NCSBON Practice Questions 91-105

The nurse is caring for a client, who is the mother of a close friend. The friend asks the nurse for an update about her mother's condition on a social networking website. How should the nurse respond? Do not respond to the friend on the social networking website Answer the question on the social networking website because only trusted contacts can access the information Do not use the social networking website to answer the question; call the friend instead Respond on the social networking website, directing the friend to ask the question in person

1 A nurse cannot disclose information about a client except to those who are directly involved in the care of the client. Also, clients must be informed about how their personal health information will be used and given the opportunity to object to or restrict the use or release of information. Nurses cannot use social networking websites, like Facebook, to disclose patient information, even with the use of privacy settings or when no names are used. Each health care organization has strict policies prohibiting the disclosure of protected health information.

A nurse reviews the history of a client diagnosed with depression from an earlier admission. Documentation of anhedonia is noted. What should the nurse understand about this note in the client's history? A lack of enjoyment in usual pleasures in life An expression of persistent suicidal thoughts A reduced senses of taste and smell A report of difficulty falling and staying asleep

1 All of the responses could be associated with a diagnosis of depression, including "anhedonia," which means the inability to experience pleasure or the loss of interest in previously rewarding or enjoyable activities. Anhedonia is one of the main symptoms of major depressive disorder (MDD).

A client develops volume overload from an intravenous infusion that has infused too rapidly. What finding should the nurse expect when assessing the client? S3 heart sound Thready pulse Hypoventilation Flattened neck veins

1 Auscultation of an S3 heart sound is an early sign of volume overload and heart failure because during the first phase of diastole, when blood enters the ventricles, an extra sound is produced due to the presence of fluid left in the ventricles.

A nurse explains an autograft to a client scheduled for excision of a skin tumor. Which of the following statements indicates the client understands the procedure? "I will receive tissue from my thigh." "I will receive tissue from a tissue bank." "I will receive tissue from synthetic skin." "I will receive tissue from a pig."

1 Autografts are done with tissue transplanted from the client's own skin. Tissue from a pig is called a xenograft or heterograft, which means it is transplanted from an organism of one species to that of a different species. Cadaveric grafts are termed allografts, or homografts because they are transplanted from one individual to another within the same species.

A nurse is caring for a client who is one day postop following a thoracotomy. The client has two chest tubes that are connected to one chest drain system. The nursing assessment reveals bubbling in the water seal chamber when the client coughs. What is the appropriate nursing action? Continue to monitor the client to see if the bubbling increases Clamp one of the chest tubes and ask the client to cough again Instruct the client to avoid coughing for the next day Call the surgeon immediately for potential return to surgery

1 Bubbling in the water seal chamber that is associated with coughing after lung surgery is an expected finding within the first 48 hours postop. Small amounts of air escape into the pleural space when pressures inside the chest increases with coughing. Monitoring for increases or decreases in the bubbling with coughing is the only nursing action required at this time. The client should be encouraged to deep breathe and cough every two hours minimally.

A pediatric clinic nurse examines a toddler with a tentative diagnosis of neuroblastoma. Which findings observed by the nurse would be associated with this problem? Abdominal mass and weakness Lymphedema and nerve palsy Headaches and vomiting Hearing loss and ataxia

1 Clinical manifestations of neuroblastoma include an irregular abdominal mass that crosses the midline. The first findings are usually fever, weakness, pallor, anorexia, weight loss and irritability. In most clients, the neuroblastoma has already spread when it is first diagnosed.

A nurse is teaching parents about accidental poisoning in children. Which action should the nurse emphasize that the parents initially take if there is a suspected poisoning? Empty the child's mouth in any case of a possible poisoning Do not induce vomiting if the poison is a hydrocarbon Keep the child as quiet as possible if a toxic substance was inhaled Call the Poison Control Center once the situation is identified

1 Emptying the mouth of poison prevents further ingestion and should be done first to limit damage from the substance. Note that all of the actions are correct, but emptying the mouth is the priority.

The nurse is caring for a client following total knee replacement surgery. Which intervention will be most effective in preventing the complication of deep vein thrombosis in this client? Encourage range of motion and ambulation Massage the legs twice daily Place pillows under the knees Use elastic stockings continuously

1 Mobility reduces the risk of deep vein thrombosis (DVT) in the postsurgical client. The postoperative client would wear either compression elastic stockings and/or external pneumatic compression devices; elastic stockings should be removed at least once a shift to assess skin integrity. Pillows should never be placed under the knees, as it can prevent appropriate venous return.

The nurse is making rounds with the pediatrician on the postpartum unit. Which of the following newborns should the pediatrician see first? The newborn with widely spaced cranial suture lines The newborn delivered sixteen hours ago, who has yet to pass the first meconium stool The term infant whose blood glucose is 50 mg/dL (2.78 mmol/L) The newborn, delivered eight hours ago, whose clamped umbilical cord has two arteries and one vein

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

A 19 year-old client is paralyzed in a car accident. Which statement would indicate that the client is using the mechanism of "suppression"? "I don't remember anything about what happened to me." "My mother is heartbroken about this." "I'd rather not talk about it right now." "It's all the other guy's fault! He was going too fast."

1 Suppression is willfully putting an unacceptable thought or feeling out of one's mind. A deliberate exclusion, "voluntary forgetting," is generally used to protect one's own self-esteem.

While caring for a client during the first hour after delivery, a nurse determines that the uterus is boggy and there is vaginal bleeding. What should be the nurse's first action? Massage the fundus Offer a bedpan Check for perineal lacerations Check vital signs

1 The nurse's first action should be to massage the fundus supporting the lower uterine segment until it is firm. Uterine atony is the primary cause of bleeding in the first hour after delivery.

A client has many delusions. As a nurse helps the client prepare for breakfast the client comments, "Don't waste good food on me. I'm dying from this disease I have." What is an appropriate response by the nurse? "I know you believe that you have an incurable disease." "Try to eat a little bit, breakfast is the most important meal of the day." "You need some nutritious food to help you regain your weight." "None of the laboratory reports show that you have any physical disease."

1 This response does not challenge the client's delusional system. Thus, the statement forms an alliance by providing reassurance of a desire to help the client.

Which of the following methods are used to correctly identify a client? (Select all that apply.) Check the client identification bracelet Compare the client to a labeled photograph Ask clients to state their name Have clients state their birth date Ask a family member or visitor

1234 Two pieces of identification are required prior to any procedure, including medication administration. Because client identification bracelets are not routinely used in long-term care facilities, nurses use a photograph to identify a resident. Visitors and even family members should not be asked to identify clients.

The 55 year-old female arrives in the emergency department and states she is having a panic attack. The client is breathing rapidly and deeply, and reports feeling dizzy, cold and "tingly." Protocol is begun to rule out a heart attack; the findings support a panic attack. What oxygen delivery system does the nurse expect to be ordered for this client? Nonrebreather mask Partial rebreather mask Venturi mask Face tent

2 A partial rebreather mask is good for short-term oxygen therapy for clients. This mask will allow the client to re-breathe some of the exhaled carbon dioxide (CO2), helping to correct the respiratory alkalosis (which is responsible for some of the client's symptoms.) The other devices would not be used in a panic attack: the nonrebreather mask provides an oxygen concentration of almost 100% and has a valve that allows CO2 to leave the mask; a Venturi mask is used for critically ill clients, especially those with COPD; and a face tent is used as an alternative to an aerosol mask.

A client is scheduled for 250 mL of enteral feeding as a bolus every four hours. Prior to the next feeding, the nurse aspirates gastric contents through the feeding tube and gets back 200 mL of gastric residual volume (GRV.) What is the next appropriate nursing action? Call the health care provider (HCP) Administer the feeding as ordered Hold the scheduled feeding Flush the tubing with cold water

2 Current evidence suggests that GRV assessment isn't a reliable way to assess tube-feeding tolerance or aspiration risk. Also, serial GRV measurements are more important than an isolated measurement. Many standing orders state to check residual volume every 4 hours and hold the feeding for one hour if the residual is greater than or equal to a specific amount (which may be as high as 400 mL) and then recheck. If the residual is still greater than or equal to the specified amount, the HCP should be notified and the feeding held. The tubing should be flushed before and after each use to maintain patency, but with warm water; cold water will cause cramping.

The nurse receives an order to give a client iron by deep injection. What is the purpose of using the deep injection route for this medication? To ensure that the entire dose of medication is given To prevent the drug from causing tissue irritation To provide more even distribution of the drug To enhance absorption of the medication

2 Deep injection (or Z-track technique) is used to prevent irritating or staining medications from being tracked through the tissue. The nurse should be sure to change the needle after drawing the medication into the syringe (if it's not prefilled). The nurse will use a 2- or 3-inch, 19- or 20-gauge needle and administer the iron (Iron Dextran) into the dorsogluteal muscle, using Z-track technique. The nurse should not massage the site afterwards.

During initial evening rounds, the nurse notices a foul smell in the room of a client diagnosed with pneumococcal pneumonia who was started on intravenous antibiotics 10 hours ago. The client makes all of these statements during their conversation. Which one would alert the nurse to a potential complication of this diagnosis? "I have a sharp pain in my chest when I take a breath." "I have been coughing up foul-tasting, brown, thick sputum." "I feel hot off and on, especially when I lie in bed." "I have been sweating off and on all day"

2 Foul smelling and tasting sputum signals the possible development of a lung abscess, a complication of pneumonia, particularly in aspiration pneumonia. This puts the client in grave danger because abscesses are often caused by anaerobic organisms. This client most likely would need a change of antibiotics. Sharp chest pain on inspiration called pleuritic pain is an expected finding with this type of pneumonia. The other options are expected in the initial 24 to 48 hours of therapy for any type of infection.

A nurse is caring for a client with a serum potassium of 3.2 mEq/L (3.2 mmol/L). The client is placed on a cardiac monitor and started on IV infusion of 40 mEq KCL in 1000 mL of 5% dextrose in water. Which ECG findings indicate that the infusion of potassium should be stopped? Shortened PR interval Tall, peaked T waves Prominent U waves Narrowed QRS complex

2 Tall, peaked T waves are a finding in hyperkalemia, and would necessitate a change in IV solution, to eliminate the potassium. If the potassium infusion were to continue it could cause worsening hyperkalemia and possible cardiac arrhythmias. The nurse should notify the health care provider of the ECG finding, and should request an order for a different IV solution without potassium. In addition, a stat serum potassium should be done to assess the severity of the hyperkalemia and to determine whether further intervention to reduce the potassium level is required. In conjunction with this, a serum creatinine should be checked to determine whether worsening renal function may have reduced potassium excretion, contributing to this new electrolyte abnormality.

