Question Bank 1-15

A client becomes acutely short of breath with an SpO2 (oxygen saturation) of 82%. Which oxygen delivery system should the nurse apply that would provide the highest concentrations of oxygen to the client?

Non-rebreather mask- When a tight seal is achieved using a non-rebreather mask, up to 100% of oxygen is available. The venturi mask, partial rebreather mask and simple mask cannot deliver oxygen concentrations as high as the non-rebreather mask. If you are unsure of the correct response, you should know that because the question is asking for the highest concentration of oxygen delivery, it would be unlikely that something with the words "partial" and "simple" would be correct, so you can eliminate those options. A Venturi mask can deliver a fixed concentration of oxygen, but in increments no higher than 40%.

The ICU nurse works in a rural hospital that has a remote electronic ICU monitoring system (eICU.) What is one of the best reasons for having access to an eICU?

An ICU nurse and intensivist remotely monitor ICU clients around the clock

When reviewing the medication lithium with a client, the client asks, "How long will it take before I can feel the effects of the medication?" Which response by the nurse is the best?

"About two weeks"- Lithium is a fast-acting mood stabilizer and quite effective in controlling mania soon after starting the medication. But it may take several weeks for it to reach maximum effectiveness.

A client is admitted to the hospital with a history of confusion. The client has difficulty remembering recent events and becomes lost when outside of the home. Which statement would provide the best reality orientation for this client?

"Good morning. You're in the hospital. I am your nurse Elaine Jones."

A client tells a nurse, "I have something very important to tell you if you promise not to tell anyone." Which statement by the nurse would be the most appropriate response?

"I can't make such a promise."

A client has had a positive reaction to purified protein derivative (PPD). Which statement made by the client suggests the client understands the teaching by the registered nurse (RN)?

"I have been exposed to mycobacterium tuberculosis."

The nurse assists with the reinforcement of information about breast self-examination to a group of college students. A female student asks when to perform the monthly exam. The appropriate reply by the nurse should include which statement?

"Right after the period, when your breasts are less tender."

A client is scheduled to have blood drawn for serum cholesterol and triglycerides tomorrow morning. What information should the nurse reinforce to the client about the test?

"Do not eat or drink anything but water for 12 hours before the blood test."

A client is discharged with a prescription for warfarin. A nurse recognizes that additional teaching is needed if the client makes which incorrect comment?

"I know I must avoid crowds."- There are no specific reasons for the client on warfarin to avoid crowds. The other options are true statements. Warfarin is used to prevent blood clots from forming and is commonly prescribed postoperatively following a major surgery, after suffering a heart attack, or for certain types of irregular heartbeats.

A client exhibits many delusional thoughts. As the nurse assists the client to prepare for breakfast, the client comments, "Don't waste good food on me. I'm dying from this disease I have." Which response by the nurse would be the best?

"I know you believe that you have an incurable disease."- The correct response is one that does not challenge the client's delusional system and provides some reassurance of a desire to help the client. The comment does not confirm the client's comment but simply reflects that the nurse has listened and heard the comment.

A nurse has reinforced teaching for a client who is being discharged after an arterial revascularization of the right lower extremity. Which statement made by the client is incorrect and requires further discussion with the nurse?

"I will put my right leg through a full range of motion."- To prevent arterial occlusion after arterial revascularization, the nurse should have the client avoid full range of motion. This prevents stress or kinking of the grafts. A throbbing pain may indicate that the blood supply is increasing in the surgical area and this is a desired effect. Smoking causes vasoconstriction and will contribute to occlusion. Coughing and deep breathing are important after any surgery.

A pregnant client asks the nurse about the scheduled blood test for alpha-fetoprotein (AFP). The nurse's explanation should include which of these comments?

"It can help identify potential neurological defects."- AFP is a substance made in the liver of the fetus. A fetus with neural tube defects, such as spina bifida and anencephaly, loses AFP to the amniotic fluid and, consequently, to maternal blood. The blood test is performed between the 15 and 17 weeks of pregnancy and can be used as part of a screening test to find chromosomal problems, such as Down sydrome.

