QT 5

The client tested positive for the tuberculosis antibody and was placed on isoniazid 4 weeks ago. The nurse is most concerned if which observation is made? 1. Fatigue and dark urine. 2. Malaise and glucosuria. 3. Proteinuria and lethargy. 4. Diluted urine and epigastric distress.

1 isoniazid think liver fatigue and dark urine relates to hepatic dysfunction.

The older client comes to the outpatient clinic for a routine health screening. The nurse learns the client is a retired teacher who lives alone on a limited income. A history indicates the client drinks about 1,500 mL a day and the client's diet consists primarily of starches. It is most important for the nurse to encourage the client to take which action? 1. Increase protein intake. 2. Increase intake of vitamins. 3. Reduce caloric intake. 4. Reduce fluid intake.

1 needs protien

The nurse cares for the client recovering from abdominal surgery. During ambulation, the client reports a dull ache in the left leg. Which action does the nurse take first? 1. Places the client on bedrest with extremity elevated. 2. Places a pillow under the client's knee. 3. Encourages client to ambulate more frequently. 4. Obtains thigh-high compression stockings.

1 this intervention reduces pressure on clot, releiving pain,

The nurse makes client assignments on a medical surgical unit. The staff includes one nurse, one nurse pulled from the pediatric unit, an LPN/LVN, and a nursing assistive personnel (NAP). Which client is assigned to the nurse from the pediatric unit? 1. The client 1 day postoperative after an appendectomy. 2. The client who had a detached retina surgically repaired 4 hours ago. 3. The client with a Sengstaken-Blakemore tube in place. 4. The client 2 days postoperative after a laminectomy with spinal fusion.

1) CORRECT — stable client with expected outcome 2) requires frequent assessment for hemorrhage; instruct client to avoid sneezing, coughing, or straining at stool 3) requires frequent monitoring due to hemorrhage 4) requires assessment and teaching

The 2-year-old child is hospitalized. The nurse assesses the child and asks the parent about the activities the child does at home. Which activity would the nurse anticipate this child to perform? Select all that apply. 1. Plays beside other children, but not with them. 2. Builds 6-7 block towers. 3. Can put toys away alone. 4. Names colors 5. Can retrieve objects when asked to do so. 6. Uses sentences of 4-5 words.

1.2.5 1) CORRECT— Participates in parallel play. 2) CORRECT— Able to build tower this high. 3) More likely at age 3-4. 4) Names colors at age 3-4 years. 5) CORRECT— Can follow simple directions/commands. 6) Occurs at age 4 years.

Normal platelets

150,000 - 400,000/mm3

The client comes to the clinic for the hepatitis B vaccine. The client asks if more than one injection is necessary. Which response by the nurse is best ? 1. "A booster shot is required yearly." 2. "Additional injections are given at one and six months." 3. "Repeat doses are given at two and four months." 4. "Revaccination is not required."

2

The client is admitted with a diagnosis of trigeminal neuralgia (tic douloureux) involving the maxillary branch of the affected nerve. It is most important for the nurse to include which instruction? 1. "Report an increase in blurred vision." 2. "Eat soft, warm foods." 3. "Change positions slowly." 4. "Chew food on the affected side."

2

The nurse cares for the client admitted with low back pain. The history indicates the client has hemophilia A. Which order does the nurse question? 1. Ketorolac. 2. Codeine phosphate. 3. Oxycodone/aspirin. 4. Hydromorphone.

3 ASA is not good with bleeding disorders

The 2-day-old infant is in surgery for repair of spina bifida. The infant's parent expresses concern because the health care provider said the infant would be confined to a wheelchair. Which statement made by the nurse is best? 1. "Physical therapy can restore the function to affected muscles." 2. "Orthopedic devices will allow your child to strengthen lower extremity muscles." 3. "Corrective surgery will return function to the affected muscles." 4. "Corrective surgery will not change your child's physical disability."

4 4) CORRECT — spinal nerves that are destroyed by the myelomeningocele cannot be corrected; nothing can return function to portions of the body that are innervated by the spinal nerves below the site of the myelomeningocele

The nurse plans the schedule for administering bromocriptine. Which information is correct? 1. The medication should be taken once a day for 6 weeks. 2. The medication should be taken with orange juice. 3. The medication should be taken in the morning and at bedtime. 4. The medication should be taken with meals.

4 decrease GI upset med acts like dopamine

The client undergoes peritoneal dialysis. The health care provider orders 2 liters to be instilled with a dwell time of 40 minutes. The nurse measures the outflow and finds it to be 1,800 mL. During the nurse's shift, the client drinks 700 mL of fluids and voids 400 mL. Record the client's intake in milliliters.

inflow and intake are recorded separately; the difference between inflow and outflow is considered intake; inflow of peritoneal fluid is 2 liter or 2,000 mL; intake is 700 mL of oral fluid; the outflow is 1800 mL; output is 400 mL; the question asks for intake; inflow minus outflow equals intake; 2000 mL - 1800 mL = 200 mL intake; add other intake amount to this figure; 700 mL + 200 mL = 900 mL

The nurse cares for the client who delivered an 8 lb, 4 oz newborn. The newborn is diagnosed with talipes equinovarus. The client confides to the nurse, "I feel so bad that my baby is abnormal." Which response by the nurse is best? 1. "It's understandable that you feel this way, but there are treatments to correct your baby's problem." 2. "Your baby is not really abnormal. The feet just look different because of the way the muscles pull." 3. "You have nothing to feel guilty about. The abnormality is not your fault." 4. "Don't feel bad. Your baby's abnormality can be corrected surgically."