The hospital is planning to downsize and eliminate a number of staff positions as a cost-saving measure. In order to prepare for the "unfreezing" phase of change, the nurse manager should take which approach? Clarify what the changes mean to the community and the hospital Explain to the unit staff why change is necessary Assist the staff for an acceptance of the new changes Discuss with the staff how to deal with any defensive behavior

2 The first phase of change, unfreezing, begins with awareness of the need for change. This can be facilitated by the manager who clearly understands the need and stands behind it and explains this to the staff. The phase is completed when the staff comprehend the need for change.

health care provider has ordered nitroglycerin transdermal patches for a client. Which of these instructions should be included by the nurse when teaching a client about how to use the patches? Remove the patch if ankle edema occurs Apply the patch to any nonhairy area of the body Remove the patch when swimming or bathing Apply a second patch with chest pain

2 The patch application sites should be rotated on body areas of the least amount of hair. If a client has poor lower leg arterial circulation, the ankle areas should be avoided.

Mobility reduces the risk of deep vein thrombosis (DVT) in the postsurgical client. The postoperative client would wear either compression elastic stockings and/or external pneumatic compression devices; elastic stockings should be removed at least once a shift to assess skin integrity. Pillows should never be placed under the knees, as it can prevent appropriate venous return.

2 These are expected findings and the nurse will record the measurements in the client's chart. Between 6 months and 2 years, an infant's head circumference and chest circumference measurements are about the same. A newborn's head is usually about 2 centimeters larger than the chest size; after age 2 years, the chest size becomes larger than the head.

A client diagnosed with chronic depression is maintained on tranylcypromine. The nurse should teach the client to avoid which of these foods? Wine, citrus fruits, yogurt and broccoli Wine, beer, cheese, liver and chocolate Wine, apples, sour cream and beef steak Beer, cheese, beef and carrots

2 These foods are tyramine-rich. Eating these foods while taking a monoamine oxidase inhibitor (MAOI), such as tranylcypromine (Parnate), can precipitate a life-threatening hypertensive crisis.

The health care provider orders blood tests for a client diagnosed with acute hepatitis B (HBV). Which serum lab test does the nurse expect to be elevated? Albumin BUN (blood urea nitrogen) ALT (alanine aminotransferase) WBC (white blood cells)

3 ALT and AST (aspartate aminotransferase) are enzymes located in liver cells that can leak out into the bloodstream when liver cells are injured. Elevated ALT (and AST) indicate liver damage. One of the liver's jobs is to make albumin; low albumin can be a sign of liver disease. Leukopenia (a decrease in the number of WBCs) is a common finding associated with HBV. BUN and creatinine are used to evaluate kidney function.

A nurse is caring for a child diagnosed with Reye's syndrome. Which action should be given the highest priority by the nurse? Monitor intake and output Provide good skin care Assess level of consciousness Assist with range of motion

3 An altered or decreased level of consciousness suggests increased intracranial pressure related to cerebral edema in the child with Reye's syndrome.

The registered nurse (RN) is responsible for the care of a client who is two days post-reconstructive nasal surgery. Which task can be safely assigned to the unlicensed assistive person (UAP)? Suggest that the client ask for pain medication every few hours Observe for restlessness or changes in breathing patterns Remind the client to report increased pain or changes in comfort Ask the client if the medication for pain was effective

3 Any activity that requires independent, specialized nursing knowledge, skill or judgement cannot be assigned to the UAP. Only the RN can assess and evaluate the client's level of pain or teach the client about pain management. However, the UAP can reinforce the nurse's teaching about pain management.

A nurse should question the use of atropine as a treatment for symptomatic bradycardia in which of these conditions? Urinary incontinence Right-sided heart failure Glaucoma Increased intracranial pressure

3 Atropine is contraindicated in clients with angle-closure glaucoma because it can cause pupillary dilation with an increase in aqueous humor. This leads to an increase in optic pressure.

A practical nurse (PN) is assigned to care for a newborn with a neural tube defect. Which dressing, if applied by the PN, would be correct and need no further intervention by the charge nurse? Sterile occlusive pressure dressing Dry sterile dressing that is occlusive Moist, sterile nonadherent dressing Telfa dressing with antibiotic ointment

3 Before surgical closure, the sac is prevented from drying by the application of a sterile, moist, nonadherent dressing over the defect. Dressings are changed frequently to keep them moist. A dry sterile occlusive dressing is placed on a central line insertion site.

The nurse is caring for a client with a deep vein thrombosis. Which finding would require the nurse's immediate attention? Temperature of 102 F (38.8 C) Pulse rate of 98 beats per minute Respiratory rate of 32 Blood pressure of 94/50

3 Clients with deep vein thrombosis are at risk for the development of pulmonary embolism (PE). The most common symptoms of PE are sudden tachypnea, dyspnea and chest pain.

A nurse is caring for clients over the age of 70. The nurse is aware that when giving medications to older clients, it is best to use what approach? Review the drug regimen yearly Do not stop a medication entirely Start with the smallest effective dose or increase dose slowly if needed Avoid drugs with side effects that impact cognition

3 Due to physiological changes in the older adult, as well as conditions such as dehydration, hyperthermia, immobility and liver disease, the metabolism of drugs may be altered to be decreased. As a result, drugs can accumulate to toxic levels and cause serious adverse reactions.

A client diagnosed with cirrhosis of the liver and ascites is receiving spironolactone. The nurse should understand that this medication spares elimination of which element? Sodium Phosphate Potassium Albumin

3 If ascites is present in the client with cirrhosis of the liver, potassium-sparing diuretics such as spironolactone (Aldactone) should be administered. Potassium-sparing diuretics will inhibit the action of aldosterone on the kidneys.

The nurse observes 4 year-old children playing in the hospital playroom. What activity does the nurse expect to see? Playing alone with hand-held computer games Playing competitive board games with older children Playing cooperatively with other preschoolers Playing with their own toys alongside other children

3 Older preschoolers (4 years) will develop the necessary social, problem-solving and creative skills by playing with friends and engaging in simple games and activities. This is cooperative play. Younger preschoolers (3 years) and older toddlers engage in parallel play (playing with their own toys next to other children) or associative play (playing separately, but talking to each other.) School-age children follow rules designed by others, as in board games.

A client with a history of asthma is admitted for a minor surgical procedure. Preoperatively, the peak flow is measured at 480 liters/minute. Postoperatively the client reports chest tightness and the peak flow is now 200 liters/minute. What action should the nurse now take? Notify both the surgeon and primary care provider Repeat the peak flow reading in 30 minutes Administer the PRN dose of albuterol Apply oxygen at two liters per nasal cannula

3 Peak flow monitoring during exacerbations of asthma is recommended for clients with moderate-to-severe persistent asthma to determine the severity of the exacerbation and to guide the treatment. A peak flow reading of less than 50% of the client's baseline reading is a medical alert condition and a short-acting beta agonist must be taken immediately. Notifying the health care provider is important, but that is not what would be done first. First, the client needs assistance. Oxygen administration will not be effective if the airway constriction is not relieved with the albuterol. Leaving the client and returning in 30 minutes will do nothing to help a client in acute distress.

During the morning rounds, a nurse observes that a client diagnosed with heart failure has developed sudden anxiety, diaphoresis and dyspnea. The nurse auscultates crackles bilaterally. Which nursing intervention should be performed first? Take the client's vital signs Administer the PRN IV morphine Place the client in a sitting position with legs dangling Contact the health care provider

3 Place the client in a sitting position with legs dangling to pool the blood in the legs. This helps to diminish venous return to the heart and minimize the pulmonary edema and helping the client breathe more easily. The next actions would be to contact the heath care provider, then take the vital signs and then administer the IV morphine. Intravenous diuretics will also be indicated to reduce the fluid volume excess.

The nurse is caring for a 68 year-old client who had a total hip replacement three days ago. Which assessment finding requires the nurse's immediate attention? "I have to use the bedpan to pass my water at least every hour." "I have bad muscle spasms in my lower leg, below the incision." "I've been having a lot of trouble breathing for the past few minutes. I have a really bad feeling about this." "It seems that the pain medication is not working as well today."

3 The nurse would be concerned about all of these comments, however the most life threatening is the respiratory focus (think ABCs). Clients who have had hip or knee surgery are at risk for developing pulmonary embolism. Sudden dyspnea, tachycardia and a feeling of impending doom are classic findings of pulmonary embolism. Muscle spasms do not require immediate attention. Frequent urination may indicate a urinary tract infection, particularly since the client likely had an indwelling urinary catheter during surgery. Although the thought that medication is not effective requires further investigation, it is not life-threatening.

A client who is recovering from alcoholism asks a nurse, "What can I do when I start to recognize relapse triggers within myself?" How might the nurse respond? "Exercise daily and get involved in activities that will cause you not to think about drinking." "When you have an impulse to stop in a bar, contact sober friends and talk with them." "Let's talk about possible options you have when you recognize these relapse triggers in yourself." "Go to an AA meeting that week when you feel the urge to drink."

3 This option encourages the process of self-evaluation and problem solving and provides an avoidance of telling the client what to do. Encouraging the client to brainstorm about response to relapse trigger options validates the nurse's belief in the client's personal competency. These behaviors reinforce a coping strategy that will be needed when the nurse is not available to offer solutions.

A newborn has hyperbilirubinemia and is being treated with a biliblanket. Which intervention is indicated during this therapy? Discontinue breastfeeding during treatment Rotate the neonate to treat all of his/her skin Restrict holding the newborn during treatment Provide more frequent feedings

4 A biliblanket consists of a fiber-optic pad and a portable illuminator. This form of phototherapy allows the baby to be diapered, clothed, held, and nursed during treatment. Frequent feedings of breast milk or formula are necessary to help with bowel motility, which, in turn, should increase excretion of bilirubin from the body. Discontinuing breastfeeding will disrupt the establishment of milk production. It is not necessary to rotate the baby during treatment.

A 6 month-old infant who is being treated for developmental dysplasia of the hip has been placed in a hip spica cast. What should the nurse be sure to teach the parents about caring for their child at home? Gently rub the skin with a cotton swab to relieve itching Place the favorite books and push-pull toys in the crib Turn the baby with the abduction stabilizer bar every two hours Check every few hours for the next day or two for swelling in the baby's feet

4 A child in a hip spica cast must be checked for circulatory impairment. The extremities are observed for swelling, discoloration, movement and sensation. For children beyond the neonatal period, traction and/or surgery followed by hip spica casting are usually needed.

