NCSBN Practice Questions 31-45

The nurse is preparing to administer ephedrine 5 mg IV push to a client with refractory hypotension. The supplied vial contains 50 mg of ephedrine in 10 mL normal saline. How many mL shall the nurse draw up? (Write the answer using whole numbers.)

1 50 mg in 10 mL equals 5 mg per 1 mL. The nurse should draw up 1 mL to administer 5 mg of ephedrine.

A nurse is reviewing and order that reads: administer conjugated estrogen 1.25 mg daily. The only available tablet strength is 625 mcg. How many tablets will the nurse administer?

2 1.25 mg = 1250 mcg: 1250 mcg/625 mcg = 2 or 2 tablets. Using Dimensional Analysis: Tablet = (1.25 mg/625 mcg) X (1000 mcg/1 mg) = 2

The nurse has performed the initial assessments of four clients admitted with an acute episode of asthma. Which assessment finding would cause the nurse to call the health care provider immediately? A. Expiratory wheezes that are suddenly absent in one lobe B. Expectoration of large amounts of purulent mucous C. Appearance of the use of abdominal muscles for breathing D. Prolonged inspiration with each breath

A Acute asthma is characterized by expiratory wheezes caused by obstruction of the airways. Wheezes are high-pitched musical sounds produced by air moving through narrowed airways. Clients often associate wheezes with the feeling of tightness in the chest. However, sudden cessation of wheezing is an ominous or bad sign that indicates an emergency - the small airways are now collapsed. Inspiratory wheezes are an emergency, whereas expiratory wheezes may not be as high a priority because some clients experience this with emphysema.

A client diagnosed with schizophrenia, talks animatedly and the nursing staff are unable to understand what the client is attempting to communicate. The client is observed mumbling to self and speaking to the radio. A desirable outcome for this client's care should be which of these behaviors? A. Engages in meaningful and understandable verbal communication B. Expresses feelings appropriately through verbal interactions C. Interprets accurately the events and behaviors of others D. Demonstrates improved social relationships within the unit

A An outcome should be related to the medical diagnosis and supporting data. The client's exhibited behaviors support a nursing diagnosis of impaired verbal communication deficit. No information is presented related to feelings or to thinking processes. Disorganized verbalizations are typically taken to indicate disorganized thinking.

The nurse is caring for a client who has a wound on the leg from a motorcycle accident. During a home visit, the nurse should use which assessment parameter as an indication that this client is experiencing normal wound healing? A. Pebbled red tissue in the wound base B. Eschar over the surface C. White patches on the outside edges D. Green drainage from the center

A As the wound granulates, pebbled red tissue in the wound base indicates healing. Any of the other findings would indicate that the wound was not healing properly.

The client is seen in the emergency one day after falling in his bathroom at home. The client reports having "a few drinks" prior to the fall. Which finding requires the nurse's immediate attention? A. Bruise behind one ear B. Blurred vision C. Nausea and vomiting D. Headache

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

The nurse is caring for a client who had a closed reduction of a fractured right wrist followed by the application of a fiberglass cast 12 hours ago. Which finding requires the nurse's immediate attention? A. Client reports burning and tingling in the right hand and arm B. Slight swelling of fingers of right hand C. Skin warm to touch and normally colored D. Capillary refill of fingers on right hand is about three seconds

A Burning and tingling as well as intense pain out of proportion to the injury may be an indication of compartment syndrome, requiring immediate action by the nurse to prevent permanent muscle damage. The other findings are normal for a client in this situation.

A client is admitted with a tentative diagnosis of congestive heart failure (CHF). Which assessment finding, consistent with this diagnosis, would the nurse expect? A. Inspiratory crackles B. Cyanosis C. Chest pain D. Heart murmur

A CHF is when the pumping action of the heart is reduced or weakened, which leads to a buildup of fluid in the lungs and surrounding body tissues. Early symptoms may include shortness of breath or chronic coughing. The person may also feel fatigued or lightheaded, and have difficulty breathing (dyspnea) and anorexia. When auscultating the lungs of a client with CHF, the nurse can expect to hear fine crackles (usually over the posterior lung bases) that do not clear after a cough. Crackles are the result of pulmonary edema or fluid in the alveoli due to heart failure.

After a myocardial infarction, a client is placed on a sodium-restricted diet. When the nurse is teaching the client about the diet, which meal plan would be the most appropriate to suggest? A. Turkey 3 oz., a fresh sweet potato, 1/2 cup fresh green beans, milk, and an orange B. Broiled fish 3 oz., a baked potato, ½ cup canned beets, an orange, and milk C. Canned salmon 3 oz., fresh broccoli, a biscuit, tea, and an apple D. A bologna sandwich, fresh eggplant, 2 ounces of fresh fruit, tea, and apple juice

A Canned fish and vegetables and cured meats are high in sodium. The correct meal does not contain any canned fish and/or vegetables or cured meats. A low-sodium diet is 2 grams of sodium as compared to a normal sodium diet of 4 grams of sodium.

The nurse is assessing an 8 month-old infant diagnosed with atonic cerebral palsy. Which statement from the parent supports this diagnosis? A. "When I put her on her back to sleep, she's still in the same position a few hours later." B. "My baby doesn't seem to follow when I shake toys in front of her face." C. "When I put my finger in her left hand she doesn't respond with a grasp." D. "When it thundered loudly last night she didn't even jump."

A Cerebral palsy is known as a condition whereby motor dysfunction occurs secondary to damage in the motor centers of the brain. Inability to roll over by eight months of age would illustrate one delay in the infant's attainment of developmental milestones. Cerebral palsy is most commonly associated with cerebral hypoxia during the birth process.

The nurse enters a client's room just as the client begins to experience a generalized tonic clonic seizure. What action should the nurse take? A. Place the client on one side B. Elevate the head of the bed C. Hold the client's arms at the side D. Insert a padded tongue blade in client's mouth

A Clients should be positioned on their side. This position keeps the airway patent and allows saliva to drain from the mouth, which prevents aspiration. The nurse should also protect the client from injury by clearing furniture (if the client is on the floor). The client should not be restrained nor should anything be forced in the client's mouth.

A client is admitted with a diagnosis of myocardial infarction (MI) and reports having chest pain. The nurse provides care based on the knowledge that pain associated with an MI is related to which of the following findings? A. Insufficient oxygenation of the cardiac muscle B. Fluid volume excess C. Arrhythmia D. An electrolyte imbalance

A Due to ischemia of the heart muscle, the client will experience pain. This happens because destroyed myocardial tissue can block or interfere with the normal cardiac circulation.

While planning care for a toddler, the nurse teaches the parents about the expected developmental changes for this age. Which statement by the mother shows that she understands the child's developmental needs? A. "I understand our child's need to use those new skills." B. "I intend to keep control over our child's behavior." C. "I want to protect my child from any falls." D. "I will set limits on exploring the house."

A Erickson describes the stage of the toddler as being the time when there is normally an increase in autonomy. The child's developmental needs are to use motor skills for an exploration of the environment.

A nurse documents "effective use of guided imagery to change pain from a 4 to a 1 (on a 10-point scale)." Which definition best describes this technique? A. Focus on pleasant, relaxed mental pictures B. Closure of the eyes to focus on the back of the eyelids or blank screen C. Inhalation to a count of four and exhalation to a count of four D. The repetition of a word to self with the eyes closed

A Guided imagery is a technique that uses pleasant mental visuals that can be recalled by the client to reduce stress, anxiety or pain. Focusing on the back of the eyelids or a repetition of a word or phrase describes meditation.

The nurse is caring for a client with inflammatory bowel disease who admits to using complementary therapies, including herbal remedies and peppermint tea. Which of the following statements made by the nurse is the most appropriate response? A. "It is important to inform your health care provider of the use of these therapies." B. "These therapies are probably not harmful but may be costing you unnecessary money." C. "These therapies are known to interfere with prescribed medications so it is important to stop using them." D. "I would suggest that you discontinue the use of these therapies as they may be dangerous."

A Herbal remedies and peppermint tea have been shown to provide some relief from symptoms but may interact with prescription medications. Therefore, the health care provider needs to be aware of the use of all complementary & integrative health therapies.

The nurse is having a discussion with the parents of a newborn who was diagnosed with hypospadias. The nurse should communicate which point? A. The surgery may be performed in stages over a period of time B. The postoperative appearance of the penis will be normal C. Circumcision can be performed at any time D. The initial repair is delayed until six to eight years of age

A Hypospadias is a condition in which the urethral opening is located on the ventral surface or the underside of the penis. Mild defects may be repaired in one procedure, while severe defects may require two or more procedures. It is corrected in stages as soon as the child can tolerate surgery and before the child turns school age.

A client with an IV antibiotic infusing is scheduled to have blood drawn at 1:00 pm for a peak antibiotic level measurement. The nurse notes that the IV infusion is running behind schedule and won't be infused until 1:30 pm. What action should the nurse take? A. Reschedule the laboratory test for 2:00 pm B. Stop the infusion at 1:00 pm and get the blood drawn C. Increase the infusion rate to finish it by 1:00 pm D. Notify the client's health care provider

A If the antibiotic infusion will not be completed at the time the peak blood level is scheduled to be drawn, a nurse should ask that the blood sampling time be adjusted. Typically the peak level should be drawn about 30 to 60 minutes after completion of the infusion. The infusion should not be increased because in this situation the volume of fluid to be infused is unknown; rates for IV infusions should not be increased or decreased by more than 10% of the ordered rate. Trough and/or peak levels are commonly drawn for aminoglycosides (such as vancomycin, gentamicin and tobramycin.)

The nurse is using the Glasgow Coma Scale to assess a client diagnosed with a traumatic brain injury. When the client does not obey verbal commands to move, which technique should the nurse use to evaluate motor function? A. Squeeze the trapezius muscle firmly B. Lift the client's arm and observe for pronation and drift C. Apply finger tip pressure for 10 seconds D. Rub the sternum with the knuckles

A If the client's eyes do not open spontaneously or to sound, the nurse will assess eye opening using physical peripheral pressure, such as finger tip pressure. But a stronger, central pressure is needed to assess motor function when the client does not obey commands to move, such as the trapezius pinch. If there is no response to the trapezius pinch, the nurse can then apply pressure to the supraorbital notch to elicit a motor response. Using the Glasgow Coma Scale, the client's response on the motor scale is scored from 1 (no movement) to 6 (obeys 2-part verbal request). Rubbing the sternum with the knuckles is no longer used since it can easily bruise the soft tissue. Observing for pronation and drift is used in neurologic assessments to detect subtle arm movement in clients who can obey commands.

A 35-year-old client of Puerto Rican-American descent is diagnosed with ovarian cancer. The client states, "I refuse both radiation and chemotherapy because they are 'hot.'" Which action should the nurse take next? A. Ask the client to talk about concerns regarding "hot" treatments B. Report the situation to the health care provider C. Document the situation and client response in the notes D. Talk with the client's family about the situation

A In Hispanic folk medicine, it is believed that disease is caused by an imbalance between hot and cold principles. Health is maintained by avoiding exposure to extreme temperatures and by consuming appropriate foods and beverages. Examples of "hot" diseases or states include pregnancy, hypertension, diabetes and indigestion. "Cold" diseases include pneumonia. These designations are symbolic and do not necessarily indicate temperature or spiciness. Care and treatment regimens can often be negotiated with clients within this framework. Also note that the correct response is the best answer because it is client-centered.