1

The nurse obtains a history for the client with hyperthyroidism. Which assessment does the nurse report to the health care provider? 1. Anxiety with extreme nervousness. 2. Slow, sluggish pulse. 3. Cool, clammy skin. 4. Husky, slow speech.

1

The nurse cares for the client following a coronary artery bypass graft (CABG). Which symptom does the nurse expect to see if the client is in the early stages of circulatory overload? 1. Change in the character of respirations. 2. Fluctuation in the blood pressure. 3. Reduced tissue turgor. 4. Increase in body temperature.

1 1) CORRECT — will see dyspnea, cough, edema, hemoptysis 2) will initially increase and then fall due to heart failure, doesn't fluctuate 3) reflects body's general hydration status, mainly shows dramatic changes with dehydration 4) would indicate infectious, inflammatory process, skin temperature will fall with circulatory overload

The nurse changes the dressing on the client who had a mastectomy 2 days ago. After the nurse removes the old dressing, the client turns the head away. Which is the best response by the nurse? 1. "I noticed you turned your head away as if you didn't want to look at your incision." 2. "It's good you turned your head away while I am doing this sterile procedure." 3. "Your incision looks like it's healing nicely." 4. "Why don't you look at the incision while I have the old dressing off?"

1 deals directly wih the avoidence behaviour

The nurse assesses the pregnant client with a diagnosis of mitral stenosis and heart failure (HF). The nurse identifies which finding in the client's history has a direct correlation with the current problem? 1. History of rheumatic fever 4 years ago. 2. Presence of ventricular septal defect as an infant. 3. Heart disease in both the maternal and the paternal families. 4. Persistent ear infections and mastoiditis as a child.

1 most common cause of miral valve problems

The nurse cares for the client diagnosed with venous thromboembolism (VTE) of the left leg. Which nursing goal is appropriate for the client? 1. Decrease inflammatory response in the affected extremity and prevent embolus formation. 2. Increase peripheral circulation and oxygenation of the affected extremity. 3. Prepare the client and family for anticipated vascular surgery on the affected extremity. 4. Prevent hypoxia associated with the development of a pulmonary embolus.

1 1) CORRECT — important to prevent the complication of pulmonary embolism in clients at high risk 2) relates to arterial disease 3) surgery is not anticipated for this client 4) preventing embolism is the first priority

The client is scheduled to have a parathyroidectomy. The nurse is most concerned if the client is observed eating quantities of food from which food group? 1. Milk products. 2. Green vegetables. 3. Seafood. 4. Poultry products.

1 1) CORRECT — low-calcium diet is recommended preoperatively 2) diet should be high in phosphorus and low in calcium 3) diet should be high in phosphorus and low in calcium 4) poultry is allowed in the diet

The nurse cares for the client 36 hours after a traditional cholecystectomy. The nurse is most concerned if which observation is made? 1. The client reports severe abdominal pain in the right upper quadrant. 2. 500 mL of greenish-brown fluid drained from the T-tube in the last 24 hours. 3. The client has received an antiemetic twice since surgery. 4. Lab tests indicate an Hgb of 14 g/dL, Hct of 44% (0.44), and WBC of 6,000/mm3 (6x109/L).

1 indicates would infection or peritonitis 500-1000 ml fluid normal initaialy

The nurse cares for the client completing the first stage of labor. The client's partner is at the bedside and has been coaching according to exercises they learned in childbirth classes. Suddenly the client begins to shake and screams,"I can't stand this anymore!" The nurse encourages the partner to take which action? 1. Instruct the client to use shallow respirations during the contractions. 2. Offer the client ice chips or sips of water to distract from the pain. 3. Stroke the client's abdomen between contractions. 4. Review with the client the breathing pattern needed at each stage of labor.

1 speaking specifically about breathing pattern..... 1) CORRECT — entering transition phase of first stage of labor, rapid shallow breaths needed (pant breathing) 2) doesn't address issue of breathing pattern needed during transition phase of labor 3) used in conjunction with controlled breathing for Lamaze 4) needs support and coaching of significant other during transition phase of labor

The nurse notes one of the staff members caring for clients has a watery discharge from the right eye and the eye appears red. Which nursing action is best? 1. Send the staff member home and notify the supervisor. 2. Assess the staff member's compliance with standard precautions. 3. Assign the staff member only to clients with chronic diseases. 4. Reassign the staff member to clean the supply closet.

1 they are sick

The client is admitted with a diagnosis of a fractured right hip. The health care provider writes an order for Buck's traction. Which nursing action is most important? 1. Turn the client every 2 hours to the unaffected side. 2. Maintain the client in a supine position. 3. Encourage the client to use a bedside commode. 4. Place a footboard on the bed.

1) CORRECT — immobility is a leading cause of problems with Buck's traction; important to turn client to unaffected side 2) head of the bed should be elevated 15-20° because the supine position can increase problems with immobility 3) client is on strict bedrest 4) would interfere with the traction

The nurse cares for the client in the third trimester of pregnancy. The client has proteinuria, blood pressure of 154/92, and +3 pitting edema of the fingers. The nurse is most concerned by which additional assessment finding? 1. The client reports epigastric pain. 2. The client reports shortness of breath. 3. The client says there is increased rectal pressure. 4. The client has gained of 33 pounds during the pregnancy.

1) CORRECT — is usually indicative of an impending convulsion 2) expected observation 3) expected observation 4) is important to address, but is not as high a priority as epigastric pain

The college student has a positive Mantoux test. The health center clinic nurse takes which action? 1. Refers the student to an appropriate center for further testing. 2. Restricts the student's activity until the parents can be notified. 3. Notifies the local Public Health Department. 4. Places the student in an isolation room in the college infirmary.

