Princeton Review NCLEX

The nurse is caring for a client who has been receiving broad-spectrum antibiotics. The client has developed frequent, watery diarrhea and a fever. Which prescription should the nurse obtain first? A. a stool specimen B. oral probiotics C. a fecal managment system D. oral antipyretic

A Rationale: Clostridium difficile is diagnosed through toxin testing of stool. Prompt diagnosis is required so treatment can begin. Probiotics, antipyretics, and a rectal tube, now known as a fecal management system, are acceptable interventions for antibiotic-associated diarrhea but are not the priority. You chose B

The nurse is caring for a client who is experiencing hypothermia following submersion in cold water. The client is unresponsive with a core body temperature of 25°C (82.5°F) and is prescribed active rewarming. The nurse should expect to use which rewarming method for this client? A. Cardiopulmonary bypass B. Warming blankets C. Heating lamps D. Compression heat packs

A Rationale: For a client with hypothermia, rewarming methods used are active and passive interventions. The client with severe hypothermia (less than 28°C to 32.2°C or 82.5°F to 90°F) will require active internal rewarming techniques such as cardiopulmonary bypass, infusion of warm IV fluids, and warmed peritoneal lavage. Clients with mild hypothermia will require passive external rewarming techniques, such as warming blankets, heat packs, and heating lamps. You chose D

The nurse is admitting a client with a history of end-stage renal disease who was found unresponsive at home. The client has a history of chronic hemodialysis. The EKG is displaying bradycardia and peaked t-waves. Which of the following immediate interventions should be anticipated? A. 50% dextrose and regular insulin administered intravenously B. Insertion of central venous line C. Oral administration of kayexalate D. Initiation of a hemodialysis treatment

A Rationale: Hyperkalemia is the most life-threatening of the fluid and electrolyte changes that occur in patients with kidney disorders. Therefore, the patient is monitored for potassium values greater than 5.0 mEq/L (5 mmol/L), ECG changes (tall, tented, or peaked T waves), and changes in clinical status. If the patient is hemodynamically unstable (low blood pressure, changes in mental status, or dysrhythmia), IV dextrose 50%, insulin, and calcium replacement may be given to shift potassium back into the cells. The shift of potassium into the intracellular space is temporary, so arrangements for dialysis will then need to be made. You chose C

The night shift nurse is caring for a client diagnosed with a hemorrhagic cerebrovascular accident. The client has new onset confusion and is agitated. Which action would be a priority for the nurse? A. Call the healthcare provider and suggest a CT scan B. Stay with the client and reorient them to the situation C. Administer the prescribed PRN anxiolytic D. Lower the lighting to promote relaxation.

A Rationale: The priority intervention here is to obtain a CT scan to assess for further bleeding. The client with new onset confusion may have increased ICP from blood in the brain. Administering an anxiolytic may mask the signs of neurologic changes. Encouraging the client to sleep may also delay identification and treatment of a medical emergency. You chose B

The nurse is caring for a client who suddenly develops a wide QRS complex. The client's blood pressure is 82/40 mm Hg and respiratory rate is 22. The client is unarousable, and the nurse cannot palpate a pulse. Which action would be most appropriate for the nurse to take? A. Administer a prescribed intravenous IV fluid bolus B. Prepare the client for synchronized cardioversion C. Prepare to defibrillate the client D. Administer prescribed metoprolol

C Rationale: The client is experiencing ventricular tachycardia, which is a lethal rhythm. The nurse should prepare to defibrillate the client. Synchronized cardioversion is indicated for tachycardic dysrhythmias but will not convert vTach. Metoprolol is a beta-blocker that has anti-dysrhythmic effects, but for vTach, defibrillation is the priority action. You chose B

The nurse is screening clients for risk factors for glaucoma. Which of the following ethnicities would have the highest risk? A. Caucasian B. Hispanic C. African American D. American Indian

C. Rationale: The African American race has the highest risk for glaucoma compared to Hispanics, American Indians, and Caucasians. You chose A

A nurse is assessing a client after morning rounds. The client tells the nurse that the healthcare provider was rude and did not explain the plan of care. How does the nurse respond to the client's concern? A. "You are entitled to receive competent and respectful care." B. "Healthcare providers are very busy during morning rounds." C. "What questions do you have regarding your plan of care?" D. Has your healthcare provider made you feel this way before?"

A Rationale: A client has a right to receive medical care from providers who are competent and treat the client with respect. The nurse acknowledges the client's concern. The nurse should not excuse the behavior of the healthcare provider. The client's questions regarding the plan of care should be answered. However, the nurse is not addressing the client's concern in its entirety. The nurse's role is to acknowledge the client's rights. Asking about past experiences does not address the current concern. You chose C

The charge nurse is required to recommend a client that can be discharged in the next hour due to a disaster plan activation. The nurse should recommend which client for discharge? A. A client post-laparoscopic cholecystectomy with a prescription for a soft diet B. A client with a comminuted pelvic fracture who is taking oral analgesics C. A client with atelectasis on oxygen via nasal cannula D. A client with a foot ulcer who is receiving intravenous antibiotics

A Rationale: A postoperative client who is tolerating oral intake is considered stable for discharge. A laparoscopic cholecystectomy is minimally invasive, and clients are usually discharged within a day. A client with a comminuted pelvic fracture cannot be mobilized until treated. A client with atelectasis who requires oxygen therapy is not stable for discharge within an hour. A client receiving intravenous antibiotics is not ready for discharge. Intravenous therapy requires care management collaboration prior to discharge. You chose B

The nurse is caring for an adult client who has a new diagnosis of diabetes type 2. The client states, "What would be the best way to keep my blood sugar low and help me lose weight?" Which member of the interprofessional team should the nurse collaborate with to provide accurate information? A. Registered dietitian B. Diabetes educator C. Healthcare provider D. Exercise physiologist

A Rationale: A registered dietitian (RD) manages and plans for the dietary needs of patients based on knowledge about all aspects of nutrition. RDs can adapt specialized diets for the individual needs of patients, counsel and educate individual patients, and supervise the dietary services of an entire facility. Diabetes educators have expertise in insulin and oral hypoglycemic treatment regimens and can provide some information regarding diets. Exercise physiologists can provide techniques to exercise but do not address the need to control blood glucose levels. You chose B. You second guessed yourself

During an annual physical, a 55-year-old client tells the nurse, "I have noticed an increase in belching." How does the nurse explain gastrointestinal changes to the client? A. "Your muscle tone decreases as you get older, and movement of food slows down." B. "Your stomach produces more enzymes as you age and causes indigestion." C. "Your metabolism decreases and causes you to eat more food." D. "Your stomach capacity decreases, and food backs up."

A Rationale: Aging causes biological changes in the gastrointestinal system and result in decreased metabolism, decreased intestinal tone, and decreased gastric enzyme production. The decrease in gastrointestinal activity can result in increased acid indigestion and belching. The stomach produces fewer digestive enzymes with aging. A decrease in metabolism requires less caloric intake, not more. Stomach capacity is influenced by the decrease in elasticity, not a physical reduction in size. You chose B

The nurse is caring for a client who experienced an atonic seizure while in bed. Which action should the nurse take? A. Reorient the client B. Administer prescribed phenytoin C. Request a CT scan of the head D. Turn the client on their side

A Rationale: An atonic seizure is characterized by loss of muscle tone and a period of confusion after the seizure occurs. The nurse should reorient the client after the seizure. Administering phenytoin is indicated for status epilepticus or for the prevention of seizures. This does not address the effects experienced after the seizure. The client's seizure occurred while in bed. Requesting a CT scan of the head to assess for injuries is not indicated. Turning the client on their side will prevent aspiration. However, an atonic seizure is not characterized by vomiting or salivation. You chose D

A nurse is caring for a client with a traumatic brain injury who has a tympanic temperature of 104°F. Which action would be most appropriate for the nurse to take? A. Administer prescribed acetaminophen B. Apply a cooling blanket C. Place ice packs in the axilla area D. Adjust the environmental temperature

