pn nclex #3

The family of a 93-year-old client in a long-term care facility asks the nurse why the client is only being bathed three times weekly. Which statement is most important for the nurse to include in the response? A. The staff has limited time and must schedule bathing for all the clients B. The client's skin is very dry, and more frequent bathing will dry the skin further C. The client has limited energy and must conserve it D. The client is not very active and therefore doesn't get dirty.

Correct Answer: B. The client's skin is very dry, and more frequent bathing will dry the skin further Elderly clients usually have very dry skin. Bathing daily is not recommended for people with very dry skin. Bathing two or three times weekly is usually recommended. Incorrect Answers:A. The nurse should not tell family members staff does not have time to care for their loved one. The reason to avoid daily baths is that elderly skin tends to be very dry and frequent bathing reduces the skin's natural moisture even more. C. The client may have limited energy tolerance, but the primary reason is to prevent excess drying of the skin. D. It may be true that the client doesn't get very dirty, but this is not the primary reason for less frequent bathing.

When a schizophrenic client claims to see demons in the room, what is the best documentation the nurse should make for the record? A. Experiencing hallucinations B. Frightened by hallucinations C. States, Seeing demons in my room D. Having distorted sensory perceptions

Correct Answer: C. States, Seeing demons in my room Charting must be clear and objective as possible. Quoting the client is always appropriate. Incorrect Answers: A. This provides a conclusion and is not in the client's own words. B. This is a judgment and should not be documented. D. This is a diagnostic statement and should not be documented. Vital Concept:Documentation should be factual and accurate, free from judgment, and as much as possible include the client's own words.

A client of 30 weeks' gestation is diagnosed as placenta previa. Which of the following should NOT be performed by the nurse? A. Monitor fetal heart rate B. Provide side lying position C. Monitor maternal vital signs D. Vaginal examination

Correct Answer: D. Vaginal examination Vaginal examination should be avoided in case of placenta previa because it can stimulate uterine activity.

Which of the following is a nasogastric tube that is used for gastric decompression? A. Salem-sump B. Levin C. Swan-Ganz D. PICC line E. A and B are nasogastric tubes

Correct Answer: E. A and B are nasogastric tubes The Levin and Salem sump tubes are both nasogastric tubes that are used for gastric decompression. The Levin tube has a single lumen and is used to prevent accumulation of gastrointestinal fluid and gas during and after intestinal surgery. The Salem-sump tube is a radiopaque tube that has a double lumen for gastric air compression and removal of fluid. A Swan-Ganz catheter is an intravenous catheter that is positioned at the pulmonary artery to record cardiac pressure. A PICC line is also known as a "peripherally inserted central catheter" and is used for long-term intravenous therapy.

A nurse is caring for a client who is admitted after hearing voices and demonstrating odd behaviors. The client's spouse asks the nurse for reassurance about the client's prognosis. Which of the following is the most appropriate response by the nurse? A. "I am sure your spouse will recover shortly and will be fine." B. "Of course, you are concerned. Can you talk about the things that are worrying you right now?" C. "You will have to ask the doctor about that." D. "Your spouse already seems better, don't you agree?"

Correct Answer: B. "Of course, you are concerned. Can you talk about the things that are worrying you right now?" This open-ended question acknowledges the spouse's concern and provides an opportunity for the client's spouse to express immediate concerns. Open-ended questions allow spontaneous expression of fears, feelings, and worries through interactive discussion. Incorrect Answers:A. This response is not therapeutic, ends the discussion, and does not encourage the client's spouse to express or explore feelings and concerns. It is not an honest response, as the nurse has no way of knowing what will occur in the future. False reassurance is a barrier to effective communication. C. The nurse has a responsibility to the client and the client's family and should address the spouse's concerns using therapeutic communication techniques. The nurse should not shift the responsibility to others. D. This is not an open-ended question. It also gives a personal opinion, which is a barrier to effective communication, and may prevent the client's spouse from offering an opinion or expressing feelings and concerns. Vital Concept:Clients and their families may ask questions that are an expression of deeper concerns or fears. While it is important to provide factual information when available, the nurse should use therapeutic communication techniques like open-ended questioning to encourage the client or family member to express and explore fears and concerns with support and acceptance.

A physician orders blood transfusion for a client. Which of the following intravenous device should the nurse use for transfusing blood? A. One which is being used by the client which is working well B. Large bore catheter C. Small bore catheter D. A device according to the physician's preference

Correct Answer: B. Large bore catheter Large bore catheters prevent damage to blood components. Usually this means 18 gauge or larger. Outside of pediatrics, a 20 gauge or larger is recommended.

A nurse is preparing to insert a rectal tube in a client with abdominal distention. Which of the following positions should the client be placed in? A. Prone and flat B. Left-side recumbent C. Right-side Fowler's D. Supine and flat

Correct Answer: B. Left-side recumbent Left-sided position allows easy insertion of the tube and recumbent position will be more comfortable to the client. Incorrect Answers:A. The prone position is not the most effective client position for insertion of a rectal tube; the nurse should have the client lie in the left lateral recumbent position. C. The right-sided Fowler's position would not be comfortable for the client and does not facilitate easy insertion of a rectal tube. D. Having the client lie on his back in the supine position would not make inserting a rectal tube easy; the nurse should position the client on his left side. Vital Concept:A rectal tube is placed to relieve the discomfort of abdominal distention and flatus caused by decreased intestinal motility. The client should be positioned in the left lateral recumbent position and don clean disposable gloves. The nurse should lubricate the tube with water soluble lubricant to ease insertion, before inserting the rectal tube tip into the rectum and advancing it 2-4 inches. The tube should be directed towards the umbilicus. The nurse should also encourage client to breathe slowly and deeply or to bear down to relax the anal sphincter. The tube is taped to the buttocks and attached to the container to collect any drainage. References:

A 32-year-old female client recently underwent gastric surgery. The nurse evaluates the client for signs of a potential infection. Which of the following observations suggest the client might have an infection? (Select all that apply). A. A temperature of 98.1° F B. Purulent drainage at the incision site C. Itching at the incision site D. The client complains of feeling cold E. Tender, firm skin around the incision site

Correct Answers: B. Purulent drainage at the incision site E. Tender, firm skin around the incision site Correct Answers:B. Purulent drainage at the incision site is a sign of an infection, and the provider should be notified. E. Tenderness and firmness felt around the incision site could be a sign of infection, and the provider should be notified. Incorrect Answers:A. This temperature is expected and does not indicate infection. C. Itching at the incision site can be an expected part of wound healing and is not an immediate concern for infection. D. The client feeling cold is not an immediate concern for infection, but if they have chills, then it would be a sign of infection. Vital Concept:Complications that may occur in the immediate postoperative period include infection, and the nurse needs to be aware of the associated signs and symptoms. For example, purulent drainage, warmth, redness, swelling, or tenderness around the incision site could indicate an infection. Fever is also a telltale sign of an infection. For any of these signs or symptoms, the provider should be notified.

A nurse is conducting an education session about maintaining confidentiality of the electronic medical record (EMR) with a group of newly hired nurses. Which of the following statements by a newly hired nurse demonstrates an understanding of the information? A. "I should log off the EMR on the client's in-room computer if I need to leave the room to collect supplies." B. "If I use worksheets for planning care for my clients, I should discard them in the wastebasket at the end of the shift." C. "I can permit any staff member in our facility to see information on my client's EMR." D. "I can share my facility computer password with the nurses on my client's care team."

Correct Answer: A. "I should log off the EMR on the client's in-room computer if I need to leave the room to collect supplies." The nurse should log off a computer terminal in a client's room upon leaving the room, even if the nurse expects to return momentarily. Protection of client information should be the nurse's priority. Incorrect Answers:B. Any printed material that contains client names or other personal information should be shredded so that the material is not accessible by others. This includes worksheets and planning sheets used for client care, as well as information from a client's EMR that was printed in order to fax material or to plan care. C. Only staff who are directly involved with a client's care should see EMR information about that client. D. The nurse should not share a facility computer password with anyone else at any time. The personal computer password should be kept private and should be changed frequently to prevent unauthorized access to a client's EMR. Vital Concept:The nurse should take responsibility for maintaining the privacy of electronic medical records and personal health information for the clients in his care. Strictly following a few specific rules can help to prevent a breach of confidentiality that could allow unauthorized persons to view a client's personal information. The electronic medical record should be used to enhance communication and provide accurate information about the client and her care.

A nurse has the following tasks to complete. Which task can be appropriately assigned to a certified nursing assistant? A. Obtain routine vital signs on a group of clients B. Administer a tube feeding for a client with a nasogastric tube C. Monitor the blood pressure of a client who is in congestive heart failure D. Complete wound care for a client with burns

Correct Answer: A. Obtain routine vital signs on a group of clients Certified nursing assistants are trained to obtain vital signs accurately. Incorrect Answers:B. Administering tube feedings is outside the scope of practice of a CNA C. This client is not stable and needs the skills of the nurse to complete a thorough assessment D. Burn care is a sterile procedure and falls outside the scope of nursing assistant practice.

A 62 -year-old female client is diagnosed with severe osteoporosis. The nurse would give instruction regarding which exercise to avoid: A. Abdominal sit-ups B. Regular stretches C. Walking D. Water exercises

Correct Answer: A. Abdominal sit-ups Abdominal sit ups need loaded forward flexion of spine which can make the client prone to fracture of weakened spine.

A procedure involving a barium enema increases the possibility of contact between the patient's body fluids and the radiographer. Which of the following is recommended in this situation? A. Use of a disposable gown and gloves B. Uniform C. Gloves only D. Shoe covering E. Head covering

Correct Answer: A. Use of a disposable gown and gloves Contact precautions that should be observed include mask, gloves, and disposable gown, in addition to observation of universal or standard precautions. A head covering or a shoe covering is intended to protect the patient. Uniforms are not a barrier to infection.

The primary risk for oral cancer is: A. Lack of dietary vitamin B12 B. Inadequate dental care C. Excessive alcohol D. Use of mouthwash

Correct Answer: C. Excessive alcohol Abuse of alcohol and tobacco are the leading causes of oral cancer. Vitamin B12, inadequate dental care and use of mouthwash have NOT been associated as primary risk factors for oral cancer.

The nurse must be extremely careful in protecting a client with leukemia from any source of infection primarily because: A. If these clients acquire an infection and antibiotics are ordered, they would suffer very serious side effects from such drugs B. They might contact pneumonia and become even more ill C. Leukemia seriously affects the blood forming system (WBCs) and its ability to ward off infection D. An infection could precipitate spontaneous bleeding and hemorrhage

Correct Answer: C. Leukemia seriously affects the blood forming system (WBCs) and its ability to ward off infection Clients with acute leukemia have an increased potential for infection because they have immature WBSs that are incapable of fighting infection.

While installing electrical wiring in the intensive care unit, the workmen start an electrical fire. The nurses' first action when caring for a ventilator dependent client should be to: A. Extinguish the fire B. Notify the nursing supervisor C. Remove the client and provide bag valve mask ventilations D. Activate the fire alarm

Correct Answer: C. Remove the client and provide bag valve mask ventilations The client is the priority of care. You must make sure the client is safe, then you can take other actions. Incorrect Answers:A. The client must be rescued first B. The client must be rescued first D. The client must be rescued first Vital Concept:In the event of a fire, the nurse should first rescue the client, then set off and alarm. Next, the nurse will confine the fire by closing doors, or other access to the fire and if possible extinguish the fire.

A nurse is caring for a client who has undergone hemorrhoidectomy. Which position would be best for the client in the early postoperative period? A. High Fowler's B. Supine C. Side-lying D. Trendelenburg

Correct Answer: C. Side-lying Positioning in the early postoperative phase should avoid stress and pressure on the operative site. The prone and side-lying positions are ideal from a comfort perspective. Incorrect Answers:A. and B. A high Fowler's or supine position will place pressure on the operative site and are not recommended. D. There is no need for Trendelenburg's position. Vital Concept:After hemorrhoidectomy, the client can be placed in the side-lying or prone position to avoid stress on the surgical site. The lateral position is more comfortable, as the prone position is associated with low back ache and pain over the pubis.

A nurse is inserting a nasogastric tube. Which of the following indicates proper placement of the tube in stomach? A. Client is unable to speak B. Client gags during insertion C. pH of aspirate is less than 6 D. Fluid is easily instilled into the tube

Correct Answer: C. pH of aspirate is less than 6 For determining the correct placement of the NG tube the nurse should aspirate stomach contents and check the pH, which should be acidic. Incorrect Answers:A. If the client is unable to speak, the NG tube is likely placed in the lung. B. The client will likely gag during insertion. This is not suggestive of placement in either the lungs or the stomach. D. Fluid should freely pass into the tube regardless of placement in the lung or stomach. This is not suggestive of placement in either the lungs or the stomach. Fluid should not be used when confirming placement. Vital Concept:Air sounds heard over the stomach and not over the lungs are suggestive of correct NG tube placement. Aspiration of stomach contents, confirmed by pH testing indicates placement in the stomach.

The nurse is helping to care for an 82-year-old female who speaks Spanish as her primary language. The client has not been compliant with the prescribed care plan for her chronic obstructive pulmonary disease (COPD). The nurse knows which of the following can be done to increase the chances that the client will adhere to the prescribed treatment plan? (Select all that apply). A. Give the treatment plan instructions verbally as well as in written form B. Provide the treatment plan in Spanish C. Scold the client for not following the plan D. Include a family member when reviewing the client's treatment plan E. Provide instructions in a large font that is easy to read

Correct Answers: A. Give the treatment plan instructions verbally as well as in written form B. Provide the treatment plan in Spanish D. Include a family member when reviewing the client's treatment plan E. Provide instructions in a large font that is easy to read Correct Answers:A. This action would likely increase adherence to the treatment plan because providing information in various formats can promote understanding of instructions. B. This action would likely increase adherence to the treatment plan because the client speaks Spanish and are more likely to understand the information in their primary language. D. This action would likely increase adherence to the treatment plan if they are the primary caretakers. E. This action would likely increase adherence to the treatment plan because older adults often have trouble with their vision, so a larger font will be easier for the client to read. Incorrect AnswersC. Clients should never be scolded for not adhering to a treatment plan. Vital Concept:To increase the chances of adherence to treatment plans, the nurse should try various methods of delivering the information. For example, the nurse should provide treatment plan instructions verbally as well as in writing. Instructions in alternate formats such as large fonts or in the patient's primary language may increase adherence to the plan. If family members are included in the client's teaching, it might increase adherence to the plan. Scolding the client is not a good strategy to increase adherence to a treatment plan.

Anemia is characterized by: A. Increased circulating red blood cells B. Decreased platelets C. Decreased hemoglobin D. Decreased white blood cells E. A and C are correct

Correct Answer: C. Decreased hemoglobin Anemia is a condition that affects red blood cells, resulting in decreased numbers of red blood cells and decreased hemoglobin, which is the molecule within red blood cells that carries oxygen to the body's tissues. There are a variety of causes of anemia that can be treated to improve the condition. Incorrect Answers:A. Increased circulating red blood cells are referred to as erythrocytosis. B. Decreased platelets refer to thrombocytopenia. D. Decreased white blood cells are referred to as leukopenia and may be further characterized by the type of white blood cell that is decreased in number.

A nurse is caring for a 54-year-old client with a diagnosis of right-sided heart failure (see image). The nurse would expect which of the following symptoms in this client? A. Dyspnea B. Crackles C. Cough D. Dependent edema

Correct Answer: D. Dependent edema Dependent edema is seen in right-sided heart failure, characterized by signs of fluid retention and overload. Incorrect Answers:A. Dyspnea is seen in left-sided heart failure, which is characterized by pulmonary signs and symptoms.B. Crackles are seen in left-sided heart failure, which is characterized by pulmonary signs and symptoms.C. Coughing is seen in left-sided heart failure, which is characterized by pulmonary signs and symptoms.Vital Concept:Right-sided heart failure is characterized by signs of fluid retention and overload resulting from right ventricular failure. This manifests as dependent edema, weight gain, a distended abdomen, distended neck veins, and polyuria at night. By contrast, left-sided heart failure is characterized by pulmonary symptoms such as dyspnea, crackles on auscultation, or a hacking cough.

Disclosure of confidential patient information by a radiographer to unauthorized individuals is known as: A. Slander B. Defamation C. Libel D. Invasion of privacy

Correct Answer: D. Invasion of privacy Disclosure of confidential patient information by a radiographer to an unauthorized individual is known as "invasion of privacy." If the information is detrimental or causes harm to the patient, this is known as "defamation. " Spoken defamation is known as "slander." Written defamation is known as "libel."

A nurse is teaching a group of assistive personnel (AP) about performing hand hygiene. Which of the following statements should the nurse include in the teaching? A. "You should avoid wearing artificial nails." B. "You may wear your rings when washing your arms and hand." C. "You can grow your fingernails any length." D. "You can use your own personal hand lotion after washing your hands "

Correct Answer: A. "You should avoid wearing artificial nails." Short, natural nails harbor fewer micro-organisms that can be harmful to clients. The CDC recommends health care workers avoid wearing artificial nails when caring for clients who are at risk for infection. Additionally, guidelines from the World Health Organization prohibit artificial nails for caregivers in every setting. Incorrect Answers:B. The nurse should include in the teaching for the AP to remove jewelry and rings to facilitate proper protocol for hand washing. C. The nurse should instruct the AP to manicure natural fingernails to be short, because short natural nails harbor fewer micro-organisms that can cause an infection. D. The nurse should include in the teaching for the AP to use only the agency-approved hand lotions and dispensers following hand hygiene. Using personal lotions can cause breakdown of latex gloves and might make hand hygiene practice less effective. A personal dispenser can become contaminated with micro-organisms if refilled. Vital Concept:A nurse who is teaching a group of assistive personnel (AP) is serving as a resource individual to staff members. As a resource individual, it is vital for the nurse to provide accurate information to the target audience. Good hand hygiene requires the AP to have an understanding of the purpose of the techniques. The goals of hand hygiene include decreasing micro-organism on the hands, lowering the risk for transmission of micro-organisms, and reducing cross-contamination between clients and oneself. Short, natural nails harbor fewer micro-organisms that can be harmful to clients. The CDC recommends health care workers avoid wearing artificial nails when caring for clients who are at risk for infection. Additionally, guidelines from the World Health Organization prohibit artificial nails for caregivers in every setting. Healthcare workers should limit the amount of jewelry worn and remove jewelry when performing hand hygiene. The nurse should include in the teaching for the AP to use only agency-approved hand lotions and dispensers following hand hygiene. Using personal lotions can cause breakdown of latex gloves and might make hand hygiene practice less effective. A personal dispenser can become contaminated with micro-organisms if refilled. All healthcare providers should follow identical protocol for hand hygiene and promote accountability.