1) CORRECT — will perform chest x-ray

The nurse receives a bedside report from another nurse. The nurse giving report begins to talk about another client. Which action by the nurse receiving report is most appropriate? 1. Ask the nurse to report on this client only. 2. Ask the nurse to use a lower voice. 3. Ask the nurse to move to another part of the room. 4. Ask the nurse to clarify which client is being reported on.

1. only one that provides client confidentiality immediately

The nurse performs discharge teaching for the client after abdominal surgery. The nurse determines that teaching is effective if the client chooses which foods for lunch? Select all that apply. 1. Chicken breast, peas, mashed potatoes, orange, and ice cream. 2. Hamburger, boiled potatoes, corn, pudding, and grapefruit juice. 3. Chicken salad with lettuce, tomatoes, carrots, zucchini, and broccoli, jello, pears, and soda. 4. Shrimp salad with green beans, and broccoli, peaches, cookies, and coffee. 5. Salmon steak, baked potato, lima beans, tangerine, and milk. 6. Ham sandwich, lettuce salad, coleslaw, apple, and low fat milk.

1.2.5 1) CORRECT— Has high protein, Vitamin C, and high calories. 2) CORRECT— Has high protein, Vitamin C, and high calories. 3) Has good protein, low calories and little Vitamin C. 4) Has average protein, low calories, and no Vitamin C. 5) CORRECT— Has high protein, high calories, and Vitamin C. 6) Has average protein, low calories, and no Vitamin C.

The nurse cares for clients in the hospital. Which nursing activities best promote nighttime rest for elderly hospitalized clients? Select all that apply. 1. Tell the client how to call for help if needed. 2. Place a clock at the bedside. 3. Postpone explanation of further tests the client will need. 4. Restrict visitors so the client is not stimulated in the evening. 5. Identify normal evening bedtime routines. 6. Keep a bright light in the room to prevent falls.

1.3.5 1) CORRECT — if the client does not need to worry about getting help, sleep will be easier 2) having a clock is not usually helpful for sleeping 3) CORRECT — giving the client information that may be troubling will not help with sleep 4) having visitors may help the client relax and should not be restricted 5) CORRECT — following normal routines will help the client fall asleep and stay asleep 6) bright lights will prevent deep sleep

The client had an aortic aneurysm resection 2 days ago. A complete blood count reveals a very low red blood cell count. The nursing assessment is most likely to reveal which information? Select all that apply. 1. Fatigue and exertional dyspnea. 2. Nausea and vomiting. 3. Pallor and dizziness. 4. Vertigo and flushing. 5. Malaise and tachycardia. 6. Hypertension and constipation.

1.3.5 1) CORRECT— Tiredness and difficulty obtaining enough oxygen. 2) Nausea and vomiting are not symptoms of lack of oxygen. 3) CORRECT— Low red cell levels cause paleness and lack of oxygen causes dizziness, especially on changing position. 4) Vertigo and flushing are not symptoms of low red cell/oxygen levels. 5) CORRECT— Malaise or tiredness comes from low red cell/oxygen levels; tachycardia is the body's way of attempting to compensate for the low oxygen levels. 6) Hypertension and constipation are not related to low oxygen levels.

An older client has an order for digoxin 0.25 mg PO daily. Which information would cause the nurse to withhold the medication and contact the health care provider? Select all that apply. 1. Apical pulse of 55 bpm. 2. Respirations of 16 per min. 3. Plasma digoxin level of 2.1 ng/mL(2.7 nmol/L). 4. Blood pressure of 122/62. 5. Apical rhythm has 20 skipped beats in 1 minute. 6. Temperature 100.5° F

1.3.5 Strategy: What are side effects or toxic symptoms related to digoxin? 1) CORRECT— Pulse below 60 bpm. 2) Respirations are not related to digoxin. 3) CORRECT— Normal digoxin plasma levels are 0.8-2 ng/mL (1.03 - 2.56 nmol/L). 4) Normal blood pressure, not related to digoxin. 5) CORRECT— Dysrhythmias may be caused by the digoxin. 6) Temperature is not significantly elevated.

The nurse cares for the client diagnosed with schizophrenia. Which statement is most descriptive of the affect of this client? 1. Answers all questions with one word. 2. Laughs while talking about being raped. 3. Exhibits no energy or interest in tasks. 4. Cries while talking about a parent's death.

2

The nurse cares for the client recently diagnosed with AIDS. The nurse identifies the nursing diagnosis: Risk for Infection. Which intervention by the nurse is best? 1. Inspect the skin daily for signs of breakdown. 2. Limit the number of health care personnel caring for the client. 3. Use standard precautions when administering parenteral medications. 4. Monitor the client's vital signs q4h.

2

Which nursing approach is most appropriate to use while administering an oral medication to a 4-month-old infant? 1. Place the medication in 45 mL of formula. 2. Place the medication in an empty nipple and allow the infant to suck. 3. Place the medication in a full bottle of formula. 4. Use a plastic syringe with the infant in a reclining position.

2 1) medication is never added to the infant's formula feeding 2) CORRECT — is a convenient method for administering medications to an infant 3) medication is never added to the infant's formula feeding 4) infant is never placed in a reclining position during procedure due to potential for aspiration

The nurse plans care for the client immediately after a cesarean birth. Which nursing goal is most important? 1. Prevent infection. 2. Prevent fluid and electrolyte imbalances. 3. Provide for pain management. 4. Prevent hazards of immobility.

2 1) not highest priority initially, usually not seen until 48-72 hours after surgery 2) CORRECT — hemorrhage and shock are the most life-threatening conditions that occur after surgery 3) not highest priority initially, not life-threatening 4) not highest priority initially, not life-threatening

The nurse prepares the client for a paracentesis. It is most important for the nurse to take which action? 1. Keep the client NPO 12 hours before the procedure. 2. Ask the client to void just before the procedure. 3. Initiate a bowel preparation program 24 hours before the procedure. 4. Place the client supine during the procedure.