A client is admitted for placement of a suprapubic catheter. Which statement by the client should the nurse identify as a misunderstanding of self-care? "I will let my health care provider know if my urine looks cloudy." "I will change the catheter every month." "I will drink lots of fluids to stay well-hydrated." "I will rinse the drainage bag with bleach once a week."

4 A suprapubic catheter is an indwelling urinary catheter that has been surgically placed to drain urine from the bladder. The client will need to change the catheter approximately once a month. To help decrease infections, the client should drink plenty of fluids, especially after changing the catheter. If the client notices a smell or change in color of the urine or the urine is cloudy, the client should call the health care provider. To clean the drainage bag, the client can disconnect the bag, swish some warm soapy water around in it and then rinse the bag with a vinegar solution - never bleach. This can be done every few days or so. This client needs additional instruction on the proper care of the drainage bag.

The client is recovering from an acute myocardial infarction. In order to prevent complications associated with the Valsalva maneuver in this client, what action should the nurse take? Maintain the client on strict bed rest Assist the client with use of the bedside commode Administer antiarrhythmic medications PRN as ordered Administer stool softeners every day as ordered

4 After myocardial infarction, the Valsalva maneuver can cause cardiac arrhythmias. Administering stool softeners every day will prevent the client from straining or bearing down on defecation (the Valsalva maneuver). If constipation occurs, laxatives would be necessary to prevent Valsalva. If the client experiences cardiac arrhythmias associated with straining on defecation, then administering antiarrhythmics would be appropriate. Maintaining bed rest with use of a bedpan can increase the likelihood of straining and difficulty with defecation as well as increased myocardial oxygen consumption, so use of the bedside commode is also appropriate to achieve this goal in this client.

The parents of a toddler who is being treated for pesticide poisoning ask, "Why is activated charcoal used? What does it do?" Which of these statements is the best way for the nurse to respond? "The action may bind or inactivate the toxins or irritants that are ingested by children and adults." "This substance helps to get the poison out of the body through the gastrointestinal system." "The charcoal stimulates bowel evacuation." "The activated charcoal binds with the poison to limit absorption from the digestive tract."

4 All of the options are correct responses. However, the correct answer is the most accurate information to answer the parents' questions about the use and action of activated charcoal. The language is appropriate for the parents' understanding.

A 2 year-old child is being treated with amoxicillin suspension, 200 milligrams per dose, for acute otitis media. The child weighs 33 lb (15 kg) and the daily dose range is 20 to 40 mg/kg of body weight, in three divided doses every eight hours. Using principles of safe drug administration, what should a nurse do next? Recognize that antibiotics are over-prescribed Call the health care provider to clarify the dose Hold the medication because the dosage is too low Give the medication as ordered

4 Amoxicillin continues to be the drug of choice in the treatment of acute otitis media. The dose range is 20 to 40 mg/kg/day divided every eight hours; 15 kg x 40 mg = 600 mg, divided by 3 = 200 mg per dose. The prescribed dose is correct and should be given as ordered.

The nurse is caring for a 14 year-old boy diagnosed with hemophilia A. The client was admitted after a fall while playing basketball. In understanding the client's behavior, and in planning care for this client, the nurse should understand what focus is associated with adolescents diagnosed with hemophilia? Physical limitations must be explained to peer groups Alternative sedentary and structured activities should be discussed Implications of taking risks after acute bleeding episodes should be emphasized Exercising and taking part in sports are important

4 An age-appropriate treatment goal is to establish an age-appropriate safe environment. Adolescents diagnosed with hemophilia should be aware that contact sports may trigger bleeding episodes. However, developmental characteristics of this age group, such as impulsivity, inexperience and peer pressure, place adolescents in unsafe environments.

The nurse is caring for a client with total parenteral nutrition (TPN). What is the most important action on the part of a nurse? Monitor for cardiac arrhythmias Record the number of stools per day Maintain strict intake and output records Sterile technique for dressing change at IV site

4 Clients receiving TPN are very susceptible to infection. The concentrated glucose solutions are a good medium for bacterial growth. Strict sterile technique is crucial in preventing infection at IV infusion site.

A nurse is teaching childbirth preparation classes. One woman asks about her rights to develop a birthing plan. Which response made by the nurse would be best? "Write your ideal plan for the next class" "What is your reason for wanting such a plan?" "Have you talked with your provider about this?" "Let us discuss your rights as a couple"

4 Discussion of the provider's role and the couple's rights and limitations in selecting birth options must precede development of a plan. To write an ideal plan is not a realistic nor the best approach because this approach does not often allow for complications.

The client is a 7 year-old child with a fractured femur and extensive skin damage. Which type of traction does the nurse expect will be used? Bryant's traction Buck's traction Russell traction 90-90 traction

4 For fractures of the femur or tibia in children in this age group, a 90-90 traction is used, that is, the hip is flexed up to 90 degrees and the knee is also flexed at 90 degrees. Either skin traction or skeletal traction can be used. In skeletal traction, a skeletal pin or wire is surgically placed through the distal part of the femur (and the lower part of the extremity is in a boot cast.) Traction ropes and pulleys are applied.

A client has been taking furosemide for the past week. The nurse recognizes that which finding may indicate the client is having a negative side effect from the medication? Edema of the ankles Gastric irritability Weight gain of five pounds Decreased appetite

4 Furosemide (Lasix) causes a loss of potassium if a supplement is not taken. Findings of hypokalemia include anorexia, fatigue, nausea, decreased gastrointestinal motility, muscle weakness and dysrhythmias.

A 2 year-old child has recently been diagnosed with cystic fibrosis. A nurse is teaching the parents about home care for the child. Which piece of information is appropriate for the nurse to include? Limit exposure to other children Schedule frequent rest periods Restrict activities to inside the house Allow the child to continue normal activities

4 Physical activity is important in a 2 year-old who is developing autonomy. Physical activity is a valuable adjunct to chest physical therapy. Exercise tends to stimulate mucus secretion and helps develop normal breathing patterns.

The nurse explains dietary restrictions to a client who is taking tranylcypromine. Which food selection would be contraindicated for this client? Apple juice, ham salad, fresh pineapple Fresh juice, carrots, vanilla pudding Hamburger, fries, strawberry shake Red wine, fava beans, aged cheeses

4 Red wine and cheese contain tyramine, as do chicken livers and ripe bananas. Foods containing tyramine are contraindicated when taking an MAOI like tranylcypromine (Parnate). Fava beans contain other vasopressors that can interact with MAOIs, causing malignant hypertension.

A nurse is teaching an 87 year-old client methods to maintain regular bowel movements. Which product would the nurse caution the client to avoid? Glycerine suppositories Stool softeners Fiber supplements Laxatives

4 Some older adults are constipated because they have used over-the-counter laxatives for a long time. The bowel can get dependent on this stimulus. In addition, this group of people do not eat enough fiber, drink enough water, or exercise adequately. Certain medications, including opioid analgesics during long-term use, result in constipation or impaction from the decrease in peristalsis.

A 30 month-old child is admitted to the hospital unit. Which of these toys would be appropriate for the nurse to select from the toy room for this child? Blunt scissors and paper Large wooden puzzle Cartoon stickers Beach ball

2 Appropriate toys for this child's age include items such as push-pull toys, blocks, pounding board, toy telephone, puppets, wooden puzzles, finger paint and thick crayons.

The nurse is teaching a client diagnosed with depression about a new prescription for nortriptyline. What information should the nurse emphasize? Episodes of diarrhea can be expected The medication must be stored in the refrigerator Alcohol use is to be avoided Symptom relief occurs in a few days

3 Alcohol enhances the effects of tricyclic antidepressants such as nortriptyline (Pamelor) and may result in dangerous side effects, including drowsiness, dizziness and suicidal thoughts.

During the initial physical assessment on a client who is a Vietnamese immigrant, a nurse notices small, circular, ecchymotic areas on the client's knees. What is the best action for the nurse to take at this time? Ask the client for more information about the nature of the bruises Document the findings on the admission sheet Discuss with the client and then the family about the findings Report the bruising to social services for follow-up

1 "Cupping" is practiced by Vietnamese. The principle is to create a vacuum inside a special cup by igniting alcohol-soaked cotton inside the cup. When the flame extinguishes, the cup is immediately applied to the skin of the painful site. The belief: the suction exudes the noxious element. The greater the bruise, the greater the seriousness of the illness. There is no need to ask or discuss with an adult's family members.

The nurse is caring for a 68 year-old male client who had a transurethral resection of the prostate (TURP) 12 hours ago. The client has an indwelling 3-way catheter with continuous bladder irrigation. Which finding requires the nurse's immediate intervention? Minimal drainage into the urinary collection bag Reports of a feeling of discomfort from the urinary catheter Light-pink urine with a continuous stream into the collection bag Occasional suprapubic cramping about every hour

1 All of the options, except the lack of drainage into the collection bag, are expected findings after this procedure. Urine will be bright red from bleeding immediately after the procedure, lightening over time as bleeding decreases. A lack of drainage needs to be reported immediately because minimal urinary drainage puts the client at risk for bladder rupture. The cause of this is likely to be a blood clot in the catheter or obstructing the catheter tip, which requires sterile irrigation of the catheter to restore its patency. The flow rate of the continuous irrigation would need to be slowed until urine flow has been restored. In some facilities, an order for syringe bladder irrigation as needed is a standing order accompanying the orders for continuous bladder irrigation.

The nurse is eating in the hospital cafeteria when a toddler at a nearby table chokes on a piece of food and turns slightly blue. What would be the most appropriate initial action taken by the nurse? Perform abdominal thrusts Begin mouth to mouth resuscitation Call for the emergency response team Give the child water to help in swallowing

1 At this age, the most effective way to clear the airway of food is to perform abdominal thrusts. As that is being done, calling for the rapid response team would be appropriate.

A client is recently diagnosed with Barrett's esophagus. Which of the following statements made by the client demonstrates that further teaching is needed about this illness? "I will have to cut back on my smoking." "I'll have to buy 4-to 6-inch blocks to raise the head of my bed." "I should avoid eating anything for two hours before I go to sleep." "I will need regular endoscopies to monitor this illness."

1 Barrett's esophagus is a complication of gastroesophageal reflux disease (GERD) and is associated with an increased risk for esophageal cancer. Endoscopies are used to monitor the progression of the disease and catch any cancer in its earliest stages. Treatment for Barrett's esophagus is the same as for GERD. Lifestyle changes include weight loss, avoiding acidic foods and fluids, not eating 90-120 minutes before bedtime, and sleeping with the head of the bed elevated or in a left side-lying position. Cutting back on smoking is too ambiguous. Since smoking aggravates GERD and is linked to the development of cancer, this client should be advised about smoking cessation programs.