The Licensed Practical Nurse (LPN/LVN) is working on a pediatric unit and is assigned to care for a 10-year-old boy who has leukemia. The client is no longer eating or drinking, oral needs have been discontinued because the client is unable to swallow them and urine output is negligible. The physician expects that the client will expire within the next 24 hours. The client is semi-conscious and is moaning. Facial grimacing is also apparent. The client's blood pressure is low and his respirations are 8 per minute. The parents ask the LPN/LVN to administer an opioid because the client is moaning and appears to be in pain. What should the LPN/LVN do? A. Administer the prescribed prn medication B. Refuse to administer the narcotic because giving the narcotic could further decrease the client's respiratory rate C. Give half the dose of the prescribed pain medication D. Ask the client's parents if they are aware that giving a narcotic could kill their son

Correct Answer: A. Administer the prescribed prn medication The client should be given pain medication. Their respirations are acceptable and are likely to increase due to pain. Client respirations are unlikely to drop to an unacceptable range (less than 8BPM) while they are experiencing pain. Incorrect Answers:B. The client having pain is unlikely to become hypopneic. C. It is inappropriate to alter the dose. D. This is an inappropriate statement. Vital Concept:All clients have the right to be free from pain and to die with dignity. The nurse should administer pain medications as long at it is reasonable to do so.

A nurse is caring for a 32-year-old pregnant client with an active genital herpes infection. The nurse should make sure the client understands which of the following about a vaginal delivery with an active infection? A. Babies delivered vaginally may become infected with the virus B. The recommended treatment for herpes is excision of the lesions C. Pain generally does not occur with a herpes outbreak D. Influenza-like symptoms occur 2 weeks after the lesions appear

Correct Answer: A. Babies delivered vaginally may become infected with the virus The client should know that babies delivered vaginally by women with active herpes infections may also become infected with the virus. Incorrect Answers:B. Herpes lesions cannot be controlled or treated with excision.C. Itching and pain accompany the process as the infected area becomes red and swollen. D. Flu-like symptoms may occur 3 to 4 days after the lesions appear in an initial or primary outbreak but is unlikely during subsequent outbreaks. Vital Concept:Herpes simplex is one of the most common sexually transmitted infections. Because the infection is common in women of reproductive age, it can be contracted and transmitted to the fetus during pregnancy. In pregnant women with active genital herpes, babies delivered vaginally may become infected with the virus. There is a risk for fetal morbidity and mortality if this occurs.

A client is receiving IV gentamicin. Which of the following may indicate an adverse response to gentamicin? A. Decreased urine output B. Blurred vision C. Orange sputum D. Hypertension

Correct Answer: A. Decreased urine output A major toxicity of gentamicin is nephrotoxicity. Diminished urine output indicates damage to the kidneys. Incorrect Answers:B. Blurred vision is not a common adverse response to gentamicin. The major adverse responses are nephrotoxicity and ototoxicity. C. Orange sputum is not an adverse response to gentamicin. Orange-colored sputum may occur with Rifampin. The major adverse responses are nephrotoxicity and ototoxicity. D. Hypertension is not an adverse response to gentamicin. The major adverse responses are nephrotoxicity and ototoxicity.

A client who has remained in bed for most of the day develops pooling of blood in the lower extremities. This situation places the client at risk of developing which of the following conditions? A. Deep vein thrombosis B. Contractures C. Urinary retention D. Constipation

Correct Answer: A. Deep vein thrombosis Pooling of blood in the lower extremities may occur with a lack of activity and ambulation. This excess blood increases the risk of blood clotting, which could result in a deep vein thrombosis if a clot forms in the veins of the lower leg. Incorrect Answers:B. While an immobile client may be at higher risk of contractures, these are not caused by excessive pooling of blood. C. Urinary retention does not develop from pooling of blood in the lower extremities. D. While an immobile client may be more likely to develop constipation, this does not develop as a result of excessive pooling of blood in the lower extremities. Vital Concept:Risk factors for venous thromboembolism, including deep vein thrombosis and pulmonary embolus, fall within three broad categories of risk: stasis, hypercoagulable states, and damage to the intima of the blood vessel. Hypercoagulable states include chronic estrogen supplementation, malignancy; damage to the lining of the vessel can occur as a result of trauma or a surgical procedure.

A nurse is teaching the parent of a 2-year-old how to instill ear drops into the child's ear. Which of the following is the correct instruction to the parent about moving the pinna of the ear before instilling drops? A. Down and to the back B. Down and to the front C. Up and to the back D. Up and to the front

Correct Answer: A. Down and to the back The child's ear canal is straighter than an adult's canal so the pinna should be pulled down and back. However, in an adult, the pinna should be pulled up and back. Vital Concept:When administering otic drops, the nurse understands that the ear canal is straightened by pulling the pinna up and back for the adult and down and back for the infant and young child less than 3 years of age. After administration of the ordered number of drops against the side of the inner ear, the parent should hold the auricle in place until the medication is no longer visible, then release the auricle of the ear. The client should remain in the side lying position with the treated ear up for at least 10 minutes to allow the medication to enter the ear.

Privacy and confidentiality are principal components of the rights of patients and clients. Which of the following statements correctly distinguishes between both, respectively? A. Privacy is the right of individuals to keep information about themselves from being disclosed; confidentiality is the how nurses and other care team members treat private information once it has been disclosed. B. Privacy is how nurses and other care team members treat private information once it has been disclosed to them; confidentiality is the right of individuals to keep information about themselves from being disclosed. C. Privacy is the right of individuals to determine their own care decision in confidential environments; confidentiality is self-determination in care decisions. D. Privacy is the ability of individuals to disclose information to care providers; confidentiality is the ability to remain informed about all personal care decisions made by others.

Correct Answer: A. Privacy is the right of individuals to keep information about themselves from being disclosed; confidentiality is the how nurses and other care team members treat private information once it has been disclosed. Each client has a right to both privacy and confidentiality. Incorrect Answers: B. This option is incorrect. The definitions are not appropriate. C. This option is incorrect. The definitions are not appropriate. D. This option is incorrect. The definitions are not appropriate. Vital Concept:Each client has the right to privacy and confidentiality. The nurse has a responsibility to understand and adhere to these practices. If they do not they can be held liable.

The nurse enters a client's room to administer her oral medications and the client states that one of the medications is different from what she has taken in the past. Which of the following nursing interventions will prevent a medication error? A. Recheck the medication in question against the physician order before proceeding B. Tell the client that it must be a new medication that her physician has ordered C. Leave her medication at the bedside and tell her that they are what the physician ordered D. Omit the medication and record the fact that it was refused

Correct Answer: A. Recheck the medication in question against the physician order before proceeding Always recheck the medication against the physician's order when a client note a discrepancy. Most often the client is correct, and this will avoid a medication error. The medication is most likely from a different manufacturer.

A nurse should instruct a client with uric acid kidney stones to avoid which of the following food? A. Red meat B. Soy milk C. Orange D. Strawberries

Correct Answer: A. Red meat Consumption of foods high in animal protein such as red meat, fish, shellfish, etc., causes increased formation of uric acid. So the clients with uric acid kidney stones should avoid intake of animal proteins. Incorrect Answers:B. Soy milk is acceptable on a low purine diet. C. Oranges are acceptable on a low purine diet. D. Strawberries are acceptable on a low purine diet. Vital Concept:Gout is largely prevented by controlling the intake of foods the lead to high levels of uric acid. Organ meats, red meats, seafood, and some other foods should be avoided.

The client reports aching and cramping in her calves when she is walking for exercise. What activity should the nurse suggest to the client to prevent this pain? A. Swimming B. Jogging C. Downhill skiing D. Golfing

Correct Answer: A. Swimming Swimming is an appropriate non-weight bearing activity for this client. Incorrect Answers: B. Jogging is not an appropriate activity to decrease pain in the calves when exercising. C. Downhill skiing is not an appropriate activity to decrease pain in the calves when exercising. D. Golfing is not an appropriate activity to decrease pain in the calves when exercising. Vital Concept:Exercise is important for clients with lower extremity venous congestion. In this case, weight-bearing exercise tends to cause the client pain so the nurse might suggest a non-weight bearing exercise such as swimming.

For a client with a lower respiratory tract infection, when is the best time for the nurse to perform postural drainage? A. When the client has an empty stomach B. When the client is short of breath C. When the client experiences coughing D. When the respiratory therapist orders it

Correct Answer: A. When the client has an empty stomach Postural drainage is performed before eating or after consumed food has left the stomach. If it is done on a full stomach, the positioning, coughing, or expectorating can cause nausea and/or vomiting.

A nurse is working in a large factory that makes wholesale furniture products. The nurse manages clients who have work-related injuries or illnesses. What is the role of this nurse? A. Occupational health nurse B. Staff nurse C. Research nurse D. Nurse educator

Correct Answer: A. Occupational health nurse Occupational health nurses provide direct care to clients in their workplace who are ill or injured while at work; they also conduct programs and screenings for the safety of the staff. Incorrect Answer: B. A staff nurse is a general term for a nurse that works in an inpatient facility providing direct care to patients. C. A research nurse works with an academic institution or hospital conducting clinical research studies. D. A nurse educator is generally a master's trained nurse that works in a nursing school or the education department within a hospital. Vital Concept: Occupational health nurses provide direct care to clients in their workplace who are ill or injured while at work; they also conduct programs and screenings for the safety of the staff.

A nurse in a provider's office is caring for a client who has type 2 diabetes mellitus. The client asks the nurse why the provider bases his medication regimen on his HbA1c level instead of his morning fasting blood glucose results. Which of the following responses should the nurse make? A. "HbA1c measures how well insulin is regulating your blood glucose between meals." B. "HbA1c indicates how well you have regulated your blood glucose over the past 90-120 days." C. "HbA1c identifies other health problems associated with diabetes you might have." D. "HbA1c determines if your doctor should adjust your insulin dosage at this time."

Correct Answer: B. "HbA1c indicates how well you have regulated your blood glucose over the past 90-120 days." HbA1c measures blood glucose control over the past 90-120 days and helps the provider to assess the client's long-term glycemic control. Incorrect Answers:A. Capillary glucose monitoring evaluates how well insulin is regulating blood glucose between meals. C. An HbA1c test, along with a fasting plasma glucose level, is used to screen for diabetes. Thereafter, the HbA1c measures blood glucose control over the past 90-120 days and helps the provider to assess the client's long-term glycemic control. D. Capillary glucose monitoring identifies the client's current blood glucose level and helps to determine if an additional dose of insulin is needed at the present time. Vital Concept:The HbA1c is a test that is used to screen a client for diabetes, along with a fasting plasma glucose level. The expected reference range for an HbA1c value is 4 to 6%. A level of 5.7 to 6.4% indicates an increased risk for diabetes, and levels above 8% indicate poor glycemic control. The HbA1c test is unique in that it is the average blood glucose reading over the last 90-120 days since the life span of a red blood cell is 120 days. The reading is not affected by eating habits that occurred the day before the test, as a capillary blood glucose reading is. An HBA1c test assesses the client's long-term glycemic control and determines the need for an adjustment of the client's medication regimen and can indicate that a client is not adhering to the prescribed therapy.

A nurse is teaching a client who has a new prescription for timolol ophthalmic drops. The client asks why she should press on the nasolacrimal duct when administering the drops. Which of the following responses should the nurse make? A. "Pressing on the duct will prevent the medication from burning or stinging." B. "Pressing on the duct will prevent the medication from being absorbed into the body." C. "Pressing on the duct will prevent infection." D. "Pressing on the duct will prevent dry eye."

Correct Answer: B. "Pressing on the duct will prevent the medication from being absorbed into the body." Pressing on the nasolacrimal duct blocks the lacrimal punctum and prevents systemic absorption of the medication, which can cause adverse cardiovascular effects, or bronchospasm. Incorrect Answers:A. Burning or stinging is a common side effect of the beta-adrenergic eye drops. C. Pressing on the nasolacrimal duct will not prevent infection. The client should be taught to wash hands, to avoid touching the tip of the dropper to the eye, and to use a clean tissue or cotton ball to press on the nasolacrimal duct. D. Pressing on the duct will not prevent dry eye, as it is a common side effect of beta-adrenergic blockers. Vital Concept:Systemic absorption of a beta blocker can cause systemic effects, especially in the cardiac and respiratory systems. One drop of 5% timolol in each eye is the equivalent of 10 mg of timolol by mouth. Caution should be taken with clients who are taking a beta-blocker orally as well. The nurse should assess the client's pulse prior to the administration of timolol.

The nurse is caring for a client who has been diagnosed with breast cancer. During the discussion, the client says that she thinks she got breast cancer because she had an affair with another man during her marriage. The most therapeutic response from the nurse would be: A. "Why don't you tell your husband about this so you can quit thinking about it?" B. "Tell me your feelings about this." C. "Would you like to talk to the chaplain about this?" D. "Breast cancer is a disease, not a punishment."

Correct Answer: B. "Tell me your feelings about this." Although all of these techniques might be useful for this client during the course of treatment, the most therapeutic response at this point in her disease is to encourage her to talk about her feelings related to this. This statement provides an opportunity for the client to identify troubling emotions or thoughts and, by demonstrating acceptance of the client's feelings, the nurse facilitates a trusting relationship with the client. Incorrect Answers:A. This does not guide the client in her thinking or educate her in any way. C. Talking to the chaplain may help but the nurse is not providing any education for the client about the cause of her cancer. D. While this is true, the client may need to talk more about why she feels the way she does. Vital Concept:After diagnosis with a terminal or life-threatening illness, an individual may begin to review his/her life and its purpose. The client may think about important events, relationships, and experiences. This may remind the client of conversations and activities that need to take place before death, and conflicts the client would like to resolve. Individuals facing a life-threatening illness may also experience feelings of guilt, anxiety and depression. They may blame their own lifestyle choices for their illness, or feel they are in some way responsible for their illness. They may worry they could have noticed their symptoms sooner or feel that they're being a burden to loved ones.

A nurse on a medical unit is assigned to five newly admitted clients. Which of the following clients will require airborne precautions? A. A client with AIDS admitted for dehydration due to severe diarrhea B. A client with a positive PPD and an abnormal chest X-ray C. A client with lymphoma involving the lungs with hemoptysis D. A client with symptoms suggestive of influenza, who has altered immune function E. A client with pneumococcal pneumonia and a possible empyema

Correct Answer: B. A client with a positive PPD and an abnormal chest X-ray A client with a positive PPD and an abnormal chest X-ray may have active TB (tuberculosis). Active TB, chickenpox and measles are examples of diseases for which airborne precautions are necessary. The microorganisms causing these diseases are transmitted through the air. Incorrect Answers:A. A client with AIDS and severe diarrhea requires standard precautions because of the bloodborne nature of AIDS, and also requires contact isolation because of the possible infectious nature of the diarrhea. C. A client with lymphoma does not require isolation precautions; however, a client who is expectorating blood should have standard precautions in place. D. Droplet precautions are designed to prevent contact with infectious material or organisms from the nose, sinuses and airway, including the lungs. Diseases require droplet isolation precautions include influenza, pertussis (whooping cough), and mumps. E. A client with pneumococcal pneumonia would not require airborne precautions. Standard or droplet precautions might be used in this case. Vital Concept:In addition to standard precautions, transmission-based precautions are necessary for clients who have documented or suspected infection or colonization with highly transmissible or epidemiologically-important pathogens for which additional precautions are needed to prevent transmission. Transmission-based precautions include contact precautions, droplet precautions, and airborne precautions.

A 14-year-old girl has given birth to a healthy infant and is now ready for discharge. The Licensed Practical Nurse (LPN/LVN) expects that this client will be referred to: A. Planned Parenthood B. A home health agency capable of supporting mothers and newborns C. An adoption agency D. Physiotherapy

Correct Answer: B. A home health agency capable of supporting mothers and newborns This client will require ongoing support in the coming days and weeks to continue to strengthen the maternal-infant bond. At some point, the mother may require referral to community resources that can help with financial, educational, and social support. Incorrect Answers:A. This is not an appropriate referral for this client C. There is no indication this referral is needed for this client D. There is no indication this referral is needed for this client Vital Concept:The 14-year-old who has had a child will likely require a great deal of assistance. Referral to a home health agency will allow an appropriate assessment to be made of their needs.

A nurse is attending to an 85-year old woman, who initiates a conversation about end-of-life planning. She indicates her preference for more information about advanced directives and minimal intervention in the case of a medical emergency. What is an proper sequence of events this nurse should follow in preparing to engage with this client? A. Immediately summon a family member, acknowledge the clients right to self-determination, schedule a consult for mental capacity to designate proxy, and document the conversation B. Acknowledge the clients right to self-determination, provide guidance regarding advance directives, commence appropriate institutional protocols, ensure living will and other documentation enter the client's record, and inform attending physicians. C. Determine client's mental capacity, summon a family member, designate a proxy, draft and enter into the record the living will and advance directive. D. Counsel the client that care may not be withheld in clients with advanced directives, summon a family member, determine mental capacity, and refer to case manager should mental capacity be established. E. Determine client's residency status, acknowledge that race, culture and religion can influence the client's request, assess client competency, enter into medical record client's preference, and inform family members.

Correct Answer: B. Acknowledge the clients right to self-determination, provide guidance regarding advance directives, commence appropriate institutional protocols, ensure living will and other documentation enter the client's record, and inform attending physicians. The best sequence includes, acknowledging the clients right to self-determination, providing guidance regarding advance directives, commencing appropriate institutional protocols, ensuring living will and other documentation enter the client's record, and informing attending physicians. A, C, D, E each are sequentially disordered action item and may include steps which violate the clients right to self-determination and privacy or confidentiality protocols.

The most common opportunistic infection in clients with HIV infection is: A. Aphthae B. Candidiasis C. Cytomegalovirus (CMV) D. Herpes simplex virus (HSV)

Correct Answer: B. Candidiasis Oral Candidiasis, or thrush, is the most common opportunistic infection in HIV clients. CMV and HSV are opportunistic infections that typically are seen in full blown AIDS. Aphthae, or canker sores, are not opportunistic infections.

A nurse knows that parents who do not use a child safety seat when transporting the child are engaging in which of the following? A. Sexual abuse B. Child neglect C. Emotional abuse D. Physical abuse

Correct Answer: B. Child neglect Child neglect can take many forms and is the most common type of child abuse, occurring in over 50% of cases. It is a failure to provide for the basic physical, medical, emotional, or educational needs of the child. Physical neglect occurs when a caretaker does not provide food, clothing, hygiene, shelter, or protection from harm. Failure to provide love, security, and emotional support characterize emotional neglect. Educational neglect is characterized by failure to ensure school attendance, appropriate homeschooling, or enrollment in school. Medical neglect is a delay in seeking medical care or refusal of care that results in a risk of damage or in actual damage to the child. Neglect includes both actual harm and the potential for harm, such as leaving a young child unattended for several hours alone in a home or failure to use a child seat, even if there is no injury. When the parents are ignorant of childbearing practices, the nurse can provide education about the child's needs. In child abuse or neglect, the nurse should protect the child from further abuse, advocate for the child, and support the family. Incorrect Answers:A. Sexual abuse refers to engagement of a child in sexual activity for which the child is not developmentally prepared, cannot consent, or cannot understand, as well as any activity that violates the law or societal norms. It includes touching and non-touching abuses like child pornography. C. Emotional abuse refers to a pattern of damaging interactions that characterize a relationship, causing the child psychological harm and impaired psychological development. The abuser may act with verbal assaults or threats if expectations are not met by the child, creating an unstable environment, or by withholding psychological support. The caretaker may reject or terrorize the child, spurn the child, and erode his/her self-esteem. D. Physical abuse is injury inflicted on a child by the caretaker or parent and includes abusive head trauma and orthopedic injuries. Vital Concept: Child neglect may result from the parents' or caregivers' ignorance of the child's needs. The nurse plays an important role in protection of the child by educating the parents about the child's physical and emotional needs.