A Rationale: Antipyretics (acetaminophen, aspirin, non-steroidal anti-inflammatory agent) are given to reset the hypothalamus thermoregulatory mechanism or thermostat for temperatures greater than 38.5°C. The use of cooling blankets and ice packs are used when antipyretics are not effective. Caution is used with cooling devices, which can cause shivering and increase intercranial pressure. Adjusting the environmental temperature will not impact the client's core temperature. You chose C

The nurse is caring for a client with an arterial line for blood pressure monitoring and frequent blood gases. To obtain accurate readings, which of the following actions should be taken? A. Level the transducer to the phlebostatic axis B. Raise the limb with the site of arterial catheter access to the level of the heart C. Turn the stopcock off to the transducer and zero it to calibrate the equipment D. Turn the stopcock off to the transducer and perform the square wave test

A Rationale: Arterial line transducers are leveled and calibrated to the phlebostatic axis, which locates the right atrium. Moving the limb will result in unreliable readings. The stopcock should be positioned off towards the client for calibrating the equipment to atmospheric pressure. A square wave test of the transducer system is performed by fast flushing the tubing for 1-2 seconds. A normal (optimally damped) waveform will be a perfect square with 1-2 oscillations. The stopcock will be closed to the atmosphere for this test. You chose B

The occupational health nurse is teaching a client about measures to reduce the risk of carpal tunnel syndrome. Which of the following should the nurse include in the teaching? A. "Geometrically designed keyboards may assist with reducing strain on your fingers and wrists." B. "Lower your chair height so that your wrists are flexed." C. "Take frequent breaks from keyboards to perform other finger motions." D. "Stretch your fingers and wrists in the morning before work."

A Rationale: Carpal tunnel syndrome is the most common repetitive stress injury. Clients should be taught proper ergonomics to reduce the risk of developing carpal tunnel syndrome, including stretching wrists frequently during the day while at work and typing, adjusting the chair height so that elbows are at a 90-degree angle without flexion of the wrists. Clients should be taught to take frequent breaks from keyboards in addition to typing on keyboards found on cellphones and handheld devices. A geometrically designed keyboard may reduce strain on fingers and wrists as well as adjustable height desks to allow for alterations in positions throughout the day. You chose C

The nurse is monitoring a client on a high-dose dopamine infusion post-resuscitation for cardiac arrest. Which finding indicates the client is having a positive response to treatment? A. Blood pressure of 109/64 mmHg B. Pedal pulses +1 C. Urine output of 30 mL/hr D. Heart rate of 110 beats/min

A Rationale: Dopamine is an adrenergic vasopressor used to increase blood pressure after cardiac arrest. The goal of therapy is to maintain the blood pressure within normal limits. A blood pressure of 109/64 mmHg is a positive finding for a client on dopamine. The normal pulse strength is +2. A strength of +1 indicates a weak, thready pulse and decreased circulation. Urinary output of 30 mL/hr is a normal finding. However, high doses of dopamine cause renal blood vessel constriction and are not intended to treat urinary output. A heart rate of 110 beats/min is not a positive response to treatment. Although vasoconstriction increases the heart rate, the intended goal is to maintain normal limits. The normal heart rate is 60 to 100 beats/min. You chose C

The nurse is caring for a client receiving an intravenous infusion using a smart pump when a system error begins alarming. Which action by the nurse will reduce the risk of injury to the client? A. Tag the device for maintenance and remove it from the unit B. Power down and restart the pump to clear the error C. Reposition the tubing in the infusion device to clear the alarm D. Place the plug in a red outlet to reduce the incidence of an energy surge

A Rationale: Electrical equipment can present a safety hazard to both the patient and health care practitioner when safety measures are ignored. IV infusion equipment has the potential to experience software and system errors that can result in delayed infusions, over-infusion, under-infusion, or failed infusions. These errors can lead to serious injury and death. When system errors occur, the best action is to remove the device from service until it has been serviced. System errors are not caused by poor tubing placement and are not prevented by placing the plug in a generator outlet. You chose C

The nursing supervisor is working in an acute care facility following an earthquake. The building has lost water supply and is on generator power. Which patients should the nursing supervisor evacuate first? A. Ventilator dependent adults in the ICU B. Ambulatory adults on the medical unit C. Ambulatory children in the pediatric unit D. Non-ventilator dependent adults in the ICU

A Rationale: Evacuation decisions after No Advanced Warning Events such as earthquakes are based on building integrity, infrastructure, and environmental factors. If there is a potential or immediate threat to staff or clients, an assessment must be made to immediately evacuate or wait and reassess. Once evacuation is determined, triage is based on the availability of critical resources. In this case, the loss of power and water makes movement of acutely ill clients the priority. The other clients may be evacuated subsequently. You chose A

The nurse is performing the Weber assessment test on a client who reports hearing loss in the left ear. Which finding would indicate to the nurse the client is experiencing conductive hearing loss? A. The client hears the sound vibrate from the top of the head in the affected ear. B. The client hears the sound by air conduction longer than feeling bone conduction. C. The client feels the bone conduction longer than hearing the sound conduction. D. The client pushes on the tragus while repeating back what is whispered.

A Rationale: For the Weber test, the tuning fork is placed on the bridge of the forehead, nose, or teeth. In a normal test, the sound is heard equally in both ears. With unilateral conductive loss, sound is heard in the affected ear. With unilateral sensorineural loss, sound is heard in the normal or better-hearing side. In a Rinne test, the tuning fork is placed on the mastoid bone behind the ear until the client can no longer feel the vibration. The fork is then moved beside the ear. In a normal test, air conduction is greater than bone conduction. The whisper test has the client repeat what is heard while pushing on the tragus. You chose C

The nurse is educating a client with end-stage renal failure about newly prescribed aluminum hydroxide. Which statement should the nurse include in the teaching? A. "This medication binds with phosphates from food to decrease absorption." B. "This medication is used to decrease urea to prevent urticaria." C. "This medication will coat the lining of the stomach to decrease acid production." D. "This medication treats hyperkalemia by exchanging sodium for potassium in the intestines."

A Rationale: Hyperphosphatemia occurs in end-stage renal failure when kidneys can no longer filter out phosphorus. Treatment of hyperphosphatemia may include the administration of aluminum hydroxide as a phosphate-binding agent. The aluminum binds with phosphates which are excreted in the feces. Sodium polystyrene is used to treat hyperkalemia by exchanging sodium for potassium in the intestines. Dialysis is used to remove urea from the blood, and diphenhydramine is used to treat urticaria. Sucralfate is a medication that coats the stomach lining to decrease acid production. You chose C

The nurse is assessing a client who had a closed-chest drainage system placed 6 hours ago for treatment of a hemothorax. The nurse should notify the primary health care provider (PHCP) of which of the following findings? A. Drainage from the chest tube has stopped B. Fluid in the water seal chamber rises with inspiration C.Bubbling of water in the water seal chamber with coughing D. Crepitus palpated in the area surrounding the insertion site

A Rationale: No drainage from a chest tube in the first 24 hours after insertion requires immediate notification to the surgeon; if drainage stops, it can lead to a tension pneumothorax. Bubbling in the water seal chamber is normal during forceful expiration or coughing because the air in the chest is being expelled. Crepitus around the insertion site indicates subcutaneous emphysema, which, unless extensive and extending to the neck, is not a serious complication. Fluid in the water seal chamber should rise with inspiration and fall with expiration, which is called tidaling. You chose D

The nurse has collected a stool specimen from a client with antibiotic associated diarrhea. Clostridium difficile is suspected. What action should the nurse take to transport the specimen to the lab? A. Place the specimen in a small biohazard bag. B. Wear gloves and an isolation gown when walking to the lab. C. Wipe the exterior of the collection cup with a disinfectant wipe. D. Place the client's label on the cap of the collection cup.