A nurse is caring for a client admitted to the hospital with a diagnosis of right lower lobe (RLL) pneumonia. On assessment, the nurse notes rhonchi and a loose but weak cough. The client has significant pleuritic pain and is unable to take a deep breath to cough effectively. Which nursing diagnosis would be most appropriate for this client based on this assessment data? A. Ineffective airway clearance related to sputum production and ineffective cough B. Impaired gas exchange related to acute infection and sputum production C. Anxiety related to hospitalization and role conflict D. Ineffective breathing pattern related to acute infection

A Ineffective airway clearance is defined as ineffective mobilization and clearance of airway secretions, usually due to a weak cough. Movement of secretions in the airway produces rhonchi on auscultation. Respiratory secretions obstruct the airway and need to be cleared to promote appropriate gas exchange and resolution of the infection. While the other diagnoses may be appropriate for this client, this is the only one supported directly by the assessment data provided.

A client diagnosed with bipolar disorder is reluctant to take lithium (Lithane) as prescribed. What is the most therapeutic response by a nurse to a refusal of the medication? A. "What is it about the medicine that you don't like or that you are afraid of?" B. "I can see that you are uncomfortable right now. I'll wait until tomorrow to discuss this with you." C. "You need to take your medicine. This is how you will get well." D. "If you refuse your medicine, we'll just have to give you a shot."

A Nursing interventions for clients with psychotic disorders are aimed at the establishment of a trusting relationship, clear communications, presentation of reality and reinforcement of appropriate behaviors. This response validates the reluctance of the client with steps to work through the reluctance for an outcome of acceptance that medication is critical for treatment.

A staff nurse complains to the nurse manager that an unlicensed assistive personnel (UAP) consistently leaves the work area untidy and does not restock supplies. The initial response by the nurse manager should be which of these statements? A. "I would like for you to approach the UAP about the problem the next time it occurs." B. "I can assure you that I will look into the matter in due time." C. "I will add this concern to the agenda for the next unit meeting so we can discuss it." D. "I will arrange for a conference with you and the UAP within the next week"

A Part of the manager's role is to help the staff manage conflict among themselves. It is appropriate to urge the nurse to confront the other staff member to work out problems without a manager's intervention when possible. This is an approach at the first level of management. If the two staff members cannot resolve the issue then the manager would have a conference with the two staff to facilitate a negotiation for a win-win result.

A nurse is teaching a client with Raynaud's phenomenon about lifestyle and behavioral changes that will improve the quality of life. Besides smoking cessation, what would be the next most important thing this client should do? A. Avoid cold temperatures B. Avoid spicy foods C. Keep feet dry D. Reduce stress

A Raynaud's phenomenon is a condition where cold temperatures or strong emotions cause blood vessel spasms, preventing blood flow to the fingers, toes, ears, and nose. Besides not smoking, the most important teaching would be to avoid cold temperatures. Both cold and nicotine cause arterial vasoconstriction and will aggrevate this phenomenon. The question is asking what is the most important teaching. The other approaches tend to be needed less frequently and so are a lower priority.

The nurse is applying silver sulfadiazine topical to severe burns on the arms and legs of an adult. Which side effect should the nurse monitor for? A. Decreased neutrophils B. Hardened eschar C. Skin discoloration D. Increased neutrophils

A Silver sulfadiazine (Silvadene) is a broad spectrum antimicrobial and is especially effective against pseudomonas. When applied to extensive areas, however, it may cause a transient neutropenia, a decrease in neutrophils, as well as renal function changes with sulfa crystal production and kernicterus.

Several clients are admitted to an adult medical unit. For which client condition(s) would the nurse institute airborne precautions? A. A positive purified protein derivative (PPD) test with an abnormal chest x-ray B. A tentative diagnosis of viral pneumonia with productive brown sputum C. Autoimmune deficiency syndrome (AIDS) with cytomegalovirus (CMV) D. Advanced carcinoma of the lung with hemoptysis mixed with a yellow tinge

A The client who must be placed in airborne precautions is the client with the findings that suggest a suspicious tuberculin lesion. A sputum smear for acid-fast bacillus would be done next. CMV usually causes no signs or symptoms in children and adults with healthy immune systems. Good handwashing is recommended for CMV. When findings do occur, they are often similar to those of mononucleosis, including sore throat, fever, muscle aches and fatigue.

The nurse is preparing a handout on infant feeding to be distributed to families visiting the clinic. Which notation should be included in the teaching materials? A. Solid foods are to be introduced one at a time beginning with cereal B. Egg white is added early to increase protein intake C. Solid foods should be mixed with formula in a bottle D. A variety of ground meat should be started early to provide iron

A Solid foods should be added, one at a time, between 4 to 6 months. If the infant is able to tolerate the food, another is then added each week. Iron-fortified cereal is the recommended first food; rice cereal is recommended due to the low risk of food allergies. Teach parents to mix the cereal flakes with either breast milk or formula. After the baby is eating cereal, pureed meat, vegetables and fruits can be introduced. Egg whites and wheat products should not be given before the baby is at least a year old because these foods are more commonly associated with allergies.

During the check-up of a 2 month-old infant at a well-baby clinic, a mother expresses concern to a nurse because a flat pink birthmark on the baby's forehead and eyelid has not gone away. What is an appropriate response by the nurse? A. "Telangiectatic nevi are normal and will disappear as the baby grows." B. "Port wine stains are often associated with other malformations." C. "Mongolian spots are a normal finding in dark-skinned children." D. "The child is too young for consideration of surgical removal of these at this time."

A Telangiectatic nevi, salmon patch or stork bite birthmarks, are a normal variation and the facial nevi will generally disappear by the time the child is 1 to 2 years old.

An unlicensed assistive person (UAP), who usually works in pediatrics, is reassigned to work on an adult medical-surgical unit. Which of these questions should the charge nurse ask prior to assigning nursing activities and tasks to the UAP? A. "Do you have your competency checklist that we can review?" B. "How long have you been a UAP?" C. "What type of client care did you give in pediatrics?" D. "How comfortable are you caring for adult clients?"

A The UAP must be competent to accept assigned task. Using a checklist is the most comprehensive and appropriate approach to determine the UAP's skill set. In order to assign the correct types of tasks to the UAP, you must further assess his/her qualifications. The length of time in a position does not guarantee competency. Client care in pediatrics may not necessarily be relevant on an adult unit. Finally, although the charge nurse should be sensitive to the UAP's feelings, this is not a priority when assigning tasks or activities.

A client is about to undergo a plaster cast application. Prior to the cast application, the nurse should be sure to include what teaching point in the discussion? A. The wet cast should be handled with the palms of hands until fully dry B. The cast material will be dipped several times into the tepid water C. The casted extremity will be placed on a cloth-covered surface D. The cast should be covered with cotton material until it fully dries

A The cast will be handled with the palms of the hands and need to be lifted at two points of the extremity while it is drying. This will prevent stress of the injury and pressure indentation areas on the cast. The cast should be uncovered and be placed on a firm surface.

During examination of the mouth of a 3 year-old child, the nurse discovers that the teeth have chalky white-to-yellowish staining with pitting of the enamel. Which of these conditions would most likely explain these findings? A. Excessive fluoride intake B. Oral iron therapy C. Ingestion of tetracycline D. Poor dental hygiene

A The described findings are indicative of fluorosis, a condition characterized by an increase in the extent and degree of the enamel's porosity. This problem can be associated with repeated swallowing of toothpaste with fluoride or the drinking water with high levels of fluoride.

A client is scheduled for an intravenous pyelogram (IVP). Which information from the client's history indicates the greatest potential hazard for this test? A. Type 2 diabetic taking metformin (Glucophage) B. Urge incontinence C. Constipation D. Hypertension

A The elderly and those with diabetes and/or heart disease are at greater risk of developing kidney failure following administration of the dye. To avoid this complication, kidney function should be tested (creatinine). If kidney damage occurs, metformin can cause additional problems, which is why clients must stop taking metformin prior to and for 48 hours after an IVP. Feces or gas in the colon can interfere with the IVP, but these are not necessarily a hazard.

A client reports to the nurse that she is experiencing a sudden, deep and throbbing pain in one leg. What is the most appropriate first action to be taken by the nurse? A. Maintain the client on bed rest B. Apply ice to the extremity C. Ambulate for several minutes D. Suggest isometric exercises

A The finding suggests deep vein thrombosis (DVT). The client must be maintained on bed rest and the health care provider should be notified urgently. Deep vein thrombosis can lead to pulmonary embolism, which is a medical emergency that can cause severe problems with gas exchange and cardiac output and can even cause cardiac arrest. Anticoagulants are used to treat DVT, initially being administered by IV (heparin drip) or subcutaneous injection (low-molecular weight heparin). This is then followed by long-term oral anticoagulation with warfarin.

A nurse is caring for a client several days after a cerebral vascular accident (CVA). Warfarin has been prescribed. Today's prothrombin level is 40 seconds (normal range 10 to 14 seconds). Which finding requires priority follow-up? A. Gum bleeding B. Generalized weakness C. Homan's sign D. Lung sounds

A The prothrombin time is high and indicates an elevated risk for bleeding. Neurological assessments remain important for post-CVA clients.

Which of these client's behaviors would indicate that the nurse-client relationship has passed from the orientation phase to the working phase? A. Identifies feelings about situations and expresses them appropriately B. Revitalizes a relationship with the family to help cope with the death of a child C. Expresses a desire to be cared for and pampered D. Recognizes regressive behaviors as a defense mechanism

A The working phase of the nurse-client relationship is also called exploration or the identification stage. That's because the client identifies his/her problems and works with the nurse to solve problems and develop coping skills, a positive self concept and, eventually, independence. These skills will help the client to adapt and behave more appropriately.

A client in acute respiratory distress is admitted with arterial blood gas results of: PH 7.30; PO2 58, PCO2 34; and HCO3 19. The nurse should make which conclusion about these results? A. Metabolic acidosis B. Respiratory alkalosis C. Respiratory acidosis D. Metabolic alkalosis

A These lab values indicate metabolic acidosis: the PH is low, PCO2 is normal, and bicarbonate level is low. The oxygen level is not used during the determination of ABG interpretation.

One hour before the first treatment is scheduled, a client becomes anxious and states, "I do not wish to go through with electroconvulsive therapy." Which response by the nurse is most appropriate? A. "You have the right to change your mind. You seem anxious. Can we talk about it?" B. "I'll go with you and will be there with you during the treatment." C. "You'll be asleep and won't remember anything." D. "I'll call the health care providers to notify them of your decision."

A This response indicates acknowledgment of the client's rights and the opportunity for the client to clarify and ventilate concerns. After this, if the client continues to refuse, the health care providers should be notified.

The nurse is providing instructions for a client diagnosed with bacterial pneumonia. What is the most important information to convey to the client? A. "Complete all of the antibiotics, even if you feel better." B. "Take your temperature every day." C. "Take at least two weeks off from work." D. "You will need another chest x-ray in six weeks."

A To avoid a recurrence of infection, the client must complete all of the prescribed medications at the prescribed dosing intervals. It should be explained to the client that it may take two weeks or more for his energy level to return to normal, but he may not necessarily need to be off of work for two weeks. The health care provider may order a follow-up CXR, but this is not the priority. It is also not important to take his temperature daily unless he experiences worsening symptoms (such as chills, shortness of breath, chest pain, night sweats.)

