientation to date is not the matter of greatest concern when the client has been hospitalized for cranial surgery.

The nurse is observing a new nurse employee perform an otoscopic examination of an adult client. The nurse determines the new nurse employee understands the procedure if the new nurse employee takes which action? A. Uses a small speculum to decrease the discomfort B. Pulls the pinna up and back before inserting the speculum C. Tilts the client's head forward before inserting the speculum D. Pulls the earlobe down and back before inserting the speculum

D. Pulls the pinna up and back before inserting the speculum Rational: The correct procedure for performing an otoscopic examination is to pull the pinna up and back and to visualize the external canal while slowly inserting the speculum. The nurse tilts the client's head slightly away and holds the otoscope upside down as if it were a large pen. A small speculum may not provide adequate visualization of the ear canal and is more appropriate for use in a pediatric setting.

A client in a manic state emerges from her room wearing provocative clothing and quickly enters the dayroom. She announces to the group that she is the star of a burlesque show and will begin her performance shortly. Which is the priority nursing action? A. Ask the client to go to her room and to change her clothes B. Tell the client firmly that burlesque shows are not allowed in the nursing unit C. Tell the client that her bathroom privileges are being suspended because of her behavior D. Quietly and firmly assist the client to her room and help her dress in appropriate clothes

D. Quietly and firmly assist the client to her room and help her dress in appropriate clothes Rational: A person who is experiencing mania lacks insight and judgment, has poor impulse control, and is highly excitable. The nurse must take control without creating increased stress or anxiety in the client. Taking a quiet, firm approach while distracting the client (i.e., walking her to her room and helping her dress appropriately) achieves the goal of preserving her psychosocial integrity. Suspending the client's bathroom privileges because of behavior, having the client change her clothes and telling the client that burlesque shows are not allowed in the nursing unit will all increase the client's anxiety.

A client's arterial blood gases (ABGs) are analyzed: pH 7.49, Paco2 31 mm Hg, Pao2 97 mm Hg, HCO3- (22 mmol/L) 22 mEq/L. Which acid-base disturbance does the nurse identify from these results? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis

D. Respiratory alkalosis Rational: Acidosis is defined as a pH of less than 7.35, whereas alkalosis is defined as a pH greater than 7.45. Respiratory acidosis is present when the Paco2 is greater than 45 mm Hg; respiratory alkalosis is present when the Paco2 is less than 35 mm Hg. Metabolic acidosis is present when the HCO3- is less than (22 mmol/L)22 mEq/L; metabolic alkalosis is present when the HCO3- is greater than (26 mmol/L) 26 mEq/L. This client's ABG results are consistent with respiratory alkalosis.

A client hospitalized on a mental health unit with schizophrenia tells the nurse, "The voices in my head say that I'm worthless and that I don't deserve to be alive." What is the nurse's priority concern for this client? A. Ineffective coping skills B. Perceptual disturbances C. Chronic low self-esteem D. Risk for self-directed violence

D. Risk for self-directed violence Rational: The altered perceptions and cognitive distortions experienced by the client with schizophrenia put the client at risk for self-harm. A fundamental responsibility of the nurse is to provide a safe environment for this client and others. Although ineffective coping skills, disturbed perceptual ability, and low self-esteem may be appropriate concerns, the risk for self-directed violence is the priority.

A nurse is monitoring a client in precipitous labor. The nurse would contact the primary health care provider on noting which concern? A. Fetal descent of 1 cm/hr B. A reassuring fetal monitoring pattern C. Cervical dilation of 2 to 4 cm/hr during the active phase D. Shortening periods of uterine relaxation between contractions

D. Shortening periods of uterine relaxation between contractions Rational: The nurse would contact the primary health care provider if inadequate relaxation were noted between contractions. This situation could interfere with the transfer of oxygen and nutrients to the fetus through the placenta. All of the other options are normal findings.

A pregnant client complains of heartburn, and the nurse provides instruction regarding measures to alleviate the problem. The nurse tells the client to take which action? A. Lie down right after meals B. Take antacids as often as necessary C. Eat three meals a day and avoid eating between meals D. Sleep with an extra pillow under the head and shoulders

D. Sleep with an extra pillow under the head and shoulders Rational: Heartburn is caused by the regurgitation of gastric acid into the esophagus. Self-care for heartburn includes eating small frequent meals, avoiding fatty or spicy foods, remaining upright for 30 minutes after eating, sleeping with an extra pillow under the head and shoulders, and drinking approximately 2000 mL of fluid per day. The client should not be advised to take antacids as often as necessary; some antacids are high in sodium and may cause fluid retention and electrolyte imbalances. Some antacids are high in calcium and may provide relief, but they may also cause rebound hyperacidity. The physician should be consulted if heartburn is not relieved with nonpharmacological measures.

A nurse is preparing to administer an injection of vitamin K to a newborn. At which site would the nurse select to administer the medication? Image shows the sites: Site 1 Site 2 Site 3 Site 4

Site 3 Rational: The preferred injection site for the administration of vitamin K in the newborn is the lateral aspect of the middle third of the vastus lateralis muscle (the newborn's thigh). This muscle is the preferred injection site because it is free of major blood vessels and nerves and is large enough to absorb the medication. Option 1 is the area of the greater trochanter. Option 2 is the area of the femoral vein. Option 4 is the patellar area.