The registered nurse is teaching a childbirth education class about postpartum depression. Which statement, made by a class member, indicates that more teaching is needed?

"It's common for women with postpartum depression to have delusions about the infant."- Postpartum depression symptoms include sleep and appetite disturbances, uncontrolled crying, with feelings of guilt and/or worthlessness. Although postpartum depression typically occurs within the first three months after delivery, it can occur up to a year later. A new mother who has symptoms of postpartum depression should take steps to get help right away. Delusions are associated with postpartum psychosis, not depression.

A client with testicular cancer has had a unilateral orchiectomy. Prior to discharge the client expresses his fears related to the prognosis. Which statement should be the initial response by a nurse?

"Testicular cancer has a very high cure rate with early diagnosis and treatment." - With early detection, diagnosis and treatment, the cure rate in testicular cancer is around 95%. The other comments are correct about testicular cancer but would not be the initial response to the client's question.

A client tells a nurse about an Internet site that claims bupropion was taken off the market because it caused seizures. What would be an appropriate response by the nurse?

"There were problems and the recommended dose was changed."- Varicella (chicken pox), influenza and the cold virus are viral illnesses that have been identified as increasing the risk for Reye's syndrome in children, particularly when aspirin has been used. Rubeola, meningitis, and hepatitis are not recognized as precursors to Reye's syndrome. The combination of a viral infection and the administration of aspirin to children from birth to 19 years of age can result in the development of Reye's syndrome; therefore, aspirin should be avoided during these ages.

The nurse enters the room of a postpartum mother and observes the baby lying at the edge of the bed while the mother sits in a chair. The mother states, "This is not my baby, and I do not want it." How should the nurse respond?

"You seem upset, tell me about how you are feeling"?- A nonjudgmental, open-ended response facilitates dialogue between the client and nurse. The correct response is the more general, client-centered option. This type of comment facilitates the flow of communication.

A client asks the nurse for information about a living will. Which statement made by the client demonstrates an understanding of a living will? (Select all that apply.)

- "I should sit down and discuss my wishes for end-of-life care with my loved ones." - "A living will is a legal document that becomes a permanent part of my health care record." - "My wishes for end-of-life treatment are stated in writing." - "I will need to identify someone to be my health care proxy."

The client needs to be moved up in bed. The client is able to partially assist and weighs 135 pounds. Which action by the nursing staff best supports an awareness of ergonomics and safe client handling? (Select all that apply.)

- Adjust the height of the bed for caregivers - Move the bed into the flat position - Use a friction-reducing device

A 28-year-old is transferred to the emergency department (ED) via ambulance with a traumatic head injury. The client is awake and reports having a headache and some amnesia. What are the priority nursing interventions for this client? (Select all that apply.)

- Assess the wound for presence of drainage or bruising on the head - Assess vital signs and neurological function - Assess the airway - Prepare for CT imaging of the head

The medication benztropine mesylate (Cogentin) is ordered, but the nurse incorrectly administers carvedilol (Coreg). What are the most important actions the nurse should take after making this medication error? (Select all that apply.)

- Document the administration of carvedilol (Coreg) - Notify the nurse manager - Monitor and document the client's blood pressure - Notify the health care provider

The client undergoes a laparoscopic removal of the appendix. Which postoperative instructions will the nurse reinforce? (Select all that apply.)

- No showering for 48 hours after surgery - Some shoulder discomfort can be expected - Use 2 tablespoons of Milk of Magnesia if no bowel movement 3 days after surgery - Restrict diet to bland, easily digestible food for a few days

The client underwent a total hip arthroplasty 48 hours ago. The client has been up in a chair and is prescribed physical therapy twice daily. What type of nursing care is needed for this client? (Select all that apply.)

- Place a soft foam triangular pillow between the client's legs when in bed - Provide a seat riser for the toilet or commode - Encourage client to perform leg exercises when in bed

The client is instructed to collect stool specimens at home using the guaiac test. In addition to explaining how to collect the specimens, the nurse instructs the client to avoid certain substances prior to obtaining the stool specimens. Which of the following substances should the client avoid? (Select all that apply.)