Nurse colleagues are discussing their nursing practice during lunch. Which statement is correct? Each state has specific regulations for licensed registered nurses (RNs) and licensed practical nurses (LPNs) The employing agency is ultimately responsible to provide practice guidelines for licensed nurses The federal government ensures the safety of clients by defining the scope of nursing practice National nurses' associations work collaboratively to update the social policy statement for nursing

1 Boards of nursing are state governmental agencies that are responsible for licensing nurses in each state/jurisdiction and enforcing the rules and regulations of the nurse practice act (NPA). The NPA is enacted by the state legislature. The NPA and rules define the scope of practice and responsibilities for nurses. The scope of practice for nurses, especially LPN/VNs, varies from state to state.

A man diagnosed with epididymitis two days ago calls the nurse at a public health clinic to discuss his diagnosis. Which information is most important for the nurse to ask about at this time? "Did your provider recommend that you be tested for Chlamydia?" "Do you have any questions about your care?" "Did you know that a consequence of epididymitis is infertility?" "What are you taking for pain and does it provide total relief?"

1 Epididymitis can result from Chlamydia, a sexually transmitted infection. The client may need to be tested, and if positive his sexual partners should be tested as well. All of the questions should be asked, however, the determination of the reason for the client's referral is the most important to start with.

The nurse is caring for several 70 to 80 year-old clients on bed rest. What is the most important action to prevent skin breakdown? Turning at least every two hours Apply moist heat to reddened areas Lubricate skin with lotion or gel Massage the legs frequently

1 Frequent turning will prevent skin breakdown by relieving prolonged pressure on any one area. This approach works with any age and build of client.

A client is admitted with low T3 and T4 levels and an elevated thyroid stimulating hormone (TSH) level. On initial assessment, the nurse should anticipate which of these findings? Lethargy Diarrhea Heat intolerance Skin eruptions

1 In hypothyroidism the metabolic activity of all cells of the body decreases, reducing oxygen consumption, decreasing oxidation of nutrients for energy, and producing less body heat. Therefore, the nurse can expect the client to report being constipated, tired and unable to get warm.

The visiting nurse makes a postpartum visit to a married female client and her husband. Upon arrival, the nurse observes that the client has a black eye and numerous bruises on her arms and legs. What should be the initial nursing intervention? Interview the client in a private place in the home to determine the origin of the injuries Call the police to report indications of domestic violence Confront the husband about the condition of his wife Leave the home because of the unsafe environment

1 It is a correct approach to assume domestic violence with further assessment. Separate the suspected abused person from the partner until any battering has been ruled out by conversation in a private location in the home. No information is given of the situation that would warrant to leave or to call the police. To confront the partner is never a correct approach. This should be left to the authorities.

A client diagnosed with bipolar disorder is prescribed lithium. What should the nurse emphasize when teaching the client about this medication? Maintain adequate daily salt intake Reduce fluid intake to minimize diuresis Take the medication before meals Use antacids to prevent heartburn

1 Lithium levels need to be regularly monitored. Clients should be advised to drink 8 to 10 glasses of water or other liquids every day and keep their salt intake the same because too little salt may cause lithium levels to rise (and more salt may cause lithium levels to fall). Lithium is a naturally occurring mineral with an electrical charge similar to salt.

A client is scheduled for a percutaneous transluminal coronary angioplasty (PTCA). What information should the nurse know about this procedure when teaching the client? The procedure compresses plaque against the wall of the diseased coronary artery to improve blood flow It is a surgical repair with an incision of a diseased coronary artery to improve blood flow Being a noninvasive radiographic examination of the heart, it has no invasive properties The placement of an automatic internal cardiac defibrillator is done

1 PTCA is performed to open blocked coronary arteries caused by coronary artery disease (CAD). It is performed during a cardiac catheterization. The balloon is inflated once the catheter is in place in the diseased artery and this compresses the fatty tissue, resulting in improved blood flow. Aorta coronary bypass (CABG) is the surgical procedure with incisions to repair diseased coronary arteries.

The nurse is caring for a client with orders for complete bed rest. Which action by the nurse is most important in the prevention of the formation of deep vein thrombosis (DVT)? Prevent pressure at back of the knees Elevate the foot of the bed Encourage isometric leg muscle exercises Apply knee high support stockings

1 Prevention of popliteal pressure will minimize venous stasis and deep vein thrombosis. The other actions would also be implemented for clients with orders for bed rest. However, the correct option is the one action directly associated with DVT.

The nurse has assessed the client's morning blood sugar level and prepares to administer rapid-acting insulin to address the elevated blood glucose. Which of the following interventions will reduce the client's risk of hypoglycemia associated with the insulin administration? Administer the insulin when the client's meal tray has been delivered to the room Administer the client's insulin right after checking the blood sugar Administer the insulin after the client has finished eating the meal Administer the insulin immediately after the client has ordered the meal

1 Prior to administering the rapid-acting insulin (Humalog or lispro, Novolog or aspart, Apidra or glulisine) the nurse should first determine that the client's breakfast tray is readily available. The client should begin eating within minutes of receiving the insulin due to the rapid onset of the insulin (ranging from 10 to 30 minutes). If the client's tray is delayed, the client may become hypoglycemic before the tray arrives. Giving the insulin after the meal is incorrect because the insulin is needed to address the increase of blood glucose before the meal; rapid-acting insulin covers insulin needs for meals eaten at the same time as the injection.

A client is receiving intravenous heparin therapy. What medication should the nurse have available in the event of a heparin overdose? Protamine sulfate (Protamines) Naloxone (Narcan) Aminocaproic acid (Amicar) Flumazenil (Romazicon)

1 Protamine sulfate injection acts as a heparin antagonist. It works rapidly (within five minutes) and is used to treat a heparin overdose. The most common adverse reactions to protamine sulfate are hypotension and bradycardia. Amicar is used to control bleeding that occurs when blood clots are broken down too quickly. Romazicon is used to reverse drowsiness and sedation caused by benzodiazepines. Narcan is used to reverse the effects of narcotics.

A client is being transfused with one unit of packed cells. A half hour after the transfusion was initiated, the client reports having chills and a headache. Which action should the nurse implement first? Stop the transfusion Check the client's temperature Notify the health care provider Obtain a urine specimen

1 The first action when a client exhibits signs of a potential transfusion reaction is to discontinue the transfusion immediately.

A 2 day-old child with spina bifida and meningomyelocele is in the intensive care unit after the initial surgery. As the nurse accompanies the grandparents for a first visit, which response should the nurse anticipate of the grandparents? Disbelief Anger Frustration Depression

1 The first phase of the grieving process is shock, denial or disbelief. Then follows anger, bargaining, depression and acceptance. Each stage can take any amount of time to work through. Clients often go back and forth between the stages until acceptance is achieved. Some clients may get stuck in any one or two of the stages to never achieve acceptance.

At 3 months, the infant has cleft lip and soft palate repair. In the immediate postoperative period for a cleft lip repair, which action is the priority? Remove soft elbow/arm restraints every 2 hours under supervision Initiate clear liquid feedings by mouth when alert and acting hungry Position the infant on side or back Provide written instructions about care of the suture line

1 The goal after surgery is to protect the new repair and stitches, which requires some temporary changes in feeding, positioning and activity for the infant. The priority is to wear arm restraints (for the first 10 days after surgery) to keep him from putting his hands in his mouth; the restraints can be removed only for bathing or for exercising the arms. When the infant acts hungry, he will be given a clear liquid feeding using either a syringe fitted with a special soft tubing or a special cleft lip feeder. The infant can be positioned on his side or back to keep him from rubbing his face in the bed. The RN will provide instructions about care of the incision line prior to discharge. Correct!

A nurse experiences a needle stick with a used hypodermic needle. What action should the nurse perform immediately? Vigorously wash the affected area with soap and water Notify the supervisor and risk management Contact employee health services Look up the policy on needle sticks

1 The immediate action of vigorously washing will help remove possible contamination. Then the sequence would be to notify the supervisor and risk management, look up the policy and then contact employee health services.

An 89 year-old with impaired mental status is transferred from a nursing home to the hospital for surgery. When assisting the client with a clear liquid diet postoperatively, the client begins to cough forcefully. What action by the nurse is indicated? Refer the client for a swallowing assessment Add a thickening agent to the fluids Order a soft diet Call the nursing home for more information

1 The nurse should contact the health care provider to request a swallowing assessment for this client. Older adults with impaired mental status are at greater risk for aspiration pneumonia. Thickening fluids and other actions may be required following the swallowing assessment. Also, remember to apply the nursing process - if a new problem develops, then further assessment is indicated.

A client states: "I do not want to be interrupted for breakfast because it interferes with my meditation time." What is the next action for the nurse to take? Talk with the client to work out a mutual plan Contact the client's provider Consult with the nurse manager to get suggestions Contact the nutritionist or dietitian

1 The nurse should talk with the client to determine how the practice of meditation can be incorporated into the morning schedule. Respect for differences must be incorporated into a client's plan of care.

The nurse is caring for a 14 month-old child who has six teeth. What is the correct way for the nurse to give mouth care to this toddler? Use a moist soft brush or cloth to clean the teeth and gums Brush the teeth with toothpaste and floss each tooth Offer a bottle of water for the child to drink Swab the teeth and gums with flavored mouthwash

1 The nurse should use a soft cloth or soft brush to do mouth care so that the child can adjust to the routine of cleaning the mouth and teeth. The mouth wash is not appropriate for a child this age. To give the bottle of water serves no purpose in cleaning the mouth and teeth. The use of toothpaste and floss is too soon for such an approach.

The client walks into the emergency department with findings consistent with tuberculosis (TB) disease, including cough, loss of appetite, night sweats and bloody sputum. Which of these initial nursing actions is indicated? Move the client into an airborne infection isolation (AII) room Notify all staff members about the client with TB disease Provide instruction to the client about cough etiquette Measure and fit the client with a N95 disposable respirator

1 The priority is to initiate TB airborne precautions for any client with symptoms of TB disease and to place him/her in a AII room (if available in the facility). Health care workers (and visitors) should wear at least N95 disposable respirators before entering an AII room. Only those having contact with the client need to be informed on the client's (unconfirmed) condition. When the client is transported to another area of the hospital, s/he will wear a surgical or procedure mask. The nurse can teach the client about cough etiquette, but this is not a priority.