A Rationale: Personal protection equipment (PPE) should be removed inside or just outside of the client's room. It is not worn in the hallway. Send or transport the specimen to the laboratory in a biohazard bag immediately or within the optimal time from collection as indicated by facility policy and guidelines. Avoid contact with soaps, detergents, and disinfectants as these may affect test results. The identification label should be attached to the cup so that when the lid is removed, the specimen remains labeled. You chose C

The nurse is preparing to administer newly prescribed intravenous phenytoin to a client. When reviewing the client's medical record, which prescription should the nurse question? A. Continuous infusion of dextrose 5% in 0.9% saline B. NPH insulin 40 units before meals C. Labetalol 100 mg orally twice per day D. Ketorolac 15 mg IV push as needed for pain

A Rationale: Phenytoin is not compatible with most IV fluids, especially those with dextrose. If the nurse observes a continuous infusion of a fluid that contains dextrose, they should understand that incompatibilities are likely and should not administer the medication as prescribed. Insulin, labetalol, and ketorolac do not have potential incompatibilities. You chose D

The nurse is caring for a client receiving continuous renal replacement therapy (CRRT) for acute kidney injury of prerenal origin. Which of the following findings indicates that the CRRT is having the intended effect? A. Serum concentrations of urea are reduced B. Urine output is increased C. Neurological status is improved D. Blood pressure is increased

A Rationale: Prerenal acute kidney injury results from poor perfusion to the kidney. The aim of CRRT is to gently remove waste and fluid while reducing the burden on the kidney to aid in recovery. Therefore, BUN/Cr and potassium levels should all decrease after the initiation of CRRT. While urine output may increase due to a recovery in kidney function, it is not the result of CRRT. Blood pressure stability is typically the result of vasoactive medication or treatment of sepsis in clients with prerenal acute kidney injury. You chose D

The nurse is assessing a client's room for safety hazards. Which finding observed by the nurse would increase the client's risk for falls? A. The client's side rails are raised on all sides of the bed. B. The client has a nonskid mat in the shower. C. The bed exit alarm is activated on the client's bed. D. The client's ambulatory aid is next to the client's bed.

A Rationale: Raising all side rails on a bed has been shown to increase the risk of client falls because clients may become entrapped and unable to get out of bed. If a client is at risk for falls, side rails are often not used at all and beds are fully lowered, and padding is placed on the floor along the sides of the bed. Nonskid mats in the shower, bed exit alarms, and keeping client ambulatory aids within easy reach are all correct techniques to reduce the risk of falls. You chose C

The nurse is caring for a client with increased intracranial pressure who is mechanically ventilated. Which of the following actions by the nurse is appropriate? A. Hyperventilating the client with 100% oxygen prior to suctioning B. Educating the client to cough to clear respiratory secretions C. Assessing oxygen saturation every 6 hours D. Increasing the positive end-expiratory pressure

A Rationale: Suctioning can increase intracranial pressure (ICP) but hyperoxygenation prior to suctioning reduces the increase in pressure. Coughing should be avoided, and positive end-expiratory pressure (PEEP) should be as low as possible to avoid increasing the ICP further. Oxygen saturation should be monitored continuously rather than every 6 hours. You chose C

The nurse is reassessing a client after resuscitative efforts. Which finding indicates the disability component of the ABCDE approach is intact? A. Client has a GCS score of 15 B. Lung sounds are clear bilaterally C. Capillary refill is 2 seconds D. Client is responsive to pain

A Rationale: The ABCDE approach is a rapid assessment of emergency conditions. The disability component represents the "D" in ABCDE. Disability determines the client's level of consciousness. The Glasgow Coma Scale (GCS) is based on eye-opening, verbal, and motor responses. The normal finding is a score of 15. Clear lung sounds evaluate breathing, the "B" in the ABCDE approach. Capillary refill of 2 seconds is a normal finding for circulation, the "C" in the ABCDE approach. A client who is responsive to pain does not have an intact level of consciousness. You chose D

A nurse is assessing a client diagnosed with diabetic ketoacidosis. The client is on a prescribed regular insulin infusion at 0.1 units/kg/hr. The client appears restless and verbalizes tingling to the extremities. Which action does the nurse perform next? A. Check the client's capillary blood glucose B. Stop the regular insulin infusion C. Increase the infusion to 0.15 units/kg/hr D. Give the client 4 oz of fruit juice

A Rationale: The client is experiencing symptoms of hypoglycemia. Prior to decreasing the dose of the infusion, the nurse should assess the client's blood glucose level to confirm the hypoglycemia. Prior to stopping the infusion, the nurse needs to assess the client's blood sugar level and notify the healthcare provider of the results. Increasing the infusion will cause further hypoglycemia. Prior to performing an intervention to correct the hypoglycemia, the nurse needs to assess the blood glucose level first. You chose B

The nurse is caring for a pregnant client who is receiving intravenous magnesium sulfate therapy. Which of the following medication prescriptions should the nurse clarify with the provider? A. Nifedipine B. Ondansetron C. Lactated ringers D. Betamethasone

A Rationale: The effect of the calcium channel blocker can be increased if it is taken with magnesium sulfate; therefore, the nurse should question a new prescription of nifedipine. All other medications will not create adverse effects if given with magnesium sulfate. You chose C

The nurse is caring for a client who has a thoracentesis and physical therapy scheduled during the nurse's shift. Which action by the nurse is most appropriate to effectively manage this client's care? A. Request that the client's physical therapy be performed in the morning B. Cancel the client's physical therapy prescription for that day C. Ensure that the thoracentesis is performed before physical therapy begins D. Medicate the client with analgesics prior to both activities

A Rationale: The most appropriate action would be to request that the physical therapy be performed in the morning prior to the thoracentesis. This action still allows both prescriptions to be completed but in the most effective way. Canceling the physical therapy and planning to complete the physical therapy after the thoracentesis are not the most effective management of care strategies. Medicating the client prior to these activities is not an incorrect action but does not address the schedule conflict. You chose D

A nurse has administered acetaminophen for pain relief to an infant. Based on the client's development stage, which action is most important to include in the medication administration record? A. The dose administered based on the client's weight B. The client's pain level after administration of the medication C. The time the dose was administered to the client D. The client's vital signs before the medication was administered

A Rationale: The most important action to document in the client's medical record is the dose administered. The dose of acetaminophen administered to infants is based on weight. Infants should not exceed more than 5 doses of 10-15 mg/kg/dose in a 24-hour period. Documenting the pain level after administration of analgesics, the time the dose was administered, and the latest vital signs should be performed on every client regardless of their developmental stage. You chose B

The nurse is caring for a client recovering from a cardiac catheterization. The introducer sheath has been removed from the right femoral artery and a pressure dressing is in place. Which of the following findings indicates a serious complication may be occurring? A. Creatinine level is increasing B. Ecchymosis is present at the insertion site C. Discomfort at the insertion site D. Extremities are warm bilaterally with trace edema

A Rationale: The risk of contrast-induced kidney injury is increased in clients with underlying moderate to severe renal disease, people with diabetes, the elderly, females, clients on diuretics, ACEI, and metformin. Adequate pre-hydration, use of iso-osmolar agents, and techniques to minimize the amount of dye used will help prevent this complication. Renal emboli can also cause renal failure. Ecchymosis and discomfort at the site are expected, but the nurse should monitor for hematomas and retroperitoneal bleeding. The nurse would monitor for signs of neurovascular impairment in the lower extremities, especially the right leg. Warmth is an expected finding, and trace edema is not a priority. You chose B

The nurse is placing a client into the supine position. Which action should the nurse take to maintain proper body alignment for this client? A. Place a folded blanket from the femur to the popliteal space B. Position a pillow under the shoulder with arm flexed C. Lift lower extremities off the bed with folded blankets D. Use pillows under the upper extremities with hands down

A Rationale: When placing the client in the supine position, the nurse should place a trochanter roll, a folded blanket, under the client's femur extending to the popliteal place. The trochanter roll will prevent the external rotation of the hip. Positioning a pillow under the shoulder and lifting feet or upper extremities are used to decrease pressure on bony prominences but do not maintain proper alignment. You chose D

The charge nurse is observing a newly hired nurse instruct a client who requires endotracheal intubation for status asthmaticus. Which of the following statements by the newly hired nurse requires intervention? A. "You will not be able to communicate once the tube is in place." B. "The mechanical ventilator may alarm, which does not always indicate a problem is occurring." C. "The tube will assist with your work of breathing and improve gas exchange." D. "You will be administered medications to maintain comfort and reduce anxiety as needed."