- Oranges - Marinated cauliflower and broccoli - Grilled sirloin steak -Foods like beef, which contain hemoglobin, will result in a false positive test and should be avoided for at least 3 days before the fecal occult blood test; chicken, pork and seafood can be consumed. Fruits and vegetables with high peroxidase activity, such as red radishes, broccoli, and cauliflower should also be avoided several days prior to obtaining specimens. Clients should also limit their intake of vitamin C because too much can lead to a false negative result. Aspirin and other nonsteroidal anti-inflammatory drugs can cause bleeding and should be avoided at least 7 days before the test; acetaminophen does not affect the test.

A newly admitted client reports taking phenytoin for several months. Which of the following assessments should the nurse be sure to include in the admission report? (Select all that apply.)

- Report of unsteady gait, rash and diplopia - Report of any seizure activity - Serum phenytoin levels

The nurse has an order for a postsurgical client to receive enoxeparin 40 mg subcutaneously once a day as prophylaxis for deep vein thrombosis. Enoxeparin is supplied from the pharmacy as 60 mg/mL. How much enoxeparin will the nurse administer? (Round the number to the nearest 10th and write only the number.) __mL.

0.7ml -Desired: 40 mg in ? mL Supplied: 60 mg in 1 mL; 60 mg/1mL = 40 mg/X mL; 60X = 40; (40/60) x 1 = 0.66 or 0.7; x = 0.7 mL

A client is scheduled for a percutaneous transluminal coronary angioplasty (PTCA). What should the nurse understand about the purpose of this procedure?

A process to compress arterial plaque to improve blood flow

A nurse is providing home care for a client diagnosed with chronic heart failure and episodes of pulmonary edema. Which nursing diagnosis should the nurse expect as a priority in the plan of care?

Activity intolerance related to an imbalance of oxygen supply and demand

Where should the nurse administer the annual purified protein derivative (PPD) to the client with a left arm Permcath™?

Always avoid using the arm with a shunt so as to prevent restriction of blood flow and possible clotting or rupture of the fistula. Using the opposite forearm for the PPD administration also reduces the chance for infection.

A nurse is caring for a client who has been diagnosed with acute sickle cell vaso-occlusive crisis. Which intervention by the nurse would be most important?

Administer analgesic treatment as ordered- Pain is very severe in sickle cell crisis, and is a priority in care. The main objectives in the treatment of a sickle cell crisis is providing analgesics for pain, adequate hydration, oxygenation, bed rest, electrolyte and blood replacement, and antibiotics to treat any existing infection that could have contributed to the crisis. Because pain causes sympathetic stimulation, which results in vasoconstriction, pain management is the most important nursing action among the given choices. Clear liquids, bed rest and temperature control measures assist in reducing the ischemia associated with a sickle cell crisis. You will note that this is a specific question, requiring a specific answer. When deciding on which option to select, you should conclude that pain control should take priority over the other options.

A newborn is diagnosed with hypothyroidism. In discussing the condition and treatment with the family, the nurse should emphasize which point?

Administration of a thyroid hormone will prevent problems- You will notice that only one option (the correct response) includes the word "thyroid." Associate this with the content of this question, which is hypothyroidism. This option also addresses replacing something that is missing (hypo) making it a "treatment" for the content of this question. Early identification and lifetime treatment with hormone replacement therapy (levothyroxine) corrects this condition.

A nurse is talking to a group of parents about how to reduce risks in the home. What is the most important factor for the nurse to consider during the discussion?

Age of children in the home- Age and developmental level of the child are most important considerations when providing a framework for anticipatory guidance to reduce risks for harm. When considering the answer to this question, look for options that are similar but dissimilar and are the options focusing on children. To decide between these two options, consider the factor that might have a greater impact on risks in the home: age or number of children.

A client is admitted with diagnosis of a right upper lobe infiltrate and to rule out active tuberculosis (TB). Which type of precautions will be needed for this client?

Airborne

The nurse is caring for a 75 year-old client with type 2 diabetes mellitus. The client should be instructed to contact the outpatient clinic immediately if which findings are present?

An open wound on the heel with minimal discomfort

A client has a diagnosis of heart failure. Which intervention is most important for the nurse to implement prior to the administration of digoxin?