To which nursing home resident could a nurse safely administer tricyclic antidepressants (TCAs) without questioning the health care provider's order? A. A 65 year-old Asian-American female with mild hypertension B. An 85 year-old Caucasian male with narrow-angle glaucoma C. An Hispanic female with coronary artery disease (CAD) D. An African-American male with benign prostatic hypertrophy (BPH)

A Tricyclics can be safely administered to the hypertensive client. The expected anticholinergic effects of tricyclic antidepressants include difficulty in urination, which is why TCAs are contraindicated with BPH. TCAs are also contraindicated in narrow-angle glaucoma (they can cause elevated pressure in the eyes) and for certain heart abnormalities.

A client with heart failure is newly referred to a home health care team. The nurse discovers that the client has not been following the prescribed diet. What should be the appropriate nursing action? A. Discuss diet with the client to learn the reasons for not following the diet B. Discharge the client from home health care because of noncompliance C. Notify the provider of the client's failure to follow prescribed diet D. Make a referral to Meals-on-Wheels for a weekly delivery of a proper meal

A When new problems are identified during client care, it is important for the nurse to collect accurate assessment data. This means that the nurse should go to the client first. Before reporting information to a health care provider, the nurse should have a complete collection of information such as an understanding of the client's behavior and feelings as a basis for future teaching and intervention.

A nurse is assigned to provide care in the pediatric unit. What must be the priority consideration for nurses when communicating with children? A. Developmental level B. Present environment C. Nonverbal cues D. Physical condition

A While each of the factors affect communication, nurses should recognize that developmental differences have implications for processing and understanding information. Consequently, a child's developmental level must be considered to select communication approaches.

After a successful alcohol detoxification, a client remarked to a friend, "I've tried to stop drinking but I just can't. I can't even work without having a drink." The client's belief that he needs alcohol indicates the dependence is primarily of which type? A. Psychological B. Socialcultural C. Biological D. Physical

A With psychological dependence, clients think thoughts and have attitudes toward alcohol or the desired substance. The results is that these thoughts produce cravings and behavior that reinforce compulsive use of the substance.

A client with a history of asthma and kidney stones is admitted with a diagnosis of recurrent renal calculi. The client experiences shortness of breath following a lithotripsy. The nurse auscultates the client's lungs and finds decreased air movement but no wheezing. The arterial blood gas (ABG) results are pH 7.31, PaO2 53 mm Hg, PaCO2 50 mm Hg, and O2 sat 82%. Which of the following actions are appropriate for the nurse to take? (Select all that apply.) A. Call respiratory therapy B. Administer a short-acting bronchodilator via nebulizer C. Start high flow oxygen via face mask D. Start oxygen via nasal cannula E. Increase IV fluids F. Contact the health care provider G. Prepare for possible intubation

A,B,C,F,E This client needs emergency treatment to open the airways and improve gas exchange. The absence of lung sounds without wheezing indicates a severe narrowing of the airways in asthma with minimal air movement. Emergent intervention to open the closed airway including possible intubation are indicated. The high PaCO and low pH indicate respiratory acidosis due to inadequate gas exchange. The low oxygen saturation and PaO2 indicate severe hypoxemia requiring high flow oxygen via mask.

The charge nurse is making assignments on the day shift for a registered nurse (RN), a licensed practical nurse (LPN) and a certified nursing assistant (CNA). Which assignments are the most appropriate for a client who fell during the night and now has a skin tear on his arm and a hematoma on his hip, and is scheduled for an x-ray of his hip? (Select all that apply.) A. Assign medication administration to the LPN B. Assign wound care to the RN C. Assign complete care to the LPN D. Assign the CNA to assist with personal hygiene tasks E. Assign the LPN to report confusion or headache

A,B,D,E The RN can assign clients to LPNs as long as the care of the client is not too complex and there is a low likelihood of an emergency. Since this client fell during the night, the RN should not assign complete care to the LPN. But the LPN could administer medications to this client and should report observations and assessment data to the RN. The CNA can assist the client with personal care activities.

The geriatric social worker is working with the nurse to assess the client's ability to perform instrumental activities of daily living (IADL). Which of the following skills are considered instrumental activities of daily living? (Select all that apply.) A. Ability to take medications B. Ability to cook meals C. Ability to eat independently/feed self D. Ability to bathe self E. Ability to write checks

A,B,E Activities of daily living (ADLs) are basic self-care tasks, such as feeding, toileting, grooming, bathing, putting on clothes. Instrumental activities of daily living (IADLs) are slightly more complex skills and include a series of life functions necessary for living independently, such as the ability to use a telephone, shopping, doing housework, preparing meals, handling finances, and being responsible to take medications. ADLs and IADLs are part of an older adult's functional assessment.

A client is admitted to the psychiatric unit after a suicide attempt. Which of the following interventions is important for the nurse to implement initially? (Select all that apply.) A. Ask the client directly if they have suicidal thoughts or plan to commit suicide B. Assign a staff member to stay with the client at all times C. Ask why the client attempted suicide D. Help the client identify the stressors that precipitated their current crisis E. Identify resources that the client may use after discharge F. Establish a trusting, therapeutic relationship

A,B,F The most important goal is for the client not to harm themselves. Therefore, client safety is the nursing priority at this time. Nursing interventions include: determining if the client has developed a plan, close observation, establishing trust, using open communication and establishing a physically and emotionally safe environment.Suicide risk assessment uses direct rather than indirect language. Close observation is necessary to ensure clients do not harm themselves in any way. Being alert for suicide and escape attempts facilitates the prevention or interruption of this and other harmful behavior. Establishing trust and open communication encourages clients to share their thoughts and feelings.Asking the client to provide the reasons for their thoughts, feelings, behavior and previous actions—asking why a client did something or feels a certain way—can be very intimidating and implies that the client must defend his or her behavior or feelings.Identifying precipitating stressors and resources for after discharge should be implemented after the initial phase.

A client is scheduled for a CT scan with contrast. What interventions should be taken by the nurse prior to sending the client to the imaging department? (Select all that apply.) A. Reassess the client's allergies B. Administer prescribed medication to sedate the client C. Confirm that a signed consent is in the chart D. Ask the client to remove all metal jewelry E. Ensure the client is well-hydrated

A,C,D Usually the client is NPO prior to a CT scan, particularly when contrast material is being used. Allergies and past reactions to contrast media should be reviewed with the client. Any metal, including body piercings, jewelry, hearing aids and removable dental work should be removed and safely stored prior to the test. Sedation is necessary only in cases of extreme anxiety.

The nurse is performing pulmonary assessment on a client. Indicate the correct sequence of pulmonary assessment by dragging and dropping the steps below into the correct order. A. Inspection B. Percussion C. Auscultation D. Palpation

A,D,B,C Inspection is first, observing for pattern of breathing, symmetry, anteroposterior and transverse chest diameters, as well as skin color, sounds and odors. The nurse will then palpate the posterior and anterior chest, noting any tenderness, crepitus, or tactile fremitus. The next step is percussion, which is performed in a systematic manner, usually from side to side from apex (top) of lungs to base (bottom), listening to changes in tone from one area to another. Lastly, the lungs are auscultated, listening over the anterior, posterior, and lateral chest for expected or adventitious sounds.

A nurse is assessing a young child at a clinic visit for a mild respiratory infection. Koplik spots are noted on the oral mucous membranes. What should the nurse assess next? A. Lungs B. Skin C. Urine D. Sputum

B A characteristic sign of rubeola is Koplik spots (tiny white spots). These are found on the buccal mucosa in the mouth about a few days before the onset of the measles rash (which appears as small red, irregularly shaped spots with a bluish white center). Although the nurse should assess the child's lungs with any reports of a respiratory infection, these spots would indicate that the skin should be checked for the presence of a rash. Sometimes a complication of measles is pneumonia, but it may be a bit premature to do a sputum culture.

The nurse is assessing a child with suspected lead poisoning. Which assessment should a nurse expect to find? A. Auditory wheezes with expiration B. Numbness and tingling in feet C. Excessive perspiration D. A history of difficulty sleeping

B A child who has unusual neurologic complaints, such as neuropathy or footdrop that cannot be attributed to other causes, may be affected by lead poisoning. This may occur when a child ingests or inhales paint chips from lead-based paint or dust during remodeling in older buildings. Other findings of lead poisoning are appearance of bluish gum line, hyperactivity and developmental delays.

A nurse is reviewing with a client how to collect a clean catch urine specimen. What is the appropriate sequence to teach the client? A. Clean the meatus, then urinate into the container B. Clean the meatus, begin voiding, then catch urine stream C. Void a little, clean the meatus, then collect specimen D. Void continuously and catch some of the urine midstream

B A clean catch urine is difficult to obtain and requires clear directions. Instructing the client to carefully clean the meatus, then void naturally with a steady stream prevents surface bacteria from contaminating the urine specimen. As starting and stopping flow can be difficult, once the client begins voiding it's best to just slip the container into the stream. Other responses do not reflect correct techniques.

The school nurse suspects that a third-grade child might have attention deficit hyperactivity disorder (ADHD). Prior to referring the child for further evaluation, what should the nurse do? A. Consult with the teacher about how to assist with impulse control B. Compile a history of behavior patterns and developmental accomplishments C. Observe the child's behavior on at least two occasions D. Compare the child's behavior with classic signs and symptoms of ADHD

B A complete behavioral and developmental history will play an important part in helping to diagnose this disorder

A client reports bilateral knee pain from osteoarthritis and is taking the prescribed nonsteroidal anti-inflammatory drug (NSAID). The nurse should instruct the client to make which lifestyle change to manage this condition? A. Avoid foods high in citric acid B. Start a regular exercise program C. Rest the knees as much as possible D. Keep the legs elevated when sitting

B A regular exercise program is beneficial in the treatment of osteoarthritis. It can restore self-esteem and improve physical functioning.

A client with chronic obstructive pulmonary disease (COPD) and a history of coronary artery disease is receiving aminophylline 25 mg/hour. Which finding would be associated with side effects of this medication? A. Flushing and headache B. Restlessness and palpitations C. Increased heart rate and blood pressure D. Decreased blood pressure and respirations

B Aminophylline is a bronchodilator often used to treat symptoms of asthma, bronchitis, and emphysema. Side effects include restlessness and palpitations (it is related chemically to caffeine).

The nurse is working with an adolescent diagnosed with morbid obesity. The nurse should recognize that obesity in adolescence is most often associated with what other finding? A. Sexual promiscuity B. Poor body image C. Drug experimentation D. Dropping out of school

B As the adolescent gains weight, there is a lessening sense of self-esteem and poor body image.

A 36 year-old female client has a hemoglobin level of 14 g/dL and a hematocrit of 42%, 24 hours after a dilation and curettage (D&C). Which of the following findings should the nurse expect when assessing the client? A. Complaints of fatigue with ambulation B. Capillary refill of less than three seconds C. Respirations 36 breaths per minute D. Pale mucous membranes

B Because the hemoglobin and hematocrit are within the normal limits for an adult female, any additional assessments should also be normal. This capillary refill time is normal. The other options could be findings of anemia.