Management of a patient who requires frequent intravenous injections can include use of which of the following venous devices? A. Hypodermic syringe B. Heparin lock C. Butterfly needle D. Intravenous infusion E. Arterial line

Correct Answer: B. Heparin lock Heparin locks are intermittent injection ports that are used for patients who require frequent or regular intravenous injections. This can help prevent sclerosis or scarring of veins. The heparin lock is an intravenous catheter with an external adapter that has a diaphragm that allows repeated injections. A heparin lock allows greater patient freedom than an intravenous line. Butterfly needles are used for venipuncture. Arterial lines are not venous devices and are used to measure arterial blood pressure accurately in conjunction with a monitor. Hypodermic syringes are used to draw blood and fluid.

The operating room nurse discovers that the surgical consent has not been signed for this elective procedure. The adult client received pre-op sedation less than five minutes ago. The best response by the nurse is to: A. Have the client sign the consent form immediately B. Inform the physician the consent form has not been signed C. Find the client's spouse to provide the signature giving consent D. Continue to prepare the client for surgery. He has given implied consent since this is an elective surgery

Correct Answer: B. Inform the physician the consent form has not been signed The physician must be notified and the surgery postponed. Incorrect Answers:A. After a client has been even mildly sedated they cannot legally sign a consent form due to the mind-altering capability of the medication. C. The client's spouse cannot sign for them unless the client would have been unable to sign before the pre-op medications were given. D. Consent forms must be signed before surgery and before any mind-altering pre-op medications are administered. The only exception is in emergency situations. Elective surgery is not an emergency. Vital Concept:A consent form must be legally signed prior to surgery.

To prepare a client for crutch walking, it would be most important for the nurse to : A. Refer the client to physical therapy B. Initiate muscle strengthening exercises for arms and shoulders C. Urge the client to conserve strength in other activities to avoid tiring D. Demonstrate crutch walking, how to sit, stand, and get up from the floor in cases of falling

Correct Answer: B. Initiate muscle strengthening exercises for arms and shoulders The client will need strength before crutch walking. Although, d is correct, it is a physical priority to have the necessary strength before crutch walking.

Which of the following characterizes an iatrogenic infection? A. It is the result of transmission of infection by droplets during sneezing or coughing. B. It is the result of physician or medical intervention. C. It is the result of direct contact with another person. D. It is the result of direct contact with a contaminated fomite. E. It is caused by a bloodborne pathogen.

Correct Answer: B. It is the result of physician or medical intervention. Iatrogenic refers to injuries or infections that occur as the result of physician or medical intervention. This can include things like ventilator-acquired pneumonia or spread of infection through contaminated instruments used during a procedure. The prefix "iatra" is from the Greek word for physician, iatros.

Which of the following is true of a chest drainage system associated with a chest tube? A. It should be above the level of the patient's chest. B. It should be below the level of the patient's chest. C. It should be even with the patient's chest. D. Position in relation to the patient's chest is not important.

Correct Answer: B. It should be below the level of the patient's chest. Chest drainage systems collect air and fluid from chest tubes placed in the pleural space. They consist of a chamber to collect draining fluid, a chamber to control suction, and a water seal chamber to prevent air from the atmosphere from entering the system. The water seal chamber prevents pressure buildup. Chest drainage systems only work correctly when placed below the level of the chest. The radiographer should be careful to keep the tubes associated with a chest drainage system from kinking or becoming entangled with other equipment.

A pregnant client of 30 weeks' gestation got admitted to prevent preterm birth. Which of the following medication should the nurse expect to administer? A. Prostaglandins B. Magnesium sulfate C. Methergine D. Oxytocin

Correct Answer: B. Magnesium sulfate Magnesium sulfate is used to stop preterm labor to prevent preterm birth. The medication causes smooth muscle relaxation. Incorrect Answers: A. Prostaglandins do not prevent preterm labor. They are released during pregnancy and serve to soften the cervix and induce labor. C. Methergine is used after birth to treat postpartum bleeding. It is contraindicated during pregnancy. D. Oxytocin is used to stimulate uterine contractions, not to stop preterm labor.

A nurse is assisting a new mother who was just discharged and notes that the baby's father has positioned a car seat for the infant in the front seat of the car. Which of the following instructions is most appropriate for the nurse to relay to the parents? A. Move the car seat to the back seat and secure it facing forward B. Move the car seat to the back seat and secure it facing backward C. Leave the car seat in the front seat but ensure that the seatbelt is tight around the base D. Tell the parents that they need to use a different car seat

Correct Answer: B. Move the car seat to the back seat and secure it facing backward According to the American Academy of Pediatrics (AAP), a newborn infant must be placed in a rear-facing car seat that is appropriate for his size and is secured in the backseat. The nurse in this situation has an opportunity to educate new parents about appropriate standards of car seat use for their infant and may also instruct them about properly securing the infant within the car seat. Incorrect Answers:A. The car seat needs to be moved to the back seat but it should be rear facing. C. The car seat needs to be moved to the back seat. D. The parents do not necessarily need a different car seat, they just need to position it in the back seat. Vital Concept:Infants should be placed in a rear-facing car seat in the back seat as early as the initial trip home from the hospital. An rear facing seat should never be placed in a front seat with an active passenger side airbag, as serious injury or death can occur if the airbag deploys. Three types of rear-facing seats are available: rear-facing-only, convertible, and 3-in-1. When children reach the highest weight or length allowed by the manufacturer of their rear-facing-only seat, they should continue to ride rear-facing in either a convertible or 3-in-1 seat. Rear-facing-only seats are used for infants up to 22 to 40 pounds. These seats have carrying handles and usually have a base that can be left in the car. The seat locks into and out of the base, so there is no need to reinstall the seat with each use.

A nurse reviews a client's laboratory report and notes that the serum calcium level is 5.2 mg/dL (low). Which of the following would the nurse note on the electrocardiogram based on the laboratory value? A. ST depression B. Prolonged ST interval C. Prolonged PR interval D. Widened QRS complex

Correct Answer: B. Prolonged ST interval The normal serum calcium level is 8.6 - 10 mg/dL. In hypocalcemia the electrocardiogram changes are prolonged ST interval and Prolonged QT interval.

A nurse is developing a plan of care for a client who has a stage 3 pressure ulcer. Which of the following interventions should the nurse include in the plan? A. Heat the solution using a microwave before cleaning the wound. B. Reposition the client at least every 2 hr. C. Clean the wound with hydrogen peroxide solution. D. Massage reddened areas during dressing changes.

Correct Answer: B. Reposition the client at least every 2 hr. The nurse should plan to reposition the client at least every 2 hr and make a schedule to record position changes in the client's medical record. Incorrect Answers:A. Microwaving the solution can cause it to become too hot. The nurse should ensure the solution is at body temperature to prevent lowering of the wound temperature, which can slow the healing process. C. Hydrogen peroxide solution is a drying agent that does not promote the healing of fragile skin. The nurse should use isotonic solutions to clean the wound, such as 0.9% sodium chloride. If cleansing the wound with an antimicrobial solution, the solution should be well diluted. D. The nurse should avoid massaging reddened skin because it can damage fragile capillaries and increase tissue necrosis. Vital Concept:Caring for a client who has a stage 3 pressure ulcer begins with repositioning the client at least every 2 hr to prevent further breakdown of the skin. Developing a schedule for position changes and then recording the changes on the client's plan of care in the medical record ensures accountability for the care of the client. Special supportive devices, such as an overlay mattress, foam or gel mattress, or a kinetic bed, can provide pressure relief to prevent shearing and friction sores and reduce moisture to vulnerable areas of the client's body. The method for cleaning the wound, which is often performed through irrigation of the wound, depends on the stage of the pressure ulcer.

The nurse is planning care for a 47-year-old client with rheumatoid arthritis (see image). Which nursing diagnosis would be most appropriate for this client? A. Ineffective airway clearance B. Self-care deficit C. Disturbed body image D. Knowledge deficit Check Answer Show Explanation Grade Pause Previous171172173174175176177178179180

Correct Answer: B. Self-care deficit Correct Answer:This client is most likely to have a self-care deficit related to pain, fatigue, and joint stiffness due to rheumatoid arthritis. Incorrect Answers:A. Ineffective airway clearance is not the most suitable choice for a client with rheumatoid arthritis.C. While a disturbed body image is possible, this is not the most appropriate choice for a client with rheumatoid arthritis.D. While a knowledge deficit is possible, this is not the most relevant choice for a client with rheumatoid arthritis.Vital Concept:Nursing diagnoses are actual or potential problems that independent nursing actions can manage. For example, the nursing diagnosis of a self-care deficit would be most applicable for a client with rheumatoid arthritis since these clients have a lot of pain, fatigue, and joint stiffness that interfere with their ability to care for themselves daily.

A nurse is caring for a client who is receiving heat therapy using an aquathermia pad. Which of the following actions should the nurse take? A. Fill the reservoir to the top with water. B. Stop the treatment if the client's skin becomes red. C. Leave the pad in place for at least 40 min. D. Use safety pins to keep the pad in place.

Correct Answer: B. Stop the treatment if the client's skin becomes red. The nurse should check the client's skin every 15 to 20 min and discontinue treatment if the client's skin becomes red or the client reports increased pain. Incorrect Answers:A. The nurse should fill the reservoir 2/3 full of water to reduce the risk for water leaking from the reservoir. C. The nurse should apply the heat application for no longer than 30 min to reduce the risk for tissue injury. D. The nurse should use gauze or tape to keep the pad in place. Safety pins can puncture the pad and cause leakage. Vital Concept:An aquathermia pad is a heating pad that can provide moist or dry heat. It is made of water filled tubes that are heated electrically. The reservoir should be 2/3 full of water to reduce the risk for water leaking from the reservoir. Gauze or tape is used to keep the pad in place. Safety pins should not be used because they can puncture the pad and cause leakage. Heat therapy is used to treat arthritis, contractures, low back pain, rectal surgery, and hemorrhoids. It causes an increase in blood flow to the injured area, relaxes muscles, increases healing of soft tissue, and reduces joint stiffness. Heat therapy is contraindicated in clients who have a neurosensory impairment, impaired mental status, impaired circulation, recent injury or surgery, open wounds, or localized infection. The nurse should check the client's skin every 15 to 20 min and discontinue treatment if the client's skin becomes red or the client reports increased pain. The nurse should apply the heat application for no longer than 30 min to reduce the risk for tissue injury. The nurse should instruct the client to not adjust the temperature setting and should use a timer to time the application. Adverse effects of heat therapy can include bleeding from open wounds or a surgical incision, burns, peripheral vasodilation, and hypotension.

The nurse is supervising a nursing assistant complete oral care on a comatose client. Which of the following observations indicate the nursing assistant needs further training? A. The client is positioned in a lateral position with the head turned to the side during oral care B. The client is positioned in high-Fowler's position during oral care C. The client remains in the lateral position for 30 minutes after the completion of oral care D. The client has a towel placed under the chin

Correct Answer: B. The client is positioned in high-Fowler's position during oral care The comatose client will be unable to maintain high-Fowler's position and will fall to the side. An unconscious client should not be placed in this position and indicated the nursing assistant needs further training. Incorrect Answers:A. The lateral position with the head turned to the side will help prevent aspiration during oral care. C. Keeping the client in the lateral position for 30 minutes after the completion helps to prevent pooling of secretions and aspiration. D. Placing a towel under the chin is appropriate. It helps to keep the area clean and dry.

The nurse is caring for a client with pancreatitis who objects to being questioned about his alcohol use. The nurse should explain to the client that the most important reason for collecting this information is that: A. The physician has asked the nurse to ask about the client's alcohol use B. There is a known link between alcohol use and pancreatitis C. Alcohol use can interfere with the lab tests used to diagnose pancreatitis D. All clients are asked about alcohol use

Correct Answer: B. There is a known link between alcohol use and pancreatitis Alcohol intake is the most common cause of acute pancreatitis. The client's health history should include information about alcohol and tobacco use, but since alcohol is one of the major causes of pancreatitis, this information is more critical in these clients. Alcohol does not interfere with the tests used to diagnose pancreatitis.

A nurse is providing teaching to a client who has a new prescription for levodopa/carbidopa to treat Parkinson's disease. Which of the following statements should the nurse include in the teaching? A. "This medication will cause you to urinate more frequently." B. "Expect muscle twitching to occur." C. "Take this medication with food." D. "Relief of symptoms should occur within 24 hours."

Correct Answer: C. "Take this medication with food." The client should take this medication with food to reduce adverse gastrointestinal effects, such as nausea and vomiting. However, the client should avoid high-protein meals. Incorrect Answers:A. Levodopa/carbidopa causes urinary retention; the client should be instructed to notify the provider if this occurs. B. The client should monitor and report muscle twitching to the provider, which can indicate toxicity; a dose reduction might be required. D. The client should anticipate relief of manifestations to take several weeks to months. Vital Concept:Levodopa/carbidopa, a dopamine replacement, is used to treat Parkinson's disease. By replacing dopamine, levodopa/carbidopa decreases the motor symptoms of Parkinson's disease, including bradykinesia, akinesia, tremors, and rigidity. The nurse should include the following in the teaching plan: • Take levodopa/carbidopa with food to reduce nausea and vomiting. Notify the provider if nausea and vomiting becomes severe. • Levodopa/carbidopa should not be taken with high-protein meals as it will reduce the therapeutic response of the medication. • Levodopa/carbidopa might cause involuntary movements such as twitching, dystonic movements, or tremors. The client should notify the prescriber if these symptoms occur. • The therapeutic response to levodopa/carbidopa is not immediate, it can take weeks or months for a reduction in symptoms to occur. • Orthostatic hypotension, characterized by lightheadedness and dizziness, can occur. Instruct the client to move slowly when changing positions. • Levodopa/carbidopa might produce cardiac symptoms, such as tachycardia, irregular heartbeat, or palpitations; the client should notify the provider if these occur. • Levodopa/carbidopa can cause a medication-induced psychosis manifested by visual hallucinations, paranoid thoughts, and vivid dreams. The client should notify the provider if these occur. • Do not take levodopa/carbidopa with the following classes of medications: MAOIs, first-generation antipsychotics, and anticholinergics.

The nurse caring for a 31-year-old client who has had bariatric surgery is reviewing the patient education for his client. Which information listed below is essential to include for the immediate postoperative period? A. Make sure to drink at least 2 cups of fluid with each meal B. Limit intake to under 2000 calories each day C. Eat 4 to 6 small liquid meals each day spaced at equal intervals D. Choose foods that are high in carbohydrates

Correct Answer: C. Eat 4 to 6 small liquid meals each day spaced at equal intervals Correct Answer:C. Eating 4 to 6 small liquid meals each day spaced at equal intervals is the best teaching advice for a bariatric client. Incorrect Answers:A. Fluids should not be consumed with meals in clients who have just had bariatric surgery. The decreased stomach capacity would cause the client to become full of fluids alone, and they would not get the nutrition they need through food. Therefore, fluids should be ingested at different times from meals. B. 2000 calories are excessive for a client who has just had bariatric surgery. The recommended intake is 1000-1200 calories per day. D. Foods high in carbohydrates should be avoided for a client who has just had bariatric surgery; foods high in protein should be encouraged. Vital Concept:Due to decreased stomach capacity after bariatric surgery, the client should consume 4 to 6 small meals at equally spaced intervals to meet nutritional requirements. This will help to avoid a feeling of fullness and complications such as dumping syndrome. The bariatric client should not consume fluids with meals. Also, foods high in protein should be suggested, and carbohydrates should be avoided. The recommended caloric intake following bariatric surgery is generally less than 1000-1200 calories per day in the immediate postoperative period.

A 39-year-old client was admitted to the emergency department (ED) after having blunt trauma to his face. The client has clear fluid draining from his nostril. Before going for x-rays, the nurse can expect the ED provider to test the fluid draining from the nostril for what? A. White blood cells B. Sodium C. Glucose D. Protein

Correct Answer: C. Glucose The provider will want to test the fluid draining from the nostril for glucose because this would suggest cerebrospinal fluid leakage. Incorrect Answers: A. Serum white blood cells would indicate if there were an infection. The presence of white blood cells will not help identify if there is a cerebrospinal leak.B. Serum sodium would be a component of a comprehensive metabolic panel. However, the sodium will not help identify if there is a cerebrospinal leak.D. Serum protein would be a component of a comprehensive metabolic panel. However, the presence of protein would not help identify if there is a cerebrospinal leak. Vital Concept:Clear fluid draining from the nostril can be a sign of a cerebrospinal leak. Cerebrospinal fluid (CSF) is a clear fluid that surrounds the brain and spinal cord; it contains glucose and can be easily differentiated from other fluids. In the emergency room, the discharge can be tested promptly for the presence of glucose using a dipstick. A leak occurs through a small tear or hole in the connective tissue surrounding the brain and spinal cord. The loss of CSF can cause headaches, vision changes, nausea, vomiting, and changes in cognition/consciousness.

Which of the following best describes a nurse who collaborates with a client directly to create and implement the plan of care? A. Clinical specialist B. Nurse manager C. Primary nurse D. Advanced practice nurse

Correct Answer: C. Primary nurse A primary nurse oversees the client's care, including client assessment, implementation of the care plan, and evaluation of the client's progress in light of the care given. The primary nurse role is based upon responsibility, accountability and authority. The primary nurse is responsible for development of a therapeutic relationship, with accountability to the client, family and members of the health-care team and the authority to develop and implement an individualized plan of care for the client. This relationship-based model of care includes elements of leadership, responsibility, work allocation, and communication with other members of the healthcare team. Incorrect Answers:A. A clinical specialist has a specific area of clinical expertise or practices in a given clinical area. B. A nurse manager oversees the care of a number of clients on a unit. D. An advanced practice nurse, such as a nurse practitioner, may provide primary care or may serve as a specialist in an area of healthcare, such as anesthesia. Vital Concept:Nurses fill a variety of roles in healthcare. A primary nurse is the nurse who oversees the client's care, from assessment to planning, implementation, and evaluation of nursing care. The role of primary nurse is based upon the responsibility to develop a therapeutic relationship; accountability to the client, family and other members of the health-care team; and the authority to develop and implement an individualized plan of care for the client.

A 58-year-old client has just had a cardiac catheterization (see image) and stent placement by the femoral route for a coronary blockage. The nurse caring for this client knows that the client should remain in which position? A. Right lateral recumbent B. Left lateral recumbent C. Supine with both legs extended D. Fowler's

Correct Answer: C. Supine with both legs extended The client should remain lying flat in a supine position with his legs extended after a cardiac catheterization procedure to allow the insertion site to heal and avoid bleeding or hematoma formation. Incorrect Answers:A. The right lateral recumbent position would put too much pressure on the insertion site, and the client would be at risk of bleeding.B. The left lateral recumbent position would put too much pressure on the insertion site, and the client would be at risk of bleeding.D. Hip flexion puts too much pressure on the insertion site, and the client would be at risk of bleeding. Vital Concept:Cardiac catheterization is a minimally invasive procedure where a flexible catheter is inserted to the heart, often through the femoral artery. After the procedure, the client must remain supine, with the leg extended (see image), for a few hours to allow the insertion site to heal and avoid bleeding or hematoma formation.