Assess the apical pulse, counting for a full 60 seconds- It is the nurse's responsibility to take the client's apical pulse before administering digoxin. The correct technique for taking an apical pulse is to use the stethoscope and listen for a full 60 seconds. Digoxin is held for a pulse below 60 beats per minute (bradycardia is a finding in digoxin toxicity).

A practical nurse (PN) team member identifies that the fundus is boggy for a woman who is gravida 4 para 4 and is two hours after a spontaneous vaginal delivery. The fundus is displaced slightly above and to the right of the umbilicus. What should be the initial nursing action?

Assist the woman to empty her bladder

The nurse is reinforcing dietary instructions to the parents of a child diagnosed with cystic fibrosis. The nurse will emphasize which of the following characteristics of this diet?

Balanced, high calorie diet with extra fat, salt, protein and calcium- A child with cystic fibrosis needs a well-balanced, high calorie diet that includes extra fat, salt, and protein. Children with CF are at risk for osteoporosis, which is why they need full fat dairy products. Carbohydrate counting is recommended for children with diabetes. Foods low in sodium, potassium and phosphorus are tips for people with chronic kidney disease. A gluten-free diet is the only treatment for celiac disease.

A child is admitted to the hospital for emergency surgery. The child's parent reports several allergies. Which of these allergies should all the operative health care personnel be notified about?

Balloons- Allergy to balloons often indicates a latex allergy. All personnel during and after surgery that are in contact with the child will need to be aware of this condition. The need to use non-latex gloves or equipment without latex components should be noted on the chart.

The parents of a school-age child are providing information to the nurse about their child. Which of these health issues should the nurse recognize as a finding that could suggest type 1 diabetes?

Bedwetting- In school-aged children, warning signs of type 1 diabetes include: fatigue, frequent urination (also bed wetting), unusual thirst, extreme hunger, and weight loss. Also, diabetics usually have dry skin. The parents may not initially think anything of the polyphagia or polydipsia, but bed wetting in a school-age child (who previously did not wet the bed at night) would prompt the parents to seek medical intervention.

A pregnant woman has been advised to alter her diet during pregnancy by increasing the intake of protein and vitamin C to meet the needs of the growing fetus. Which diet choice would best meet the woman's needs?

Beef, one-half cup of lima beans, glass of skim milk, three-fourths cup of strawberries- Beef and beans are an excellent source of protein, as is skim milk. Strawberries are a good source of vitamin C.

The client is seen in the emergency one day after falling in his bathroom at home. The client reports having "a few drinks" prior to the fall. Which finding requires the nurse's immediate attention?

Bruise behind one ear

The nurse is assessing a client who has been treated long-term with glucocorticoid therapy. Which finding might the nurse expect?

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

There's a new order to apply one-inch of nitroglycerin paste to the client's chest every 12 hours, but the medication is not in the automatic medication dispensing system's drawer for this client. What should the nurse do next?

Call the pharmacy to send up a tube of nitroglycerin paste

A nurse gathers data related to delayed gross motor development in a 3 year-old client. Which observation by the nurse should confirm this finding?

Cannot stand on one foot- At this age, gross motor development allows a child to balance on one foot. A child who is 3 years old should be able to hop, ride a tricycle and throw a ball (but they would have trouble catching it). Most young children with fetal alcohol syndrome, for example, show delays in motor skill development (both fine and gross motor).

A 6 month-old infant is being treated for developmental hip dysplasia and has been placed in a hip spica plaster cast. Which discharge information is important for the nurse to reinforce with the parents?

Check frequently for swelling in the baby's feet- Notice that only two of the options focus on cast care. Of those two options, the crossbar on the cast should never be used to lift or move the child. The parents of a child in an initial hip spica cast must check for circulatory impairment. The nurse should reinforce the importance of observing the extremities for swelling, discoloration, movement and sensation. Remember to look for the six Ps of impaired tissue perfusion: pain, paresthesia, pallor, pulselessness, paralysis and poikilothermia (coolness). Sometimes blowing cold air (never warm or hot) from a hand-held hair dryer into the cast can help with itching, but care should be taken never to insert anything into the cast.