2 Pt should be sitting upright at the side of the bed with the feet supported. Bladdder should be emptied to prevent puncture of bladder

The nurse cares for the client with a long history of alcohol and drug dependence. It is most important for the nurse to include which action as part of discharge planning? 1. Refer to a social service agency for assistance with housing. 2. Refer to an aftercare center in the community. 3. Encourage participation in Alcoholics Anonymous (AA) meetings with a sponsor. 4. Ask the client to obtain a prescription for an antidepressant medication.

2 directly addresses sobriety

The client begins doxepin hydrochloride 75 mg PO tid. The nurse recommends a change in the client's therapy if which occurs? 1. The client refuses to speak and sits quietly in the room. 2. The client becomes excitable and develops tremors. 3. The client refuses to eat breakfast. 4. The client sleeps 18 hours a day.

2 doxepin in an antideppresent

The client diagnosed with schizophrenia has become increasingly withdrawn to the point of mutism. It is most important for the nurse to take which action? 1. Ignore the client until the client is ready to respond. 2. Sit with the client for brief periods of time. 3. Read to the client in a quiet area of the unit. 4. Encourage the client to play dominoes with the group.

2 no demands of client to participate while offering theuraputic relationship

The nurse assists the client from the bed to the chair for the first time after a right total hip replacement. It is most important for the nurse to take which action? 1. Assist the client to stand on the right leg and pivot to a low soft chair, keeping the hips straight. 2. Assist the client to stand on the left leg and pivot to a straight-backed chair, flexing the hips slightly. 3. Ask the client to bear weight equally on both legs, bend at the waist, and sit in a low soft chair. 4. Assist the client to stand on both legs and take a few steps to a straight-backed chair.

2 prevents dislocation NWB on affected leg

An abdominal wound irrigation with a normal saline solution is ordered for the client. To perform this procedure, the nurse takes which action? 1. Warms the irrigating solution to 110.0º F (43.3º C). 2. Establishes a sterile field that includes the irrigating equipment. 3. Directs the irrigating solution at the outer edges of the wound, then the center of the wound. 4. Aspirates the irrigating fluid with a syringe to prevent accumulation in the wound.

2 this requires aseptic flush frm middle out

The client receives thrombolytic therapy. The health care provider orders morphine IM for pain. Before administering the injection, the nurse takes which action? 1. Confirms that all lab work has been completed. 2. Verifies the order with the health care provider. 3. Checks the client's aPTT. 4. Determines that all of the thrombolytic agent has infused.

2 2) CORRECT — implementation, complications of thrombolytic therapy include bleeding, which can occur with intramuscular injections; nurse should confer with the health care provider about the appropriateness of the order

The nurse in a long-term care facility reviews the nurse's notes in the client's record. The nurse is most concerned by which entry? 1. "Indwelling catheter draining clear urine and the pH is 6.5." 2. "The client's skin is blanched over the scapular areas." 3. "Vital signs are within normal limits." 4. "The client drinks three glasses of orange juice every day."

2 sign of skin breakdown

The nurse cares for the client with a three-chamber water-seal drainage system. The nurse notices the fluid in the water-seal chamber does not fluctuate. Which action by the nurse is best? 1. Milk the tube gently toward the collection chamber. 2. Anticipate the need for a chest x-ray. 3. Add water to the water seal chamber to re-establish the system. 4. Clamp the chest tube and call the health care provider.

2- CORRECT — fluctuations stop with re-expansion of lung, x-ray will confirm need order to milk, water to be kept at 2 ml, only clamp when looking for air leaks or changing equipment

The home care nurse visits the client reporting episodes of vomiting for 3 days. The client has a low-grade temperature and reports feeling lethargic. Which nursing action is most appropriate to evaluate for fluid volume deficit? 1. Obtain a urinalysis for casts and specific gravity. 2. Determine client's weight and assess gain or loss. 3. Ask client to provide a 24-hour intake and output record. 4. Determine the quality of the client's skin turgor.

2- gives most accurate measurment of fluid loss (by weight) 1) provides information regarding the fluid volume level, but is not the best action for evaluation 2) CORRECT — daily weight is the best way to evaluate for fluid volume deficit 3) provides information regarding the fluid volume level, but is not the best action for evaluation 4) provides information regarding the fluid volume level but is not the best action

The nurse observes late decelerations of the fetal heart rate while the client is receiving oxytocin IV to stimulate labor. Which actions should the nurse take? Select all that apply. 1. Change the fluids to Ringers lactate. 2. Discontinue the oxytocin infusion. 3. Assist client to bathroom and measure urine. 4. Turn client to the left side. 5. Apply oxygen at 8 L/min by mask. 6. Increase the primary IV infusion flow rate.

2.4.5.6 Get baby oxygen. this means decrease pit, increase moms o2 and give mom more fluid for the opportunity to bring more water (primary IV rate up)

The nurse observes the student nurse check the placement of a nasogastric (NG) tube prior to administering an intermittent feeding. Which student nurse actions require an intervention by the nurse? Select all that apply. 1. The student nurse checks the pH of the contents aspirated from the NG tube. 2. The student nurse positions a stethoscope on the upper abdomen and listens as air is introduced into the NG tube. 3. The student nurse uses a large-barreled syringe to aspirate for stomach contents. 4. The student nurse flushes the NG tube with 30 mL of air before aspirating fluid. 5. The student nurse places the end of the NG tube in a cup of water and watches for bubble formation.