A nurse is caring for a client who continually makes sexually suggestive comments to the nurse and other staff. How should the nurse handle this situation? A. Ignore the client, whose behavior will stop if it does not elicit a reaction from you B. Report the client's behavior to the client's healthcare provider. C. Tell the client that the behavior is inappropriate and will not be tolerated D. Avoid going into the client's room unless it is an emergency situation

Correct Answer: C. Tell the client that the behavior is inappropriate and will not be tolerated Respectfully informing the client that the behavior will not be tolerated will let the client know that the nurse is not going to tolerate the abuse. Most facilities have a zero tolerance for abuse, whether verbal, physical, or sexual in nature. The nurse should firmly inform the client that such behavior is not welcome and will not be permitted to continue. Incorrect Answers:A. Ignoring the situation will not be helpful. It may encourage the client to escalate the behavior rather than stop it. B. The nurse should be able to manage this behavior independently by addressing the behavior with the client. If the behavior persists, the nurse should report to the nursing supervisor. D. Avoiding the client's room may reinforce the behavior. The nurse has an obligation to care for the client, regardless of how distasteful the client's behavior may be. Vital Concept:The Employment Opportunity Commission (EEOC) defines sexual harassment as "unwelcome sexual advances, requests for sexual favors, and other verbal or physical conduct of a sexual nature...when submission to or rejection of this conduct explicitly or implicitly affects an individual's employment; unreasonably interferes with an individual's work performance; or creates an intimidating, hostile, or offensive work environment." Incidents of sexual harassment in the workplace should not be tolerated. If the behavior does not stop, the nurse should report the behavior to the nursing supervisor.

The clinic nurse is caring for a 19-year-old male client prescribed an antibiotic for 10 days to treat tonsillitis. When the nurse calls the client for follow-up 4 days later, he states he is feeling better and is stopping the medication because all of his symptoms have resolved. What priority information does the nurse need to tell the client? A. The remaining antibiotics can be stored and taken the next time he has an infection B. The client should dispose of the remaining medication in a biohazard bin. C. The client must complete the entire course of antibiotics for the full 10 days even if he feels better. D. The client can share his leftover medication with his spouse, so they don't develop tonsillitis.

Correct Answer: C. The client must complete the entire course of antibiotics for the full 10 days even if he feels better. Correct Answer:C. The client must complete the entire course of antibiotics for the full 10 days even if he feels better to ensure the infection has been completely cleared and the infectious organism is eliminated. Incorrect Answers:A. Antibiotics should never be stored and used for a later time but should be taken for their entire prescribed course. B. The antibiotics should not be disposed of but should be taken for their entire prescribed course. D. Antibiotics should never be shared with anyone besides the person for whom they were prescribed. Vital Concept:It is essential for the nurse to inform this client about the correct use of antibiotics immediately. The client should always be instructed to complete the entire course of antibiotics as prescribed, even if he is feeling better. This will ensure the infection has been completely cleared and the infectious organism is eliminated. Antibiotics should never be stored and used for later use. The nurse should not tell the client to dispose of them. Antibiotics should never be shared with anyone and should only be taken by the person for whom they were prescribed. The spouse should get evaluated by a provider if they are showing signs of tonsillitis.

A nurse is reviewing snake bite management with a group of parents. Which of the following information should the nurse include in the teaching? A. Apply ice as soon as possible after the bite occurs. B. Attempt to orally suck out the venom. C. Wash the bite area with soap and water. D. Perform passive range-of-motion exercises to facilitate circulation

Correct Answer: C. Wash the bite area with soap and water. Washing the bite area with soap and water is part of the initial management for a snake bite. Management of a snake bite: Clean the area with soap and water. Cover with a clean dry dressing. Immobilize the area. Keep the child calm. Place the child in a reclined position. Remove restrictive clothing. Arrange for immediate transport to a medical facility. When possible and can be done safely, take a picture of the snake and bring it to the medical facility with the client so that it can be tested. Incorrect Answers:A. Ice is contraindicated because it slows the circulation to the area. B. While attempting to remove the venom is beneficial in some instances, a suction device should be used. D. When a snake bite occurs, the bite area should be immobilized. Vital Concept:Most snake bites occur while people attempt to handle a snake. Snakes that are kept as pets can also bite handlers. The best way to prevent snake bites is to avoid snakes.

A nurse is reviewing postpartum nutrition needs with a client who is breastfeeding. Which of the following statements by the client indicates an understanding of the instructions? A. "I can continue to smoke as long as I do it 30 minutes prior breastfeeding." B. "I should take folic acid to increase my milk supply." C. "I will continue adding 200 calories per day to my diet." D. "I will continue taking my vitamins while I am breastfeeding."

Correct Answer: D. "I will continue taking my vitamins while I am breastfeeding." Clients who breastfeed are instructed to consume a well-balanced, nutritious diet and can continue to take vitamin supplements. This can assist the client to ensure they receive adequate nutrition while breastfeeding. The client should balance their calories burned and consumed as well. Incorrect Answers:A. Clients who are breastfeeding should avoid smoking because it will impair milk production. If a client continues smoking, it is recommended that she should not smoke within 2 hr prior to breastfeeding. B. Folic acid does not increase milk production. C. Clients who are breastfeeding require an additional 450 to 500 calories per day to support adequate nutrition. Vital Concept:Clients who are breastfeeding should increase their daily caloric intake by 450 to 500 calories to support adequate nutrition and breast milk production. Smoking alters breastmilk production. Consuming large amounts of caffeinated beverages is not recommended while breastfeeding due to caffeine entering the breast milk. Clients who breastfeed are instructed to consume a well-balanced, nutritious diet and should be informed that they can continue to take their vitamin supplements. This can assist the client to ensure they receive adequate nutrition while breastfeeding.

The pediatric nurse is caring for two 3 year olds who are playing in the common playroom. The most appropriate response when the two children argue over a toy is: A. "I will take the toy since you two can't get along." B. "I want you both to go to your rooms since you can't get along." C. "Take turns playing with the toy." D. "I will find another toy so both of you can have one."

Correct Answer: D. "I will find another toy so both of you can have one." Toddlers have not developed the concept of sharing so the most appropriate response is to get another toy that is the same or similar to the toy the children are fighting over. Incorrect Answers: A. The 3-year-old child will not understand why the toy has been taken and this likely will make the situation worse. B. This is not an appropriate response for the toddler. C. Toddler children do not understand the concept of taking turns. Vital Concept:Finding a toy that both children can play with is the most appropriate response to toddlers fighting over a toy.

A nurse is caring for a client who is a veteran and was recently hospitalized after reporting feeling suicidal. The client states, "I can't go on feeling like this. It's just not worth it." Which of the following responses should the nurse make? A. "How do you think hurting yourself would make your children feel?" B. "There are a lot of veterans who have it a lot worse than you." C. "I understand. My partner is also a veteran, and she gets sad sometimes too." D. "I'll sit here with you for a while."

Correct Answer: D. "I'll sit here with you for a while." The nurse should open communication by informing the client that his feelings are important. The nurse should offer self by sitting with the client and listening to how the client feels. Incorrect Answers:A. This response implies judgment by the nurse and could make the client feel guilty, angry and unsupported by the nurse. B. This response implies a lack of feeling and minimizes how the client feels. It indicates that the nurse doesn't understand the client's feelings and could make the client feel insignificant. C. This response implies a lack of feeling and minimizes how the client feels. It indicates that the nurse doesn't understand the client's feelings and could make the client feel insignificant. Vital Concept:The nurse should be aware of overt and covert statements made by clients who are considering suicide. Talking openly can reduce feelings of isolation and can increase problem-solving. Effective communication facilitates a therapeutic nurse-client relationship. Assessment should include a conversation with a client to gain insight into a client's thoughts, behaviors, and risk factors. It is appropriate to be direct when asking the client about suicidal thoughts. The nurse should avoid minimizing the client's feelings or making the client feel guilty.

A nurse is speaking with a client who has a chronic productive cough and a new prescription for a sputum specimen. The client asks, "What will I do if they find that I have cancer?" Which of the following responses should the nurse make? A. "Why do you think you might have cancer?" B. "I don't see any reason for you to worry about that." C. "I think that's something you need to discuss with your doctor." D. "I'm hearing that you are concerned that you might have cancer."

Correct Answer: D. "I'm hearing that you are concerned that you might have cancer." This response illustrates the therapeutic communication techniques of seeking clarification and restating. It demonstrates the nurse's willingness to explore the client's fears and encourages communication. Incorrect Answers:A. This response illustrates the nontherapeutic communication technique of requesting an explanation. Asking "why" questions can be intimidating and might cause the client to become defensive. B. This response illustrates the nontherapeutic communication technique of giving false reassurance. C. By offering to pass the client's concerns to someone else, the nurse is demonstrating that she does not wish to discuss the issue. This is a dismissive action. Vital Concept:By using the therapeutic technique of restating, the nurse is acknowledging how the client feels. This gives the client an opportunity to explore their feelings or clarify any misunderstood communication by the nurse.

A patient has a severe allergic reaction after injection of intravenous contrast. Her blood pressure drops to 60/30 mm Hg. Which of the following best describes this patient's reaction? A. Cardiogenic shock B. Neurogenic shock C. Hypovolemic shock D. Anaphylactic shock E. Septic shock

Correct Answer: D. Anaphylactic shock Anaphylactic shock is caused by a severe allergic reaction that occurs rapidly and results in a life-threatening response that includes cardiovascular collapse and shock. The patient must have been previously exposed to the antigen (substance that caused the reaction) for anaphylactic shock to occur. The response is mediated by immunoglobulin E. Histamine is produced by cells in the immune system that are triggered by exposure to the antigen. In addition to contrast material used during radiologic procedures, anaphylactic shock may occur after blood transfusion, in response to shellfish, nuts and other foods; after exposure to a sting by a venomous insect, including wasps or honeybees; or after exposure to latex. Patients typically have swelling in their airways, which makes it difficult to breath. Shock can result in loss of consciousness and may result in cardiac arrest. Anaphylactic reactions involve two or more body systems, usually including skin, cardiovascular, or respiratory systems. Rapid medical care is essential. A radiographer should stop the procedure, place the patient in the recumbent (Trendelenburg) position, call for immediate help (code if necessary); administer oxygen and determine blood pressure.

A nurse is caring for a client who has been hospitalized for 8 days. The client is crying and expresses feelings of guilt for being in the hospital. Which of the following is the most appropriate intervention by the nurse? A. Call the healthcare provider for medication to relieve her anxiety B. Call for a consult from the chaplain C. Reassure the client that she has no reason to feel guilty D. Ask the client to talk about her feelings of guilt

Correct Answer: D. Ask the client to talk about her feelings of guilt The nurse should provide an opportunity for the client when the client is ready to talk about her feelings. This should not be deferred to a future time with another member of the team. The most therapeutic intervention is to ask the client open-ended questions about her feelings of guilt. At this point, the client does not need to be medicated; she simply needs someone to actively listen to her feelings and concerns. The nurse should not attempt to reassure the client that she has no reason to feel guilty; the nurse should demonstrate acceptance of the client's feelings. Incorrect Answers:A. Medication is not necessary in this situation; the nurse should help the client to talk about her feelings of guilt. B. A chaplain may be helpful, but it is also the nurse's responsibility to address the client's thoughts and emotions. C. This response is not necessarily helpful and does invite the client to talk about her feelings. Vital Concept:A nurse should avoid asking "why" questions except when asking simple questions that relate directly to client care. The nurse can offer more assistance if she assists the client to describe his/her feelings. There are two types of questions the nurse can ask to obtain information: closed and open questions. A closed question is phrased so that a yes or no answer is the response or so that a specific choice of answers is given within the questions, e.g. "Do you want your lunch now or in an hour?" Although this type of question does not encourage the client to explore feelings or concerns, it can be useful to elicit specific information needed to assist the client. Open questions let the client provide his/her own answers. Words such as "who", "what", "when", and "where" elicit factual information and help the client describe emotions, concerns, and experiences.

A nurse is caring for a client who has been unsuccessful at breastfeeding her newborn. Which of the following interventions are appropriate for the nurse? A. Explain that the use of an electrical breast pump is discouraged. B. Provide supplemental formula for feedings until breastfeeding improves. C. Refer the client to a lactation consultant immediately. D. Assess the baby's sucking reflex and position during feeding.

Correct Answer: D. Assess the baby's sucking reflex and position during feeding. Newborns should be put to the mother's breast within the initial hour of life and should remain in skin-to-skin contact with the mother until they are able to breastfeed for the initial time. Factors that can result in ineffective breastfeeding include prematurity, poor latching by the infant, poor sucking reflex, use of formula feeding, and breast anomaly or previous breast surgery. Nursing interventions that are appropriate in this situation include assessment of the infant's physical condition and sucking reflex; assessment of the mother's technique when breastfeeding, including positioning and behavior or anxiety during the feeding; and teaching the client how to express milk by hand and how to use an electric pump to increase milk production. Incorrect Answers:A. A nurse can teach a client how to hand express breast milk and how to use an electric pump to increase production of milk. Before a mature milk supply is established, the mother may be able to pump or hand express colostrum to feed to the infant using a syringe or spoon. Colostrum is a concentrated high-protein fluid that contains enzymes, hormones, anti-infective agents, and growth factors. It is expressed during the first 3 days of life. Breastfeeding intake increases from 15-30 mL per feeding initially to 60 to 90 mL of milk by the end of the first week of life. B. Use of supplemental formula for feedings interferes with the mother's ability to breastfeed exclusively and should be used only for medical indications, including dehydration and hypoglycemia in the neonate. Artificial nipples should also be discouraged. C. A lactation consultant is not the most appropriate intervention, but the referral should be made if ineffective breastfeeding continues for more than 24 hours. Vital Concept:Newborns should be put to the mother's breast within the initial hour of life and should remain in skin-to-skin contact with the mother until they are able to breastfeed for the initial time. After assessment of the mother and infant and providing assistance, consultation with a lactation expert may be necessary after 24 hours without success.

An LPN/LVN is given an order by a client's physician to administer pain medication to a client. The LPN/LVN believes that the dose of pain medication ordered by the physician is too high and is uncomfortable about giving the medication. The LPN/LVN should: A. Give the ordered dose of medication B. Ignore the order C. Give the dose that the LPN/LVN feels is safe in this case D. Clarify the dose with the client's physician, stating the concerns if necessary

Correct Answer: D. Clarify the dose with the client's physician, stating the concerns if necessary Nurses are obligated to carry out a physician's order unless the order is inappropriate or unsafe in the nurse's opinion. When there is doubt or concern regarding a specific order, the nurse should attempt to clarify the order with the ordering physician. If there is no resolution after talking to the ordering physician, the nurse should contact the nurse supervisor or manager to discuss the situation. A nurse carrying out an improper or inaccurate order may be legally responsible should the client suffer any harm.

The nursing instructor is discussing diabetes mellitus with the nursing class. What should the instructor tell the class may develop in a client when ketones accumulate in excessive amounts? A. Blurred vision B. Urinary retention C. Constipation D. Diabetic ketoacidosis

Correct Answer: D. Diabetic ketoacidosis Correct Answer:D. Diabetic ketoacidosis occurs when ketones accumulate in excessive amounts disturbing the acid-base balance of the body. Incorrect Answers:A. Although blurred vision can be a symptom when ketone bodies accumulate in excessive amounts, there is a better answer choice to choose from to describe the condition. B. Urine retention is not a symptom when ketone bodies accumulate in excessive amounts. C. Constipation is not a symptom when ketone bodies accumulate in excessive amounts. Vital Concept:Diabetic ketoacidosis is a complication of diabetes that occurs when the body produces high levels of ketone bodies. Ketone bodies are acids that disturb the acid-base balance of the body when they accumulate in excessive amounts. Signs and symptoms include abdominal pain, nausea, vomiting, hyperventilation, fruity odor of breath, and if left untreated, possible death.

Which best describes an intravenous pyelogram? A. A physician inserts a camera into the urethra to view the interior of the bladder B. A portion of the kidney is obtained with a needle for study under a microscope C. Urine is collected and a small amount is introduced to a growth medium for culture D. Dye is injected into the kidneys, ureters, and bladder so they can be examined by X-ray

Correct Answer: D. Dye is injected into the kidneys, ureters, and bladder so they can be examined by X-ray An intravenous pyelogram is a test in which contrast dye is injected into vein and X-rays are obtained as the dye is moves through the kidneys, ureters, and bladder. The test can demonstrate obstruction or other problems that block flow. Incorrect Answers:A. Cystoscopy is a test in which a small camera is inserted into the bladder through the urethra. B. A kidney biopsy is a test in which tissue is obtained from the kidney for microscopic evaluation. C. A urine culture is a test in which a sample of urine is introduced to growth medium to see if any bacterial colonies grow. Vital Concept:An intravenous pyelogram (IVP) is a test in which contrast material is administered intravenously and a series of radiographs are obtained. This test provides information about the anatomy and some information about function of the kidney, ureters, and bladder.

A nurse in the emergency department is caring for a client with a spinal cord injury. Which intervention should the nurse prioritize? A. Place a small pillow under the client's head for comfort B. Move the client gently to decrease pain C. Restrain the client's arms and legs to limit movement D. Immobilize the client's head and neck

Correct Answer: D. Immobilize the client's head and neck The head and neck of a client with a spinal cord injury must be maintained in strict alignment with the rest of the spine. If the client is transported by EMS, it is likely that the paramedics will have applied a hard cervical collar, which is critical to maintain alignment and prevent injury to the spinal cord during transport. The client should be "logrolled" by 2-3 personnel when repositioning or moving, to ensure that spinal alignment is maintained. It is not appropriate to restrain the client or use pillows for comfort until X-rays of the cervical spine and clinical exam confirm there is no spinal instability. Incorrect Answers:A. The nurse must keep the client's head and neck in alignment and should not provide a pillow at this time. B. The nurse should avoid moving the client to reduce the risk of further cord injury. C. It is not appropriate to restrain the client's arms and legs; the nurse must keep the client's head and neck in alignment. Vital Concept:Spine injury should always be considered a possibility in any client who experiences significant trauma to the head or thorax. Common causes of trauma implicated in spinal cord injury include motor vehicle accidents (MVA), falls, and pedestrian-vehicle accidents. To protect the spinal cord from additional injury, healthcare personnel should institute "spinal precautions‟ in these clients. Estimates of neurologic damage caused as a result of inadequate spinal cord immobilization after a traumatic event range from 3 to 25%. Spinal precautions include holding the head in position, application of a cervical collar, maintenance of neutral alignment, and log rolling when repositioning or moving the client.

The nurse is working in a clinic when a client is brought in with an acute asthma attack. The nurse knows that immediate treatment is needed when the client has: A. A respiratory rate of 20 per minute B. A productive cough C. Thin, clear secretions D. Intercostal retractions

Correct Answer: D. Intercostal retractions Intercostal retractions in a client is an abnormal sign and should be treated immediately since it indicates severe respiratory distress. Accessory muscle use such as retractions are signs of respiratory distress. Incorrect Answers:A. Respiratory rate of 20 per minute is normal. B. A productive cough producing thin, clear secretions is normal for a client with asthma and is not indicative of a need for immediate intervention. C. A productive cough producing thin, clear secretions is normal for a client with asthma and is not indicative of a need for immediate intervention. Vital Concept:Intercostal retractions are an ominous sign in asthma and should be investigated and treated immediately.