A nurse is caring for a client with a new order for bupropion hydrochloride for treatment of depression. The order reads "Wellbutrin 175 mg twice a day for four days." What is the appropriate action? A. Observe the client for mood swings B. Question this medication dose C. Monitor neurologic signs frequently D. Give the medication as ordered

B Bupropion should be started at 100 mg twice a day for three days then increased to 150 mg twice a day. When used for depression, it may take up to four weeks for effective results. Common side effects are dry mouth, headache and agitation. Doses should be administered in equally spaced time increments throughout the day to minimize the risk of seizures.

Decentralized scheduling is used on a nursing unit. What is the advantage of this management strategy? A. Conserves time spent on planning B. Considers client and staff needs C. Frees the nurse manager to handle other priorities D. Allows requests for special privileges

B Decentralized staffing takes into consideration specific client needs and staff abilities and interests. This means the staffing is decided on the lowest level which is at the unit level.

The client is diagnosed with heart failure and oral digoxin is prescribed. What is the priority nursing assessment for this medication? A. Monitor serum electrolytes and creatinine B. Measure apical pulse prior to administration C. Maintain accurate intake and output ratios D. Monitor blood pressure every 4 hours

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

The nurse is preparing a client and her healthy newborn for discharge. The nurse provides information about hormonal effects in newborns and tells the client to expect which of the following conditions in her baby? A. Edema of the scrotum B. Gynecomastia C. Mongolian spots D. Lanugo

B Exposure to maternal hormones in utero may cause temporary conditions in the newborn. About three days after birth, both newborn boys and girls may experience swelling of the breasts as a result of the withdrawal of maternal estrogen. This should go away by the second week after birth.

A client says, "It's raining outside and it's raining in my heart. Did you know that St. Patrick drove the snakes out of Ireland? I've never been to Ireland." What should the nurse document this behavior as? A. Perseveration B. Flight of ideas C. Neologisms D. Circumstantiality

B Flight of ideas is characterized by over productivity of talk and verbally skipping from one idea to another. It is classic with clients diagnosed with bipolar disorder and occurs in the manic state of this disease. Flight of ideas can also occur with the diagnosis of schizophrenia and in clients who are intoxicated with psychoactive substances.

A nurse is assessing a 12 year-old child who has been diagnosed with hemophilia A. Which lab result would the nurse expect? A. An excess of white blood cells B. A deficiency of clotting factor VIII C. An excess of red blood cells D. A deficiency of clotting factors VIII and IX

B Hemophilia A is characterized by an absence or deficiency of Factor VIII.

The parents of a 2 year-old child report that the child has been holding the breath during temper tantrums. What is an appropriate approach for the response by a nurse? A. Recommend that the parents give in when the child holds the breath to prevent anoxia B. Advise the parents to ignore breath holding because breathing will begin as a reflex C. Instruct the parents on how to reason with the child about possible harmful effects D. Teach the parents how to perform cardiopulmonary resuscitation

B If temper tantrums are accompanied by breath holding, the parents need to know that this behavior will not result in harm to the child. Ignoring the breath holding is the best response to this benign behavior.

A nurse is administering lidocaine to a client with a myocardial infarction. Which assessment finding requires the nurse's immediate action? A. Respiratory rate of 22 B. Pulse rate of 48 beats per minute C. Central venous pressure reading of 11 D. Blood pressure of 144/92

B Some of the side effects of lidocaine is bradycardia, heart block, cardiovascular collapse and cardiac arrest. This medication should not be administered without continuous cardiac monitoring.

A nurse is assessing a healthy child at the two-year check up. Which finding should the nurse report immediately to the health care provider? A. Growth pattern appears to have slowed B. Height and weight percentiles vary widely C. Short-term weight changes are uneven D. Recumbent and standing height are different

B On the growth curve, height and weight should be close in percentiles at this age. A wide difference may indicate a problem.

The nurse is teaching the client about the patient controlled analgesia (PCA) planned for postoperative care. Which statement by the client is incorrect and indicates that further teaching is needed? A. "I will receive a continuous dose of medication." B. "I should call the nurse before I take additional doses." C. "The machine will prevent an overdose of the medication." D. "I will call for assistance if my pain is not relieved."

B Patient controlled analgesia offers the client more control in the prevention and relief of severe pain. The client should be instructed to initiate additional doses as needed when the pain is increased. The client needs to know to call for assistance when insufficient control of the pain is present. The other statements illustrate correct knowledge.

The nurse assesses a client who has been re-admitted to the psychiatric inpatient unit with a diagnosis of schizophrenia. The client's symptoms have been managed for several months with fluphenazine (Prolixin). Which should be the initial focus of the questioning during the admission assessment? A. "How long have you been outside in the hot weather this prior week?" B. "Tell me about your medication routine and when do you take it?" C. "What stressors do you have living in your home by yourself?" D. "How much alcohol in the form of beer, wine of hard liquor do you use each day?"

B Prolixin is an antipsychotic/neuroleptic medication useful in the management of the symptoms of schizophrenia. A side effect of this medication is increased sensitivity to sunlight, but asking about being outside in the hot weather would not be an initial focus. Medication compliance is a priority to investigate in the initial part of the admission assessment and it is a priority to convey this noncompliance to the health care provider because it may be associated with the need for admission to an inpatient unit.

A client who is being treated for paranoid schizophrenia becomes loud and boisterous. The nurse immediately places the client in seclusion, and the client willingly complies. How might the nurse's action be interpreted by the case manager? A. It was appropriate in view of the client's behaviors of violence B. It may result in charges of unlawful seclusion and restraint C. It leaves the nurse vulnerable for charges of assault and battery D. It was necessary to maintain the therapeutic milieu of the unit

B Seclusion should only be used when there is an immediate threat of violence or threatening behavior toward the staff, the other clients or the client himself. In this situation, the client exhibited loud behaviors without any suggestion of threat to the staff or self.

The nurse is planning care for a 2 year-old hospitalized child. Which situation would the nurse expect to most likely affect the child's behavior? A. Unfamiliar toys and games B. Separation from parents C. Presence of other toddlers D. Strange bed and surroundings

B Separation anxiety is most evident and at a peak from 6 months to 30 months of age. It is the greatest stress imposed on a toddler by hospitalization. If separation is avoided, young children have a tremendous capacity to withstand other stress.

The mother of a child diagnosed with poison ivy tells the nurse that she does not know how her child contracted the rash because the child had not been playing in wooded areas. As the nurse asks questions about possible contact, which of these situations should the nurse recognize as the highest risk for exposure to poison ivy? A. Throwing a ball to a neighborhood child who has poison ivy B. Playing with cars on the pavement near burning leaves C. Eating small amounts of grass while playing "farm" D. Playing with toys in a backyard flower garden

B Smoke from burning leaves or stems of the poison ivy plant can produce a reaction. Direct contact with the toxic oil, urushiol, is the most common cause for this dermatitis. Throwing a ball to a child with the rash is not a highest risk because direct contact has the greatest risk.

During the admission process, the staff nurse realizes that the information on the identification (ID) bracelet does not match the information on the client's admission face sheet. What action should the nurse take? A. Use a permanent marker to change the incorrect information on the ID bracelet B. Contact the admission department to create a new ID bracelet C. Write the corrected information on the whiteboard in the client's room D. Communicate with staff that the two-identifiers requirement must be verified using the admission face sheet

B The admissions office has the responsibility to verify the client's identity, apply the correct bracelet and keep all the records in the system consistent. While the Joint Commission does not require the use of arm bands, correct identifying information must be attached to the client at all times. The other options are unsafe practices.

A nurse has asked the second staff nurse to sign for a wasted narcotic, which was not witnessed by another person. What should be an appropriate initial action? A. Counsel the colleague about the risky behaviors B. Report this immediately to the nurse manager C. Confront the nurse about the suspected drug use D. Sign the narcotic sheet and document the event in an incident report

B The incident must be reported to the appropriate manager, for both ethical and legal reasons. This is not an incident that a coworker can resolve without referral to a manager.

During a nursing staff meeting, there is discussion of perceived inequities in weekend staff assignments. As a follow-up, the nurse manager should initially take which action? A. Help staff see the complexity of issues B. Facilitate creative thinking about staffing C. Allow the staff to change assignments D. Clarify reasons for current assignments

B The manager, as a change agent, can facilitate the staff's solving the problem. Referred to as the "moving phase" of Lewin's change theory, the problem is first viewed from a different perspective and a variety of solutions are examined and decided upon; a new approach for weekend assignments can then be tried out.

A client with paranoid delusions stares at a nurse over a period of several days. The client suddenly walks up to the nurse and shouts, "You think you're so perfect and pure and good." Which statement would be the most appropriate response for the nurse to make? A. "Is that why you've been staring at me?" B. "You seem angry right now." C. "Perfect? I don't quite understand." D. "You seem to be in a really bad mood."

B The nurse recognizes the underlying emotion with a matter of fact attitude. The nurse should avoid telling the clients how the nurse feels. A general rule for interactions between clients with a psychiatric diagnosis and staff members is to focus on feelings first when giving responses to behaviors.

A newly admitted adult client has a diagnosis of hepatitis A. The charge nurse should reinforce to the staff members that the priority routine in infection control strategy, in addition to handwashing, is which of these approaches? A. Wear a gown to change linens soiled from incontinence B. Have gloves on while handling bedpans with feces C. Use a mask with a shield if there is a risk of fluid splash D. Place appropriate precaution signs outside and inside the room

B The specific measure to prevent the spread of hepatitis A is careful handling and protection while working with fecal material. All of the other actions are correct but not the priority routine in infection control strategy that is used with hepatitis A.

An emergency department nurse admits a child who experienced a seizure at school. When the parent comments that this is the first occurrence and denies any family history of epilepsy, what is the best response by the nurse? A. "Long-term treatment will prevent future seizures." B. "This seizure may or may not mean your child has epilepsy. Further evaluation is needed." C. "Since this was the first convulsion, it may not happen again." D. "Do not worry. Epilepsy can be treated with medications."

B There are many possible causes for a childhood seizure. Some causes are transient, others require long-term treatment to prevent further seizures. Causes of seizure in childhood include include fever, central nervous system conditions, trauma, metabolic alterations and idiopathic (unknown) etiologies. EEG, electroencephalogram, is a test commonly used to evaluate seizure disorders.

A hospitalized 8 month-old infant is receiving gentamicin. While monitoring the infant for drug toxicity, the nurse should focus on which laboratory result? A. Platelet counts B. Serum creatinine C. Thyroxin levels D. Growth hormone levels

B Toxicity to the aminoglycoside antibiotic gentamicin is seen in increased BUN and serum creatinine levels. Kidney damage may be reversible if the drug is stopped at the first sign of toxicity. In addition to nephrotoxicity, this medication has a Black Box warning for neurotoxicity and ototoxicity.

A client is prescribed trimethoprim/sulfamethoxazole for recurrent urinary tract infections. Which information would be important to reinforce during client teaching? A. "It is safe to take with oral contraceptives." B. "Drink at least eight glasses of water a day." C. "Be sure to take the medication with food." D. "Stop the medication after five days."

B Trimethoprim/sulfamethoxazole (Bactrim) is a highly insoluble drug and clients should drink plenty of fluids while taking this medication to lower the risk of developing kidney stones. It is not necessary to take it with food, unless it causes stomach upset. When taking antibiotics, women who normally use oral contraceptives should be counseled to use additional forms of birth control. Clients should take the medication for the prescribed length of time.