A nurse is assigned to care for a client diagnosed with deep vein thrombosis who is receiving IV heparin. The latest aPTT is 50 seconds. If the laboratory normal range is 16 to 24 seconds, the nurse should anticipate taking which action? Maintain the current heparin dosage Call to increase the heparin dosage as it does not appear therapeutic Repeat the blood test one hour from this blood result Check to see if protamine sulfate can be ordered as an antidote

1 The range for a therapeutic aPTT is generally 1.5 to 2 times the control values. Therefore, the client is getting a therapeutic dose of heparin.

An ambulatory client reports edema during the day in the feet and ankles that disappears while the client sleeps during the night. What is the most appropriate follow-up question for a nurse to ask? "Do you become short of breath during your normal daily activities?" "Have you had a recent heart attack?" "How many pillows do you use at night to sleep comfortably?" "Do you smoke daily or every other day?"

1 The symptoms described by the client suggest right-sided heart failure, which is why the best follow-up question is to ask the client if s/he becomes short of breath during normal daily activities. Afterwards, the nurse could ask more specific questions about the client's health history, if s/he needs to sleep propped up by pillows or if s/he is a smoker.

The client is diagnosed with superficial thrombophlebitis of the left leg. Which nursing intervention should be given the highest priority? Elevate the affected leg Apply cool compresses Apply elastic support stockings Maintain complete bed rest

1 Unlike deep vein thrombosis, superficial venous thrombosis involves a sudden inflammatory reaction (redness, pain, swelling), but it rarely involves an embolism. Treatment involves elevating the leg because dangling the extremity will increase the swelling and the pain. Other treatment options include warm compresses and analgesics (aspirin or another NSAID); sometimes a low-molecular weight heparin is also prescribed. Clients do not need to be on bed rest but they should wear elastic support stockings (or multiple elastic bandages) when out of bed.

The nurse is caring for two children who have had surgical repair of congenital heart defects. For which defect is it the highest priority to assess for findings of heart conduction disturbance? Ventricular septal defect Patent ductus arteriosus Atrial septal defect Aortic stenosis

1 While assessments for conduction disturbance should be included following repair of any defect, it is a priority for ventricular septal defect. A ventricular septal defect is an abnormal opening between the right and left ventricles. The atrioventricular bundle (bundle of His) is a part of the electrical conduction system of the heart. It extends from the atrioventricular node along each side of the interventricular septum and then divides into right and left bundle branches. Surgical repair of a ventricular septal defect consists of a purse-string approach or a patch sewn over the opening. Either method involves manipulation of the ventricular septum, thereby increasing risk of interrupting the conduction pathway. Consequently, postoperative complications often include conduction disturbances.

The nurse is caring for a client undergoing chemotherapy for colon cancer. Which of the following statements made by the client would the nurse be most concerned about? "I take 10 multivitamin tablets daily to help my immune system fight the cancer." "I think the green tea I'm drinking is helping me to fight the cancer." "I am using relaxation techniques when I need to so I can cope with the stress of having cancer." "I pray several hours a day to God to help me deal with this cancer."

1 While the other common complementary and integrative health therapies may or may not have a direct beneficial effect on the cancer, the megadoses of vitamins may interfere with the chemotherapeutic agents and may have toxic effects.

There is an order to administer an intramuscular influenza vaccine to an adult. What actions should the nurse take prior to administration of the injection? (Select all that apply.) Ask the client if she or he can eat eggs without adverse effects Record the manufacturer of the vaccine and lot number Check the expiration date on the vaccination bottle Provide the client with the federal Vaccine Information Statement (VIS) Record the site and time of injection Record the client's reaction to the injection

1,3,4 Prior to administration, the nurse should identify the expiration date on the bottle and give a current copy of the federal Vaccine Information Statement to the client. The nurse should also verify any allergies, particularly hypersensitivity to eggs, prior to administering the vaccine. Observing for a reaction to the injection and recording the site, time of injection, the manufacturer and lot number are performed after administering the medication.

The nurse is performing a prekindergarten physical on a 4 year-old child and will administer a series of scheduled vaccines, including the DTaP, IPV, MMR and VAR. What information does the nurse need to know about these vaccinations? (Select all that apply.) Either the deltoid muscle of the arm or anterolateral thigh muscle can be used A 20 gauge needle is used to administer the varicella (VAR) vaccine intramuscularly (IM) A 5/8 inch needle length is often used for subcutaneous (SubQ) injections The vaccines contain the preservative thimerosal Multiple immunizations should be administered a minimum of 1 inch apart The vaccines all contain weakened live viruses

1,3,5 A 4-6 year-old should get the Diphtheria-Tetanus-Pertussis (DTaP), Inactivated Polio (IPV), Measles-Mumps-Rubella (MMR), and Varicella (VAR) vaccines. DTaP is given IM; VAR and MMR are administered SubQ (using a 5/8 inch, 25-gauge needle); IPV can be given either SubQ or IM. The IPV contains inactivated viruses; the MMR and VAR contain live viruses and DTaP is made up of dead bacteria. Vaccines no longer contain thimerosal, which is a form of mercury. Multiple immunizations should be spaced a minimum of 1 inch apart. Either the deltoid muscle of the arm or the anterolateral thigh muscle can be used.

A client has just returned from the post anesthesia care unit (PACU) to the surgical unit after a cholecystectomy. When initial vital signs are taken the nurse notes a temperature of 94.8 F (34.8 C). Which nursing action is appropriate to do first? Call the health care provider and obtain further orders for warming Apply a warm blanket and check the temperature in 10 minutes Continue to monitor the vital signs as indicated Ask the PACU nurse more details of what happened in PACU

2 A client's postoperative temperature should be at least 95 F (35 C). If the temperature does not increase in 10 minutes, the nurse should call the provider for orders for an electric warming blanket or other actions. It is not sufficient to continue monitoring without taking any action.

The nurse is teaching a group of clients who are all diagnosed with schizophrenia and are taking an atypical antipsychotic medication. What statement made by one of the clients needs to be corrected? "I'll probably gain a lot of weight on this medication and I may even develop diabetes." "I'm so glad that this medication won't cause any of the tremors or tics I had when I was taking my old medication." "I should be careful when I get out of bed because this medication can cause my blood pressure to drop." "I know I need to be patient but I wish it didn't take so long for this medication to really start working."

2 Although atypical antipsychotics may cause fewer extrapyramidal side effects, the client should know that they may still cause some of the same symptoms, like tics, slow speech, tremors or retarded movement. Most of these medications do take two to four weeks or more to take effect. In addition to weight gain and developing diabetes, there is a risk for higher cholesterol and triglyceride levels.

The nurse must remove a fecal impaction in a 75 year-old client. During the procedure, the nurse should remember what critical information? Family members should be taught the procedure Cardiac dysrhythmias can result during the process Increased dietary fiber and fluids can minimize such problems The procedure is to be done prior to the bath

2 Cardiac dysrhythmias such as severe bradycardia can occur from vagal nerve stimulation during fecal impaction removal. The other actions are appropriate though they are not the priority consideration.

A 64 year-old client scheduled for surgery with a general anesthetic refuses to remove a set of dentures prior to leaving the unit for the operating room. What would be the most appropriate intervention by the nurse? Notify the anesthesia department and the surgeon of the client's refusal Ask the client if the preference would be to remove the dentures in the operating room receiving area Explain to the client that the dentures must come out as they may get lost or broken in the operating room Ask the client if there are second thoughts about having the procedure

2 Clients anticipating surgery may experience a variety of fears. This choice allows the client control over the situation and fosters the client's sense of self-esteem and self-concept.

A client has just been diagnosed with breast cancer. A nurse enters the room and the client tells the nurse that the nurse is stupid. What is the most therapeutic response by the nurse? Accept the client's statement without comment Explore what is going on with the client Tell the client that the comment is inappropriate Leave the client's room and refer to the charge nurse

2 Exploration of feelings with the verbally aggressive client helps to put angry feelings into words. After that then the approach is to get the client to engage in problem solving.

The nurse is providing the client who takes digoxin and furosemide with dietary instructions. The nurse should reinforce that the combination of these medications can result in which outcome? Oliguria Arrhythmias Irritability and excitability Weight gain

2 Furosemide is an effective diuretic but electrolyte depletion may occur. Concurrently taking furosemide and digoxin exaggerates the metabolic effects of hypokalemia, especially alterations in cardiac rate and rhythm, and contributes to digitalis toxicity. Digitalis toxicity may stimulate almost every known type of dysrhythmia. The effects of hypokalemia include fatigue (not excitability) and polyuria (not oliguria); digitalis toxicity can cause nausea, vomiting, anorexia and weight loss (not weight gain). Foods rich in potassium include avocados, bananas, peas and beans, spinach and tomatoes.

A mother telephones the clinic and says, "I am worried because my breast-fed 1 month-old infant has soft, yellow stools after each feeding." A nurse's best response would be which of these? "The stool should have turned to light brown by now. We need to test the stool." "This type of stool is normal for breast-fed infants. Keep doing as you have." "Water should be offered several times each day in addition to the breast-feeding." "Formula supplements might need to be added to increase the bulk of the stools."

2 In breast-fed infants, stools are frequent and yellow to golden, and vary from soft to thick liquid in consistency. No change in feedings is indicated.

The nurse finds a client unconscious, following a tonic-clonic seizure. What should a nurse do first? Administer the ordered Ativan Place the client in a side-lying position Prepare for suctioning Check the pulse

2 Place the client in a side-lying position to maintain an open airway, drain secretions, and prevent aspiration if vomiting occurs. After that, any ordered medication should be given.

A client has a percutaneous endoscopic gastrostomy (PEG) tube that is used to administer feedings and medications. Which nursing action is best to ensure patency of the tube? Encouraging the client to cough to relieve abdominal bloating prior to or following a feeding Adequately flushing the tube with water before and after use Completely crushing all medications prior to administration Squeezing the tube to dislodge obstructions

2 Prior to using the tube, it must be checked to make sure it is free from obstruction and leaks. Milking the tube may help dislodge an obstruction, but flushing the tube before and after use is the best way to ensure patency (while providing hydration). Liquid medication preparations are best, but tablets and pills can be dissolved in water (and flushed with 30-50 mL of water afterwards.) If the client experiences abdominal bloating, the nurse can encourage the client to cough, which will speed up the removal of excessive air, but the tube still needs to be flushed with water before and after use

A nurse is preparing to administer an enteral feeding to a client via a nasogastric feeding tube. The priority action of the nurse should be which of these? Check that the feeding solution matches the dietary order Verify correct placement of the tube Aspirate abdominal contents to determine the residual Ensure that feeding solution is at room temperature

2 Proper placement of the tube prevents aspiration. The other options are correct actions but this question asks for the priority action. The approach to use is to ask: What is the outcome if I do not do this action? The worst outcome is commonly associated with the priority action. In this case, it is aspiration for the correct answer.