The nurse is planning care with a Mexican American client who is diagnosed with depression. The client believes in "mal ojo" (the evil eye) and uses treatment by a root healer. The nurse should do which of the following? A. Avoid talking to the client about the root healer B. Explain to the client that Western medicine has a scientific, not mystical, basis C. Explain that such beliefs are superstitious and should be forgotten D. Involve the root healer in a consultation with the client, primary health care provider, and nurse

Correct Answer: D. Involve the root healer in a consultation with the client, primary health care provider, and nurse The nurse should provide culturally competent, client centered care. By Including the root healer in the care provided to the client, the nurse demonstrates respect for the client's cultural beliefs. Incorrect Answers:A. This option is incorrect because it demonstrates lack of cultural awareness and disregard for the client's cultural values. B. This option is incorrect because it is not centered on the client's needs and it is dismissive of the client's beliefs. C. This statement is hostile and could result in loss of trust by the client, which is a barrier to therapeutic communication and effective care. The nurse should provide support, encouragement, and advocacy for the client in the therapeutic relationship. This is an important part of care in individuals with depression and anxiety. Vital Concept:A nurse must have cultural awareness to be able to provide culturally competent care. Failure to provide culturally competent care can increase the stresses experienced by ill clients and can result in provision of inadequate healthcare.

Which leadership style leaves decision-making to the group, with the leader providing little or no feedback or guidance? A. Bureaucratic B. Democratic C. Situational D. Laissez-faire

Correct Answer: D. Laissez-faire Laissez-faire management leaves decision-making to the group, with the leader/manager providing little, if any, guidance or support. All responsibility is relinquished to the group. Incorrect Answers: A. The bureaucratic leader/manager relies on organizational procedures/policies in making decisions. B. The democratic leader/manager acts as a facilitator more than a leader, and believes that every member of the group is equally important and deserves to be heard. C. The situational leader/manager uses a combination of styles based on the circumstances, the parties involved and the needs of the group.

A nurse is providing education to a client with a new prescription for furosemide (Lasix). What is the primary reason the nurse will advise the client to take this medication in the morning? A. Prevent electrolyte imbalance B. Slow drug absorption C. Excrete excessive fluids accumulated during the night D. Prevent sleep disturbances during the night

Correct Answer: D. Prevent sleep disturbances during the night When diuretics are given early in the day, the client will void frequently during the daytime hours and will not need to void frequently during the night, decreasing the chance of disrupting the client's sleep to use the restroom. Incorrect Answers:A. and B. Taking Lasix in the morning has no effect on preventing electrolyte imbalances or slowing drug absorption. C. The client should not accumulate excessive fluids throughout the night. Vital Concept:Lasix causes diuresis 1 hour following oral administration. The peak effect occurs within the first or second hour. The diuretic effect lasts for 6-8 hours. If taken early in the day, the effects of the medication will be lessened, and the patient will not need to void as much at nighttime.

The practical nurse knows that the preschooler will usually see illness as: A. Part of life B. The will of God C. A reflection of his self-worth D. Punishment for misbehaving

Correct Answer: D. Punishment for misbehaving A preschooler has a lower level of cognitive ability and may regard illness as a punishment for being "bad". Incorrect Answers: A. At the preschool age, children do not typically have a concept of the will of god or illness as being a part of life. B. At the preschool age, children do not typically have a concept of the will of god or illness as being a part of life. C. Self-worth is a developmental task that is more appropriate for an adult. Vital Concept:It is important to understand how the toddler will view illness so the nurse can address their illness with the appropriately.

After an oral surgery or radical neck surgery, hemorrhage can occur. What may be the most immediate nursing action if this occurs? A. Treat for shock B. Notify the physician C. Provide High Fowler's position D. Put pressure over blood vessels in the neck

Correct Answer: D. Put pressure over blood vessels in the neck Putting pressure over the common carotid and jugular vessels in the neck may be lifesaving because a severe blood loss can occur rapidly, leading to shock and death.

A nurse places her client in this position. Which of the following exams would this position most likely be used for? A. Posterior lung exam B. Musculoskeletal exam C. Pedal exam D. Rectal exam

Correct Answer: D. Rectal exam A nurse may need to position a client in different ways, depending on the type of exam or procedure being performed. The Sims' position is used when the nurse or the provider needs to examine the client's rectum, although other positions, such as the lithotomy position, could be used for this as well. The nurse can place the client in the Sims' position by turning the client onto the side with the arm on the bottom positioned behind and the upper arm positioned forward. The upper leg is bent and placed in front of the lower leg. The extremities are supported by pillows. Vital Concept:The Sims' position, also called the lateral recumbent position, is used for rectal examination and for treatments that include enemas.

The practical nurse is caring for a client who has been receiving factor VIII concentrate. The nurse should be concerned about the risk of hepatitis if the client exhibits: A. Constipation B. Abdominal distention C. Facial swelling D. Scleral yellowing

Correct Answer: D. Scleral yellowing Factor VIII may place the client at risk for hepatitis since it is pulled from large pools of plasma rather than from one donor. Scleral and skin yellowing is a clinical sign of hepatitis. The other symptoms are not indicative of hepatitis.

A nurse is providing teaching to a client who has a new prescription for phenelzine. Which food should the nurse instruct the client to omit from the diet to avoid a hypertensive crisis? A. Grapefruit juice B. Dark green vegetables C. Cottage cheese D. Smoked fish

Correct Answer: D. Smoked fish Smoked fish is high in tyramine, which has hypertensive effects similar to other amines. Because tyramine is metabolized by monoamine oxidase, clients who are taking MAOIs, such as phenelzine, and consume tyramine can experience a hypertensive crisis. Incorrect Answers:A. Grapefruit juice interferes with the metabolism of many medications, but it will not cause a hypertensive crisis in a client who is taking phenelzine. B. Dark green vegetables can decrease the anticoagulant effects of warfarin, but they will not cause a hypertensive crisis in a client who is taking phenelzine. C. Cottage cheese is a high-protein source; 1 cup, or 226 g, contains 27 g of protein. High-protein foods, such as cottage cheese, can increase the metabolism of levodopa, but it will not cause a hypertensive crisis in a client who is taking phenelzine. Vital Concept:Clients who are taking an MAOI should avoid the consumption of foods containing tyramine. Examples include any aged cheeses, bananas, beer, ale, red wine, caffeinated beverages, chocolate, peanuts, and yogurt. Clients should be provided a comprehensive list of all foods and beverages that contain tyramine.

A nurse begins rounds on assigned clients on the 7 a.m. to 7 p.m. shift and finds a used needle in a client's room that was not properly disposed of after medication administration the previous shift. Which of the following is the most appropriate immediate response? A. The nurse should notify the healthcare provider. B. The nurse should complete an incident report. C. The nurse should contact the nurse who administered the medication. D. The nurse should dispose of the needle in the sharps container.

Correct Answer: D. The nurse should dispose of the needle in the sharps container. The most appropriate immediate response is to dispose of the needle into the sharps container. Incorrect Answers:A. It is not necessary to notify the healthcare provider. B. It is only necessary to complete an incident report if an incident has resulted in harm to the client or others in the facility. C. Although the nurse should notify the nurse who administered the medication, the primary concern is proper disposal of the sharp. Vital Concept:When failure to follow correct procedures to dispose of sharps and hazardous waste is discovered, the priority intervention is to correctly dispose of the item(s), to prevent injury to the client and others in the healthcare facility. An incident report is only necessary if the lapse resulted in harm or injury to the client or others.

The nurse is caring for an adolescent female who has had an anaphylactic reaction after a bee sting. The nurse is providing client teaching prior to discharge. In the event of an anaphylactic reaction, the nurse informs the client that she should self-administer epinephrine (EpiPen) in what part of the body? A. Abdomen B. Deltoid C. Forearm D. Thigh

Correct Answer: D. Thigh Correct Answer:D. For an anaphylactic reaction, the client is taught to self-administer epinephrine (EpiPen) into the upper, outer mid-thigh. Incorrect Answers:A. Epinephrine self-injection should not be given in the abdomen. B. Epinephrine self-injection should not be given in the deltoid. C. Epinephrine self-injection should not be given in the forearm. Vital Concept:To self-inject epinephrine (EpiPen) for an anaphylactic reaction, the client is taught to position the device at the middle portion of the upper thigh and push the device into the thigh as far as possible. The device will auto inject a premeasured dose of epinephrine into the subcutaneous tissue.

Which of the following is a responsibility of the nurse with regard to informed consent? A. Inform the client of alternative treatments B. Explain about the procedure C. Obtain informed consent from the client D. Verify that the physician has explained about the procedure Check Answer Show Explanation Grade Pause Previous121122123124125126127128129130

Correct Answer: D. Verify that the physician has explained about the procedure The nurse's responsibility is to verify that the physician or other healthcare provider has explained the procedure to the client. Incorrect Answers:A. It is the physician's job to inform the client of alternative treatments. B. It is the physician's job to explain the procedure. C. It is the physician's job to obtain consent from the client. Vital Concept:The nurse must verify that the physician has explained the procedure to the client and verify the client has signed the consent and understands the procedure.

A nurse is teaching a client who has a new prescription for depot medroxyprogesterone acetate (DMPA). Which of the following statements by the client indicate an understanding of the information? (Select all that apply.) A. "I might gain weight after getting this injection." B. "This injection will protect me from getting a sexually transmitted infection." C. "I should increase my intake of calcium after getting this injection." D. "I should avoid taking antibiotics after getting this injection." E. "This injection can cause irregular vaginal spotting."

Correct Answers: A. "I might gain weight after getting this injection." C. "I should increase my intake of calcium after getting this injection." E. "This injection can cause irregular vaginal spotting." Weight gain is a common adverse effect that can occur after receiving the DMPA injection. This is related to the hormones in the medication. It can also cause headaches and depression. Clients should increase their intake of calcium and vitamin D to prevent loss of bone density, which can occur after receiving the DMPA injection. They should take up to 1,200 mg of calcium/day and also increase weight-bearing exercise. DMPA can cause irregular vaginal bleeding and spotting. Menstrual bleeding can be heavy or irregular for the first year and can disappear after the first year. Incorrect Answers:B. DMPA does not provide protection against sexually transmitted infections. It is a hormonal injection with a medication that has no anti-infective properties and offers no barrier protection. D. Antibiotics do not interact with DMPA. DMPA is a hormonal preparation that contains only progesterone, which does not interact with anti-infective medications. Vital Concept: Clients receive depot medroxyprogesterone acetate (DMPA) by intramuscular or subcutaneous injection every 12 weeks. It prevents pregnancy by inhibiting follicular maturation and ovulation. It also thickens the cervical mucus, making it difficult for sperm to travel through it and decreasing the chance of fertilization. It also thins the endometrium, reducing the likelihood of implantation if fertilization does occur. However, this medication does not protect against sexually transmitted infections. The common adverse effects of DMPA include weight gain, amenorrhea, irregular bleeding, headache, and depression. Nurses should instruct clients who receive this medication to increase their calcium intake to prevent osteoporosis, because DMPA can cause a loss of bone density.

A student nurse is reviewing charts of clients who were diagnosed with chronic pharyngitis. Which of the following clients would be at the greatest risk of developing chronic pharyngitis? (Select all that apply). A. A client who smokes 1 pack per day for 20 years B. A client who is an alcoholic C. A client who is a singer D. A client who eats a lot of spicy foods E. A client who works at a construction site

Correct Answers: A. A client who smokes 1 pack per day for 20 years B. A client who is an alcoholic C. A client who is a singer E. A client who works at a construction site Correct Answers:A. A client who is a smoker for many years is at a higher risk of developing chronic pharyngitis due to the chemicals and pollutants found in tobacco smoke that cause swelling and inflammation. B. A client who is an alcoholic is at a higher risk of developing chronic pharyngitis due to the constant irritation of chemicals from alcohol. C. A client who is a singer is at a higher risk of developing chronic pharyngitis due to excessive use of their voice. E. A client who works in a dusty environment like a construction site is at a higher risk of developing chronic pharyngitis. Incorrect Answers:D. A client who eats spicy foods is not at higher risk of developing chronic pharyngitis. Vital Concept:Pharyngitis is the inflammation of the pharynx or the back of the throat. Pharyngitis can be acute due to an infection. Chronic pharyngitis lasts longer and does not respond to the same treatments as acute pharyngitis. Adults who live and work in dusty environments such as construction sites are at greater risk of developing chronic pharyngitis. Other clients who are at risk of this condition are singers, voice actors, or news anchors who overuse their voice, those who suffer from a chronic cough, and those who excessively use alcohol and tobacco. Spicy foods have not been linked with chronic pharyngitis.

A client is receiving hemodialysis. After some time, the client develops dyspnea and chest pain. When the nurse assesses the client, she finds that there is reduced oxygen saturation, tachypnea, and hypotension. Which are the best nursing actions? (SELECT ALL THAT APPLY) A. Administer oxygen B. Stop the hemodialysis C. Notify the physician D. Place the client in reverse Trendelenburg's position

Correct Answers: A. Administer oxygen B. Stop the hemodialysis C. Notify the physician Air embolism is a complication of hemodialysis. When the symptoms of air embolism such as dyspnea, chest pain, low oxygen saturation, tachypnea, hypotension, etc. occur, the nurse should stop hemodialysis immediately and the client should be placed on left side-lying with head down. Vital Concept:In the event of a suspected embolus notify the physician immediately and also administer oxygen.

The nurse is trying to assess the nutritional status of a 47-year-old client. Which of the following factors should be considered when assessing nutritional status? (Select all that apply). A. Albumin levels B. Echocardiogram findings C. Body mass index (BMI) D. A dietary history E. Weight

Correct Answers: A. Albumin levels C. Body mass index (BMI) D. A dietary history E. Weight Correct Answers:A. Albumin is a protein produced in the liver. Serum albumin levels are a good indicator of a client's nutritional status. Low albumin levels can indicate malnutrition, but they can also indicate liver disease or inflammation. Albumin levels can be used along with a comprehensive metabolic panel to show a complete clinical picture of nutritional status. C. BMI is the measure of body fat based on height and weight. It is an assessment that can be taken into consideration to assess nutritional status. Having a high BMI increases the risk of certain health conditions such as obesity, diabetes, high blood pressure, and cardiovascular problems. A low BMI may indicate a client is underweight and may be at risk of malnutrition. D. Asking the client about their diet would be an important component of their nutritional status, amongst other assessments such as BMI and a comprehensive metabolic panel. E. Weight should be evaluated when assessing nutritional status. A client who is underweight for their age may be at risk of malnutrition. A client who is overweight or obese is at risk of developing certain health conditions such as diabetes, high blood pressure, and cardiovascular problems. Incorrect Answers:B. An echocardiogram is an ultrasound of the heart; it uses sound waves to produce cardiac images. Findings from an echocardiogram would not be relevant for assessing nutritional status. Vital Concept:Many factors are to be taken into consideration when assessing the nutritional status of a client. Evaluation of nutritional status should include one or more of the following: measurement of BMI and waist circumference, weight, laboratory values such as serum albumin and serum protein, as well as a comprehensive metabolic panel to assess electrolytes, clinical examination findings, and dietary history.

A 53-year-old client is admitted after being found unconscious outside a bar and brought in by his friends. His friends report that he has a habit of heavy drinking multiple times per week. Therefore, the nurse needs to monitor him closely for signs and symptoms of alcohol withdrawal, including which of the following? (Select all that apply). A. Hallucinations B. Tachycardia C. Perspiration D. Tremors E. Low blood pressure

Correct Answers: A. Hallucinations B. Tachycardia C. Perspiration D. Tremors Correct Answers:A. Hallucinations are a common sign of alcohol withdrawal as the brain struggles to adapt to the absence of alcohol. B. Tachycardia is a common sign of alcohol withdrawal as the brain struggles to adapt to the absence of alcohol. C. Perspiration is a common sign of alcohol withdrawal as the brain struggles to adapt to the absence of alcohol. D. Tremors are a common sign of alcohol withdrawal as the brain struggles to adapt to the absence of alcohol. Incorrect Answers:E. High blood pressure, not low blood pressure, is a common sign of alcohol withdrawal. Vital Concept:Symptoms of alcohol withdrawal can start within hours after cessation of drinking. Symptoms include tremors, anorexia, nausea and vomiting, tachycardia, sweating, elevated blood pressure, headache, anxiety, seizures, and transient hallucinations. People with severe withdrawal symptoms remain in the hospital for part or all of the detoxification process to be closely monitored due to blood pressure, breathing, and heart rate changes.

The nurse is caring for a 73-year-old male client in a long-term rehabilitation facility. Which of the following interventions can the nurse expect to use for a male client with urinary incontinence? (Select all that apply). A. Incontinence pads B. Indwelling catheter C. Intermittent self-catheterization D. External condom catheter

Correct Answers: A. Incontinence pads C. Intermittent self-catheterization D. External condom catheter Correct Answers:A. Incontinence pads would commonly be used when caring for a client in a long-term care facility with urinary incontinence. For most older clients, incontinence pads are a convenient and minimally invasive intervention to deal with urinary incontinence, provided they are changed frequently. C. Intermittent self-catheterization may be encouraged for an incontinent client as it is less invasive and carries less of a risk of infection than an indwelling catheter. D. External condom catheters may be used when caring for a client in a long-term care facility with urinary incontinence. They are less invasive and carry less of a risk of infection than an indwelling catheter. Incorrect Answer:B. Indwelling catheters should be avoided for long-term care clients with urinary incontinence due to the high risk of urinary tract infection associated with their use. Vital Concept:Nurses in long-term care facilities such as rehabilitation centers have to manage interventions safely and appropriately. For most older clients, incontinence pads are a convenient and minimally invasive intervention to deal with urinary incontinence, provided they are changed frequently. Intermittent self-catheterization is also an appropriate intervention for managing urinary incontinence, urinary retention, and overflow incontinence related to an overdistended bladder. External catheters or condom catheters are also a practical and less invasive intervention to manage urinary incontinence than indwelling catheters. Indwelling catheters should be avoided and might be used only as a last resort for urinary incontinence due to the high risk of urinary tract infection with their use.

A charge nurse is conducting a staff in-service about medications used during the care of a client who is experiencing acute alcohol withdrawal. Which of the following medications should the charge nurse include in the discussion? (Select all that apply). A. Lorazepam B. Carbamazepine C. Diazepam D. Naloxone E. Acamprosate

Correct Answers: A. Lorazepam B. Carbamazepine C. Diazepam Lorazepam is a benzodiazepine used during alcohol withdrawal to decrease anxiety and reduce the risk for seizures. Carbamazepine is an anticonvulsant used during alcohol withdrawal to prevent seizures. Diazepam is a benzodiazepine used during alcohol withdrawal to decrease anxiety and reduce the risk for seizures. Incorrect Answers:D. Naloxone is an opioid antagonist used to reverse over-sedation due to opioid overdose. E. Acamprosate is used to maintain abstinence from alcohol following detoxification. It is not given in the acute stage of withdrawal. Vital Concept:Benzodiazepines, including lorazepam and diazepam, are used to treat a client undergoing alcohol withdrawal. Benzodiazepines have the following effects: • Decrease withdrawal symptoms • Stabilize vital signs • Prevent seizures • Prevent delirium tremens Other medications used in withdrawal include beta-adrenergic blockers, central alpha2-adrenergic agonists, and antiepileptics. During alcohol withdrawal therapy, the nurse should assess the client for reduction of symptoms, including tremors, agitation, delirium, and hallucinations.