2.5

The nurse provides care for a client diagnosed with a flaccid bladder following a spinal cord injury. The nurse teaches the client about dietary changes. Which beverage selected by the client indicates the teaching is effective? (Select all that apply.) 1. Lemonade. 2. Prune juice. 3. Milk. 4. Orange juice. 5. Cranberry juice. 6. Blueberry juice.

2.5.6 1) Lemons are a citrus fruit and promote alkaline urine. The client should avoid excessive amounts of milk and carbonated beverages. 2) CORRECT - Prune juice and the plums from which it is made promote acidic urine and minimize the risk of urinary tract infections and calculus formation. 3) Excessive amounts of milk promote alkaline urine, which increases the risk of urinary tract infections. 4) Orange juice is a citrus fruit drink, which promotes alkaline urine; therefore, this item increases the risk of urinary tract infections. 5) CORRECT - Cranberry juice promotes acidic urine and minimizes the risk of urinary tract infection and calculus formation. 6) CORRECT - Blueberries and the juice promote acidic urine and minimize risk of urinary tract infection and calculus formation.

The nurse cares for the bulimic client. The nurse analyzes the client's eating habits and the circumstances that precipitate the client's eating problems. Which strategy is most therapeutic for making the analysis? 1. Observe family communication patterns at a "monitored mealtime." 2. Distract the client at mealtime. 3. Assign the client a food/thought/feelings/actions journal. 4. Assign the client to write a "lifeline" in relation to eating behaviors.

3

The nurse cares for the child diagnosed with a fractured right femur. The child is in balanced suspension traction with a Thomas splint and Pearson attachment. The nurse finds the weights on the floor and the child's feet touching the foot of the bed. Which nursing action is most appropriate? 1. Release the traction weights and reposition the child in bed. 2. Pull on the traction weights while two nursing assistive personnel pull the child up in bed. 3. Steady the traction and ask the child to bend the left leg and push up in bed. 4. Assess the child's right leg for proper position and alignment.

3

The nurse prepares to suction the client with a new tracheostomy. Which nursing action indicates a break in proper technique? 1. The nurse sets the suction source at 120 mm Hg and obtains a #14 French suction catheter. 2. The nurse inserts the suction catheter until resistance is met, and then applies intermittent suction as the catheter is withdrawn. 3. The nurse suctions the client's mouth prior to suctioning the tracheostomy to ensure a patent airway. 4. The nurse administers oxygen to the client using an Ambu bag attached to 100% oxygen prior to suctioning.

3 1) use suction 90-120 mm Hg and #12 or #14 suction catheter 2) use a twirling motion to remove catheter while applying suction 3) CORRECT — break in sterile procedure, suction mouth after trachea 4) hyperoxygenates client to prevent hypoxia from procedure

The nurse monitors the client in active labor. The client is receiving oxytocin 1 mU/min IV. The nurse stops the infusion if which observation is made? 1. The contractions occur at 3-minute intervals and last more than 60 seconds. 2. The contractions occur at 2.5-minute intervals and last more than 90 seconds. 3. The contractions occur at 2-minute intervals and last more than 90 seconds. 4. The contractions occur at 2-minute intervals and last more than 60 seconds.

3 1) normal frequency and duration 2) normal frequency and duration 3) CORRECT — contractions should be less frequent (longer than 2-minute intervals) and should be of shorter duration (less than 90 seconds); allows for longer resting time between contractions 4) normal frequency and duration

The client had abdominal surgery 4 days ago. The client has been coughing and says it "feels like something gave." The nurse observes the edges of the incision have separated and a small loop of the bowel protrudes through the incision. In which position does the nurse place the client? 1. Head of the bed elevated 30° 2. Head of the bed tilted down 3. Head of the bed elevated 15° 4. Head of the bed elevated 90°

3 1) semi-Fowler's; too high, puts pressure on abdominal area 2) Trendelenburg position; impedes respiratory excursion 3) CORRECT - low Fowler's; reduces stress on suture line; client may also be placed supine with hips and knees bent 4) high Fowler's; too high, puts pressure on abdominal area

The primipara attends a class for women who plan to breast feed. To prepare for breast feeding, the nurse encourages the women to perform which implementation? 1. Apply moisturizer to the breasts every day after bathing. 2. Nurse the infant every 4 to 5 hours after delivery. 3. Wash the breasts with warm water only. 4. Massage the breasts to increase circulation twice daily.

3 1) use of creams not recommended, could cause breast tissues to become tender, sebaceous glands keep skin pliable 2) infant should be nursed immediately after birth and every 2 to 3 hours after; will prevent breast engorgement and nipple damage 3) CORRECT — soap avoided to prevent drying 4) could cause breast tissues to become tender

The client has been on bedrest for 48 hours in an unsuccessful attempt to arrest premature labor at 33 weeks gestation. The lab reports a lecithin/sphingomyelin (L/S) ratio of 3:1. Based on this result, the nurse anticipates which occurrence? 1. Administration of ritodrine hydrochloride. 2. Initiation of a terbutaline sulfate drip. 3. Delivery of the infant by cesarean birth. 4. Continuation of bedrest until otherwise indicated.

3 1- lungs are good, dont need it 2-this is to induce, not the right course 4-good lungs and csect preferred for premis

An intravenous pyelogram (IVP) is ordered for the client scheduled to have the left kidney removed due to renal disease and hypertension. Which nursing action has the highest priority the evening before the IVP? 1. Administer a cathartic enema to cleanse the bowel. 2. Obtain information about client allergies. 3. Instruct the client to be NPO after midnight. 4. Teach the client x-rays will be taken at multiple intervals.