The registered nurse (RN) needs to make assignment for the unlicensed assistive persons (UAP). Which activity should the RN ask the UAP to perform? A. Adjust the rate of a gastric tube feeding B. Check the blood pressure of a two-hour postoperative client C. Ask a client receiving chemotherapy about pain D. Record a history on a newly admitted client

B UAPs must be assigned tasks that are routine, have expected outcomes and require no nursing judgment or decision-making situations. Vital signs on stable clients are commonly assigned to unlicensed staff.

A client, who had his entire stomach surgically removed six months ago, is now readmitted. Which of the following assessment findings would indicate that the client is experiencing complications associated with this surgery? A. Decreased night vision B. Findings consistent with fatigue C. Poor wound healing D. Tendency to bruise easily

B When clients have the stomach surgically removed, they no longer have the stomach's production of intrinsic factor, leading to poor Vitamin B12 absorption. This results in anemia with symptoms of fatigue, due to the decreased number of red blood cells to carry oxygen to the body. The client with gastrectomy or gastric bypass surgery is also at risk of experiencing dumping syndrome with abdominal cramping pain, diarrhea, lightheadedness, tachycardia and hypoglycemia. Dumping syndrome is usually associated with eating too much or too rapidly, and can be avoided by following the proper diet (five to six small meals per day, high protein, low carbohydrate and fat, eaten slowly) and by avoiding fluids with meals that move food rapidly into the small intestine.

The nurse is assessing a client who sustained multiple fractures, contusions, and lacerations in a motor vehicle accident three days ago. The client suddenly becomes confused. Which of the following findings would support the nurse's suspicion that the client has developed a fat embolism? (Select all that apply.) A. Hypertension B. Petechiae on the upper anterior chest C. Elevated temperature D. Dyspnea E. Low oxygen saturation

B,C,D,E Manifestations of acute confusion, hypoxia, fever and hypotension may indicate fat embolism in a client who has sustained multiple fractures, particularly fractures of the long bones. The occlusion of dermal capillaries by fat with increased friability of the capillaries can result in skin petechiae. This is most common on the chest, neck, upper arm, axilla, shoulder, oral mucous membranes and conjunctiva.

The nurse is preparing to administer total parenteral nutrition (TPN) through a central line. Indicate the correct order in which the following nursing actions should be performed. A. Use aseptic technique when handling the injection cap B. Check the solution for cloudiness or sediment C. Set the infusion pump at the prescribed rate D. Thread the intravenous tubing through an infusion pump E. Connect the tubing to the central line F. Select and prime the correct tubing and filter

B,F,D,A,E,C TPN solution should not be cloudy or have any kind of particles or sediment. The nurse should prepare the equipment by priming the tubing and threading it through the pump. To prevent infection, the nurse must use aseptic technique when inserting the connector into the injection cap and connecting the tubing to the central line. The nurse should then set the pump at the prescribed rate.

A nurse is examining an infant in a clinic. Which nursing assessment for the infant is most valuable in the identification of serious visual defects? A. Cover test B. Visual acuity C. Red reflex test D. Pupil response to light

C A brilliant, uniform red reflex is an important sign because it virtually rules out almost all serious defects of the cornea, aqueous chamber, lens, and vitreous chamber.

A nurse is teaching a parent how to administer oral iron supplements to a 2 year-old child. Which intervention should be included in the teaching? A. Stop the medication if the stools become tarry green B. Add the medicine to a bottle of formula C. Give the medicine with orange juice and through a straw D. Administer the iron with your child's meals

C Absorption of iron is facilitated in an environment rich in vitamin C. Because liquid iron preparation will stain teeth, a straw should be used. Parents should be informed that dark, tarry stools are expected outcomes of taking iron supplements. Iron is best absorbed on an empty stomach (but it may be given after meals if the child experiences an upset stomach).

The nurse is assessing the newborn of a mother with diabetes. The nurse should understand that hypoglycemia is related to what pathophysiological process? A. Maternal insulin dependency B. Pancreatic insufficiency C. Disruption of fetal glucose supply D. Reduced glycogen reserves

C After delivery, high glucose levels, which crossed the placenta to the fetus, are suddenly stopped. The newborn continues to secrete insulin in anticipation of the glucose. When oral feedings begin, the newborn will adjust insulin production within a day or two.

The nurse is talking with the family of an 18 month-old toddler who is newly diagnosed with retinoblastoma. Which point is a priority when discussing this diagnosis with the parents? A. Suggest that total blindness may follow surgery B. Prepare them for their child's permanent disfigurement C. There is a need for genetic counseling D. Inform them that even aggressive treatment is usually ineffective

C Aggressive treatment of retinoblastoma can be effective. If the tumor does not respond to chemotherapy and/or radiation therapy, the eye may need to be removed; however, that does not necessarily mean the child will be permanently disfigured. Regardless, the oncologist is the person who will discuss treatment options and anticipated outcomes with the parents. The parents should be prepared for the effects of the cancer on their child, but they should also understand that retinoblastoma is a rare cancer that runs in families and there is a high risk for future offspring to be affected.

A parent has numerous questions regarding normal growth and development of a 10 month-old infant. Which growth or development parameter should be of the most concern to a nurse? A. Cries when the parents leave the room B. Able to stand up briefly in play pen C. Fifty percent increase in birth weight D. Head circumference is about the same as chest size

C Although a lot of factors affect weight gain, birth weight usually doubles by 5 months and triples by about 12 months. Between 6 months and 2 years, head circumference and chest size are about the same. A 10 month-old may be able to stand alone (very briefly) or even walk unassisted. Stranger anxiety also starts around this time.

A nurse is suctioning a tracheostomy tube in a client. The nurse should take what action in order to prevent unnecessary hypoxia during this procedure? A. Maintain sterile technique throughout the procedure B. Withdraw catheter in a circular motion with intermittent suction C. Apply suction for no more than 10 seconds D. Lubricate three to four inches of the catheter tip

C Although all responses are correct and important steps of the suctioning process, hypoxia can result from applying suction for more than 10 sections. The nurse should be sure to apply oxygen immediately before and after suctioning and allow the client to rest a bit if more suctioning is indicated.

A nurse is caring for a 10 year-old child who will be started on heparin therapy. Which assessment is critical for the nurse to make before initiating this therapy? A. Skin turgor B. Vital signs C. Weight D. Lung sounds

C Check the client's weight because the dosage for anticoagulants in children is calculated on the basis of weight.

A 6 year-old child diagnosed with acute glomerulonephritis (AGN) presents with anorexia, moderate edema and elevated blood urea nitrogen (BUN) levels. The child requests a peanut butter sandwich for lunch. How should the nurse respond to this request? A. "I'm sorry, that is not a good choice, but you could have pasta." B. "That's a good choice, and I know it is your favorite. You can have it today." C. "I know that is your favorite, but let me help you pick another lunch." D. "You cannot have the peanut butter until you are feeling better."

C Children with AGN who have edema, hypertension, oliguria and azotemia may have dietary restrictions limiting sodium, fluids, protein and potassium. Because peanuts are made of protein, fats, and carbohydrates, and the sodium content of a tablespoon of peanut butter can be as high a 80 mg, a different choice for lunch might be best. Giving the child a short explanation and offering to talk about an alternative food is appropriate for this age.

Which statement by an older adult with chronic obstructive lung disease (COPD) indicates an understanding of the major reason to use pursed-lip breathing for episodes of dyspnea? A. "This position of my lips helps to keep my lungs open." B. "I can breathe better when I pucker up my lips because I can control how fast I breathe in and out." C. "I can breathe better using pursed-lip breathing because less air will be trapped in my chest." D. "My mouth doesn't get as dry when I breathe with pursed lips."

C Clients with chronic obstructive pulmonary disease (COPD) have difficulty exhaling fully as a result of air trapping in the alveoli due to the weakened alveolar walls from the disease process. Alveolar collapse can be avoided with the use of pursed-lip breathing, allowing the client to exhale more effectively. This technique facilitates appropriate gas exchange as carbon dioxide-rich air that has been trapped in the lungs is blown off, allowing oxygen-rich air to be inhaled. This is the major reason to use pursed-lip breathing. The other options are additional beneficial effects of this breathing technique.

A client continually repeats phrases that others have just said. The nurse should document this behavior as which term? A. Autistic B. Echopraxis C. Echolalia D. Catatonia

C Echolalia is repeating words or phrases heard before. Catatonic behavior is defined as that of extreme inactivity or activity that's disconnected from the environment or encounters with other people. Catatonic behaviors are associated with autism and schizophrenia. Autism is one of a group of serious developmental problems called autism spectrum disorders (ASD) that appear in early childhood — usually before age three. Although symptoms and severity vary, all autism disorders affect a child's ability to communicate and interact with others. Echopraxis is the the involuntary imitation of the actions of others.

The nurse is caring for a 14 year-old child in the postanesthesia care unit (PACU) following corrective surgery for scoliosis. Which action should receive priority in the plan? A. Assist to stand up at bedside within the first few hours B. Initiate the antibiotic therapy prescribed for 10 days C. Evaluate the movement and sensation of extremities D. Teach client isometric exercises for the legs

C Following corrective surgery for scoliosis, the neurological status of the extremities requires priority attention in the PACU, as well as on the postop surgical unit. The other options may be done after the neurological status.

The school nurse is teaching the faculty the most effective methods to prevent the spread of lice (Pediculus humanus capitis) in the school. The information that would be most important to include is reflected in which of these statements? A. "The treatment medication may require reapplication in 8 to 10 days." B. "Nit combs should be used to remove the eggs (nits) from your child's hair." C. "Children should not share hats, scarves and combs." D. "Bedding and clothing should be washed in hot water and dried in the dryer."

C Head lice live only on human beings and can be spread easily by sharing hats, combs, scarves, coats and other items of clothing that touch the hair. All of the options are correct statements. However they do not best answer the question of how to prevent the spread of lice in a school setting.

The nurse manager interviews several nurses for a staff position and the best qualified nurse is one with a sensory impairment. To better understand the issue of accommodations needed for this nurse, the nurse manager meets with the director of human resources. Which approach is suggested for the nurse manager? A. Make every necessary accommodation for the nurse with the disability B. Maintain an environment that's free from associated hazards C. Provide reasonable accommodations for the nurse with the disability D. Don't offer the position to the nurse with the disability due to financial burden

C In the U.S., for example, the Americans with Disabilities Act (ADA) is designed to permit individuals with motor, cognitive, psychiatric or sensory impairment access to job opportunities. Employers must evaluate an applicant's ability to perform the job on a case-by-case basis; however, employers cannot discriminate on the basis of a disability. Employers are required to make "reasonable accommodations."

A client is being discharged with a prescription for an iron supplement. What statement indicates a need for further teaching by the nurse? A. "I will have greenish-black stools from the medication." B. "I should not take antacids with my iron supplement." C. "I should take the iron supplement with a full glass of milk." D. "I should take vitamin C with the iron supplement."

C Iron should also be taken with vitamin C or orange juice because this increases the absorption of the medication; conversely, antacids, milk, caffeinated beverages, and calcium supplements can decrease the absorption of iron. Iron will cause the client's stool to turn greenish-black and tarry. Iron should be taken one hour before or two hours after meals to enhance absorption, although clients with GI intolerance may take the pills with food.