A 67-year-old client just had cataract surgery with a right-sided lens implant. The nurse is providing discharge teaching to the client. Which statements from the client indicate an understanding of the proper post-op care after cataract surgery and lens implantation? (Select all that apply). A. "I will sleep on my right side." B. "I will not bend over to tie my shoes." C. "I will not lift heavy items." D. "I will resume my normal exercises of doing pushups." E. "I will sleep on my left side."

Correct Answers: B. "I will not bend over to tie my shoes." C. "I will not lift heavy items." E. "I will sleep on my left side." Correct Answers:B. Clients should not bend over after cataract surgery and lens implantation because this will increase intraocular pressure and pressure around the eyes. C. Clients should not lift heavy items after cataract surgery and lens implantation because this would cause straining muscles that can increase intraocular pressure, which should be avoided. E. Clients should sleep on the opposite side of the lens implant to avoid pressure on the affected area. Incorrect Answers:A. Clients should sleep on the opposite side of the lens implant to avoid pressure on the affected area. D. Clients should not do pushups or any other straining exercises as this would increase intraocular pressure around the eyes. Vital Concept:After cataract surgery and lens implantation, clients should not assume positions or do any activities that would increase intraocular pressure. For example, bending over, heavy lifting, exercises, or actions that require straining the muscles can all increase intraocular pressure, leading to injury of the surgical site and damage to the lens implant. The client should also sleep on the opposite side of the implant to avoid pressure on the affected area.

A nurse in the inpatient psychiatric unit is caring for a client who is experiencing an acute manic state. Which of the following activities might be appropriate for this client? (Select all that apply) A. Relaxation exercises B. Watching television C. Alternating aerobic exercise with scheduled periods of rest D. Listening to music

Correct Answers: B. Watching television C. Alternating aerobic exercise with scheduled periods of rest D. Listening to music Watching television may help to engage the client's mind and would be appropriate. Exercise is an engaging activity for the client and would be an appropriate intervention. Listening to music helps to engage the client's mind and thoughts; this would be appropriate. Incorrect Answer:A. A client in an acute manic state has poor concentration and attention span and will typically not be able to quiet his mind or his body enough to participate in relaxation exercises. An activity that allows the client to move around or to engage the client's thoughts is more appropriate. Vital Concept:Bipolar disorder type 1 is characterized by alternating periods of depression and mania. Mania is characterized by periods of time where the client's mood is abnormally and persistently elevated, expansive, or irritable PLUS impairment in social or occupational relationships; need for hospitalization to prevent harm; or psychosis. The symptoms cannot be due to substance use or another medical condition. Symptoms of mania include Inflated self esteem, decreased need for sleep, pressured speech, "flight of ideas," distractibility, need to fulfill goal oriented activities; psychomotor agitation; and excessive involvement in pleasurable activities with the potential for harm. Activities appropriate for clients experiencing an acute manic episode include those that provide an outlet for excess physical energy and activities that require a short amount of time and minimal concentration, attention to detail, and adherence to rules. Inappropriate activities for a client with mania include activities that require the use of social skills, teamwork, or cooperation with others.

A nurse is caring for a 43-year-old client with acute leukemia. The nurse knows which of the following tests would be ordered to assess the client's risk of infection? A. Creatinine clearance (CrCl) B. Alkaline phosphatase C. White blood cell count D. Albumin

Correct Answer: C. White blood cell count To monitor the risk of infection, the nurse should check the white blood cell count to assess the risk for infection. Incorrect Answers:A. Creatinine is a test used to measure kidney function. It does not play a role in determining the risk of infection.B. Alkaline phosphatase is an enzyme found in the liver, bones, intestine, and kidneys and is used to screen for liver diseases. It does not play a role in determining the risk of infection.D. Albumin levels would help assess a client's nutritional status. However, it does not play a role in determining infection risk.Vital Concept:Clients with hematologic malignancies like leukemia are at increased risk of infection and have associated morbidity and mortality. Leukemia is a cancer of the blood and bone marrow characterized by the rapid production of abnormal white blood cells that cannot fight off infection. Leukemia also impairs the bone marrow's ability to produce red blood cells and platelets.

A nurse is assisting with the care of a child who is experiencing respiratory failure. Which of the following findings are considered early cardinal manifestations of this condition? (Select all that apply.) A. Stupor behavior B. Peripheral cyanosis C. Tachycardia D. Diaphoresis E. Restlessness

Correct Answers: C. Tachycardia D. Diaphoresis E. Restlessness Tachycardia is an early manifestation of respiratory distress. The heart tries to compensate for the lack of perfusion by pumping harder. Diaphoresis is an early manifestation of respiratory distress due to decreased oxygenation and perfusion. Restlessness is an early manifestation of respiratory distress due to decreased oxygenation and perfusion to the tissues. Incorrect Answers:A. Stupor behavior is an advanced manifestation of respiratory failure related to oxygen deprivation of the cerebral tissue. B. Cyanosis is an advanced late manifestation of severe hypoxia. Vital Concept:Cardiac arrest can cause respiratory failure. During respiratory failure, the lungs cannot adequately exchange carbon dioxide and oxygen. This results in hypoxemia and increased carbon dioxide retention. It is imperative that the nurse recognize the early signs of respiratory failure to improve oxygenation status. The classic cardinal signs of respiratory failure are restlessness, tachypnea, tachycardia, and diaphoresis. Respiratory failure is diagnosed by physical examination and laboratory results, such as arterial blood gases. Treatment for respiratory failure includes CPR intubation, oxygen, repositioning, and careful observation and monitoring.

Which of the following are elements of tier 1 of infection control? (Select all that apply.) A. Placing the client in a private room B. Using negative pressure in the room of an infected client C. Wearing gloves when coming in contact with blood or body fluids D. Performing hand hygiene between client care encounters E. Bagging contaminated laundry before removing it from the room

Correct Answers: C. Wearing gloves when coming in contact with blood or body fluids D. Performing hand hygiene between client care encounters E. Bagging contaminated laundry before removing it from the room Precautions to prevent the spread of infection are classified into two tiers. Tier 1 consists of standard precautions that should be used to prevent disease transmission during any client care encounter. Elements of standard precautions include wearing gloves when contacting potentially infectious blood or body fluids, bagging contaminated linen, and performing hand hygiene between clients. Tier 2 consists of specific precautions against certain types of transmission, such as airborne or droplet precautions. Incorrect Answers: A. Placing the client in a private room B. Using negative pressure in the room of an infected client Vital Concept:Epidemiologically important pathogenic organisms may require a second-tier isolation precaution. These precautions include contact, droplet, and airborne precautions, in addition to standard precautions.

A nurse is caring for an unconscious client. Which of the following should the nurse use to prevent wrist deformities? A. Plaster cast B. Splint C. Restraints D. Bandages

Correct Answer: B. Splint In an unconscious client to prevent wrist deformities, the nurse should apply splint at the wrist.

A nurse is reviewing a client's laboratory results and notices a creatinine level of 7 mg/dL. This finding would lead the nurse to place the highest priority on assessing: A. Pupillary reflex B. Intake and output C. Capillary refill D. Vital signs

correct Answer: B. Intake and output Elevated creatinine level indicates impaired renal functional. To know about renal function, the nurse should assess intake and output since urinary output can be decreased in renal failure.

A nurse is assessing a client with suspected atrial fibrillation. Where on the drawing should the nurse place the stethoscope in order to best hear the second (S2) heart sound created by the closure of the pulmonic valve? Check Answer Show Explanation Grade Pause Previous

S2 is best heard over the patient's left second intercostal space. It is the result of the closure of the semilunar valves at the end of ventricular systole. A "split S2," also known as physiological split, normally occurs during inhalation due to the decrease in intrathoracic pressure and subsequent increase in the time needed for pulmonary pressure to exceed that of the right ventricular pressure. Wide splitting of the second heart tone may result from heart conditions such as right bundle branch block, atrial septal defect, and pulmonary stenosis. Vital Concept:S2 is best heard over the patient's left second intercostal space. It is caused by the closure of the semilunar valves (the aortic valve and pulmonic valves) at the end of ventricular systole and the beginning of ventricular diastole. Closure of the aortic valve precedes closure of the pulmonic valve, causing a "split" S2 best heard during inspiration. The interval between S1and S2 corresponds to the systolic phase, so a systolic murmur refers to a murmur heard between S1 and S2. Likewise, a diastolic murmur is heard between S2 and S1, which corresponds to the diastolic phase of the cardiac cycle.

A nurse is caring for a child who was admitted with a suspected diagnosis of Wilms' tumor. Which of the following signs should the nurse place over the child's bed? A. "Do not palpate abdomen." B. "No venipuncture or blood pressure in left arm." C. "Fall precautions" D. "Collect all urine."

Correct Answer: A. "Do not palpate abdomen." Wilms' tumor is a neoplasm of the kidney. This tumor is encapsulated, and palpation can cause it to rupture, which allows seeding of the tumor into the pelvic cavity. Incorrect Answers:B. There is no contraindication for venipuncture or obtaining blood pressure in either of the child's arms. C. There is no indication to place the child on fall precautions. D. There is no indication to collect urine for a 24-hr urine specimen. Vital Concept:It is important for the nurse to reinforce the need to inform other providers about the client's suspected diagnosis. The nurse should place a sign over the child's bed that reads, "Do not palpate the abdomen." The nurse should also instruct members of the health care team who are caring for the child to be careful when bathing and handling the child to prevent trauma to the tumor site.

The nurse is collecting assessment data on a new 44-year-old client for the provider in the clinic. The client states that she does not have menses. What term will the nurse use in their documentation to describe the absence of menstrual flow? A. Amenorrhea B. Dysmenorrhea C. Menorrhagia D. Metrorrhagia

Correct Answer: A. Amenorrhea Correct Answer:A. Amenorrhea refers to the absence of menstrual flow. Incorrect Answers:B. Dysmenorrhea is painful menstruation. C. Menorrhagia is prolonged or excessive bleeding at the time of the regular menstrual flow. D. Metrorrhagia is vaginal bleeding between regular menstrual periods. Vital Concept: Amenorrhea refers to the absence of menstrual flow. Dysmenorrhea is painful menstruation. Menorrhagia is prolonged or excessive bleeding at the time of the regular menstrual flow. Metrorrhagia is vaginal bleeding between regular menstrual periods.

Which of the following clients is at highest risk for skin cancer? A. A 48-year-old client who goes on frequent hikes in the mountains B. A 13-year-old client who is a highschool student C. A 38-year-old client whose occupation is in clothing design D. A 50-year-old client who is a nurse in the Emergency Department

Correct Answer: A. A 48-year-old client who goes on frequent hikes in the mountains The risk of skin cancer is higher in individuals who spend time in the sun. High altitudes such as those associated with mountain climbing also increase the risk of skin cancer. Incorrect Answers:B. A high school student is not at increased risk for skin cancer C. A clothing designer is not at an increased risk of skin cancer. D. An ED nurse is not at increased risk for skin cancer Vital Concept:Long term sun exposure and repeated sunburn greatly increase the risk of skin cancer.

A nurse is caring for a client who is receiving total parenteral nutrition (TPN) through a central line. The pharmacy notifies the nurse that the next bag of solution will not be available for administration for 2 hr. Which of the following actions should the nurse take? A. Administer 10% dextrose in water IV until the next bag is available. B. Slow the infusion rate of the current bag until the solution is available. C. Monitor the client for hyperglycemia. D. Monitor the client for fluid overload.

Correct Answer: A. Administer 10% dextrose in water IV until the next bag is available. Administering 10% dextrose in water IV until the TPN solution is available helps to prevent hypoglycemia. Incorrect Answers:B. The nurse should not decrease the rate of the TPN infusion, because a decreased rate can cause hypoglycemia. C. The nurse should monitor the client for hypoglycemia when the TPN solution is not infusing because the client is not receiving adequate glucose. D. The client is not at risk for fluid overload unless the nurse has increased the rate of the TPN infusion. Vital Concept:A client who has been receiving TPN can experience several adverse effects, including hypoglycemia if the infusion is suddenly discontinued. Clients who have diabetes are at increased risk. The nurse should monitor the client's blood glucose levels every 6 hr and infuse 10% dextrose when discontinuing the TPN infusion suddenly.

A nurse is teaching a class to expectant mothers. Which of the following should the nurse advise the group to avoid in order to prevent toxoplasmosis? A. Contact with cat feces B. Eating freshwater fish C. Excessive exposure to radiation D. Working with heavy metals

Correct Answer: A. Contact with cat feces Toxoplasma gondii can be transmitted by exposure to infected cat feces or by ingesting undercooked contaminated meat. Incorrect Answers:B. The parasite is found in warm-blooded animals, not in fish. C. Toxoplasmosis is not associated with radiation. D. Toxoplasmosis is not associated with heavy metals. Vital Concept:If a pregnant woman has been infected with Toxoplasma before becoming pregnant, the unborn child is usually protected by maternal immunity. Experts suggest waiting for 6 months after a recent infection to become pregnant. Infected infants but are often asymptomatic at birth but can develop serious symptoms later in life, including blindness or mental disability. Infected newborns sometimes have eye or brain damage at birth. Pregnant women should avoid changing cat litter if possible. If no one else can change cat litter, the woman should wear disposable gloves and wash her hands with soap and water afterwards. The cat litter box should be changed daily. The parasite does not become infectious until 1 to 5 days after it is shed in a cat's feces. Household cats should be kept indoors and fed with commercially prepared foods.

The nurse is using principles of rehabilitation when he or she: A. Encourage a client to dress in street clothes B. Bathes a client and combs hair C. Brushes a client's teeth when the client has trouble or forgets D. Ask the physician to order a Foley catheter for occasional urinary incontinence

Correct Answer: A. Encourage a client to dress in street clothes The nurse should promote activity that allows a client to function and look as normal as possible.

A nurse teaching a health promotion class teaches participants that the tetanus-diptheria vaccine is given to healthy adolescents and adults: A. Every 10 years, to boost immunity B. Every 5 years, to boost immunity C. Because it contains the pertussis vaccine which cannot be given to infants D. To protect against herpes virus

Correct Answer: A. Every 10 years, to boost immunity Td is administered every 10 years, or after exposure to tetanus in some circumstances. Incorrect Answers:B. The Td vaccine is given every 10 years, not every 5 years. C. The Td vaccine does not contain pertussis. It is a vaccine designed as a booster for adults and is not indicated for infants. D. The Td vaccine protects against tetanus and diphtheria; it does not protect against herpes. Vital Concept:Tetanus is an infection caused by Clostridium tetani bacteria. Four kinds of vaccines are used today to protect against tetanus. All are combined vaccines that also protect against other diseases. They include diphtheria and tetanus (DT) vaccines; diphtheria, tetanus, and pertussis (DTaP) vaccines; tetanus and diphtheria (Td) vaccines; and tetanus, diphtheria, and pertussis (Tdap) vaccines. Individuals younger than 7 years old receive DTaP or DT, while older children and adults receive Tdap and Td. Td boosters are recommended every ten years.

An LPN/LVN notices the smell of alcohol on a colleague's breath while working. The Licensed Practical Nurse (LPN/LVN)should: A. Report suspicions of alcohol use while working to the nursing supervisor B. Confront the colleague with the LPN/LVNs suspicions C. Call the police and report the colleague D. Call the state Board of Nursing and report the colleague

Correct Answer: A. Report suspicions of alcohol use while working to the nursing supervisor The nurse should report any employee who is suspected to be using alcohol while on the job. Incorrect Answers:B. It is most appropriate to notify the supervisor. C. It is most appropriate to notify the supervisor. D. It is not up to the nurse to contact the board of nursing Vital Concept:The LPN/LVN has an obligation to report impaired nurses. The LPN/LVN should follow the chain of command and report his/her suspicions to the nursing supervisor, who is obligated to notify the state board of nursing, who may develop plans for counseling, treatment, and/or supervision. The LPN/LVN should not directly confront the colleague as this could lead to conflict.

A client is admitted for an elective cholecystectomy the next morning. She takes no routine medication. The nurse should prioritize notification of which of the following assessment data to the healthcare provider before surgery? A. Temperature of 100.8°F with a productive cough B. Platelet count of 210,000/mm^3 C. International normalized ratio (INR) of 1.1 D. Hematocrit of 42%

Correct Answer: A. Temperature of 100.8°F with a productive cough Of the options listed, the client's temperature and productive cough are most concerning. Although it is a low-grade fever, it is accompanied by a cough, and both findings are important to communicate to the healthcare provider prior to administration of anesthesia and elective surgery. Decreased respirations secondary to pain, the stress associated with surgery, and potential exacerbation of an existing but diagnosed infection, whether viral or bacterial, increases both the risk of pulmonary complications and wound healing complications. Incorrect Answers:B. Normal platelet counts range from 150,000/mm^3 to 400,000/mm^3. C. The INR is high-normal. A value ≤1.1 is considered normal in individuals who are not taking anticoagulant medication. D. Normal hematocrit ranges are between 39% and 50%. Vital Concept:A nurse's responsibilities in the immediate preoperative period include assessment and communication of pertinent findings to the healthcare provider; ensuring completion of all preoperative orders; ensuring that records and reports are complete and accompany the client to the OR; and final preoperative education. If a client has abnormal findings on assessment or laboratory studies, the nurse should notify the healthcare provider immediately.

Most breast tumors are found in the: A. Upper outer quadrant. B. Upper inner quadrant. C. Lower outer quadrant. D. Lower inner quadrant.

Correct Answer: A. Upper outer quadrant. Most breast tumors are found in the upper outer quadrant of the breast but can be found in any area. Incorrect Answers:B. Most breast tumors are found in the upper outer quadrant of the breast but can be found in any area. C. Most breast tumors are found in the upper outer quadrant of the breast but can be found in any area. D. Most breast tumors are found in the upper outer quadrant of the breast but can be found in any area. Vital Concept:Most breast tumors are found in the upper outer quadrant of the breast but can be found in any area.

A nurse is caring for a client who has bipolar disorder and a new prescription for lithium. The client states that he wants to take ibuprofen for osteoarthritis pain relief. Which of the following statements should the nurse make? A. "That is a good choice. Ibuprofen does not interact with lithium." B. "Aspirin would be a better choice than ibuprofen." C. "Lithium decreases the effectiveness of ibuprofen." D. "The ibuprofen will make your lithium level fall too low."

Correct Answer: B. "Aspirin would be a better choice than ibuprofen." Aspirin is recommended as a mild analgesic rather than ibuprofen due to the risk for lithium toxicity. Incorrect Answers:A. Ibuprofen is not recommended for clients taking lithium. C. Lithium does not decrease the effectiveness of ibuprofen. However, concurrent use is not recommended due to the risk for toxicity. D. Ibuprofen increases the risk for a toxic, rather than low, lithium level. Vital Concept:When reinforcing teaching with a client, it is important for the nurse to provide alternative methods to solve a problem instead of simply telling the client what he should and should not do. If the client has an alternative, it is more likely he will adhere to the medication regimen.

A nurse is planning to assist a client with taking a shower. Which of the following information should the nurse provide regarding the use of a shower chair? A. "I will turn the water on once you feel comfortable in the shower chair." B. "Using a shower chair will minimize fatigue while taking a shower." C. "The shower chair can assist you with getting in and out of the shower." D. "Having a shower chair can allow you to spend up to 20 minutes or more in the shower."