A client experiences postpartum hemorrhage eight hours after the birth of twins. Following administration of IV fluids and 500 mL of whole blood, the hemoglobin and hematocrit are within normal limits. The client asks the nurse whether she should continue to breast-feed the infants. Which statement by the nurse is supported by evidence-based practice? "Breast-feeding twins will take too much energy after the hemorrhage." "Nursing the twins will help contract the uterus and reduce the risk of bleeding." "The blood transfusion may increase the risks to you and the babies." "Lactation should be delayed until the "real milk" is secreted."

2 Stimulation of the breast during nursing releases oxytocin, which contracts the uterus. This contraction is especially important to enhance the prevention of hemorrhage.

A 16 year-old adolescent is admitted for Ewing's sarcoma of the tibia. In discussing the care with the parents, the nurse should understand that the initial treatment for this diagnosis usually includes which approach? Surgical excision of the mass Radiation with adjunctive chemotherapy Amputation above the tumor Bone marrow graft in the affected leg

2 The initial approach for the treatment of Ewing's sarcoma is usually a combination of radiation and chemotherapy to reduce the size of the tumor.

A client with a documented pulmonary embolism has the following arterial blood gases (ABG): PaO2 70 mm Hg, PaCO2 30 mm Hg, pH 7.48, SaO2 87%, HCO3 22. Based on this data, what is the first nursing action? Have the client do slow, deep breathing Administer the PRN oxygen by nasal cannula Notify the health care provider of the results Review prior ABG data from the prior shift

2 The low PaO2, along with the low oxygen saturation, is a priority. The first priority should be to administer oxygen to the client. Then the client should be guided to do slow, deep breathing because the PaCo2 is low, reflecting a hyperventilation effect of an increased respiratory rate with slight respiratory alkalosis. Prior lab results should be reviewed before notifying the health care provider.

The nurse is caring for a client diagnosed with major depressive disorder. The nurse understands that this client is at highest risk for a suicide attempt at which of these times? Within 24 to 48 hours following an angry outburst with the family Seven to 14 days after initiation of antidepressant medication and psychotherapy When the client is removed from the security room and placed in an individual room One to two days after admission to an inpatient facility

2 The point to apply is that as the depression lessens, these clients often have energy to implement their plan of suicide. Thus, the discharge plan needs to inform the family members of what behaviors of the client should alert them to act. The characteristic alert is a sudden change in the client's mood to elation or happiness that was not present before the sudden change.

A nurse is assessing a woman in early labor. When positioning her for a vaginal exam, the client reports feeling dizzy and nauseous. She appears pale and her blood pressure has dropped slightly. What should be the initial nursing action? Elevate the foot of the bed Turn her to her left side Call the health care provider Encourage deep breathing

2 The weight of the uterus can put pressure on the vena cava and aorta when a pregnant woman is lying flat on the back which results in supine hypotension. Action is needed to relieve the pressure on the vena cava and aorta. Turning the woman to the left side reduces this pressure and relieves postural hypotension.

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

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

A female client diagnosed with genital herpes simplex virus 2 (HSV-2) reports having dysuria, dyspareunia, leukorrhea and lesions on the labia and perianal skin. Which intervention will provide symptomatic relief? (Select all the apply.) Soak in a tub of hot water Local application of ice packs Dry the genital area with a blow dryer on the cool setting Echinacea juice extract capsules twice daily Over-the-counter medications such as ibuprofen Increase fluid intake

2,3,5 Symptomatic relief includes lukewarm (not hot) baths and applying cold packs to the genital area. Sometimes using a hair dryer set to a low or cool setting can help relieve symptoms. Over-the-counter medications such as ibuprofen and acetaminophen can help with local tenderness. A client with HSV-2 should increase their fluid intake when using acyclovir, but increasing fluids will not directly relieve symptoms. There's no evidence that echinacea can relieve the symptoms of HSV-2.

The nurse is caring for the following clients. The nurse understands that which of these clients is at the highest risk for falling? The 59 year-old who had hip replacement surgery four days ago and is going to physical therapy The 67 year-old who is diabetic and has a draining ulcer on the right leg The 81 year-old who fell at home last week and is confused The 79 year-old who has arthritis and walks with the aid of a walker

3 Although all of the individuals might be at risk for falling, evidence shows that the greatest risk of falling is a person who is older than age 80, is confused, and has a history of falling.

A client with a new diagnosis of diabetes mellitus is referred for home care. A family member present expresses concern that the client seems depressed. The nurse should initially focus further assessment by using which approach? Obtain a family health history, including emotional problems or mental illness Inquire about use of alcohol or other non-prescribed substances Observe the client's affect and behavior during the visit Administer a standardized tool that measures depression

3 Although it is important to begin an assessment for depression immediately, the assessment should not be aggressively intrusive. A direct assessment should be conducted to confirm the observations and concerns of the family member.

The nurse is in a crowded shopping area in an urban setting when a radiologic dispersal device (RDD) explodes scattering radioactive dust and material into the environment. What should the nurse instruct the victims in proximity to the explosion to do first? Stay out of any buildings until help arrives Lie down flat and cover the head with anything available Keep the nose and mouth covered Remove all exposed clothing right away

3 An RRD, or "dirty bomb," generates radioactive dust and smoke, which can be dangerous if inhaled. The nurse should initiate measures to limit contamination, instructing victims to cover their noses and mouths. Neither lying down or covering the head does anything to limit exposure. Victims should move into a building where the walls and windows have not been broken and then remove their outer layer of clothing (sealing them in a plastic bag, if available) to help minimize exposure.

A mother calls the clinic, concerned that her 5 week-old infant is "sleeping more than her brother did." What is the best initial response by a nurse? "Do you remember his sleep patterns?" "How old is your other child?" "Why do you think this a concern?" "Does the baby sleep after feeding?"

3 Asking this client "why" allows her to focus on her concern about her newborn's sleep patterns - the reason for the call to the clinic. This is the most open-ended question and will encourage further discussion and conversation about the newborn, and not the other child.

While discussing issues with colleagues on the unit, the novice nurse seems surprised when the other nurses state that the manager makes all decisions and rarely asks for staff input. What is the best description of the nurse manager's management style? Ultraliberal or communicative Laissez-faire or permissive Autocratic or authoritarian Participative or democratic

3 Autocratic leadership style is suggested in this situation. It is appropriate for groups with little education and experience who need strong direction. A Participative or democratic style is usually more successful on nursing units with a mix of staff of differing experience.

A nurse is assigned to an 83 year-old client with Parkinson's disease. Which findings would the nurse anticipate? Nonintention tremors and urgency with voiding Muscle spasm and a bent over posture Muscle rigidity and a shuffling gait Voluntary tremor and jerky movement of the elbows

3 Clients with Parkinson's disease have a very distinctive gait with quick short steps (shuffling) that may increase in speed so that they are unable to stop, as well as muscle rigidity. In the other options, only one of the two findings listed is associated with Parkinson's disease: clients may have nonintention tremors, but there is no urgency with voiding; their posture may be "bent over," but there are no muscle spasms; and while they may experience a cogwheel or jerky movement of the elbows, their tremors are not voluntary.

What is the major purpose of community health research? Evaluate illness in the community Explain the health conditions of families Describe the health conditions of populations Identify the health conditions of the environment

3 Community health focuses on aggregate population care.

A client was admitted to the eating disorder unit with a diagnosis of bulimia nervosa. A nurse should expect the client's history to include which of these findings? Bacterial gastric infections, spastic colon Respiratory distress, dysphagia Dental erosion, parotid gland enlargement Metabolic acidosis, ulcerative colitis

3 Dental erosion and parotid gland enlargement occur as a result of the purging. These are common complications of binge eating followed by self-induced vomiting. Often these clients will have a callous on one of the fingers on either hand. This is from the use of the finger to gag self until emesis occurs.

Staffing for the shift includes several registered nurses (RNs) and one licensed practical nurse (LPN). Which of these clients should the charge nurse assign to an RN? A 60-year-old with a history of asthma and reported shortness of breath during the previous shift An 80-year-old who is postoperative day one following a right hip replacement A 24-year-old newly diagnosed with type 1 diabetes mellitus who is scheduled for discharge A 56-year-old admitted with atrial fibrillation who converted to normal sinus rhythm without cardioversion

3 LPNs can care for clients whose conditions are not too complex or variable and if there is a low likelihood of an emergency. Also, RNs are responsible for providing client education; LPNs can only reinforce the plan of care and information already taught by the RN. Although the condition of the client scheduled for discharge would be considered "stable," the RN is responsible for discharge teaching and ensuring continuity of care after discharge.

An infant who has recently been diagnosed with cystic fibrosis (CF) is being assessed by the nurse. Which finding of this disease would the nurse not expect to see at this time? Bulky, greasy stools Positive sweat test Moist, productive cough Meconium ileus

3 Moist and productive cough is a later sign in CF. Noisy respirations and a dry nonproductive cough are commonly the first respiratory signs to appear in a newly diagnosed client with CF. The other options are the earlier findings. CF is an inherited (genetic) condition affecting the cells that produce mucus, sweat, saliva and digestive juices. Normally, these secretions are thin and slippery, but in CF a defective gene causes the secretions to become thick and sticky. Instead of acting as a lubricant, the secretions plug up tubes, ducts and passageways, especially in the pancreas and lungs. Respiratory failure is the most dangerous consequence of CF.

The nurse is providing care to a client who is receiving oxygen therapy via a nasal cannula. During the provision of care, which nursing intervention would be appropriate? Maintain sterile technique when handling cannula Determine that adequate mist is supplied Inspect the nares and areas around the ears for skin breakdown Lubricate the tips of the cannula before insertion in the nose

3 Oxygen therapy by nasal cannula can cause drying of the nasal mucosa. Pressure from the plastic tubing can cause skin irritation inside the nares or around the tops of the ears (padding is available, which helps, but does not eliminate, the problem around the ears). Nasal cannula tips for the administration of oxygen should be cleaned regularly and should never be lubricated with petroleum jelly.