3 Assessment 1) implementation; contains correct information, but is not a priority 2) CORRECT — assessment; clients sensitive to iodine can develop anaphylaxis; client should be asked specifically about allergies to iodine; iodine is present in the radiopaque material that is injected IV 3) implementation; contains correct information, but is not a priority 4) implementation; test may be canceled if the client is allergic to iodine

Which nursing action is the priority for the infant admitted with a positive stool culture for Salmonella? 1. Change diet to clear liquids. 2. Initiate intravenous fluids. 3. Maintain contact precautions. 4. Apply cloth diapers.

3 PREVENT transmission

The nurse notices the elderly client has a dry, parched mouth and tongue. The nurse takes which action? 1. Brushes the client's teeth with a hard-bristled toothbrush before meals and at bedtime. 2. Uses glycerin swabs to give mouth care every 4 hours. 3. Rinses the client's mouth with room-temperature tap water before and after meals. 4. Uses a water pick, then rinses with commercial mouthwash every 8 hours to freshen the mouth.

3 Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? 1) should use soft-bristled toothbrush so gums are not injured 2) should be avoided, causes dryness of mucous membranes 3) CORRECT — will hydrate the mucous membranes and keep mouth clean 4) most commercial mouthwashes contain alcohol, would dry mucous membranes

The parent of the 8-month-old infant prepares to take the child home after treatment for bacterial meningitis. The parent confides to the nurse of being afraid the child will have brain damage as a result of the illness. Which is the best response by the nurse? 1. "Trust your health care providers. They are excellent and will know what to look for." 2. "There is a 20% incidence of residual brain damage after this type of illness, but the odds are in your favor." 3. "It is an unlikely possibility, but if your child doesn't develop normally, your health care provider will help you with any problems." 4. "You feel guilty about your child's illness, and that's understandable. You will feel better after you get home."

3 Strategy: Remember therapeutic communication. 1) nontherapeutic, diminishes person's concerns and feelings 2) nontherapeutic to discuss statistics with clients, wrong emphasis for discussion 3) CORRECT — if treated early, good prognosis; may be complications and long-term effects (seizure disorders, hydrocephalus, impaired intelligence, visual and hearing defects); therapeutic response 4) nontherapeutic, interprets person's feelings

The 4-week-old infant with symptoms of pyloric stenosis is brought to the outpatient clinic by the parent. Which statement does the nurse expect the parent to make about the infant's symptoms? 1. "My infant's bowel movements have turned black and sticky." 2. "I really have to encourage my infant to suck the bottle." 3. "My infant is fussy and seems hungry all the time." 4. "My infant spits up green liquid after feeding."

3 becomes lethargic, dehydrated and malnurished. would not expect it to be bile- it would be milk or formula

The nurse prepares the client for a liver biopsy. How does the nurse position the client? 1. Prone with the head turned to the side 2. On the right side with the head slightly elevated 3. Supine with arms raised above the head 4. On the left side with the bed flat

3 needle inserted between two of the lower ribs or below the right ribcage

The health care provider prescribes cimetidine 300 mg PO qid for the client. The nurse instructs the client about the medication. Which client statement indicates further teaching is needed? 1. "I'll take this pill with meals and before bed." 2. "I may experience mild diarrhea for a while." 3. "My stools may change color while I'm on this medication." 4. "I should call my health care provider if I get an acne-like rash."

3 no change in stool color

The nurse cares for the client hospitalized with an acute asthma attack. The nurse is most concerned if which finding is observed? 1. The client becomes more diaphoretic. 2. The client's respirations increase from 14 to 16 per minute. 3. The client's pulse increases from 86 to 100 beats per minute. 4. The client shows increasing pallor.

3 pulse increases d/t decrease in oxygenation of tissue

The child comes to the school nurse with a honey-colored crusted lesion below the right nostril. Which action does the nurse take first ? 1. Removes the scab. 2. Applies a wet cloth to the lesion. 3. Notifies the child's parents. 4. Contacts the health department.

3 tell paretns so they can take kid to HCP. then loosen scab w/ burrows solution compress

The client with chronic pain due to cancer receives morphine 10 mg PO q4h PRN for pain without much relief. Which change in narcotic pain management is the most valid suggestion for the nurse to make to the health care provider? 1. Decrease medication to twice a day. 2. Decrease medication to every 6 h PRN. 3. Administer medication every 4 h around the clock. 4. Administer medication every 2 h PRN.

3 1) decreases the amount of pain medication 2) decreases the amount of pain medication 3) CORRECT — around-the-clock (ATC) administration of analgesics is more effective in maintaining blood levels to alleviate the pain associated with cancer 4) might be too frequent an interval to administer the medication

The nurse cares for the client diagnosed with vasoocclusive crisis. The nurse instructs the client how to use patient-controlled analgesia (PCA). The nurse determines teaching is effective if the client makes which statement? 1. "If I start feeling drowsy, I should notify the nurse." 2. "This button will give me enough to kill the pain whenever I want it." 3. "If I start itching, I need to call you." 4. "This medicine will help me feel no pain."

3 1) may feel sleepy because of medication 2) preset dose administered with preset lock-out times 3) CORRECT — itching is a common adverse effect of narcotics used in PCA pain management 4) indicates a need for further teaching or clarification

The teenager comes to the clinic reporting fatigue, a sore throat, and flu-like symptoms for the previous 2 weeks. Physical exam reveals enlarged lymph nodes and temperature of 100.3° F (37.9° C). Which statement by the nurse is best? 1. "Cover your mouth and nose when you sneeze or cough." 2. "Eat in a separate room away from your family." 3. "Don't share your drinking glass or silverware with anybody." 4. "Stay in your room until all of your symptoms are gone."