Correct Answer: B. "Using a shower chair will minimize fatigue while taking a shower." The use of a shower chair will assist the client with independence in performing personal hygiene tasks and will increase the safety of the client in the shower. It will also facilitate the client with the process of bathing and minimize physical exertion during the bathing process. Incorrect Answers:A. The nurse should have the water running prior to the client entering the shower. This allows the nurse to adjust the water temperature to avoid accidentally burning the client. C. The nurse should teach the client how to use safety rails and bars to assist with getting in and out of the shower. The nurse should reinforce with the client not to rely on the use of the shower chair for this purpose due to a lack of stability. D. The nurse should not instruct the client to spend more than 15 min in the shower. A client who has prolonged exposure to warm water can experience vasodilation and pooling of blood which can lead to light-headedness or dizziness. Vital Concept:The nurse assisting a client with personal hygiene care should provide information about any assistive devices used for the process. The nurse should explain the purpose of any assistive devices and should teach the client how to use the device safely.

A new mother states that she is afraid to have a bowel movement because she remembers the discomfort she experienced after delivering her other child. The nurse should encourage her to: A. Eat low roughage and drink plenty of water B. Eat fresh fruits and vegetables, drink plenty of water, and ambulate C. Eat small amounts of food for several days so she will be less likely to have a bowel movement until her perineum heals D. Eat whatever she wishes, take a mild laxative, and keep up the Kegel exercises

Correct Answer: B. Eat fresh fruits and vegetables, drink plenty of water, and ambulate Eating plenty of fiber, staying hydrated, and staying active will help prevent constipation and painful bowel movements. Incorrect Answers:A. This will exacerbate painful bowel movements. C. This is inappropriate advice as it may lead to malnutrition. D. Laxatives are not appropriate for this client and some laxatives may be inappropriate if she is breastfeeding. Lifestyle interventions should be attempted with this client first. Vital Concept:Normal evacuation of the bowel being restored is desired. Ambulating, eating fruits, and drinking plenty of water will help this normal process.

A nurse is caring for a client who has major depressive disorder and was prescribed citalopram 2 weeks ago with a planned dosage increase after the first week. The client reports sleeping better at night, but still feels very depressed and is still experiencing anorexia and severe fatigue. Which of the following actions should the nurse take? A. Speak to the provider about adding an MAOI to the current medication regimen. B. Explain to the client that antidepressants often take several weeks to be fully effective. C. Tell the client that the provider will need to replace the citalopram with a different medication. D. Recommend that the client take St. John's wort daily to help decrease depression.

Correct Answer: B. Explain to the client that antidepressants often take several weeks to be fully effective. SSRIs, such as citalopram, are frequently prescribed to treat major depressive disorder. The nurse should explain to the client that it can take up to 4 weeks before therapeutic effects occur after beginning an antidepressant medication. Incorrect Answers: A. Administering an SSRI, such as citalopram, along with an MAOI is contraindicated due to a greatly increased risk for serotonin syndrome. C. The nurse should not tell the client that the citalopram needs to be replaced with a different medication. The nurse should teach the client about expected effects of citalopram and should monitor the client for changes in depression. The client should be instructed to take citalopram as directed and to take any missed doses as soon as they remember the dose, unless it is almost time for the next dose. The client should not take double doses of the medication because this can increase the client's risk for serotonin syndrome. D. St. John's wort is a supplement that is sometimes taken to decrease mild to moderate depression. When it is taken with an SSRI antidepressant like citalopram or any medication that increases serotonin levels, serotonin syndrome can result. Vital Concept:The nurse should carefully assess clients who begin taking an SSRI, such as citalopram, for warning signs of suicide. The risk for suicide is increased early in the treatment period for a client who has major depressive disorder and begins taking an antidepressant medication. The warning signs include increasing manifestations or new manifestations of depression, thoughts of suicide, or thoughts about death. The nurse should monitor the client and report manifestations which indicate the client has suicidal ideation.

Which of the following measures should be used to prevent the transmission of respiratory infections? A. Individuals should not be admitted as visitors or staff without proof of immunization for seasonal influenza and pneumonia. B. Individuals with signs of respiratory infection should wear a surgical mask. C. A distance of separation of at least 10 feet should be maintained from an individual with signs of respiratory infection. D. Infected individuals should be encouraged to sneeze or cough into their hand.

Correct Answer: B. Individuals with signs of respiratory infection should wear a surgical mask. Respiratory hygiene/cough etiquette is intended to prevent transmission of respiratory infections and is directed at visitors and clients who have signs of a respiratory illness, including a cough, congestion, or rhinorrhea. The recommended elements of respiratory hygiene and cough etiquette include education, posted signs, hand hygiene, and use of a tissue or surgical mask to cover the nose and mouth, with prompt disposal of any tissue used. Incorrect Answers:A. This is not a recommended as a standard measure for respiratory hygiene, although it is important to ensure clients receive adequate immunization against infection when available. C. The recommended distance from an individual who appears to have a respiratory illness is 3 feet at the minimum. D. The shirt sleeve should be used for sneezing or coughing when a tissue or surgical mask is not available. Hand hygiene should be emphasized to prevent the spread of infection. Vital Concept:Respiratory precautions have been added as an element of Standard Precautions, to prevent the spread of respiratory pathogens. In addition to providing signs and education, measures include covering the mouth/nose with a tissue when coughing and prompt disposal of used tissues; using surgical masks on the coughing person when tolerated and appropriate; hand hygiene after contact with respiratory secretions; and separation of persons with respiratory infections in common waiting areas by at least three feet, when possible.

A nurse is providing discharge teaching about diet and fluid restrictions to a client who has a calcium oxalate kidney stone. Which instruction should the nurse include in the teaching? A. Increase intake of spinach. B. Limit sodium to no more than 2,300 mg/day. C. Increase intake of vitamin C supplements. D. Limit consumption of high-purine foods.

Correct Answer: B. Limit sodium to no more than 2,300 mg/day. Increased sodium intake may result in urinary calcium excretion by decreasing calcium reabsorption. Incorrect Answers:A. Spinach is a food that is high in oxalate and, when combined with calcium, might result in calcium stone formation. C. Large doses of vitamin C can cause calcium stone formation. D. Foods that contain purine, such as organ meats and red wine, cause uric acid stone formation. Vital Concept:Stones that consist of calcium oxalate require a limitation of the client's dietary calcium intake to no more than 1,000 to 1,200 mg of calcium a day. Clients should avoid calcium supplements.

A nurse is conducting health teaching concerning human immunodeficiency virus (HIV) for new nursing students. Which of following individuals is considered to have the highest risk of acquiring the infection? A. Volunteer who assists HIV-positive clients with referrals B. Phlebotomist who collects blood from high-risk clients C. Nurse who is assessing the history of an HIV-positive client who is coughing D. Laboratory technician who gathers a saliva sample for ELISA testing

Correct Answer: B. Phlebotomist who collects blood from high-risk clients Human immunodeficiency virus (HIV) infection is transmitted through blood and body fluids. The virus attacks the T-cells of the body's immune system, making the client vulnerable to other opportunistic infections and some forms of cancer. HIV is also transmitted through sexual contact. The phlebotomist, who is regularly at risk for needlestick injury, is at greatest risk. Incorrect Answers:A. Individuals performing tasks such as referrals and interviews are unlikely to be exposed to infectious blood or fluids. C. Saliva carries a lower viral load than blood and HIV is not an airborne pathogen. D. Collecting a saliva sample for ELISA is a procedure with less risk than a blood draw. Saliva carries a small risk of transmission, but it is less than the risk of exposure to blood or through sexual contact. Vital Concept:The risk of a healthcare worker acquiring HIV infection from a client is exceedingly small, having been repeatedly measured at approximately 0.3 to 0.5% following significant needlestick/sharps exposure to HIV clients. No quantifiable risk has been identified for mucous membrane or intact skin-blood contact

A nurse is providing care for a client who is prescribed a Level 2 mechanically altered dysphagia diet following a recent cerebrovascular accident (CVA). Which of the following dietary selections should the nurse make? A. Turkey sandwich B. Scrambled eggs C. Peanut butter crackers D. Granola

Correct Answer: B. Scrambled eggs A Level 2 diet requires foods that are moist and semi‑solid and that can be formed readily in a bolus, such as a scrambled egg. This diet eliminates most raw fruits and vegetables with the exception of a ripe banana. Incorrect Answers:A. A Level 2 diet requires foods that are moist and semi‑solid. A turkey sandwich is too dry, and breads are not allowed on the Level 2 diet. This is an appropriate choice for a client receiving a regular diet. C. A Level 2 diet requires foods that are moist and semi‑solid. Peanut butter crackers are too sticky and dry for a Level 2 diet. This is an appropriate choice for a client who is receiving a regular diet. D. A Level 2 diet requires foods that are moist and semi‑solid. Granola is too hard and crunchy for a client who is receiving a Level 2 diet. This is an appropriate choice for a client who is receiving a regular diet. Vital Concept:A Level 2 mechanically altered dysphagia diet allows foods that are moist, soft, and easily form a bolus. Other foods that are permitted include well-moistened pancakes with syrup, noodles, soft fruit, well-cooked vegetables and moist ground meat with gravy.

A student nurse is shadowing in the operating room. Their preceptor is teaching them about the signs and symptoms of malignant hyperthermia. Which sign often presents the earliest in those with malignant hyperthermia? A. Hypotension B. Tachycardia C. Oliguria D. Elevated temperature

Correct Answer: B. Tachycardia Tachycardia is often one of the earliest signs of malignant hyperthermia. Incorrect Answers:A. Hypotension is a later sign of malignant hyperthermia.C. Oliguria is a later sign of malignant hyperthermia.D. Elevated temperature is a later sign of malignant hyperthermia.Vital Concept:Malignant hyperthermia is a severe reaction to certain drugs used for anesthesia, and without prompt treatment, it can be fatal. The initial symptoms of malignant hyperthermia are related to cardiovascular and musculoskeletal activity. Tachycardia is often the earliest sign of malignant hyperthermia. Oliguria, hypotension, and increased temperature are later signs of malignant hyperthermia.

A charge nurse is providing education to staff about skin care in the elderly client. The nurse will review all of the following changes associated with the normal aging process, EXCEPT: A. The amount of fat and water begin to decrease, resulting in loss of turgor B. The outer layer of skin sloughs off and is replaced with new cells every few days C. The vascularity of the skin decreases, resulting in lowered ability to regulate body temperature D. Collagen begins to lose its elasticity and strength

Correct Answer: B. The outer layer of skin sloughs off and is replaced with new cells every few days As a person ages, the skin begins to lose fat, water, and collagen, resulting in loss of turgor and elasticity. Blood supply to the skin decreases, making it harder for an aging adult's body to regulate the temperature. This is one of the reasons older adults feel cold at higher temperatures. Although the outer layer of skin is replaced every few days in younger people, this cell replacement does not occur as quickly in older adults. Incorrect Answers:A. The amount of fat and water decreases in an older adult, resulting in loss of skin turgor. C. An older adult's skin vascularity decreases, lowering the ability to regulate body temperature. D. The collagen found under the skin of most older adults begins to lose its elasticity and strength. Vital Concept:There are many anatomical and physiological changes experienced in the course of aging. This results in increased vulnerability and special skin care needs in the elderly. Elderly individuals have fragile skin and injury can result in scar tissue, slow healing, infections, and wounds that will not heal.

A nurse finds the mother of a dying child in the child's room, visibly upset, who wants to take her child home. Which of the following responses by the nurse is most appropriate? A. "I know how you feel, but the medication will make your child feel better." B. "You can't let your child see that you are upset." C. "Is there a particular concern that we can discuss?" D. "I can imagine how hard this is for you, but it's not what's best for the child."

Correct Answer: C. "Is there a particular concern that we can discuss?" When a parent is visibly upset, it is best to try to determine the cause. Asking the mother an open-ended question about why she wants to take the child home can provide insight into the problem and provides an opportunity for the mother to express her fears and concerns with the support of the nurse, who should listen actively and encourage the client to talk through her feelings. Incorrect Answers:A. The nurse does not necessarily know how the mother feels; she should instead allow the mother to talk about her feelings. B. The nurse should work with the mother to find solutions that are agreeable to both parties instead of telling her what she can't do. D. Although the nurse may be able to imagine the mother's pain, she should encourage the mother to express her feelings. The nurse should not tell the client what she is doing wrong. Vital Concept:The nurse helps the client to know that her feelings are understood and accepted and encourage the mother to continue expressing emotions, thoughts, and concerns. If the mother says, "I hate it here. I wish I could go home with my child", the nurse can respond by stating, "It must be difficult to stay here when you want to go home." When a client talks about something that is upsetting to her or expresses a complaint or criticism, the nurse conveys acceptance by acknowledging the feelings she is expressing without agreeing or disagreeing. By sympathetically recognizing that it must be difficult or embarrassing or frightening or frustrating, etc. to feel as the client does, the nurse does not pass judgment on the thought or feeling itself. Successful communication must reflect to the client that the nurse accepts the thoughts and feelings the client is expressing, irrespective of whether or not the nurse thinks and feels the same way. If the client senses or is told that the nurse does not approve of or does not agree with what she is expressing, it is unlikely that the client will continue to be forthcoming or build a relationship of trust with the nurse.

A mother brings her two-month-old infant to the clinic for a routine checkup. She asks the nurse when she should begin solids. The baby is drinking about 30 ounces of formula each day. What is the most appropriate response by the nurse? A. "That is too much formula. You should start him on solids now." B. "When he is drinking about a quart of formula per day." C. "Most babies are ready to begin solids between four and six months of age." D. "Every baby is different. Some are ready sooner than others."

Correct Answer: C. "Most babies are ready to begin solids between four and six months of age." Babies are not ready for solids before the protrusion reflex disappears, usually around four and six months of age. Incorrect Answers:A. Two months of age is too soon to begin introducing solids. The protrusion reflex is still very strong. B. Babies less than four months of age usually take more than a quart of formula per day. The protrusion reflex disappears around four months of age. D. There may be some truth to this statement, but it offers no guidelines for the mother to follow.

Before suctioning a client with a tracheostomy, which nursing action should the nurse perform? A. Clean the tracheostomy stoma with a sterile, cotton-tipped applicator B. Instill 5 mL of sterile saline within the tracheostomy C. Administer 100% oxygen for 1 to 2 minutes D. Occlude the vent on the catheter for 15 seconds

Correct Answer: C. Administer 100% oxygen for 1 to 2 minutes The nurse gives the client oxygen to prevent hypoxemia and hypoxia while removing air and debris from the upper airway. After inserting the catheter, the tip is positioned between 6 and 10 inches, the air vent is occluded, and is removed while suction is applied on the way out of the airway. It is no longer recommended to instill saline into the tracheostomy tube.

A nurse is caring for a 30 year old client whose father is a physician on the hospital staff. What is the most appropriate response by the nurse if the client's father approaches the nursing station and asks to read the client's chart? A. Allow the client's father to read the chart since he is a physician with hospital staff privileges. B. Ask the client's father to leave the nursing station immediately C. Inform the client's father that written permission must be obtained from the client. D. Tell the client's father that he cannot read the chart but staff can answer his questions about the client's condition. E. Refer the father to the nursing supervisor

Correct Answer: C. Inform the client's father that written permission must be obtained from the client. Clients have a right to confidentiality. Family members should not be permitted to read the client's chart unless written consent is provided by the client. Incorrect Answers:A. Although the client's father is a physician on the hospital staff, he is not they client's healthcare provider and should not be allowed to read the chart without written consent. B. This could potentially escalate the situation and does not solve the problem. D. Providing information that is contained in the chart is still a breach of confidentiality without the client's written permission. E. The nurse should be capable of handling this situation independently. Vital Concept:A health care provider should only share the client's personal health information with the client's permission, unless the client cannot give permission when a health care provider believes, based on professional judgment, that sharing the information is in the client's best interest, such as in an emergency when the client is unconscious. Under HIPAA, the health care provider may also discuss client health information with family members if the client is present and does not object to sharing the information.

When a client receives a permanent prosthesis, the nurse should teach the client to: A. Wash the prosthesis daily B. Wear it only when going out or having company C. Inspect the prosthesis daily for loose or worn parts D. Oil all joints daily

Correct Answer: C. Inspect the prosthesis daily for loose or worn parts The prosthesis should be maintained in good working order. All other options are false.

A typical 8-year-old girl will prefer to: A. Play alone B. Play with family members C. Play with other girls her age D. Play team games and sports

Correct Answer: C. Play with other girls her age School age children typically prefer to play with same sex children of approximately the same age. If another girl is available to play with the child, she will usually pick the girl over other family members or playing by herself.

A nurse is providing dietary teaching to the guardian of a school-age child who has celiac disease. Which of the following food items should the nurse suggest for the child's afternoon snack? A. Raisins B. Unsalted nuts C. Potato chips D. Ham sandwich

Correct Answer: C. Potato chips The nurse should suggest potato chips to the guardian as an acceptable food choice for the child's afternoon snack. Potato chips are gluten-free and low in fiber. Therefore, they are an acceptable food choice for a child who has celiac disease. Incorrect Answers:A. Clients who have celiac disease are placed on a gluten-free diet indefinitely. In addition to gluten, the child must avoid foods high in fiber because decreased absorption leads to bowel inflammation. Therefore, because raisins are high in fiber, they are not a recommended snack for the child. B. Clients who have celiac disease are placed on a gluten-free diet indefinitely. In addition to gluten, the child must avoid foods high in fiber because decreased absorption leads to bowel inflammation. Therefore, because nuts are high in fiber, they are not a recommended snack for the child. D. Clients who have celiac disease are placed on a gluten-free diet indefinitely. Therefore, because the bread on most sandwiches contain gluten and also some prepared luncheon meats such as bologna, this it is not a recommended snack for the child. Vital Concept: Potato chips are gluten-free and low in fiber. Therefore, they are an acceptable food choice for a child who has celiac disease. Foods that are high in fiber must be avoided for children who have celiac disease because decreased absorption leads to bowel inflammation.

The nurse is planning care for a client who is hearing impaired. Which of the following actions by the nurse will be the most helpful in establishing effective communication with the client? A. Repeat every statement twice B. Speak loudly C. Speak slowly and clearly D. Use gestures

Correct Answer: C. Speak slowly and clearly Incorrect Answers:A. Unnecessary repetition is potentially insulting and degrading. Speaking slowly and clearly helps to facilitate communication. B. Speaking loudly can make it even harder for the hearing impaired person to understand what is said. D. Speaking slowly and clearly is more effective than the use of gestures. Vital Concept:The nurse should speak slowly and clearly to the client who is hearing impaired. This will enable the client to hear better if they are able, read lips, and understand more clearly in both situations.

A nurse is caring for a client with a decubitus ulcer. The nurse would do all of the following except: A. Frequent repositioning B. Positioning that avoids the affected area C. Keep the area clean and dressed D. Massage the affected area

Correct Answer: D. Massage the affected area Massaging and manipulation of the already damaged tissue can worsen the condition.