A client who is pregnant comes to the clinic for a first visit. The nurse gathers data about the client's obstetric history, which includes 3 year-old twins at home and a miscarriage 10 years ago at 12-weeks gestation. How should the nurse accurately document this information? Gravida 2 para 1 Gravida 3 para 2 Gravida 3 para 1 Gravida 4 para 2

3 Para is the number of deliveries (of an infant more than 20 weeks gestation). Regardless of how many babies are delivered at one time (twins, triplets, etc.), the delivery is still counted as 1. Gravida is the number of pregnancies. This woman had a miscarriage (at 12 weeks), so that would be gravida 1, para 0. With the twins, the count would be gravida 2, para 1. With the current pregnancy, she is gravida 3, para 1 - 3rd pregnancy to date, but only one previous delivery (of the twins).

A nurse discovers that the parents of a 2 year-old child continue to use an apnea monitor each night. The parents state: "We are concerned about the possible occurrence of sudden infant death syndrome (SIDS)." In order to take appropriate action, the nurse must understand which point? The peak age for occurrence of SIDS is 8 to 12 months of age The child is within the age group most susceptible to SIDS About 95% of SIDS cases occur before 6 months of age The apnea monitor is not effective on a child in this age group

3 Peak age of SIDS occurrence is 2 to 4 months-old and about 95% of cases occur by 6 months of age. It is the leading cause of death in infants 1 month to 1 year of age. These parents would benefit from understanding this information.

A nurse is assessing a 4 month-old infant. Which motor skill should the nurse anticipate finding? Wave "bye-bye" Bang two blocks Hold a rattle Drink from a cup

3 The age at which a baby will develop the skill of grasping a toy with help is 4 to 6 months.

The charge nurse in the pediatric unit is reviewing the diagnoses of four children while making the shift assignments and recognizes that one child is at a high risk for cardiac arrest and should not be assigned to the nurse who is floating from orthopedics. The child with which diagnosis should not be assigned to the nurse from orthopedics? Severe multiple trauma An acute febrile illness Prolonged hypoxemia Congenital cardiac defects

3 The cause of cardiac arrest in the pediatric population is typically prolonged hypoxemia. Children usually go into both cardiac and respiratory arrest. It would be best not to assign a float nurse to the child with the highest risk of cardiac arrest.

The nurse is planning care for a client during the acute phase of a sickle cell vaso-occlusive crisis. Which action would be most appropriate? Encourage increased caloric intake Ambulate in hallway four times a day Administer analgesic therapy as ordered Fluid restriction 1000 mL per day

3 The main general interventions in the treatment of a sickle cell crisis are bed rest, hydration, electrolyte replacement, analgesics for pain, blood replacement, and antibiotics (to treat an existing infection).

The hospital has a mentor program for novice nurse managers. Which of these actions is a priority for the mentor-mentee relationship and will result in a positive experience? The mentee accepts feedback objectively The mentor is randomly assigned by administration A teacher-coach role is used by the mentor Information is clarified as needed

3 The mentor needs to adopt the role as teacher-coach. Teaching and coaching are essential elements of the professional role and will facilitate the transition from one role to another, e.g., from staff nurse to nurse manager. The mentor will also assist the novice manager to manage familiar clinical situations and to achieve a level of comfort in solving clinical problems with which s/he is less familiar.

A nurse is preparing to perform a physical examination on an 8 month-old who is sitting contentedly on the mother's lap. Which assessment should the nurse do first? Elicit the reflexes Examine the ears Auscultate the heart and lungs Measure the height and weight

3 The nurse should auscultate the heart and lungs during the first quiet moment with the infant so as to be able to hear sounds clearly. Other assessments may follow in any order.

A triage nurse has four clients arrive in the emergency department within a 15-minute period. Which client should the triage nurse send back into the unit to be seen by the health care provider first? An older adult client with complaints of frequent liquid brown-colored stools A 2 month-old infant with a history of rolling off the bed, who has bulging fontanelles and is crying A teenager who got a singed beard while camping at a site that's more than an hour away A middle-aged client with intermittent pain behind the right scapula

3 This client is in the greatest danger with a potential of respiratory distress. Any client with singed facial hair has been exposed to heat or fire in close range that could have also caused damage to the interior of the lung. Note that the interior lining of the lung has no nerve fibers so the client will not be aware of swelling nor have any pain.

A health care provider orders digoxin 0.125 mg by mouth daily and furosemide (Lasix) 40 mg daily by mouth. Which of these foods should the nurse reinforce for the client to eat at least one serving daily? Blueberries Wheat cereal Tomato juice Pear nectar

3 Tomato juice is highest in potassium per serving of the given foods. The other three foods are in a category of low potassium foods and will do little to replace potassium lost by the diuretic. Tomato juice (½ cup) has about 400 mg potassium; pear nectar (1 cup) has 33 mg; blueberries (½ cup) is 64 mg; and wheat cereal (1 cup) is 62 mg. The low potassium foods would be recommended for clients diagnosed with renal failure.

The nurse is administering an enteral feeding to a client via a jejunostomy tube. With which frequency would the nurse administer the formula? Every hour In a bolus Continuously Every four to six hours

3 Usually small intestinal feedings, such as jejunostomy feedings, are given continuously to ensure proper absorption. However, initial feedings may be given by bolus to assess the client's tolerance to formula. Gastric feedings are more often given in a bolus every so many hours.

A client is brought to the emergency department with a blood sugar of 52 mg/dL (2.89 mmol/L). The client is weak and diaphoretic but awake, and the client's blood sugar does not rise above 70 mg/dL (3.89 mmol/L) after drinking one 4-ounce (118 mL) glass of orange juice. Which of the following actions should be taken? (Select all that apply.) Offer a 12-ounce (355 mL) can of cola with added sugar Instruct the client to not take more insulin today Offer 8-ounce (237 mL) glass of milk Recheck blood sugar in 15 minutes Determine blood sugar management medications

3,4,5 Treatment for hypoglycemia is to consume approximately 15-20 grams of glucose or simple carbohydrates. Common examples of 15 grams of simple carbohydrates include: 2 tablespoons of raisins; 118 mL of juice or regular soda (not diet); 237 mL of nonfat or 1% milk; and 1 tablespoon of honey. In a clinical setting, the client may also be given glucose tablets. If after 15 minutes the blood sugar is still below 70 mg/dL (3.89 mmol/L), the client can be given another 15-20 grams of simple carbohydrates (this is also known as the "15 - 15 rule.") It's always a good idea to confirm how the client manages his/her diabetes.

A client is admitted with the diagnosis of testicular cancer. Which factor in the client's history should the nurse know to associate with this disease? Genital herpes Sexual relations at an early age Epididymitis Undescended testis

4 A history of undescended testis or cryptorchidism is a known risk factor for testicular cancer. HIV and AIDS may increase the risk of testicular cancer, but no other infection has been associated with this type of cancer.

The client is scheduled to have a pulmonary artery catheter (PAC) inserted. Prior to the procedure, what basic information can the nurse teach the client about a PAC? "The catheter is inserted through the groin into the left side of the heart." "You will be unable to eat or drink anything for several hours after the procedure." "The procedure is performed under general anesthesia." "The catheter will measure different pressures in the heart and lungs."

4 A pulmonary artery catheter, also known as a Swan-Ganz catheter or right heart catheterization, is inserted into the right side of the heart and into the arteries that lead to the lungs. It is inserted either through the groin or neck, using conscious sedation and local anesthetic, at the bedside (usually in an intensive care unit.) PAC can measure right atrial pressure, pulmonary artery pressure, and pulmonary capillary wedge pressure; these measurements can be used to assess oxygenation of the blood in the right heart and overall cardiac output. Clients can eat or drink after the procedure

A client is admitted with a diagnosis of myocardial infarction (MI). Which lab value is most commonly used to confirm this diagnosis? Elevated C-reactive protein Elevated myoglobin Elevated creatine kinase (CK) Elevated troponin levels

4 All of these lab tests may be elevated during an MI. Although CK-MB (along with total CK) is a very good test, it has been replaced by troponin. Elevation of troponin is the most reliable because it is more specific to heart damage; it elevates within a few hours and remains elevated for about 10 days. CK-MB is one of three separate forms (isoenzymes) of the enzyme creatine kinase (CK); it is found mostly in heart muscle and rises when there is damage to the heart. An elevated C-reactive protein is associated with a risk of cardiovascular disease.

A nurse admits a 7 year-old to the emergency department after a leg injury. The x-rays show a femur fracture near the epiphysis. The parents ask what will be the outcome of this injury. The appropriate response by the nurse should be which of these statements? "Bone growth is stimulated in the affected leg as therapy is initiated." "This type of injury shows more rapid union than that of younger children." "The injury is expected to heal quickly because of thin periosteum." "In some instances this type of injury can cause retarded bone growth."

4 An epiphyseal (growth) plate fracture in a 7 year-old often results in retarded bone growth. The leg often will be different in length than the uninjured leg. Of the given options, this is the best response.

The nurse is providing information to a client with diarrhea. Which of the following food choices should the client be advised to avoid? Tender, well-cooked meat Macaroni made from white or refined flour Pulp-free fruit juice Steel-cut oatmeal with nuts and dried fruit

4 Clients should drink plenty of water and limit foods and beverages that contain caffeine, sugar, lactose, fructose or sorbitol. High potassium foods are recommended, such as bananas, potatoes (without the skin) and fruit juices. Spicy or fried foods, raw vegetables, nuts, dried fruit, whole grains and highly processed or fatty meats should be avoided.

While planning care for a preschool-aged child, the nurse takes developmental needs into consideration. Which of these behaviors would be of the most concern to the nurse? Identifying with family Playing imaginatively Exploring the playroom Expressing shame

4 Erikson describes the stage of the preschool child as being the time when there is normally an increase in initiative. The child should have resolved the sense of shame and doubt in the toddler stage.

The nurse is working with a client with anxiety. An appropriate treatment goal for this client would be which of these items? Establish contact with reality Ventilate anxious feelings to a nurse Become desensitized to past trauma Learn self-help techniques

4 Exploration of alternative coping mechanisms should decrease present anxiety to a manageable level. Assistance to the client for learning self-help techniques should enhance the abilities to cope with anxiety.

A client diagnosed with gouty arthritis is admitted with severe pain and cellulitis of the right foot. Which intervention should be included when the nurse develops the plan of care? High protein diet Active range of motion exercises Hot compresses to affected joints Fluid intake of at least 3000 mL/day

4 Fluid intake should be increased to prevent precipitation of urate in the kidneys; a lack of sufficient fluids enhances the formation of urate renal calculi or kidney stones. Treatment for acute attacks include supportive measures, such as applying ice and resting the affected joint. The client should avoid eating foods high in purines, such as organ meats (liver), and limit eating beef, pork and lamb.