A. Rationale: Clients who are undergoing endotracheal intubation should be instructed, if possible, about what to expect during and after the procedure. Clients should be taught that their ability to talk will be eliminated, however, alternative forms of communication, such as a whiteboard or pen and paper will be provided to ensure client needs are met. Clients should be educated that ventilator sounds may occur and reassured that each sound does not always indicate a problem, which can cause anxiety in clients. Clients should be educated on the purpose of the tube insertion, which is to reduce the work of breathing and improve gas exchange. Clients should be assured that their comfort will be managed with medications, such as anxiolytics, as needed. You chose B

The nurse is teaching a parenting class to clients at a community center. Which information should be included in the education related to infant growth and development? A. "Most babies gain about 2 pounds every month until they reach 6 months old." B. "Your baby should double birth height by their first birthday." C. "Babies don't start to hold their head up until about 4 months of age." D. "You should see a doctor if your baby is not able to walk by 11 months old."

A. Rationale: In the first six months of life, infants gain about 2 pounds per month; weight gain then slows to about 1 pound per month for months 6-12. Height at one year old is typically 1.5 times the infant's birth height. Infants begin holding their head up around 2 months of age, and while some infants may walk at 11 months old, it is not a cause for concern if the baby is not walking at this age. You chose B

A nurse is educating a female client about using basal body temperature to assist in determining when ovulation will occur. Which of the following statements will the nurse include in the teaching? A. "You will need to check your temperature each day before getting out of bed." B. "Take your temperature in the evening each day, so you will get a true basal temperature." C. "Take your temperature during the time that you believe you are ovulating." D. "Choose a time that is convenient to take your temperature at the same time each day."

A. Rationale: The basal body temperature (BBT) refers to the lowest temperature reached on awakening. BBT is slightly lower in the follicular phase (the first half of the menstrual cycle) and rises after ovulation and stays raised throughout the luteal phase (the second half of the menstrual cycle). This rise in temperature happens in response to progesterone, which is released after ovulation occurs. To measure basal temperature, the client must take her temperature every morning at the same exact time before getting out of bed. The client must try not to move too much, as any activity can raise the body temperature slightly. You chose D

During a clinic visit, a 49-year-old female client tells the nurse, "I think I am beginning to experience hot flashes." The client asks the nurse what she can do to minimize menopausal symptoms. Which of the following is an appropriate nursing response? A. "Incorporate yoga into your exercise routine." B. "Long-term use of soy supplements can help you with your symptoms." C. "Eat raw flaxseed with plenty of water." D. "Acupuncture can provide the same benefits as hormone therapy."

A. Rationale: Research has shown that yoga and other meditation-based exercises can reduce the frequency and intensity of menopausal symptoms, such as hot flashes, joint pain, and mood disturbances. Long-term use of soy supplements has been associated with thickening of the lining of the uterus. There are conflicting studies on whether flaxseed is effective in lowering menopausal symptoms. Additionally, raw flaxseed can contain potentially toxic ingredients. Research has shown that acupuncture is less effective than hormone therapy. Additionally, acupuncture can cause infections and tissue damage if not performed correctly. You chose D

The nurse is working in the local health department, and over the last six months, there has been an increase in chlamydia infections. In order to help reduce the rates of infection, the nurse suggests which of the following for the next three months? A. Giving handouts to sexually active clients on discharge B. Making condoms accessible to clients on discharge C. Assessing the client's knowledge of sexually transmitted infections D. Assessing each client's knowledge of safe sex practices

B Rationale: Everyone who is sexually active is at risk for sexually transmitted infections. For the nurse to help decrease the instances of infection, providing condoms would be a noninvasive and private way to assist clients in safer sex practices. This would also allow non-clinical staff to assist with the intervention. Giving handouts, especially to minors, could induce shame or embarrassment. Assessing a client's knowledge could be difficult due to less-than-truthful responses due to confidentiality concerns. Intervention that does not require the client to engage their personal information is most helpful. You chose D

The nurse is assisting with the placement of a central venous catheter into the subclavian vein. Which action should the nurse take? A. Place the client in Trendelenburg position and turn head away from insertion site B. Obtain full sterile drape and personal protection equipment (PPE) C. Soak sterile cotton in povidone-iodine and place in the sterile field D. Obtain a prescription for an ultrasound to confirm line placement

B Rationale: A central venous catheter/line (CVC or CVL) is a large-bore central venous catheter that is placed using a sterile technique (unless an urgent clinical scenario prevents sterile technique placement) in certain clinical scenarios. There are three possible sites for CVL placement in the adult patient, including the internal jugular (IJ) vein, femoral vein, and subclavian (SC) vein. The client is placed in reverse Trendelenburg for SC and IJ insertion. The client is supine for femoral insertion. CVC insertion bundles require that the provider wear head-to-toe sterile PPE and that the client be maximally draped with a sterile barrier. Chlorhexidine is the preferred antiseptic for CVC insertion due to its antibacterial efficacy. CVC insertion may be performed with the aid of ultrasound; however, placement is confirmed with a chest radiograph. You chose C

A charge nurse is performing the daily check of the code cart on the unit. Which finding will the nurse report immediately for further inspection? A. The oxygen tank is empty B. The defibrillator charging light is off C. One of the wheels on the cart does not lock D. The last inspection is not signed

B Rationale: A defibrillator should always be fully charged in case of emergencies. Drained batteries can result in equipment failure. The oxygen tank is required for transport. However, the tank can be replaced with a full tank from the unit. The wheel locks prevent the crash cart from moving. Although the wheel needs to be inspected, it is not a priority action. Inspection signatures are important for quality improvement and documentation. However, ensuring the defibrillator is charged is the priority. You chose A

The nurse is caring for a client who is in a second-degree heart block and reports dizziness and shortness of breath. The nurse notes the client's blood pressure is 90/40 mmHg. Which action should the nurse take? A. Administer prescribed atropine B. Prepare for transcutaneous pacing C. Perform synchronized cardioversion D. Administer prescribed vasopressin

B Rationale: A second-degree block occurs when the electrical conduction is interrupted, usually at the AV node, and does conduct through the Purkinje fibers. This results in the failure of the ventricles to contract, which decreases cardiac output. To treat a second-degree block, the nurse should prepare the client for transcutaneous pacing, which will increase cardiac output. Synchronized cardioversion is used to treat tachycardia dysrhythmias, such as SVT or atrial fibrillation. Atropine contraindicating in treating a second-degree block. Vasopressin causes vasoconstriction which increases blood pressure but will not treat second-degree block. You chose A

The nurse is caring for an adult client with septic shock who has a right radial arterial line. The nurse recognizes an overdamped waveform on the monitor. Which of the following is the likely cause? A. The pressure on the flush bag is at 300 mmHg. B. The pressure tubing is kinked under the client. C. The client has a 10-point drop in systolic blood pressure. D. The transducer is improperly leveled.

B Rationale: Arterial pressure monitors provide continuous information on a patient's hemodynamics. This information is invaluable to assist in timely clinical decision-making and intervention. If the system is overdamped, there will be a falsely low systolic pressure, but the diastolic pressure is usually accurate. A system that is not optimally damped will be apparent in waveform analysis. An overdamped trace will show less than 1 1/2 oscillations below the baseline with an unclear dicrotic notch. Overdamping can be due to a clot or buildup of fibrin in the catheter tip, loose connections, air in the system, or kinks in the pressure tubing. The pressure on the flush bag should be set to 300 mmHg. If there is fluid loss or air entry, a damped waveform could occur. Transducer leveling is essential for accurate readings but does not affect damping. You chose D

The nurse is preparing to administer prescribed baclofen to a client with multiple sclerosis who is experiencing bladder spasms. The client states, "I do not want to take that medication; it makes me sleepy." Which statement by the nurse would be most appropriate? A. "This medication is needed to stop the spasms." B. "We can discuss alternative interventions to treat the spasms." C. "You can discuss your concerns with your healthcare provider." D. "I can give the medication before bedtime."