3 1) mononucleosis is spread by direct contact 2) no reason to be isolated 3) CORRECT — symptoms indicate mononucleosis, spread by direct contact; advise family to avoid contact with cups and silverware for about 3 months 4) clients with mononucleosis are not isolated

The client takes chlorpromazine. The client is instructed to notify the nurse immediately if which sign or symptom is experienced? 1. Dry mouth and nasal stuffiness. 2. Increased sensitivity to heat. 3. Difficulty urinating. 4. Weight gain and constipation.

3 1) possible adverse effect of antipsychotic medications, but client can be instructed on measures to take at home to resolve this problem 2) possible adverse effect of antipsychotic medications, but client can be instructed on measures to take at home to resolve this problem 3) CORRECT — is an anticholinergic reaction that may become a severe health problem unless treated 4) possible adverse effect of antipsychotic medications, but client can be instructed on measures to take at home to resolve this problem

The 5-year-old child is scheduled for a lumbar puncture (LP). Which nursing action best prepares the child for the procedure? 1. Explain the procedure in detail. 2. Show a video of the procedure. 3. Do a mock run-through of the procedure. 4. Answer all questions simply and honestly.

3 1) would be very difficult to prepare a 5-year-old child for a totally foreign procedure with only words 2) may be frightening without additional preparation 3) CORRECT — excellent method to use with a child because it incorporates actually "feeling" many aspects of the procedure as they are explained 4) child probably doesn't know enough to ask many questions

The nurse cares for the postoperative client. Four hours after surgery, the client voids 200 mL of urine with a specific gravity of 1.019. The nurse takes which action? 1. Palpates the client's lower abdomen for distention. 2. Encourages an increased intake of oral fluids. 3. Records the time and the amount of urine. 4. Encourages the client to void again in 2 hours.

3 normal specific gravity (1.010-10.30)

The elderly adult is admitted to a medical unit with shortness of breath. The client is diagnosed with an upper respiratory infection (URI). The client is placed on droplet precautions. The nurse administers oral medications to the client. As the nurse leaves the room, the nurse takes which action? 1. Washes hands, removes the gown and mask, and throws the trash in a container outside of the room. 2. Removes the mask, washes hands, and throws the trash in a container inside the room. 3. Washes hands, removes the mask, and throws the trash in a container inside the room. 4. Removes the gown and gloves, washes hands, removes the mask, and throws the trash in a container inside the room.

3- no gown for droplet 1) gown unnecessary, trash should be left inside room 2) wash hands then remove mask, so microbes aren't transferred from hands to face 3) CORRECT — hands should be washed before removing mask to prevent transfer of microbes to face 4) gown unnecessary

The nurse makes rounds on the postpartum unit. The nurse notes that a client's uterus is relaxed. The nurse should take which actions? Select all that apply. 1. Encourage the client to drink warm oral fluids. 2. Check the client's pulse and respirations. 3. Massage the fundus until firm. 4. Put the infant to the client's breast. 5. Assess the bladder for fullness. 6. Continue to monitor the fundal height.

3.4.5

Place the answers in order of priority. All options must be used. - The 34 year old client w/distended abdomen and splenomegaly -8mo infant crying loudly with facial ecchymosis -44 year old client possible whip lash from MVA -12 yo w/ possible fractured ankle

34 yo 12 yo 8mo 44yo Strategy: Which clients are unstable? Move from the most unstable to the most stable. Unstable, circulation; Distended abdomen indicates possible bleeding. Unstable: Possible fracture needs to be attended to as soon as possible. Stable, potential airway; Young children need assessment as their problems may not be visible. Stable, potential pain; The client with whiplash is stable and not urgent.

The charge nurse cares for young children in the hospital. Which client requires the nurse to use droplet precautions? 1. The child with cystic fibrosis. 2. The child with tonsillitis. 3. The child with bronchitis. 4. The child with pertussis.

4

The client diagnosed with Addison's disease is admitted with pneumonia. The nurse suggests salted broth for lunch. The appropriateness of this decision is based on which statement about Addison's disease? 1. The client requires increased sodium intake to prevent hypotension. 2. A decrease in sodium intake may lead to seizures. 3. Steroid replacement causes rapid loss of sodium. 4. Sodium intake should be increased during periods of stress.

4

The client has a spinal cord injury resulting in paraplegia. The client has a reorientation outing with the recreational therapist. Which documented activity indicates the client is ready for discharge? 1. The client states enjoyment in being outside the hospital environment. 2. The client participated in a structured team sport by keeping score. 3. The client independently ordered a meal and fed self. 4. The client is independent in transfers and wheelchair mobility.

4

The nurse assesses the client diagnosed with a detached retina. Which observation supports this diagnosis? 1. Loss of acuity in the peripheral visual field. 2. Increased lacrimation, blurred vision. 3. Conjunctivitis, dilated pupils bilaterally. 4. Photophobia, loss of a portion of the visual field.

4

The nurse cares for the client receiving atorvastatin. It is most important for the nurse to report which client statement to the health care provider? 1. "I no longer drink grapefruit juice." 2. "I have my liver enzymes checked regularly." 3. "I take a daily multivitamin." 4. "I take colchicine."

4 1) appropriate action; grapefruit juice decreases the enzyme that breaks down atorvastatin 2) appropriate action 3) not contraindicated 4) CORRECT — concurrent use of colchicine and atorvastatin increases the risk of rhabdomyolysis

The nurse cares for the client diagnosed with Cushing's syndrome. Which nursing action is the priority? 1. Implement measures to prevent skin breakdown. 2. Plan measures to prevent infections. 3. Teach the client signs and symptoms of hyperglycemia. 4. Instigate measures to prevent fluid overload.