A 9 year-old is taken to the emergency department with right lower quadrant pain and vomiting. During the preparation of the child for an emergency appendectomy, what should the nurse expect to be the child's greatest fear? Change in body image An unfamiliar environment Guilt over being hospitalized Perceived loss of control

4 For school-age children, major fears are loss of control and separation from friends/peers.

The registered nurse (RN) is planning care at a team meeting for a 2 month-old infant in bilateral leg casts for congenital clubfoot. Which of these outcomes suggested by the practical nurse (PN) should be considered a priority nursing goal following the cast application? The infant will experience minimal pain Mobility will be managed as tolerated Muscle spasms will be relieved Tissue perfusion will be maintained

4 Immediately following cast application, the chief goal is to maintain circulation and tissue perfusion around the cast. With swelling of an injured extremity, inappropriate application of the cast or shrinkage of cast material during the curing or drying process, the cast may become too tight, compromising circulation. Permanent tissue damage can occur in the limb within a few hours if perfusion is not maintained. Assessment of the extremity for the 6 Ps of poor tissue perfusion/ischemia is the most important goal during this period.

A nurse is caring for a woman two hours after a vaginal delivery. Documentation indicates that the membranes were ruptured for 36 hours prior to delivery. What is the priority nursing diagnosis at this time? Risk for fluid volume deficit High risk for hemorrhage Altered tissue perfusion Risk for infection

4 Membranes that have been ruptured for more than 24 hours prior to birth significantly increases the risk of infection to both mother and the newborn.

A neonate born 12 hours ago to a methadone-maintained woman is exhibiting a hyperactive Moro reflex and slight tremors. The newborn passed one loose, watery stool. Which of these actions is a nursing priority? Hold the infant at frequent intervals Offer fluids to prevent dehydration Administer paregoric to stop diarrhea Assess for neonatal withdrawal syndrome

4 Neonatal withdrawal syndrome is a cluster of findings that signal the withdrawal of the infant from the opiates. The findings seen in methadone withdrawal are often more severe than for other substances. Initial signs are central nervous system hyperirritability and gastrointestinal symptoms. If withdrawal signs are severe, there is an increased mortality risk. Scoring the infant ensures proper treatment during the periods of withdrawal.

A client has been diagnosed with Zollinger-Ellison syndrome. Which information is most important for the nurse to reinforce? Treatment consists of medications to reduce acid and heal any peptic ulcers and, if possible, surgery to remove any tumors With the average age of diagnosis at 50 years, the peptic ulcers may occur at unusual areas of the stomach or intestine It is a condition in which one or more tumors called gastrinomas form in the pancreas or in the upper part of the small intestine (duodenum) It is critical to promptly report any signs of peptic ulcer to your health care provider

4 Night-time awakening with burning, cramp-like abdominal pain, vomiting (even hematemesis), and change in appetite are some of the findings of peptic ulcers. Abdominal pain, rigidity and tenderness can signal perforation of the ulcer and should be reported to the provider immediately. Zollinger-Ellison syndrome can occur in both children and adults. All of the other options are correct information about this syndrome but are less important to reinforce when teaching the client.

A nurse is caring for a 2 year-old child after corrective surgery for tetralogy of Fallot. The mother reports that the child has suddenly begun having a seizure. The nurse should recognize that this situation is most likely from which complication? Postoperative meningitis Medication reaction Metabolic alkalosis A cerebral infarction

4 Polycythemia occurs as a physiological reaction to chronic hypoxemia, which commonly occurs in clients with tetralogy of Fallot. Polycythemia and the resultant increased viscosity of the blood increase the risk of thromboembolic events. Cerebral infarctions, also called cerebrovascular accidents, may occur. Findings include sudden degrees of paralysis, altered speech, extreme irritability or fatigue, and grand mal seizure activity accompanied with incontinence of bowel and bladder.

The nurse is assessing a client with portal hypertension. Which findings should the nurse expect during the assessment? Expiratory wheezes Blurred vision Dilated pupils Ascites

4 Portal hypertension can occur in a client with right-sided heart failure or cirrhosis of the liver. Portal hypertension can lead to ascites from the increased portal pressure as well as a lowered colloid osmotic pressure because of low albumin. When liver functioning deteriorates, protein metabolism is decreased with the result of a low serum albumin.

A client has a serum glucose of 385 mg/dL (21.4 mmol/L). Which of these verbal orders would be a priority for the nurse to question and call back the health care provider for a revision? Repeat glycosolated hemoglobin in 24 hours IV fluids of 0.9% normal saline at 125 mL per hour Document peripheral glucose sticks every four hours Humulin N 20 units IV push over 10 minutes

4 Short-acting insulin, such as regular or semilente insulin, is the only insulin that can be given by the intravenous route. Humulin insulin IV is the order to question. Repeating the glycohemoglobin should also be questioned, although it is not a priority because the client would not be harmed by this action. This lab test gives the average glucose on the hemoglobin molecule for the past two to three months; there would be no need to repeat it at this time. A fasting glucose in the morning would be a more appropriate assessment. The other orders are within expected actions in this situation.

An adolescent client is admitted in respiratory alkalosis after being diagnosed with an aspirin overdose. The nurse should recognize that this imbalance was caused by which finding? Vomiting Hypokalemia Hyperpyrexia Tachypnea

4 Stimulation of respiratory center in aspirin overdose leads to tachypnea and hyperventilation, decreasing CO2 levels as the client "blows off" carbon dioxide. This results in a respiratory alkalosis which is characterized by low PaCO2, pH above 7.4 and normal HCO3. This is the first phase of salicylate toxicity. Hyperventilation will eventually progress to hypoventilation (with mixed respiratory and metabolic acidosis) and respiratory failure. The other findings are seen in aspirin toxicity, but are not the cause of respiratory alkalosis.

A practical nurse (LPN) from the pediatric unit is reassigned to work in an adult ortho-neuro unit. Which client assignment would be appropriate for this staff member? The client who is one day post total knee arthroplasty experiencing shortness of breath The client who experienced a cerebral vascular accident and is ready to be transferred to a long term care facility The client with a newly applied long leg cast experiencing uncontrolled pain The client in balanced traction admitted three days ago after a motor vehicle accident

4 The RN can assign clients to LPNs as long as the care required is not too complex and there is a low likelihood of an emergency. This is especially important reassigned workers. The most stable client is the one in balanced traction who was admitted three days ago. The clients experiencing SOB and uncontrolled pain are unstable and there is an increased risk of an emergency. Admitting or discharging a client is a complex process and requires the skills, knowledge and abilities of the RN.

The nurse is caring for a 16 year-old client who had surgical repair of a fractured femur 14 hours ago. Assessment findings include tachycardia, increased shortness of breath, a temperature of 100.2 F (37.8 C), feelings of anxiety, and an oxygen saturation level of 88%. The nurse immediately notifies the health care provider, recognizing that the client is at risk for which complication? Myocardial infarction Compartment syndrome Atelectasis Fat embolism

4 The findings are cardinal signs of a fat embolism, which is a complication of orthopedic surgery. Compartment syndrome does not cause increased shortness of breath or feelings of anxiety. Atelectasis occurs when ventilation is decreased and secretions accumulate. Myocardial infarction is characterized with chest pain and generally does not occur in adolescents unless there is a history of cardiac health issues.

The parents of a 3 year-old ask the nurse about preventing injuries. What is one of the most effective methods caregivers can use to teach young children about injury prevention? Make sure the child understands the safety rules Discuss the consequences of not wearing protective devices Protect the child from outside influences Set good examples themselves

4 The preschool years (3 - 6 years) are the time for caregivers to begin emphasizing safety principles as well as providing protection. Parents should provide examples of safe behavior because preschoolers often imitate behaviors in others and they are quick to notice discrepancies between what they see and what they are told to do. Preschoolers are in the "preoperational" stage (Piaget) and their logic is ruled by perception, not reasoning.

A nurse is teaching parents about the appropriate diet for a 4 month-old infant with gastroenteritis and mild dehydration. In addition to oral rehydration fluids, what should the diet include? Rice cereal and apple juice Broth and tea Gelatin and ginger ale Formula and breast milk

4 The usual diet for an infant this age should be followed. The clue is "mild" dehydration. If it was severe then a different approach might be used.

A parent brings a 3 month-old infant into the clinic, reporting that the child seems to be spitting up all the time and has a lot of gas. The nurse expects which findings on the initial history and physical assessment? Increased sleeping and listlessness Increased temperature and lethargy Diarrhea and poor skin turgor Restlessness and irritability

4 This infant could be experiencing gastroesophageal reflux or perhaps an allergic response to the formula. Restlessness, irritability and increased mucus production can develop if an allergy is present. Soy-based formula may be recommended when allergies to the proteins in cow's milk formulas are suspected. Protein hydrolysate formulas are available when babies have a milk or soy allergy. Reflux would be treated with an acid-reducing medication such as ranitidine and positioning with the head elevated after feeding and while sleeping to reduce symptoms causing esophageal irritation.

Which statement correctly describes time management strategies applied to the role of a nurse manager? Assume a fair share of direct client care on a daily basis to act as a role model Schedule staff efficiently to cover the anticipated needs on the unit Delegate manager tasks to reduce conflicts associated with direct care and meetings Set daily goals with a prioritization of the issues and management tasks

4 Time management strategies include setting goals and prioritization of not only management tasks but issues that arise on a daily basis on the unit. This is similar to time management of direct care for clients which has tasks and issues for prioritization. The approach for a manager to do a "fair share" of direct client care on a daily basis is a poor use of the managers time. Direct client care should be done by a unit manager only in extreme circumstances.

A school-aged child had a long leg (hip to ankle) plaster cast applied four hours ago. Which statement from the parent indicates that teaching has not occurred or is inadequate? "I will keep the cast uncovered for the next day to prevent burning of the skin." "I can apply an ice pack over the area to relieve itching inside the cast." "The cast should be propped on at least two pillows when my child is lying down." "I think I remember that my child can stand on the casted leg in 24 hours."

4 Unlike fiberglass casts, the set up and drying time of plaster casts can take up to 72 hours, especially with a long leg cast. Therefore, the child should not stand until the cast has dried. Clients may complain of a chill from the wet cast and can be covered with a sheet or blanket, but the cast should be uncovered for the first 24 hours. Applying ice in an ice bag is a safe method to relieve the itching. Swelling can be managed by elevating the leg when lying down.