B Rationale: Clients who report unpleasant side effects of medications may be reluctant to continue taking the medications. Clients have the right to refuse treatments or procedures, and the nurse should recognize and respect the client's choice. WHEN A CLIENT REFUSES TREATMENT, THE NURSE SHOULD DISCUSS ALTERNATIVE OPTIONS WITH THE CLIENT. Telling the client to discuss the concerns with the healthcare provider does not address the need to treat the spasms. Explaining what the medication is for is important but does not address the client's refusal and dismisses their concerns. This medication is prescribed three times a day; a nurse cannot change the dosing times without discussing it with the healthcare provider. You chose D

The charge nurse is observing a newly hired nurse who is caring for a client with hypomagnesemia and is receiving an intravenous magnesium sulfate infusion. Which of the following actions by the newly hired nurse requires intervention? A. Requesting to discontinue the client's prescribed furosemide B. Assessing the client's deep tendon reflexes every 4 hours C. Requesting a prescription for a stool softener D. Initiating continuous cardiac monitoring

B Rationale: Clients with hypomagnesemia who are receiving intravenous magnesium sulfate should have deep tendon reflexes monitored hourly to monitor effectiveness and prevent hypermagnesemia. Clients with hypomagnesemia should be started on continuous cardiac monitoring to assess for dysrhythmias, have stool softeners ordered due to decreased gastrointestinal peristalsis, and have high-ceiling diuretics discontinued to prevent further magnesium losses. These actions all indicate correct management of a client with hypomagnesemia You chose C

A nurse has administered sublingual nitroglycerin to a client in the emergency department. Which clinical finding indicates an adverse response to the medication? A. Persistent chest pain B. Orthostatic hypotension C. Decreased heart rate D. Labored breathing

B Rationale: Decreased blood pressure when changing positions is an unexpected response to nitroglycerin. The nurse should instruct the client to lay down and elevate the feet to promote venous return. Persistent chest pain is not an unexpected response. Additional doses may be required to alleviate angina. A side effect of nitroglycerin is tachycardia, not a decreased heart rate. Nitroglycerin is not associated with respiratory effects. You chose D

The nurse is evaluating a client after initiation of a warm bath to the hands due to frostbite. Which client response indicates the treatment is effective? A. Erythema is noted to bilateral hands B. Client reports increasing pain to bilateral hands. C. Client's oral temperature is 37°C (98.6°F) D. Bilateral radial pulses are +1

B Rationale: Frostbite of the extremities leads to numbness and paresthesia. When the tissues rewarm and thaw, the client will experience burning pain to the extremities, signaling improved circulation. Erythema is due to vasodilation and is an expected finding for superficial frostbite. Rewarming results in white or yellow skin tone. The client's oral temperature is a normal finding; however, this does not directly evaluate the effectiveness of therapy to the extremities. Bilateral radial pulses of +1 do not indicate effective treatment. The normal pulse strength is +2. You chose A

The nurse is assessing the client with a hearing deficit for pre-existing knowledge of hearing aid care. Which of the following statements by the client demonstrates correct care? A. "I clean my hearing aids with a disinfectant cleanser weekly." B. "I open the battery door at night." C. "I use a paper clip to clean the microphone port." D "A whistling sound means I need to have my hearing aid checked."

B Rationale: If the patient uses a hearing aid, check the batteries routinely and clean the earpieces or ear mold daily with mild soap and water. A whistling sound that is audible when the hearing aid is held in the hand with the power on and the volume high indicates that the battery is functioning properly. The microphone port should be cleaned with a hearing aid brush and pick. The shell and molds of the hearing aid should be cleaned with a chemical-free damp cloth. You chose A

The nurse is assessing a client who wishes to refill a prescription for intramuscular depot medroxyprogesterone acetate (Depo-Provera). Which statement by the client indicates that refilling this prescription would be contraindicated? A. "I want to start a family in the next five years." B. "I have been taking the Depo shots for three years." C. "My period typically lasts six days." D. "My last pregnancy was four years ago."

B Rationale: Long term use (more than 2 years) of Depo-Provera is contraindicated due to the medication's ability to decrease bone mineral density. The client stating that she has been taking this medication for three years indicates that they should not be prescribed this method any longer. All other responses are not contraindications. You chose A

The nurse is caring for a pediatric client who is experiencing a febrile seizure. Which action should the nurse take first? A. Administer anticonvulsant medication B. Protect the child's head from injury C. Loosen any clothing around the neck D. Apply a cooling blanket over the client

B Rationale: Protecting the child from injury would be the highest priority action. Seizure activity may cause the child to have involuntary movements which could result in hitting their head. Loosening the clothing will help maintain the airway but would not be done first. The cooling blanket can help reduce the fever but would not be done first. Administering anticonvulsant medication would not happen first. You chose C

The nurse is reviewing written education with a client. The nurse notes the client squinting and moving the document close to their eyes. What assessment tool would be used to collect additional information about this patient's problem? A. Snellen chart B. Jaeger test C. Confrontation test D. Ishihara cards

B Rationale: The Snellen chart is used to assess far vision; the Jaeger test is used for near vision. Confrontation tests assess visual field and peripheral field deficits. Ishihara cards assess for the ability to differentiate color You chose A

A nurse is assessing a client for hip flexion contractures. Which test will the nurse use to perform this assessment? A. Lasegue test B. Thomas test C. McMurray test D. Phalen test

B Rationale: The Thomas test assesses the presence of a flexion contracture of the hip. The client should be supine, with one leg extended and the other with a flexed knee. When the knee is brought to the chest, the opposite leg will rise if a flexion contracture is present. The Lasegue test is used to check for lumbar disc herniation and nerve irritation. The McMurray test is used to assess for a meniscus cartilage injury to the knee. The Phalen test is used to evaluate carpal tunnel syndrome. You chose D

A nurse is evaluating the effectiveness of urinary habit training for a client with functional incontinence. Which finding indicates the program was successful? A. The client's voiding episodes increase in frequency. B. The client urinates at scheduled intervals. C. The client verbalizes a decrease in bladder spasms. D. The client's bladder distention is decreased.

B Rationale: The goal of bladder training for clients with functional incontinence involves establishing predictable patterns of urination. The ability of the client to urinate at scheduled intervals indicates the training was successful. Increased episodes of voiding is not the goal of bladder training for functional incontinence. Bladder spasms and bladder distention are not associated with functional incontinence or a urinary habit training program. You chose D

The nurse is caring for a client who is going to have an invasive procedure. The healthcare provider has completed the informed consent discussion. Based on knowledge of the nurse's role in informed consent, what action by the nurse is most appropriate? A. Answer any additional questions that the client has about the procedure B. Determine if the client has additional questions about the proposed procedure C. Sign the documentation in the role of the witness D. Encourage the family to support the client's decision

B Rationale: The most important part of the consent process is informing the client. A client's signature is meaningless if the client is not informed. Nurses are often told that when they obtain a client signature on a consent form, they are only witnessing the signature and not verifying that informed consent was obtained. However, nurses have ethical and professional accountabilities to ensure the client is fully informed and capable of giving consent. It is appropriate for the nurse to assess if the client has full understanding of the proposed treatment and then advocate to ensure that the client received the necessary information from the provider. You chose C

A nurse is reviewing new prescriptions for a client diagnosed with heart failure. The nurse notes captopril 25mg PO. Which action does the nurse perform next? A. Administer the medication before meals B. Clarify the prescription with the healthcare provider C. Take the client's weight D. Check the client's latest creatinine level

B Rationale: The nurse should clarify the prescription with the healthcare provider. The prescription is missing a frequency, a necessary component of a medication prescription. Captopril should be administered before or after meals. However, the prescription does not have a frequency and should be clarified. Taking the client's weight and checking renal labs are important interventions after the prescription is clarified. You chose D

A nurse is assessing a client on continuous IV therapy. The client's IV access site is cool to the touch, and the dressing feels moist. Which action should the nurse take? A. Discontinue the intravenous infusion B. Initiate IV access in a different site C. Apply a new dressing to the access site D. Place a warm compress on the client's extremity

B Rationale: The nurse should initiate IV access in a different site. The signs at the current access site are indicative of infiltration. Continuous intravenous therapy should not be discontinued without a healthcare provider's prescription. Applying a new dressing and placing a warm compress does not address the issue of possible infiltration. The intravenous catheter should be removed, and access should be initiated in a different site. You chose A