Diagnosed with heart failure, the client had an implantable cardioverter-defibrillator (ICD) implanted several years ago. The client now has end-stage heart failure and is receiving home hospice care. Which end-of-life care option could have the greatest impact on client comfort?

Deactivating the implantable cardioverter-defibrillator (ICD)- Family or caregivers can help the client to sit upright, which will help decrease cardiac workload and facilitate breathing, but oxygen and morphine are also needed to help with shortness of breath and comfort. Eating several smaller meals of appealing and easily digestible food is recommended, but caregivers should not try to force the client to eat because it does not help the person live longer and may be uncomfortable. Discussing advanced directives can provide some peace of mind for the client and family, but this client would have a do-not-resuscitate order. Deactivating the ICD will have the greatest impact on comfort. Repeated shocks delivered by an ICD can be painful for the client and difficult for the family to witness, which is why the health care provider should discuss and encourage deactivating the ICD.

Lactulose has been prescribed for a client with advanced liver disease. Which finding should the nurse use to evaluate the effectiveness of this treatment?

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

An 80 year-old client is scheduled for a cardioversion. The nurse is reviewing the client's medication administration records for the previous 24 hours. Which medication would prompt the nurse to notify the health care provider?

Digoxin (Lanoxin)- Digoxin increases ventricular irritability and increases the risk of ventricular fibrillation following cardioversion. The other medications do not increase ventricular irritability.

The nurse is reinforcing information about the side effects of fluoxetine to a client. Which group of findings should be included?

Diarrhea, dry mouth, weight loss, reduced libido- Fluoxetine (Prozac) is a selective serotonin reuptake inhibitor (SSRI). it is used to treat depression, obsessive-compulsive disorder, some eating disorders and panic attacks. Commonly reported side effects include diarrhea, dry mouth, weight loss and reduced libido.

A 2 day-old infant born with spina bifida and meningomyocele is recovering after an initial surgery. As the nurse accompanies the grandparents for their first visit since the child's birth, which of these responses might the nurse expect from the grandparents?

Disbelief- The first phase of the grieving process is shock, disbelief or denial. The next steps in the process of grief are anger, bargaining, depression and then acceptance.

A couple experienced a miscarriage at seven months of pregnancy. The nurse makes a home visit one week after discharge from the hospital. What intervention should the nurse emphasize to the couple during the home visit?

Discuss feelings with support persons and each other

A client with heart failure is newly referred to a home health care agency. The nurse determines that the client has not been following the prescribed diet. It would be most appropriate for the nurse to take which action at this time?

Discuss the diet with the client to learn the reasons for not following the diet

The nurse is assisting with the delivery of a newborn infant. What is the priority nursing intervention for a normal newborn immediately after delivery?

Dry off infant with a warm blanket or towel- The priority interventions are in recovering a normal newborn. Maintaining the infant's temperature by drying, warming, and removing any wet blankets or towels are the priority interventions. All interventions are correct, but warming and drying would be the priority.

A nurse is caring for a child who has been recently diagnosed with cystic fibrosis. Which finding should the nurse anticipate?

Dry, nonproductive cough- Noisy respirations and a dry nonproductive cough are usually the first respiratory findings to appear in a newly diagnosed cystic fibrosis client. Because the question relates to a respiratory condition, you should select a respiratory option (and there is only one option related to the respiratory system).

The nurse is caring for a client who is diagnosed with chronic renal failure with hemodialysis three times per week. The client becomes confused and irritable six hours before the next treatment. Which of these findings might explain the reason for the client's behavior?

Elevated blood urea nitrogen (BUN)- Confusion and irritability are findings of renal encephalopathy secondary to elevated levels of BUN and creatinine in the blood. Potassium levels are generally high in renal failure along with phosphate levels. Calcium may be low in chronic renal failure. However, the side effects of low calcium levels are exhibited as abdominal or muscle cramping, parasthesias of the extremities, and hyperactive reflexes. Metabolic acidosis, not alkalosis, results from renal failure.

An adolescent client arrives at a clinic three weeks after the birth of her first baby. She tells the nurse she is very worried about not returning to her pre-pregnancy weight. Which approach should the nurse take first?