A 78 year-old client has just returned from having an intravenous pyelography. Which information is a priority for the nurse to reinforce? A. Rest for the next 24 hours because the preparation and the test are tiring B. Eat a light diet for the rest of the day C. Measure the urine output for the next day and immediately notify the health care provider if it is less than usual D. Drink at least one 8-ounce glass of fluid every hour while awake for the next two days

C It is important for the client to monitor urine output because this information would alert the client to the complication of acute renal failure. Renal failure may occur as a complication of the dye used during the procedure. Renal failure occurs most often in older adult clients who are often dehydrated before the dye injection. Unless contraindicated, they should force fluids for 24 hours after the test.

A nurse is caring for a client with extracellular fluid volume deficit. Which assessment would the nurse anticipate finding? A. Rapid respirations B. Bounding pulse C. Oliguria D. Distended neck veins

C Kidneys maintain fluid volume through adjustments in urine volume. When clients are dehydrated the kidney will conserve fluid and the urine output will be decreased.

Lactulose has been prescribed for a client with advanced liver disease. Which finding should the nurse use to evaluate the effectiveness of this treatment? A. Less jaundice B. Increased appetite C. Decreased lethargy D. Less edema

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

The client diagnosed with heart failure is admitted to an acute medical-surgical unit. The nurse completes medication reconciliation between the home medications and current prescribed medications. The nurse notes that the prescriber has added lisinopril 5 mg by mouth daily to the list of daily medications. What medication would the nurse question as a possible drug interaction with lisinopril? Acute Care Prescribed Medications: 1. lisinopril 10 mg by mouth daily 2. metoprolol 50 mg by mouth twice a day 3. glipizide 5 mg by mouth daily 4. naproxen 500 mg three times a day 5. enoxaparin 80 mg subQ every 12 hours Home Medications: 1. metoprolol 50 mg by mouth twice a day 2. glipizide 5 mg by mouth daily 3. naproxen 500 mg three times a day 4. enoxaparin 80 mg subQ every 12 hours A. metoprolol (Lopressor) 50 mg by mouth twice a day B. glipizide 5 mg by mouth daily C. naproxen 500 mg as needed three times a day D. enoxaparin 80 mg subQ every 12 hours

C Nonsteroidal anti-inflammatory (NSAID) drugs, such as naproxen, reduce the antihypertensive effects of ACE inhibitors (lisnopril). The use of NSAIDs and ACE inhibitors may also predispose patients to the develop acute renal failure. Additionally, naproxen increases the risk of heart attack or stroke with heart disease. The nurse would clarify the prescribed medications with the health care provider. The metoprolol and enoxaparin are appropriate to continue. Enoxaparin for antiplatelet action may also be continued.

A nurse is teaching a child and family members about the medication phenytoin prescribed for seizure control. Which side effect is most likely to occur? A. Vertigo B. Drowsiness C. Gingival hyperplasia D. Vomiting

C Overgrowth of the gums (gingival hyperplasia) is the most common side effect of long-term use of phenytoin (Dilantin); excessive hair on the face or body, acne, and coarseness of facila features are also common with long-term use. Good oral hygiene and regular visits to the dentist should be emphasized.

An infant has just had a pyloromyotomy. Initial postoperative nursing care would include which of these approaches? A. Intravenous fluids for three to four days B. Bland diet appropriate for age C. NPO then glucose and electrolyte solutions D. Formula or breast milk as tolerated

C Pyloric stenosis is caused when a muscle between the stomach and duodenum grows too large and thick, blocking food from being pushed from the stomach into the duodenum. During a pyloromyotomy, the surgeon cuts through the thickened muscle. Postoperatively, the initial feedings for infants are small quantities of clear liquids, such as glucose water or water with electrolytes in it. If the infant tolerates clear liquids, caregivers will give watered-down breast milk or formula; feedings are then advanced to regular breast milk or formula.

A nurse admits a premature infant who has been diagnosed with respiratory distress syndrome (RDS). In planning care for the infant, the nurse understands that the pathophysiology of this disorder affects the infant's ability to do what? A. Stabilize thermoregulation B. Regulate intrapulmonary airway pressures C. Maintain alveolar surface tension D. Adequately clear thick, sticky mucus from the lungs

C RDS is primarily a disease related to a developmental delay in lung maturation. Although many factors may lead to the development of the disorder, the central factor is the lack of a normally functioning surfactant system in the alveolar sac from immaturity in lung development because the infant is premature. A lack of surfactant production results in the collapse of the alveolar sacs.

Due to a recent outbreak in the community, the nurse is speaking to a group of parents and elementary school teachers about rheumatic fever. Which information is most important for the nurse to emphasize? A. Home schooling is preferred to classroom instruction B. Most play activities will be restricted indefinitely C. Clumsiness and behavior changes should be reported D. Children may remain strep carriers for years

C Sydenham chorea is a major sign of acute rheumatic fever; it may be the only sign of rheumatic fever in some clients. Symptoms include jerky, uncontrollable, and purposeless movements that look like twitches (these disappear during sleep); loss of fine motor control (causing changes in handwriting); and loss of emotional control (as evidenced by inappropriate crying or laughing). Sydenham chorea usually clears up in a few months and no complications are expected.

A nurse is teaching about nonsteroidal anti-inflammatory agents (NSAIDs) to a group of clients diagnosed with arthritis. The nurse should emphasize which of these actions to minimize a side effect of these drugs? A. Continue to take aspirin for short-term pain relief B. Use alcohol in moderation when driving or operating heavy machinery C. Take the medication after meals or with food D. Report joint stiffness in the morning

C Taking NSAIDs after meals or with food should help to minimize gastric irritation. The client should also take the medication with a full glass of water and remain in an upright position for 15 to 30 minutes after administration. Clients should be cautioned to avoid concurrent use of aspirin or alcohol with these medications to minimize possible gastric irritation; three or more glasses of alcohol per day may increase the risk of GI bleeding.

During the admission process, the client reports heavy alcohol use for at least one year. What effect does the nurse anticipate the hospitalized client will experience when alcohol consumption stops? A. Bradycardia B. Somnolence C. Withdrawal D. Craving

C The findings of alcohol withdrawal develop within 24 to 48 hours after people either stop or significantly reduce their alcohol consumption. Findings of withdrawal can range from "mild" (shaking or sweating, or perhaps nausea, headache, anxiety, tachycardia or hypertension) to severe (delirium tremens or DTs), which are characterized by rapid heartbeat, fever, hallucinations or seizures.

A nurse is assigned to a newly hospitalized adolescent. What should be the major threat experienced by this hospitalized adolescent? A. Restricted physical activity B. Pain management C. Altered body image D. Separation from family

C The hospitalized adolescent may see each of these as a threat. However, the major threat felt when hospitalized for this age group is the fear of an altered body image. There is great emphasis on physical appearance during this developmental stage.

The nurse is assessing a client who has been treated long-term with glucocorticoid therapy. Which finding might the nurse expect? A. Jaundice B. Peripheral edema C. Buffalo hump D. Increased muscle mass

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

Postoperative orders for a client who had a mitral valve replacement include monitoring pulmonary artery pressure together with pulmonary capillary wedge pressure with a pulmonary artery catheter. What is the purpose of these actions by a nurse? A. Determine the changes in an acid-base balance B. Establish coronary artery stability C. Assess the left ventricular end-diastolic pressure D. Compare the right ventricular pressures

C The pulmonary capillary wedge pressure is reflective of left ventricular end-diastolic pressure. Pulmonary artery pressures are an assessment tool used to determine the ability of the heart to receive and pump blood effectively.

The client is prescribed a new antipsychotic medication. The nurse is teaching a client about the medication and possible side effects, including tardive dyskinesia (TD). Which statement is true about tardive dyskinesia? A. The high fever, sweating and muscle stiffness will last about one week B. TD occurs within minutes of the first dose of any antipsychotic drug C. The longer someone is treated with an antipsychotic medication, the higher the risk for developing TD D. Almost every client treated with antipsychotic medications will eventually develop TD

C The symptoms of tardive dyskinesia (TD) are characterized by random movements of different muscles and the tongue, lips or jaw. Longer treatment with antipsychotic medication, being female, being African American or Asian American are common risk factors for developing TD. Research shows that the overall risk of developing TD is about 30-50%. Decreasing the dose of the antipsychotic or switching antipsychotic medication can help, but there is no cure. Neuroleptic malignant syndrome is a rare and potentially life-threatening reaction to antipsychotic medications, when the client presents with hyperthermia, rigidity and autonomic dysregulation (hypertension, tachycardia, tachypnea, agitation, diaphoresis).

A newborn presents with a pronounced cephalohematoma after a birth in the posterior position. Which nursing diagnosis should guide the plan of care? A. Injury related to intracranial hemorrhage B. Impaired mobility related to bleeding C. Parental anxiety related to knowledge deficit D. Pain related to periosteal injury

C This hematoma is caused by pressure and/or trauma during labor; it is often caused by forceps used in the delivery. This painless condition is usually benign and resolves on its own in four to six weeks. The swelling does not cross the suture lines. Parental anxiety must be addressed by listening to their fears and explaining the nature of this common alteration.

The health care provider orders the antidepressant trazodone ER 150 mg at bedtime. Which common side effect of this drug should the client understand? A. Reduces arthritic pain B. Relieves nasal stuffiness C. Causes drowsiness D. Decreases acne breakouts

C This medication is chemically unrelated to the SSRIs, TCAs or MAO inhibitors, even though it inhibits the uptake of serotonin by nerves in the brain. The sedative effects of this antidepressant is why this medication is also successfully used to treat insomnia. People with insomnia may sleep better immediately, but it may take a week or two before maximum antidepressant effects are noticed. Other common side effects of trazodone include dry mouth, stuffy nose, constipation or change in sexual interest/ability.

A 60 year-old male client underwent inguinal hernia repair in a day-surgery clinic. He is awake and alert, but has not been able to void since he returned from surgery six hours ago. He has received 1000 mL of IV fluid. Which action would most likely help him to void? A. Perform Credé's method on the bladder from the bottom to the top B. Wait two hours and have the client attempt to void again C. Assist the client to stand by the side of the bed to void D. Have him drink several glasses of water

C When a male client is not able to use a urinal in the bed, the client should stand by the side of the bed to attempt voiding. This is the most natural physiological position of normal voiding for male clients. Also, given the client's age, the client most likely has some degree of prostate enlargement which may interfere with ease of voiding.

The registered nurse is giving instructions to an unlicensed assistive person (UAP) regarding client care activities for the shift. Which directive provides the best information about the assigned tasks? A. "Stop by room 215 A and let me know how the new admission is doing and tell me if you need any help." B. "You will need to frequently take an oral temperature for the client in room 212 B today and report the results to me immediately if it is too high." C. "Beginning at 0800, empty the urinary catheter bag hourly for the client in room 210 A and write the amount with the time on the whiteboard." D. "Ambulate the client in room 214 A today and replace the sequential compression device (SCD) afterwards."

C When assigning tasks, directions must be clear, concise, correct and complete. Emptying the catheter bag and recording the amount hourly starting at 0800 meets these guidelines. The options related to ambulation and measuring the client's temperature are vague and incomplete. The option about the new admission is also vague and requires assessing the client; only nurses can assess clients.