The emergency room nurse is caring for a client who reports palpitations. When assessing the client's telemetry strip, the nurse notes a fast rhythm, with a narrow QRS complex, as shown in the figure below. Which action should the nurse do first? A. Administer prescribed adenosine B. Assess the client's blood pressure and pulse oximetry C. Prepare the client for synchronized cardioversion D. Instruct the client to bear down and hold their breath

B Rationale: The rhythm in the figure is supraventricular tachycardia (SVT). When a client is experiencing an abnormal rhythm, the first action the nurse should take is to obtain the client's blood pressure and pulse oximetry. Assessing the client's blood pressure and pulse oximetry will evaluate if the client is stable or unstable with this abnormal rhythm. Interventions for SVT include administering prescribed adenosine, synchronized cardioversion, and instructing the client to perform Valsalva maneuvers, but the first action is to assess the client. You chose C

A nurse is performing psychosocial assessments on several clients in an obstetric clinic. Based on the history obtained, which client is at risk for impaired coping during pregnancy? A. A client who verbalizes feeling irritable and has lost sexual desire towards her partner B. A client who lives in a multi-generational household and believes pregnancy is a transitional period of illness C. A client with a history of sexual abuse who is highly involved in her church community D. A client with a history of depression who is married and has two other children

B. Rationale: Hormonal changes during pregnancy and cultural norms can decrease the client's ability to cope. Strong social support from family, friends, and community members can assist the client during overwhelming mood swings. A client who believes pregnancy is an illness will have difficulty coping and adjusting to her new lifestyle. Cultural beliefs should be assessed, and unsafe practices should be further evaluated. Mood swings and loss of sexual desire are common responses to hormonal changes during pregnancy. The nurse should encourage stress relieving strategies. While previous history of sexual assault may cause anxiety during the birthing process, a strong social support system can help the client cope. Although the client has a history of depression, the client has a support system as indicated by a partner and children. You chose D

The nurse is preparing to perform a prescribed gastric lavage on a conscious client. How will the nurse position the client to facilitate the procedure? A. Trendelenburg B. Supine C. High-Fowlers D. Prone

C Rationale: A gastric lavage includes introducing fluid into the stomach via a nasogastric tube. Clients should be positioned sitting up (high-Fowler's) to avoid aspiration of fluid. Placing the client in a Trendelenburg position, with the head of the bed lower than the foot of the bed, increases the risk of aspiration. A supine (flat back) and a prone (face down) position increase the risk of aspiration and do not promote gastric emptying. You chose A

The nurse is participating in the implementation of a hospital's disaster response plan. Which of the following indicates correct understanding of disaster planning? A. All hospital staff must receive training on identifying signs of bioterrorism activities within the community. B. All hospital staff must receive training on handling of hazardous materials and decontamination. C. Annual drills are required and should include community-wide resources with a simulation of a large influx of clients. D. The hospital pharmacy is required to stockpile antibiotics and nerve agent antidotes in the event of a bioterrorist attack.

C Rationale: All facilities are required to carry out internal and external disaster drills, one of which includes implementing community-wide resources and simulation of a large influx of clients in the event of a disaster. Typically, nurses, emergency department physicians and other medical providers are required to receive training on handling hazardous materials, decontamination and recognizing patterns of illness that indicate potential bioterrorism in the community. While it is ideal for pharmacies to stockpile antidotes to nerve agents and antibiotics, this is not a federal requirement, although resources are becoming more available for facility pharmacies to obtain these medications. You chose B

A nurse is providing care to a client with urinary incontinence who has an abrasion to the left inner thigh. Which action should the nurse perform to maintain skin integrity? A. Apply antimicrobial ointment to the abrasion B. Insert an indwelling urinary catheter C. Spray the abrasion with an alcohol-free barrier film D. Place a gauze dressing on the client's thigh

C Rationale: An alcohol-free barrier film will protect the abrasion from constant moisture as a result of incontinence. The nurse should protect the skin to prevent breakdown. An antimicrobial ointment will protect the abrasion from bacteria. However, incontinence causes constant moisture, and the abrasion should be kept dry. Urinary catheters should not be inserted for the purpose of incontinence. The nurse should use other methods to keep the skin and abrasion dry. Placing a gauze dressing on the client's thigh will cover the abrasion but will not protect it from constant moisture. You chose B

A nurse is implementing seizure precautions for a client with tonic-clonic seizures. Which action should the nurse take? A. Raise all side rails on the bed B. Instruct client to ambulate slowly to the restroom C. Ensure patency of the saline lock D. Position the overbed table in front of the client

C Rationale: Clients with tonic-clonic seizures are at risk for injury due to rhythmic jerking of the extremities and changes in breathing patterns. The nurse should ensure intravenous access is patent in case pharmacologic treatment is required. Raising all of the siderails is considered a restraint. Clients should be instructed to call for assistance with ambulation. The client may fall and injure themselves during a seizure. Positioning the overbed table in front of the client can cause injury if the client experiences a seizure. You chose A

The nurse is planning care for a client with methicillin-resistant staphylococcus aureus pneumonia. Which type of precaution should the nurse implement for this client? A. Airborne precautions B. Droplet precautions C. Contact precautions D. Standard precautions

C Rationale: Contact precautions involve the use of barrier protection (e.g. gloves, mask, gown, or protective eyewear as appropriate) whenever direct contact with any of the body fluids is expected. When determining the type of isolation to use, one must consider the mode of transmission. The hands of personnel continue to be the principal mode of transmission for methicillin-resistant staphylococcus aureus (MRSA). Because the organism is limited to the sputum in this example, precautions are taken if contact with the patient's sputum is expected. Standard precautions are not enough to prevent transmission. Droplet and airborne precautions are not needed since the bacteria is not floating in the air. You chose B

The nurse is educating a client with a deep vein thrombosis to the right lower extremity about preventing complications. What should the nurse include in the teaching? A. "Maintain bedrest throughout your therapy." B. "Massage your right leg if you are feeling pain." C. "Wear thigh-high compression stockings while in bed." D. "Apply ice packs to the extremity as needed

C Rationale: Deep vein thrombosis (DVT) is a blood clot that impairs circulation. Thigh-high compression stockings improve circulation and help pump blood back to the heart. Prolonged bed rest increases the risk of further clot formation. Clients should be encouraged to ambulate after initiation of anticoagulant therapy. Extremities with a DVT should never be massaged. Massaging the extremity can dislodge the blood clot and travel to smaller vessels throughout the body. Ice will constrict blood vessels and further impair circulation. Warm, moist compresses are recommended. You chose A

A nurse is caring for a client who has right-sided paralysis from a stroke. Which intervention should the nurse implement to prevent footdrop? A. Place a sandbag to maintain right plantar flexion B. Position soft pillows against the bottom of the feet C. Apply a protective boot to the right ankle D. Splint the right lower extremity to maintain proper alignment

C Rationale: Footdrop occurs when the foot is permanently fixed in the plantar flexion position. To prevent foot drop, the nurse should apply a protective boot on the affected foot aligning the ankle. The nurse should avoid positioning the client with extended right plantar flexion. Pillows do not provide adequate support. The nurse should avoid splinting the entire extremity, which could limit the mobility of the extremity. You chose A

The nurse is caring for a client experiencing left-sided homonymous hemianopsia after a cerebrovascular accident. The client has been leaving the left side of the meal plate untouched. Which of the following interventions should be implemented to improve intake? A. Assist the client by feeding them the remaining food. B. Provide the client with modified utensils for the left limb. C. Encourage the client to perform visual scanning of the environment. D. Move all food into the functioning visual field.