4 1) clients are susceptible to skin breakdown and infections 2) clients are susceptible to skin breakdown and infections 3) impaired glucose tolerance often leads to hyperglycemia, but is not highest priority 4) CORRECT — respirations are the first priority; clients with Cushing's syndrome are prone to fluid overload and heart failure due to sodium and water retention

The nurse visits the client with newly diagnosed type 1 diabetes. The health care provider placed the client on an 1,800-calorie ADA diet, ordered the client to self-administer 15 units of intermediate-acting insulin each day before breakfast, and check the blood glucose qid. When the nurse visits the client at 1700, the nurse discovers the client has not eaten since noon and has just returned from jogging. The client's vital signs are: BP 110/80, pulse 120/min, respirations 18/min, and temperature 98.2° F (36.8° C). The nurse anticipates the client's blood glucose to be which value? 1. 250 mg/dL (13.88 mmol/L). 2. 160 mg/dL (8.88 mmol/L). 3. 90 mg/dL (5 mmol/L). 4. 50 mg/dL (2.78 mmol/L).

4 1) hyperglycemia symptoms are hot dry skin, rapid, deep respirations (Kussmaul), lethargic, polyuria, polydipsia, polyphagia, glycosuria, nausea, and vomiting 2) intermediate-acting insulin has onset 3—4 hours, peak 8—16 hours, duration 18—26 hours 3) normal blood glucose 70—110 mg/dL (3.9—6.1 mmol/L) 4) CORRECT — hypoglycemia symptoms are cool, clammy skin, diaphoresis, nervousness, weakness, hunger, confusion, headache, slurred speech, coma

The client has a subclavian triple lumen catheter used for administration of parenteral nutrition (PN). The health care provider orders all lumens be flushed with a diluted heparin solution BID. When the nurse attempts to flush the distal lumen, resistance is met. The nurse takes which action? 1. Clamps off the lumen and labels it as "clotted off." 2. Gradually increases the pressure on the irrigating solution. 3. Aspirates blood from the lumen to restore patency. 4. Secures the lumen with a Luer-Lock cap and notifies the health care provider.

4 1) should be reported to the health care provider to see if patency can be re-established before it is labeled as clotted off 2) force should never be used to irrigate the catheter 3) blood should not be aspirated from the catheter 4) CORRECT — streptokinase may be used to dissolve clot; if unsuccessful, lumen is labeled as clotted off

The client sustained an electrical burn. A family member states, "I don't understand why my sibling has been here a week. The burn does not look that bad." Which response by the nurse is best? 1. "Electrical burns are more prone to infection." 2. "Electrical burns are always much worse than they look on the outside." 3. "Cardiac monitoring is important because electrical burns affect cardiac function." 4. "Electrical burns can be deceptive because underlying tissue is also damaged."

4 Strategy: Determine which statement correctly states the facts. 1) incorrect regarding electrical burns 2) not the most accurate statement 3) is true in the immediate post-burn phase, not a week later 4) CORRECT — electrical burn injuries are typically more injurious to underlying tissue, such as nerve and vascular tissue, which require complex and timely treatment

The preschooler is brought to the emergency department after ingesting a bottle of baby aspirin. The nurse observes the preschooler for which signs and symptoms? 1. Nausea and vertigo. 2. Epistaxis and paralysis. 3. Dysrhythmia and hypoventilation. 4. Tinnitus and gastric distress.

4 tinnitus and gastric distress signs of overdose. vertigo, and change of heart does not happen with asa

The nurse cares for the client who experienced a thermal injury 2 weeks ago. The nurse is most concerned if which vital sign is observed? 1. Increased heart rate and elevated blood pressure. 2. Temperature of 100.6° F (38.1° C) and decreased respiratory rate. 3. Increased heart rate and decreased respiratory rate. 4. Increased respiratory rate and decreased blood pressure.

4 SEPSIS

The client returns to the room following an appendectomy. There is a large amount of serosanguineous drainage on the dressing. It is most important for the nurse to obtain an answer to which question? 1. "Were there any intraoperative complications?" 2. "Has the dressing been changed?" 3. "Why didn't the recovery room nurse report any drainage?" 4. "Was a tissue drain placed during surgery?"

4 drain usually placed, dressing can be reinforced but first dressing change typically done by provider

The client is seen in the emergency department with severe right-flank pain. The client is 20 pounds overweight, lives a sedentary lifestyle, and was treated for urinary tract calculi 4 years ago. Which nursing action is most important? 1. Ensure the client has nothing to eat or drink. 2. Obtain a mid-stream urine specimen for analysis. 3. Provide warm packs to relieve discomfort. 4. Measure and strain the client's urine.

4 will document if passes calculus vs. testing for infection

The newborn is diagnosed with cystic fibrosis (CF). Which parental statement to the nurse indicates understanding of the cause of CF? 1. "The gene came from my husband's side of the family." 2. "The gene came from my wife's side of the family." 3. "There is a 50% chance that our next child will have the disease." 4. "Both of us carry a recessive trait for cystic fibrosis."

4) CORRECT — cystic fibrosis is inherited by an autosomal recessive gene

The client is transferred to the neurology unit after developing right-sided paralysis and aphasia. The nurse includes which intervention in the client's plan of care? 1. Encourage client to shake head in response to questions. 2. Speak in a loud voice during interactions. 3. Speak using phrases and short sentences. 4. Encourage the use of radio to stimulate the client.

Strategy: Topic of question is unstated. Read the answer choices for clues. 1) does not encourage verbal communication 2) inappropriate for the situation 3) CORRECT — will decrease tension and anxiety; client may understand some of the incoming communication if it is kept simple; speech may be relearned with appropriate support and interventions 4) inappropriate for the situation