The health care provider writes a new order for a fentanyl (Sublimaze) patch to manage the chronic pain experienced by the client in hospice care. The nurse is teaching a client and family members about the fentanyl patch and knows that teaching was effective when the client makes which of the following statements? (Select all that apply.) A. "I can soak in a hot tub to help decrease my pain." B. "I should cut up the patch before I throw it away so no one else can use it." C. "It may take up to a half day or longer for the patch to start working, the first time I use it." D. "If my pain is too great while I am on the patch, I can take a supplemental pain medication." E. "I will take the old patch off before I apply the new patch on."

C,D,E Fentanyl patches are slowly absorbed via the subcutaneous tissue at a predetermined rate for up to 72 hours. Due to the slow absorption rate, the first patch may take 12 to 24 hours before effective analgesia is felt; a short-acting opioid may be given for breakthrough pain. The client can shower or bathe with the patch, but it should not be exposed to heat (hot tubs, heating pads) because it speeds up the absorption of the medication. Old patches are removed and the new patch is applied to a different skin area. Old patches are disposed by folding the old patch in half, not by cutting them up and throwing them in the trash (which may be dangerous for people and pets).

A nurse is caring for a 13 year-old after a spinal fusion to treat scoliosis. Which nursing intervention is appropriate in the immediate postoperative period? (Select all that apply.) A. Maintain bedrest with the head of the bed elevated at least 30 degrees B. Assist the client to stand and walk to the bathroom as needed C. Encourage passive leg and ankle exercises D. Position the client flat in bed and logroll every 2 to 4 hours E. Encourage use of patient-controlled analgesia F. Perform neurovascular checks every 8 hours

C,D,E The client should remain flat in bed for at least 6 hours and turned from side to side every 2 to 4 hours. The day after surgery, the client can sit up in bed a few times; the client will get out of bed to sit in a chair on the second or third day after surgery. Clients should be encouraged to perform isometric exercises right after surgery. Neuro checks will be performed every 2 hours for the first 24 hours.

The nurse is caring for a child diagnosed with nephrotic syndrome. What finding should the nurse expect when assessing the child? A. Increased appetite B. Increased activity levels C. Weight loss D. Swelling around the eyes

D Nephrotic syndrome in children causes excess excretion of protein and retention of fluid, causing edema (around the eyes, feet, ankles) and weight gain. In this type of kidney disease, large amounts of protein are lost in the urine (proteinuria). Children may be more tired and irritable than usual.

A 14 month-old child ingested half a bottle of aspirin tablets. Which finding should the nurse expect to see in this child? A. Dyspnea B. Hypothermia C. Edema D. Epistaxis

D A large dose of aspirin inhibits prothrombin formation and lowers platelet levels. With an overdose, clotting time is prolonged. Spontaneous bleeding often occurs from the nose or mucous membranes in the mouth.

There's an order to check the pH of aspirate every four hours for a client who has a continuous tube feeding. The nurse checks the aspirate at the designated time and the pH is 8. What action should the nurse take? A. Continue the tube feeding as scheduled B. Hold the tube feeding and notify the health care provider C. Irrigate the tube with water and reassess pH D. Stop the tube feeding for about an hour and then reassess aspirate

D A pH of less than 4 indicates that the tube is in correct placement in the stomach, which is a highly acidic environment. A higher pH (alkaline pH) indicates either small intestine placement or even in the lungs. However, to promote accuracy, continuous tube feedings should be stopped one hour prior to obtaining aspirate, so the best response would be to stop the feeding and then recheck the aspirate. If the pH of the aspirate remains high, the health care provider should be contacted. Although not indicated in this question, the nurse should understand that several things can alter the pH of aspirate. For example, clients taking H2 receptor blockers or those diagnosed with HIV, pernicious anemia, and GERD will have higher pH concentrations.

The nurse is teaching a client about an oral hypoglycemic medication. The nurse should place primary emphasis on which of the following points? A. Increasing the dosage based on blood glucose B. Distinguishing hypoglycemia from hyperglycemia C. Recognizing the findings of toxicity D. Taking the medication at specified times

D A regular interval between doses should be maintained because oral hypoglycemics stimulate the islets of Langerhans to produce insulin. The other actions would be discussed after this point.

The nurse is preparing a client diagnosed with deep vein thrombosis (DVT) for a venous doppler evaluation. Which of these actions should be necessary to prepare the client for this test? A. Determine if the client has any allergies to the contrast material B. Ask client not to eat or drink anything after midnight C. Administer a sedating medication prior to the test D. Ensure the client is wearing a hospital gown prior to the test

D A venous doppler examination uses ultrasound to create a 2-dimensional picture of the veins in the legs. The purpose is to detect blood clots. This is a noninvasive test and does not require sedation; a venography would require injecting contrast material into a vein. The client may eat or drink prior to the test.

Upon entering an adult client's room, the client is found to be unresponsive. After calling for help, what is the next action that should be taken by the nurse? A. Give two rescue breaths B. Deliver five abdominal thrusts C. Maintain an open airway D. Check for a carotid pulse

D According to the American Heart Association's basic life support, the first step after determining a victim is unresponsive is to call for help. The next step is to check for a pulse (for no more than 10 seconds). If there is no pulse, the rescuer should begin CPR (30 chest compressions followed by 2 ventilations).

The nurse is reviewing various group activities with the health care team. When planning a therapeutic milieu, what is the most important factor when selecting a group activity? A. Match them to the clients' preferences B. Provide consistency with clients' skills C. Build the skills of group participation D. Achieve clients' therapeutic goals

D Activity groups are used to enhance the therapeutic milieu and to meet the clinical and social needs of clients, eg., to minimize withdrawal and regression and to develop self-care skills.

The nurse is reviewing the surgeon's discharge instructions with a client who experienced a myocardial infarction. The client asks the nurse why the waiting period is four to six weeks before having sexual intercourse. Which response best explains this instruction? A. "If you can maintain an active walking program, you will have less risk." B. "Have a glass of wine to relax you, then you can try to have sex." C. "You need to regain your strength before attempting such exertion." D. "When you can climb two flights of stairs without problems, it is generally safe."

D Although it depends on the client's overall medical condition, most experts say that sexual activity is physically therapeutic and heart-healthy. If the client can comfortably climb up a flight of stairs without feeling tired, short of breath or having chest pain, then s/he is probably ready to resume having sex.

During an initial home visit, a nurse is discussing with family members the care of their 86 year-old mother who is newly diagnosed with Alzheimer's disease. Which of these interventions would be most helpful at this time? A. List actions to improve the client's daily nutritional intake B. Leave a book about relaxation techniques C. Write out a daily exercise routine for them to assist the client to do D. Discuss communication strategies to try using with the client

D Alzheimer's disease is a progressive chronic illness. Communication between caregivers and clients can be some of the most challenging issues. At this initial visit a nurse can help the family to know when to use communication strategies to enhance their ability to relate to the client. By use of select verbal and nonverbal communication strategies, the family can best support the client's strengths and cope with any aberrant behavior. The other actions are more specific and should be addressed when the need arises.

A nurse is caring for a client in the coronary care unit. The display on the cardiac monitor indicates ventricular fibrillation. What should the nurse do first? A. Initiate CPR B. Assess the pulse C. Perform defibrillation D. Assess the level of consciousness

D Artifact (interference) can mimic ventricular fibrillation on a cardiac monitor. Always treat the patient, not the monitor. If the client is truly in ventricular fibrillation the client will be unresponsive and no pulse will be present. The standard of care is to verify the monitor display with an assessment of the client's level of consciousness, shaking and shouting to arouse followed by a carotid pulse check. If the client is unresponsive without a pulse in ventricular fibrillation, the most effective treatment will be electricity or defibrillation. This should be the priority, supplementing circulation using chest compressions until the defibrillator is set up and ready to deliver the shock.

The nurse provides regular mouth care to the hospice client who is actively dying at home. The family wants to know why the doctor doesn't order an IV since the client's mouth seems so dry. What information can the nurse provide to the family that best answers their question. A. The client will need to be hospitalized if an IV is started B. The client will need to have a indwelling catheter inserted if an IV is started C. Intravenous hydration will increase episodes of delirium D. Intravenous hydration can delay death

D Clients who are dehydrated may experience delirium and may benefit from IV therapy. However, intravenous hydration does not improve dry mouth and can even delay death. The nurse should explain that the client's comfort can be enhanced by providing frequent mouth care and that decreased oral intake is a natural and nonpainful part of the dying process.

A client initially experiences a large local reaction with swelling of the entire leg after being stung by a bee. A concerned family member drives the client to the emergency department. The client is now having difficulty breathing and has swelling of the tongue. Which of the following medications should be administered first? A. Methylprednisolone (Solu-Medrol) IV B. Albuterol (Proventil) inhaler C. Diphenhydramine (Benadryl) subQ D. Epinephrine (Adrenaline) IV

D Difficulty breathing and swelling of the face, eyes or tongue are severe and life-threatening allergic reactions to the allergen. Epinephrine, 0.3-0.5 mL of a 1:1000 solution may be administered IM but airway obstruction due to angioedema, respiratory compromise due to bronchospasm, or circulatory collapse (or combination of these 3 conditions) requires IV administration. The other medications are more appropriate for mild-to-moderate distress: antihistamines, such as diphenhydramine or hydroxyzine, or oral steroids can help reduce the severity of the itching and albuterol may be used for treatment of bronchospasm without obstruction.

A nurse is teaching a client about the healthy use of ego defense mechanisms. An appropriate goal for this client should be which of these? A. Increase independence and communicate more often B. Avoid conflict and leave unpleasant situations C. Minimize anxiety and delay apprehension D. Reduce fear and protect self-esteem

D Ego defense mechanisms are unconscious proactive barriers that are used to manage instinct and affect in the presence of stressful situations. Healthy reactions are those in which clients admit that they are feeling various emotions.

The nurse works in the pediatric emergency department. In which situation would a child be treated by using enemas followed by an antitoxin? A. A school-aged child who has swallowed a handful of iron-fortified vitamins B. A toddler who has eaten an undetermined number of ibuprofen tablets C. A preschooler who bit into a laundry detergent pod D. An infant who is diagnosed with botulism

D Food-borne botulism can be treated by removing whatever contaminated food is in the stomach by using enemas (or by inducing vomiting) and administering a Botulinum antitoxin. Children with iron poisoning and who are breathing normally can be given a strong laxative fluid; severe poisonings require IV chelation therapy. For NSAID poisoning, sometimes activated charcoal is given (usually within 1 hour of ingestion); massive overdoses may require orogastric lavage because there is no specific antidote for ibuprofen. Since laundry detergent is an alkaline substance, the most commonly used therapy is dilution/irrigation/wash, especially for burns to the skin and eyes. Tracheal intubation with ventilation may be required if the child swallowed the laundry detergent.

At the day treatment center, a client diagnosed with schizophrenia-paranoid type sits alone alertly watching the activities of clients and staff. The client is hostile when approached and asserts that the health care provider prescribes medication to control the client's mind. The client's behavior most likely indicates what associated nursing diagnosis? A. Impaired verbal communication related to impaired judgment B. Feelings of increased anxiety related to paranoia C. Sensory perceptual alteration related to withdrawal from environment D. Social isolation related to altered thought processes

D Hostile alertness and absence of involvement with people are findings supporting a nursing diagnosis of social isolation. The psychiatric diagnosis and the client's idea about the purpose of medication suggest altered thinking processes.