C Rationale: Homonymous hemianopsia is a condition in which a person sees only one side ― right or left ― of the visual field of each eye. The condition results from a problem in brain function rather than a disorder of the eyes themselves. The most common cause is a stroke. Clients may bump into or fail to notice objects, including food on a plate. This is a problem with vision and not will weakness or paralysis, therefore the client does not need assistance being fed. Treatment includes training the client to move the eyes purposefully and move the head and eyes to the affected side. This is known as visually scanning the environment. Moving all food to the unaffected side does not promote independence/autonomy. You chose D

A nurse is assessing a client with multiple sclerosis who is on bed rest. Which respiratory finding indicates the client is developing complications from immobility? A. Oxygen saturation of 92% B. Inspiratory to expiratory ratio of 1:2 C. Decreased cough response D. Bronchial lung sounds auscultated

C Rationale: Immobility causes the respiratory muscles to weaken, leading to a decreased ability to cough up secretions. A decreased cough response is indicative of weakened respiratory muscles. An oxygen saturation of 92% is a normal finding. The normal oxygen saturation is ≥ 92%. An inspiratory to expiratory (I:E) ratio of 1:2 is a normal finding. Expiration should be longer than inspiration. Bronchial lung sounds are a normal finding. This indicates adequate airflow through the lungs. You chose A

A nurse is providing care to a female client who is 32-weeks pregnant. The client has been diagnosed with hypertension and will begin prescribed pharmacological treatment. The nurse will clarify which medication if observed in the client's record? A. Spironolactone B. Methyldopa C. Lisinopril D. Hydralazine

C Rationale: Lisinopril is an angiotensin-converting enzyme (ACE) inhibitor used in the treatment of hypertension. ACE inhibitors are pregnancy risk category D and are contraindicated during the second and third trimesters of pregnancy. Spironolactone and methyldopa are pregnancy risk category B and have been used routinely and safely during pregnancy. Hydralazine is a pregnancy risk category C, but its use has been proven to be safe during pregnancy. You chose B

A nurse is preparing to administer plasma to a client with a coagulation disorder. Which identification step will the nurse verify prior to initiating the transfusion? A. Cross match B. Expiration date C. ABO compatibility D. Hemoglobin level

C Rationale: Plasma is a blood product that needs to be typed prior to administration to avoid a reaction. Typing determines if the blood product is compatible with the client's blood type. A cross match for antigens is only required for transfusions containing red blood cells. The expiration date is an important component to check prior to administration. However, this DOES NOT IDENTIFY the client. Plasma does not contain red blood cells, so checking the hemoglobin level is not indicated and does not identify the client. you chose B. Good example of fully reading question and thinking about what it is asking you

The nurse is caring for a client experiencing diarrhea after radiation therapy. Which of the following would the nurse include in a teaching plan to help the client manage this side effect? A. "Try to avoid food and drinks that are high in sodium and potassium." B. "Eat three large meals each day." C. "Increase the amount of clear liquids consumed each day." D. "Look for foods that are high in fiber

C Rationale: Severe diarrhea can cause fluid and electrolyte imbalances, so clients should increase fluid intake and look for sources of sodium and potassium as these electrolytes are lost from the gastrointestinal tract. Often clients will have nausea or decreased appetite when experiencing diarrhea; therefore, it is best to encourage frequent small meals. Foods that are high in fiber can make diarrhea worse. The nurse should recommend low-fiber foods, such as bananas, white rice, or white toast when the client is experiencing diarrhea. You chose A

The nurse is assisting a client who has hypothyroidism with meal planning. Which food should the nurse recommend the client choose? A. white rice B. poached eggs C. wheat bread D. baked chicken

C Rationale: The client with hypothyroidism is at high risk for constipation and should be instructed to eat foods that are high in fiber, such as wheat bread, beans, and broccoli. White rice, poached eggs, and baked chicken are not good sources of fiber and could increase constipation. You chose B

The nurse is reviewing the communicable disease policy about what information needs to be provided to the health department. Which statement by the nurse indicates the need for additional education about the policy? A. "The results of testing should be provided." B. "I will need to report the onset of symptoms." C. "HIPAA prevents the reporting of personal information." D. "Patient information such as name, age, and gender are reported."

C Rationale: This type of required reporting uses personal identifiers and enables the states to identify cases where immediate disease control and prevention are needed. Each state has its own laws and regulations defining what diseases are reportable. The list of reportable diseases varies among states and over time. HIPPA does not apply to reportable diseases. You chose D

A nurse is reviewing the laboratory results of a client admitted with orthopnea, fatigue, and frothy sputum. Which finding indicates a diagnosis of heart failure? A. PaO2 level of 75 mmHg B. INR level of 1.2 C. BNP of 300 pg/ml D. WBC count of 12,000/mm³

Correct Answer C Rationale: A brain natriuretic factor (BNP) of 300 pg/ml indicates heart failure. The normal value is less than 100 pg/ml. BNP is a hormone produced by the ventricles of the heart and is increased in response to ventricular pressure overload. A partial pressure of oxygen level (PaO2) of 75 mmHg is not specific to heart failure. Low PaO2 levels may indicate a respiratory disorder. An international normalized ratio (INR) level of 1.2 is not associated with a heart failure diagnosis. INR levels are used to evaluate anticoagulation therapy. A white blood cell (WBC) count of 12,000/mm³ is not indicative of heart failure. Elevated WBCs indicate an infectious process You chose A

The nurse is providing an in-service to graduate nurses on the risk of malpractice litigation. Which is the best strategy to decrease personal risk in the healthcare environment? A. Discuss any errors with the client and family in detail B. Keep incident reports on file C. Carry personal malpractice insurance D. Maintain expertise in practice

D Rationale: Maintaining expertise in practice fosters continued competence in current knowledge and skills which is the best way to reduce personal risk and malpractice litigation. Incident reports are filed with a healthcare agency but do not decrease the risk of malpractice litigation. Discussing errors in detail with the client and family does not reduce the risk of a malpractice claim. Although a nurse can carry personal malpractice insurance, it does not decrease the risk of malpractice litigation. You chose c. But the question is asking how do you decrease your risk? Answer what the question is asking!

A nurse is witnessing a surgical consent for a client. The client tells the surgical resident that they need time to think about the risks of the procedure. The resident tells the client there is no time to discuss the consent further. The client hesitantly signs the consent. Which action does the nurse take next? A. Signs the consent as a witness B. Informs the charge nurse of the situation C. Tells the client the consent is not valid D. Contacts the surgical attending

D Rationale: The nurse should contact the surgical resident's supervisor or attending. The client's concerns and the resident's behavior should be addressed thoroughly before the procedure occurs. Signing the consent as a witness disregards the client's concerns about the risks of the procedure. Informing the charge nurse of the situation should occur after the nurse addresses the concern with the resident's supervisor. Telling the client that the consent is not valid after it has been signed does not address the ethical issue. You chose B

A nurse is providing care to a client experiencing substance withdrawal. Which prescription by the healthcare provider requires clarification? A. Implement seizure precautions. B. Keep client NPO. C. Initiate cardiac monitoring. D. Ambulate ad lib.

D Clinical manifestations of substance withdrawal include tremors, irritability, and unsteady gait. These manifestations increase the risk for falls. A prescription for ambulation as desired requires clarification. Substance withdrawal is one of the main risk factors for seizure activity. Seizure precautions are indicated. A nothing by mouth (NPO) order is indicated for a client experiencing substance withdrawal. Nausea and vomiting are common manifestations. Substance withdrawal can cause tachycardia and elevated blood pressure. Cardiac monitoring is indicated. You chose B

The nurse is preparing to perform prescribed gastric lavage for a client who ingested a toxic chemical. Which action should the nurse take first? A. Take the client's blood pressure B. Connect the client to a cardiac monitor C. Start a secondary intravenous line (IV) D. Set up suction equipment

D Rationale: A gastric lavage irrigates the stomach and removes its contents. The solution is administered via an oral or nasogastric tube and removed via suction. The nurse should ensure suction equipment is set up properly before the procedure. Monitoring the client's blood pressure is important for assessing circulatory status but is not specific to gastric lavage. Connecting the client to a cardiac monitor will ensure the client is reacting well to the procedure. However, a gastric lavage requires suction equipment to function. Starting a secondary intravenous line is not related to the procedure of gastric lavage. YOu chose B

The nurse is providing teaching to client on the use of range of motion exercises while on bedrest. Which statement made by a client indicates the need for further teaching? A. "I will move each joint through the full range at least 3 times." B. "I should raise my foot 6 inches off of the bed" C. "I can move the joint until I feel resistance." D. "I will hold my leg when someone rotates the joint."