The nurse is teaching a new nursing assistant how to correctly transfer a client who has right hemiplegia from the bed into a wheelchair. Which of the following observations indicates the nursing assistant understands how to correctly complete the transfer? A. The nursing assistant places the wheelchair parallel to the bed on the affected side B. The nursing assistant lifts the client up, asking the client to place her arms around her neck C. The nursing assistant places the wheelchair at a 45-degree angle to the bed on the client's unaffected side D. The nursing assistant asks if a trapeze bar is available to use for the transfer

Correct Answer: C. The nursing assistant places the wheelchair at a 45-degree angle to the bed on the client's unaffected side The wheelchair should be placed on the unaffected side so the client can pivot on the unaffected foot and sit down into the chair. Incorrect Answers:A. The wheelchair should be placed on the unaffected side so the client can pivot on the unaffected foot and sit down into the chair. B. A hemiplegic client will not be able to put her arms around the neck of the nursing assistant. D. A hemiplegic client will not be able to use a trapeze bar effectively. Trapeze bars are effective for clients who have paraplegia. Vital Concept:The nurse must learn how to properly maneuver patients in order to avoid injury to the client or to the nurse

The nurse is caring for a client with Raynaud's phenomenon. The nurse should emphasize that the client can reduce symptoms of this disease by: A. Increase coffee to three cups each day B. Keeping the house at 68 degrees Fahrenheit C. Wearing gloves when handling frozen foods D. Running cold water over her hands during an episode

Correct Answer: C. Wearing gloves when handling frozen foods Raynaud's phenomenon is characterized by vasospasm caused by extreme changes in temperature. Wearing gloves when handling cold foods can help prevent the problem. Incorrect Answers:A. This phenomenon is exacerbated by caffeine so the client should not increase caffeine intake. B. A house temperature of 68 degrees F is likely to increase vasospasm. D. During a vasospastic incident, the client can run warm water over their hands. Vital Concept:The nurse must remain aware that Raynaud's is characterized by vasospasm associated with extreme temperature changes. Most commonly when the client with Raynaud's is exposed to cold is when they will experience vasospasms and pain. In order to prevent this, the nurse must remain aware of strategies that will prevent vasospasm, such as limiting time in the cold, wearing gloves when exposure is inavoidable, and limiting caffeine.

While assisting the physician, during which component of the exam should the nurse provide the physician with a topical anesthetic agent? A. When testing deep tendon reflexes B. When removing vaginal secretions C. When measuring intraocular pressure D. When examining the tympanic membranes

Correct Answer: C. When measuring intraocular pressure Topical anesthesia is needed when a tonometer is used to measure the pressure within a client's eye. The anesthetic, prepared in liquid eyedrop form, makes it possible to apply the tonometer to the cornea without the client feeling as if something is touching the eye.

A urinalysis is performed on a client suspected to have bacteriuria. Which of the following tests is a common indicator? A. left frontal lobe hematoma on CT scan B. greenstick fracture finding on MRI C. positive dipstick for leukocyte esterase or nitrates D. right lateral femur displacement

Correct Answer: C. positive dipstick for leukocyte esterase or nitrates A positive dipstick for leukocyte esterase or nitrates is a common test used to detect elevated bacteria in the urine. Incorrect Answers:A. Computerized tomography would not be completed for suspected bacteriuria B. Magnetic resonance imaging would not be completed for suspected bacteriuria D. Femur displacement would not be consistent with bacteriuria Vital Concept:Urinalysis testing should be completed for suspected UTI. The presence of leukocytes or nitrates in the urine is indicative of urinary tract infection.

A Licensed Practical Nurse (LPN/LVN) is reviewing the lab results of a group of clients. All of the clients are adult females. Which of the following results should be reported to the physician immediately? A. A hematocrit of 37.1 percent B. An albumin level of 3.9 g/dL C. A creatinine of 0.9 mg/dL D. A serum potassium level of 2.8 mEq/L

Correct Answer: D. A serum potassium level of 2.8 mEq/L All of the lab results are within range except the potassium level. The normal range for serum potassium is 3.7 to 5.2 mEq/L. Incorrect Answers:A. Normal hematocrit for women is 34.9 to 44.5 percent. B. The normal range for albumin is 3.5 to 5.5 g/dL. C. The normal creatine level is 0.5 to 1.1 mg/dL in adult females. Vital Concept:A potassium level of 2.8 mEq/L is low and should be treated quickly.

A 34 year old male is admitted to the hospital with a diagnosis of pheochromocytoma. Which of the following symptoms would the nurse not expect to see during an attack? A. Orthostatic hypotension B. Diaphoresis C. Apprehension D. Bradycardia

Correct Answer: D. Bradycardia This is a catecholamine producing tumor of the adrenal gland. Most are benign, however the tumor synthesizes the catecholamine's epinephrine and norepinephrine, which stimulates beta receptors. This stimulation causes tachycardia, peripheral vasodilation, diaphoresis, and postural hypotension due to decreased blood flow to the brain.

A nurse is providing discharge instructions about a high-fiber diet to a client who has chronic constipation. Which food choice by the client indicates an understanding of the teaching? A. Peanut butter B. Roast chicken C. Fruit juice without pulp D. Dried beans

Correct Answer: D. Dried beans Dried beans are a good source of fiber and are low in fat. Incorrect Answers:A. Peanut butter is a good protein source and has a high fat content; however, it is not a high-fiber food source. B. Roast chicken is not a good source of fiber. C. Fruit juice without pulp is not a good source of fiber. Vital Concept:Constipation is treated by increasing the amount of dietary fiber and fluid the client consumes. The amount of fiber recommended is determined by the individual client's needs and is increased gradually to avoid manifestations of intolerance, such as gas and diarrhea. The client should also increase daily physical activity to promote bowel regularity.

What phase of the nursing process is the nurse in when they determine a medication is effective and documents this in the client's medical record? A. Assessment B. Diagnosis C. Planning D. Evaluating

Correct Answer: D. Evaluating Evaluating is the final step in the nursing process that allows the nurse to determine the effectiveness of a client's response to the nursing interventions. Incorrect Answers:A. Assessment includes systematically collecting data to find out what the client's needs are.B. Diagnosis involves using nursing judgment to determine the exact conditions or needs of the client.C. Planning involves using set measurable and achievable goals for the client.Vital Concept:Assessment includes systematically collecting data to find out what the client's needs are. Diagnosis involves using nursing judgment to determine the exact conditions or needs of the client. Planning involves using set measurable and achievable goals for the client. Evaluation, the final step of the nursing process, allows the nurse to determine the client's response to the nursing interventions and the extent to which the objectives have been achieved.

The nurse is extremely busy and all of the following tasks need to be completed. Which task should the nurse assign to the certified nursing assistant? A. Changing the dressing on a client who has a Stage III decubitus ulcer B. Administering acetaminophen to a client who has a headache C. Obtaining a sterile urine specimen from a client D. Performing hygienic care for a person who has had a CVA

Correct Answer: D. Performing hygienic care for a person who has had a CVA A certified nursing assistant is well trained and qualified to perform hygienic care and this task may be delegated. Incorrect Answers:A. A Stage III decubitus ulcer is a sterile procedure and a skilled professional is required for accurate wound assessment. This task should not be assigned to a CNA. B. Certified nurse's aides are not qualified to administer any type of medication. C. The only type of sterile urine specimen is that obtained by catheterization. CNAs are not qualified to perform catheterizations so this task cannot be delegated.

A nurse is preparing to remove nasogastric tube. What instruction should the nurse give to the client? A. To speak B. To lean forward C. To breathe normally D. To take deep breath and to hold it

Correct Answer: D. To take deep breath and to hold it Taking deep breath and then holding closes the glottis, thereby preventing accidental aspiration of the gastric contents.

A nurse is caring for a client who follows a vegan diet. Which of the following foods should the nurse offer the client? A. Bagel with cream cheese B. Boiled egg C. Fruit with yogurt D. Wheat toast with peanut butter

Correct Answer: D. Wheat toast with peanut butter A client who follows a vegan diet does not eat animal products. Peanut butter and wheat bread are plant‑based foods and are an appropriate choice for a client who follows a vegan diet. Incorrect Answers:A. A client who follows a vegan diet does not eat animal products, such as cream cheese. B. A client who follows a vegan diet does not eat animal products, such as a boiled egg. C. A client who follows a vegan diet does not eat animal products, such as yogurt. Vital Concept:A nurse should clarify dietary restrictions with a client who identifies as vegan or vegetarian. A brief summary of vegetarian-style eating patterns is as follows: Category of VegetarianEating PatternSemi-vegetarianPlant-based with the occasional intake of fish, meat, poultry, or dairy products.Lacto-ovoIncludes dairy and eggs, but no meats.Lactoincludes dairy, but no meats or eggs.VeganNo meat, dairy, fish, or eggs permitted.

A patient's medical record must contain which of the following? A. Medical history B. Informed consent C. Diagnostic orders D. Therapeutic orders E. All of the above

Correct Answer: E. All of the above Standards for medical records are set by the Joint Commission, which is the organization that provides accreditation for healthcare organizations in the United States. The standards set by Joint Commission state that the patient's medical record must contain patient identification information, medical history, consent forms, and all diagnostic and therapeutic reports.

A nurse is educating the guardians of a toddler about snack food selections to minimize the risk for choking. Which of the following foods should the nurse include in the teaching? (Select all that apply). A. Graham crackers B. Apple slices C. Raisins D. Jelly beans E. Yogurt

Correct Answers: A. Graham crackers E. Yogurt Graham crackers are appropriate snack foods for toddlers. Yogurt is an appropriate snack food for toddlers. Incorrect Answers:B. Hard fruits such as apples and pears can pose a choking hazard to toddlers. This is especially true if the skin of the fruit remains. C. Raisins are difficult to chew and pose a choking hazard for toddlers. D. Sticky foods, such as gummy candies and jelly beans, are difficult to swallow and pose a choking risk for toddlers. Vital Concept:As infants become toddlers, they become increasingly independent and can be quite selective about the foods they eat. Toddlers are also at increased risk for choking because they might not chew food adequately prior to swallowing. Foods that pose an increased risk of choking are those that are hard and shaped like a tube or those that are dry, sticky, and fibrous. The nurse should instruct parents and guardians regarding foods that present choking hazards and provide prevention strategies to avoid choking in toddlers. Such prevention strategies include supervision of eating, minimizing distractions during eating, cutting food into bite-sized pieces or thin slices, and steaming hard vegetables such as broccoli and cauliflower. The nurse should recommend parents and guardians avoid allowing toddlers to snack or eat in the car because of the increased danger in pulling over safely if a child is choking. Finally, the nurse should recommend parents and guardians take a safety class and learn how to properly perform the Heimlich maneuver should choking occur.

A nurse in an outpatient clinic is collecting data from a client who reports night sweats, fatigue, cough, nausea, and diarrhea. The client asks the nurse if it is possible he has HIV. Which of the following actions should the nurse take? (Select all that apply.) A. Measure vital signs. B. Determine when manifestations began. C. Obtain a weight. D. Reinforce teaching about HIV transmission. E. Obtain a sexual history from the client.

Correct Answers: A. Measure vital signs. B. Determine when manifestations began. C. Obtain a weight. E. Obtain a sexual history from the client. The nurse should measure the client's vital signs to gather data about the client's condition. The nurse should gather more data to determine whether the manifestations are acute or chronic. The nurse should weigh the client to gather data and monitor the client's condition. The nurse should obtain a sexual history to determine how the client might have acquired the illness. Incorrect Answer: D. The nurse should not reinforce teaching with the client about HIV transmission until a diagnosis is determined. Vital Concept:Human immunodeficiency virus (HIV) is an infection that invades and attacks the immune system. The nurse should know that the manifestations of HIV are very similar to those found with any virus (e.g., fever, night sweats, muscle, and joint aches, headaches). It is important to identify any instances where the client came into contact with potentially infected body fluids, which can increase the potential for HIV infection.

A nurse is planning care for a client who has end stage renal disease (ESKD) and is receiving hemodialysis. Which of the following actions should the nurse include in the plan of care? (Select all that apply.) A. Monitor the client's weight daily. B. Encourage the client to comply with fluid restrictions. C. Evaluate intake and output. D. Instruct the client about restricting calories from carbohydrates. E. Monitor the client for elevated potassium levels.

Correct Answers: A. Monitor the client's weight daily. B. Encourage the client to comply with fluid restrictions. C. Evaluate intake and output. E. Monitor the client for elevated potassium levels. The nurse should plan to monitor the client's daily weight to determine fluid retention. Implementing fluid restriction for a client helps to slow fluid retention. Restrictions are based on several factors, including weight gain between dialysis procedures and residual kidney function. Evaluating the client's intake and output allows the nurse to determine if there is an increase in fluid retention. The amount of dietary potassium allowed for daily consumption varies depending upon urinary output. Typically, as the glomerular filtration rate decreases, the excretion of potassium decreases. Incorrect Answer:D. Carbohydrates are not restricted for a client who has ESKD. Vital Concept:Clients who have ESKD and who are receiving hemodialysis will require close monitoring of calories, protein, sodium, potassium, and fluids to determine adequate levels of each.

The nurse knows that which of the following clients with peripheral vascular disease are at high risk for amputation? (Select all that apply). A. A client who is 35 years old B. A client who is a cigarette smoker C. A client whose work requires prolonged standing D. A client with poorly controlled diabetes E. A client with elevated cholesterol

Correct Answers: B. A client who is a cigarette smoker D. A client with poorly controlled diabetes E. A client with elevated cholesterol Cigarette smoking, poorly controlled diabetes, and cholesterol levels over 200 mg/dl are all known risk factors for increasing peripheral vascular disease. Incorrect Answers:A. PVD is normally associated with older clients. C. Prolonged standing is not typically considered a risk factor for PVD but may cause varicose veins associated with poor venous return.

A nurse is assisting with planning an in-service for a group of elementary school teachers about identifying risk factors for maltreatment of children. Which of the following findings place a child at risk for maltreatment? (Select all that apply.) A. The child was born premature and has developmental delays. B. The child's grandparents frequently provide care while the parents work. C. The child's father, who is an educated executive, is often absent from family meals. D. The child's parents consistently provide clear direction and have high expectations. E. The child lives in a single-parent home.

Correct Answers: A. The child was born premature and has developmental delays. E. The child lives in a single-parent home. The nurse should identify that risk factors for child maltreatment include prematurity, physical disabilities, developmental delays, and chronic illnesses. The nurse should identify that children who live in a single-parent home can be at risk for child maltreatment. Incorrect Answers:B. Grandparents frequently provide care for their grandchildren while the parents are working. This does not place the child at risk for maltreatment. C. A child who has an educated executive for a father who is often absent during family meals does not place the child at risk for maltreatment. D. The nurse should identify that it is appropriate for parents to consistently provide clear directions and have high expectations for their child. This behavior does not place the child at risk for maltreatment. Vital Concept:The nurse should recognize risk factors for child maltreatment and report any suspicion of maltreatment to ensure the safety of the child. The presence of a single risk factor does not prove child maltreatment is occurring; however, when these risk factors occur with other concerning assessment findings, the nurse should consider the possibility of child maltreatment. Child maltreatment can consist of neglect, physical abuse, emotional abuse, and sexual abuse.

A client is an ovo-vegetarian. Which of the following food item should not be kept in the client's tray? A. Raw vegetables B. Orange juice C. Milk D. Eggs

Correct Answer: C. Milk An ovo-vegetarian does not eat meat or dairy products but does eat eggs. Incorrect Answers:A. This is acceptable on an ovo-vegetarian diet B. This is acceptable on an ovo-vegetarian diet D. This is acceptable on an ovo-vegetarian diet Vital Concept:An ovo-vegetarian diet excludes all animal-based products except eggs

By the age of 2 months, the following skull structure should be closed: A. Anterior fontanel B. Frontal suture C. Posterior fontanel D. Sagittal suture

Correct Answer: C. Posterior fontanel During the first 2 months, the posterior fontanel will close. Incorrect Answers: A. By the age of 18 months to 2 years, the other cranial structures should close. B. By the age of 18 months to 2 years, the other cranial structures should close. D. By the age of 18 months to 2 years, the other cranial structures should close. Vital Concept:In order to complete an appropriate assessment and identify expected vs. unexpected findings, the nurse should understand when suture lines close.

A postpartum client asks the nurse how long her vaginal discharge will last. The nurse's best response would be to explain that it will last: A. About 3 days B. Longer than if she were breast feeding C. Until her checkup in 6 weeks D. Until the placental site has healed

Correct Answer: D. Until the placental site has healed Vaginal discharge will continue until the placental site has healed, which can take up to 10 days. Incorrect Answers:A. Drainage can last up to 10 days. B. Drainage can last up to 10 days. C. Drainage can last up to 10 days. Vital Concept:Vaginal discharge can last up to 10 days after delivery. Healing times vary.

A nurse is teaching the parents of a 6 month old infant about risk factors for acute otitis media (AOM). Which of the following factors should the nurse include? (Select all that apply.) A. Infant is exclusively breastfed B. Infant attends day care 4 days per week C. Absence of routine vaccinations D. Siblings have a history of chronic ear infections. E. Parents smoke cigarettes

Correct Answers: B. Infant attends day care 4 days per week C. Absence of routine vaccinations D. Siblings have a history of chronic ear infections. E. Parents smoke cigarettes Infants who attend day care have an increased risk for AOM because of the exposure to multiple people and children with infections. The pneumococcal conjugate vaccine decreases the incidence of AOM. This routine vaccination is administered in 4 doses beginning at 2 months of age. Receiving the influenza vaccination after the child is 6 months of age has also been shown to decrease the incidence. Infants who have siblings or parents with a history of chronic otitis media are at risk for developing AOM. Exposure to secondhand smoke increases an infant's risk for AOM by impairing the ability of the respiratory tract to clear pathogenic organisms, which can then block the Eustachian tubes, causing increased pressure and fluid build-up and facilitating the growth of microorganisms. Acute Otitis Media: What is it?Inflammation and accumulation of fluid in the middle ear along with signs of illness. Often preceded by illness due to respiratory syncytial virus or influenza. Appears more commonly in children less than 7 years of age.What does it look like?Pain and pressure in earFever: can be highEnlarged postauricular and cervical lymph nodesLoss of appetiteWhat actions does the nurse take?Administer analgesics/antipyreticsApply heat over the ear and position child with the affected ear downward.Clean external ear canal with sterile cotton swabs with topical antibiotic ointment if draining.Reinforce need to complete the prescribed course of antibiotics.Reinforce education to reduce reoccurrence:Feed infant in upright position.Eliminate the infant's exposure to tobacco smoke.Avoid forceful nose-blowing during an upper respiratory infection. Incorrect Answers:A. Breastfeeding helps protect against AOM because breast milk contains secretory immunoglobulin A. Bottle feeding can put the infant at greater risk for AOM because of improper positioning while feeding, which can result in collection of milk in the infant's ear. Parents should sit or hold their infant in an upright position while bottle feeding and should never prop the infant's bottle on a pillow. Vital Concept:Otitis media (OM) is a common childhood disease caused by the accumulation of fluid in the middle ear, which leads to infection and inflammation. The nurse should provide education for the parents about preventive measures, such as avoiding propping up the infant's bottles, positioning the infant upright while bottle feeding, eliminating tobacco smoke exposure, and minimizing risks associated with crowded places, such as daycare. Adherence to recommended vaccination schedules also reduces the risk of AOM.