The nurse is reviewing the list of new client admissions. For which of these clients should contact precautions be implemented? A. A 45 year-old diagnosed with pneumonia B. A 3 year-old diagnosed with scarlet fever C. A 6 year-old diagnosed with mononucleosis D. A 60 year-old diagnosed with herpes simplex

D In addition to standard precautions, clients with herpes simplex infections must have contact precautions implemented due to the associated, potentially weeping, skin lesions. The child with scarlet fever would be on droplet precautions. Precautions other than standard may need to be implemented for pneumonia, but the causative organism would need to be identified. There are no special precautions for mononucleosis.

A nurse is caring for a client with sickle cell disease who is scheduled to receive a unit of packed red blood cells. Which is an appropriate action for the nurse during the administration of the infusion? A. Slow the rate of infusion if the client develops a fever or chills B. Assess vital signs every 15 minutes throughout the entire infusion C. Store the packed red cells in the refrigerator while starting IV line D. Limit the infusion time to a maximum of four hours

D Infuse the specified amount of blood within four hours; blood is not to be infused for longer than four hours because of the risk of bacterial growth in the bag. Similarly, blood should not be stored in an unapproved refrigerator because of the concern of bacterial growth. If the client develops fever or chills, the nurse does not slow the rate of infusion; this would be considered a reaction and the blood should be stopped and the blood bank and health care provider notified. Vital signs are per agency protocol but are usually not this frequent for the duration of the infusion.

A client who is diagnosed with cirrhosis of the liver is started on lactulose. What should the nurse understand about the main action of the drug? A. Control portal hypertension B. Add dietary fiber C. Stimulate peristalsis D. Reduce ammonia levels

D Lactulose (Kristalose) is a synthetic disaccharide that can be given orally or rectally. It blocks the absorption and production of ammonia from the gastrointestinal tract and secondarily stimulates bowel elimination (with the goal of two to four diarrhea stools per day). Lactulose is used to prevent portal-systemic encephalopathy.

A nurse is talking to parents about nutrition for their school-aged children. What is the most common nutritional disorder found in this age group? A. Anorexia B. Bulimia C. Malnutrition D. Obesity

D Many factors contribute to the high rate of obesity in school-aged children. These include heredity, sedentary lifestyle, social and cultural factors and poor knowledge of balanced nutrition.

The client is using nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, to manage arthritis pain. The nurse should caution the client about which common side effect? A. Urinary incontinence B. Nystagmus C. Constipation D. Occult bleeding

D Nonsteroidal anti-inflammatory drugs (NSAIDs) taken for long periods of time may cause serious side effects, including bleeding in the gastrointestinal tract. Clients should be instructed to take the medication with meals if stomach upset occurs. To avoid esophageal irritation, the client should take the drug with a full glass of water and to avoid lying down for 30 to 60 minutes after taking a dose.

The nurse recognizes that cultural practices affect health outcomes. Which statement best reflects what nurses can do to improve health outcomes in clients from different cultures? A. Incorporate high personal standards and values for all interactions B. Use conventional wisdom to gain a deeper understanding about the client's health practices C. Reinforce the correct Western medical perspective D. Recommend a plan that meets client goals as well as professional nursing standardS

D Nurses must provide culturally and linguistically appropriate care in order to help ensure successful outcomes. Nurses should advocate for clients from diverse ethnic and cultural groups by asking them about their health practices. As long as these practices are not harmful, the nurse can recommend a plan that both meets the goals of the client and professional nursing standards. Nurses can emphasize the science behind the plan of care without disparaging the client's culture.

A client is treated in the emergency department for diabetic ketoacidosis (DKA) and a glucose level of 650 mg/dL (36 mmol/L). The nurse would expect which serum lab value to be altered as a result of therapy associated with the client's condition? A. Magnesium B. Creatinine C. Calcium D. Potassium

D Potassium is lost in diabetic ketoacidosis during rehydration and insulin administration. Initial laboratory studies for DKA would include blood test for glucose and serum electrolytes every 1-2 hours until the client is stable; initial blood urea nitrogen (BUN) and initial arterial blood gas (ABG) measurements are also ordered. Repeat potassium and glucose (and sometimes phosphorus) are critical during treatment. An ECG may be used to assess the cardiac effects of extremes in potassium levels.

A client diagnosed with tuberculosis is started on rifampin and isoniazid. Which statement by the nurse would be most important to include in teaching the client about rifampin? A. "You should not skip doses or stop your medicine even if you feel better." B. "You should avoid drinking alcohol while taking this medication." C. "You may experience some nausea if you take the medication with food." D. "You may notice an orange-red color to your urine."

D Rifampin can cause a harmless reddish-orange discoloration of saliva, sweat, tears, feces, urine and skin; clients should not wear soft contact lenses while taking this medication. Even though all responses are correct, this is the most important effect that clients should know about. Rifampin should be taken with a full glass of water on an empty stomach, one hour before or two hours after a meal. Clients should not drink alcohol while taking this medication due to its effect on the liver. As with any antibiotic, clients need to understand that they must continue taking the medication even if they start to feel better, especially since clients are taking this medication for many months.

The charge nurse assigns the unlicensed assistive person (UAP) to measure vital signs. Despite written and verbal instructions not to take the blood pressure on the left arm of a client who is 48 hours postmastectomy, the charge nurse later observes a blood pressure cuff on that client's left arm. Which of these statements is accurate about this situation? A. The charge nurse has no accountability for this situation B. The UAP is covered by the charge nurse's license C. The charge nurse did not appropriately make assignments D. The UAP is responsible for following instructions given by the charge nurse

D The UAP is responsible for carrying out the activity correctly once directions have been clearly communicated both verbally and in writing. The licensed nurse retains accountability for the delegation and is responsible for tasks assigned to the UAP. However, the UAP is not covered under the nurse's license.

The nurse is assessing a client diagnosed with chronic obstructive pulmonary disease (COPD). The client is on oxygen for low PaO2 levels. Which assessment is a nursing priority to evaluate the outcome of the therapy? A. Assess lung sounds B. Observe for skin color changes C. Assess coughing frequency and sputum characteristics D. Evaluate oxygen saturation (SaO2) levels frequently

D The best method to evaluate a client's oxygenation is to evaluate the SaO2. The oxygen saturation should be around 88% to 91% for someone with COPD. This method is equally as effective as an arterial blood gas reading to evaluate oxygenation status, and is less traumatic and expensive. Assessment of lung sounds, coughing and sputum and color should also be components of the respiratory assessment for a client with COPD, but are less precise indicators of the response to oxygen therapy than the oxygen saturation level.

The nurse is working to improve relationships with clients. To establish the feeling of trust in a nurse-client relationship, the nurse should exhibit which of the following qualities? A. Flexibility and kindness B. Confidence and optimism C. Sympathy and understanding D. Honesty and consistency

D The client needs to understand that the nurse-client relationship will be safe, confidential, reliable, and consistent, with appropriate and clear boundaries. The relationship must always be focused on the client's problem and needs. Developing a positive relationship is one of the best predictors of outcomes in therapy.

A client is being discharged with a prescription for warfarin. Which information is critical to be included in the nurse's discharge teaching? A. Take Tylenol for minor pains B. Use a soft toothbrush C. Don't increase your intake of green leafy vegetables D. Report any nose or gum bleeds

D The client should notify the health care provider if blood is noted in stools or urine, or if any other signs of bleeding occur. This is the most important information to include in the teaching. The other options are correct but are not the priority. The client should not increase intake of dark green leafy vegetables because these are high in vitamin K. Recommending the use of a soft-bristled toothbrush and taking Tylenol for pain are also indicated for someone taking an anticoagulant.

The nurse is planning care for a 3 month-old infant in the immediately postoperative period after the placement of a ventriculoperitoneal shunt for hydrocephalus. The nurse should take which action with anticipation of complications of the procedure? A. Pump the shunt at intervals to assess for proper function B. Maintain the infant in an upright position in a car seat C. Begin formula feedings when infant is alert D. Assess for abdominal distention or taunt abdominal wall

D The nurse should observe for abdominal distention or a taunt abdominal wall because cerebrospinal fluid could cause peritonitis or a postoperative ileus as a complication of distal catheter placement. The child may be in a car seat afterwards. However, it does not answer the question being asked about potential complications. The infant would be started on clear liquids initially, not formula. The shunt will not be pumped.

A client with schizophrenia receives haloperidol 5 mg three times a day. The client's family is alarmed and calls the clinic nurse when "his eyes rolled upward." The nurse should recognize this finding as what type of side effect? A. Dysphagia B. Nystagmus C. Tardive dyskinesia D. Oculogyric crisis

D This refers to involuntary muscles spasm of the eye. There are medications to treat such side effects, for example trihexyphenidyl or benztropine.

A mother, who has been exclusively breastfeeding her 6 month-old, requests more information about meeting the nutritional needs of her infant. What information will the nurse provide? A. Begin a regular schedule of meals and snacks, offering a variety of foods B. Offer finger foods to encourage self-feeding during family meals C. Cut back on the number of times a day the infant receives breastmilk D. Gradually begin adding pureed iron-rich meat and/or cereal as the first foods

D The nurse should recommend increasing the number of times a day that complementary foods are offered while continuing to breastfeed. Pureed iron-rich meat, meat alternatives, and/or iron-fortified cereal should be the first complementary foods. After pureed foods, the next transition should be to add strained or mashed foods and then finger foods. From about one year of age, young children begin to have a regular schedule of meals and snacks.

A client treated for depression tells the nurse at the mental health clinic, "I recently purchased a handgun because I am thinking about suicide." Which of these should be the FIRST action taken by the nurse? A. Respect the client's confidential disclosure B. Phone the family to warn them of the risk C. Suggest inpatient psychiatric care D. Notify the primary care provider immediately

D This client has two critical points in suicide guidelines: a report of suicidal intent and a formulated plan with steps to implement it. The primary care provider, with other members of health care team, will arrange for treatment given the client's serious risk for self-destructive behavior. Hospitalization with family therapy is indicated. The nurse should never agree to help a client "keep secrets" from the health care team.

Which statement made by a client to an admission nurse suggests that the client is experiencing a manic episode? A. "I think all of my contacts last week have attempted to poison me." B. "I think all children should have their heads shaved." C. "I have been restricted in thought and harmed." D. "I have powers to get you whatever you wish, no matter the cost."

D This statement reflects grandiosity which is characteristic of a manic episode. Thinking that someone has been attempted to be poisoned is a paranoid thought.

The charge nurse is planning assignments on a surgical unit. A client with which need could be assigned to an unlicensed assistive person (UAP)? A. Review dietary needs with client prior to transfer to long-term care facility B. Change post-op hip dressing after removal of a drainage tube C. Assist with meals and monitor ability to swallow following a mild stroke D. Apply compression stockings and ambulate in hall three times a day

D UAP can be assigned routine tasks that have predictable outcomes. Many of the tasks a UAP can do involve activities of daily living (ADLs), such as personal hygiene (shaving, bathing, oral hygiene, hair care and toileting), assisting with dietary needs, and measuring vital signs. Sometimes a UAP may be allowed to change a dry, nonsterile dressing. Although UAP routinely assist clients with delivering and setting up food trays, UAP cannot assess a client's ability to swallow. Client teaching prior to discharge is a nursing responsibility.