D Rationale: Active range of motion exercises are movements that the client does independently. The client should be instructed to perform the active range of motion exercises. The nurse should instruct the client to perform the movement until resistance is felt. When exercising a joint, the movement should be done at least 3 times. When performing leg exercises, the client should lift the foot about 6 to 12 inches off the bed. Passive range of motion exercises are done with someone performing the exercise. You chose A

The nurse is caring for a client who had a below-the-knee amputation (BKA) 4 weeks ago and is experiencing phantom limb pain. Which of the following instructions should the nurse provide to the client? A. "Avoid massaging your stump for the next 4 weeks." B. "Apply cold compresses to your stump 4 times daily." C. "Avoid any physical activity until the pain subsides." D. "Take your prescribed antiepileptic medication even if pain is not present."

D Rationale: Clients who are experiencing phantom limb pain are often prescribed antiepileptic medications to treat nerve pain. These medications should be taken regularly as prescribed to ensure maximum effectiveness and are not intended to be used for breakthrough pain on an as-needed basis. Additional interventions for clients experiencing phantom limb pain include exercise, massage, and heat therapy. You chose B

A charge nurse is assigning a room to a client with a history of moderate Alzheimer's. The charge nurse will assign the client to a room in which area of the unit? A. Next to the client activity room B. At the end of the hallway C. In front of the elevator D. Across from the medication room

D Rationale: Clients with moderate Alzheimer's may have personality and behavioral changes that lead them to wander and get lost. Medication rooms are frequently used by nurses. This placement ensures frequent visual checks of the client. Assigning the client to a room at the end of the hallway is not appropriate. Most stairwells are at the end of hallways and can be an area for the client to escape. A room in front of the elevator is not appropriate for a client with Alzheimer's. Assigning the client next to an activity room provides overstimulation. Noise should be kept to a minimum. You chose A

The nurse is assisting a client with denture care. Which of the following actions is appropriate? A. Use toothpaste when brushing the dentures B. Leave the dentures to air dry C. Rinse the dentures in hot water D. Line the sink with a towel when cleaning

D Rationale: Dentures should be soaked in and brushed with a nonabrasive denture cleanser. Hot water may warp the plastic used to make the denture. Similarly, leaving them to air dry may cause warping. Lining the sink may prevent damage to the dentures if they are accidentally dropped. You chose C

A nurse is performing a physical assessment on a toddler. Which activity will the nurse use to assess for fine motor skills? A. Hopping up and down B. Throwing a ball C. Throwing a ball D. Matching shapes and sizes

D Rationale: Matching shapes is an activity used to assess for fine motor skills. A developmental milestone for a toddler is being able to match shapes such as circles, triangles, and squares. The abilities to throw a ball, clap hands, and hop up and down assess for gross motor skills. You chose B

A nurse is providing hygiene care to a client with urinary incontinence. Which skin breakdown prevention strategy should the nurse implement? A. Initiating a turning schedule B. Providing the client with disposable briefs C. Cleansing the perineal area frequently with soap D. Applying moisture barrier ointments

D Rationale: Moisture barrier ointments help maintain the skin's integrity by repelling urine and preventing maceration of the skin. A turning schedule will help prevent pressure ulcer formation. However, it will not prevent breakdown due to incontinence. Disposable briefs will not prevent the skin from having constant moisture due to incontinence. The nurse should apply products that repel moisture. Cleansing the perineal area with soap is not recommended. Soap may irritate the skin. You chose C

The nurse is caring for a client with chronic pain who was prescribed oxycodone extended release for pain management. The client is concerned about developing constipation. Which response by the nurse is appropriate? A. "Only take the medication when your pain is severe." B. "Increase your intake of dairy products." C. "We will ask your provider to order a daily stimulant laxative. D. "You can use a bulk forming laxative to help relieve your constipation.

D Rationale: Opioids are a common cause of medication-induced constipation and can result in significant distress for the patient. Increasing fluid and fiber in the diet are ways to prevent constipation. Psyllium, a form of insoluble fiber, is considered a bulk-forming laxative. Daily stimulant laxatives are avoided if possible due to significant side effects and rebound constipation. Dairy is constipating. Clients should be encouraged to increase their intake of fruits and vegetables. Extended-release opiates are scheduled and should not be taken in an as-needed fashion. You chose C

The nurse is obtaining a health history from a female client who has a family history of breast cancer. Which of the following findings would increase the client's risk? A. The client breast-fed for one month after pregnancy. B. The client has a history of multiple episodes of mastitis. C. The client started menses at age 14. D. The client had her first full-term pregnancy at age 33.

D Rationale: Risk factors for breast cancer can include late age (after age 30) at first full-term pregnancy and early menarche (before age 12). Not breastfeeding increases the client's risk for ovarian cancer. Mastitis is not a risk factor for cancer. you chose C

The nurse is educating a client with newly diagnosed gout about dietary restrictions. Which statement made by the client would indicate to the nurse that further teaching is required? A. "I will limit the amount of fruit juices I drink." B. "I should avoid carbonated beverages." C. "I will need to avoid alcohol." D. "I should choose shellfish over red meat."

D Rationale: The client with gout should be instructed to avoid foods that are high in purine, which includes organ meats, seafood, fructose, and all alcohol. You chose B

A nurse is teaching a client how to do fecal occult blood testing. Which statement by the client indicates a need for further teaching? A. "I will continue taking aspirin 81 mg daily." B. "I will refrain from eating raw fruits and vegetables." C. "I will avoid steak and other red meats." D. "I will avoid taking ferrous sulfate 24 hours before the test."

D Rationale: The fecal occult blood test is done to detect the presence of blood in the stools. The nurse should teach the client to avoid foods and medications that could alter the results. Clients should avoid red meat, raw fruits and vegetables, aspirin doses greater than 325 mg, and ferrous sulfate for three days prior to the test. You chose A

The nurse is evaluating a client's understanding of the teaching on crutch walking. Which of the following statements indicates an understanding of the teaching? A. "I should put my weight on the pads under my arms." B. "I will keep my crutches close to my feet when walking." C. "I should be done with my crutches before I need to replace any parts." D. "I will go up the stairs with my good leg and crutches first."

D Rationale: The top of the crutches should be about 2 finger width below the armpit. Weight should be placed on the hand grips. Crutches should be routinely checked for wear and damage. Rubber crutch tips will need to be replaced when they are worn or cracked. Clients should be taught to ascend up the steps with the crutches and "good" leg first. Crutches should be at least 12 inches away from the feet to prevent falling. You chose B

The nurse is caring for a client prescribed warfarin therapy for treatment of persistent atrial fibrillation. Which of the following may potentiate the effect of this medication? A. St. John's wort B. Estrogen C.Vitamin K D. Green tea

D Rationale: Warfarin, an anticoagulant agent used to prevent thrombosis and risk of stroke in clients with atrial fibrillation, is associated with many drug and food interactions. Careful assessment with a pharmacist/formulary is recommended to avoid potential complications. Green tea can potentiate the effect of warfarin and increase bleeding. St. John's wort, estrogen, and vitamin K may inhibit the action requiring higher doses of the anticoagulant. You chose A

A nurse is preparing to transfer a client who has been on bed rest to a chair. Which action should the nurse take first? A. Place a transfer belt on the client B. Position the bed at an appropriate height C. Assist the client to a seated position D. Obtain orthostatic vital signs

D (THIS IS THE ONLY ASSESSMENT) Rationale: A client who has been on bed rest is at risk for orthostatic blood pressure due to the decrease of venous return from muscle contraction. Before moving a client who has been on bed rest, the nurse should assess orthostatic blood pressure first. Then, the nurse will position the bed at an appropriate height, assist the client to a seated position, and then place the transfer belt on the client. You chose B

The nurse is caring for a client who is 28 weeks pregnant. Which of the following physical changes should the nurse identify as an expected finding? A. Facial edema B. Kyphosis C. Lower extremity erythema D. Linea nigra

D. Rationale: Extra integumentary pigmentation during pregnancy can create a darkened vertical line down the abdomen called linea nigra. Facial edema is an abnormal finding that requires follow-up from the healthcare provider. Lordosis is expected in pregnancy, kyphosis is not, and erythema of the lower extremities is an abnormal finding. You chose B