Encourage her to talk about her self-image

A nurse is working with parents to plan home care for a toddler with a heart problem. What should be the priority nursing intervention on the plan of care?

Encourage the parents to enroll in child cardiopulmonary resuscitation (CPR) class

A practical nurse (PN) is observing an 8 month-old infant in the clinic waiting room. Which activity should be reported to the registered nurse (RN)?

Falls forward when sitting- Sitting without support is normal for infants between seven to nine months of age. You will note that the question implies there is a problem. As you read each answer, ask yourself if the behavior is normal for an 8 month-old child. You will also note that there are two options with neurologic components and two options focusing on musculoskeletal development. Because the nervous system would be a priority over the musculoskeletal system, you should then identify the 8 month-old who cannot sit up as the abnormal condition.

The nurse works in a psychiatric inpatient setting. What information should the nurse be aware of as one of the most frequent reasons for suicide in adolescents?

Feelings of alienation or isolation from peers- The isolation may occur gradually resulting in a loss of all meaningful social contacts. Isolation can be self-imposed or can occur as a result of the inability to express feelings. Notice that two of the options deal with "feelings." When deciding between the two, ask yourself which feelings would "most frequently" lead to suicide - anger or isolation?

A client diagnosed with gout is admitted with severe pain, swelling and redness in the proximal toe joint of the right foot. The nurse should anticipate that the plan of care would include which focus?

Fluid intake of at least 3000 mL/day- Gout is a very painful condition in which uric acid crystals collect in a joint causing severe pain and inflammation. Fluid intake should be increased in the client with gout to prevent kidney stones from precipitation of urate in the kidneys. The diet should be low in purines to prevent uric acid formation. NSAIDs, such as ibuprofen or naproxen, are often prescribed to reduce inflammation and pain. If compresses are used, they would be warm, not hot.

A client diagnosed with head trauma is in a non-responsive state. Vital signs are stable and breathing is regular and spontaneous. What should the nurse document to accurately describe the client's status?

Glasgow Coma Scale 8, respirations regular

The client undergoes a gastrectomy. Several hours after surgery, the nasogastric (NG) tube stops draining. What action does the LPN anticipate the RN will take first?

Gently irrigate the tube with sterile normal saline- The RN will assess the position and patency of the NG tube, as well as the color and amount of gastric drainage. The RN can gently irrigate the NG tube with sterile normal saline if it becomes clogged. But if that does not resolve the issue or if repositioning the tube is needed, the RN must call the surgeon. The NG tube inserted in surgery should not be repositioned by a nurse because of the risk of disrupting any internal sutures. It would be contraindicated to increase the suction.

A pregnant client comes to the clinic for a first visit. A nurse gathers data about her obstetric history, which includes: three year-old twins at home and a miscarriage at 12-weeks gestation 10 years ago. Which documentation should the nurse make?

Gravida 3 para 1- Gravida is the number of pregnancies and parity or para is the number of pregnancies that reach viability (which is considered 20 weeks). This woman is now pregnant. She has also had two prior pregnancies, with one of those pregnancies reaching viability (the twins). Remember to simply count the number of pregnancies, as well as the number of pregnancies that reached viability; avoid confusing twins or multiple births with the number of viable births. If asked to document information using the five number system, it would be: 3-1-0-1-2 (gravida, term pregnancies, preterm, abortions, living children).

The nurse is to administer meperidine 100 mg, atropine 0.4 mg, and promethazine 50 mg IM to a client preoperatively. Which action should the nurse take initially?

Have the client empty the bladder

The mother of a hospitalized 2 year-old child asks a nurse's advice about the child's screaming every time the mother gets ready to leave the hospital room. The best advice by the nurse would include which approach?

Help the mother understand that this is a normal response to hospitalization- The protest phase of separation anxiety is a normal response for a child this age. Separation anxiety is at its peak during toddler years of 12 to 36 months.

The client is receiving a thrombolytic agent to open a clot-occluded coronary artery following a myocardial infarction. Which finding would be the greatest concern and should be immediately reported to the registered nurse?

Hematemesis- Frank bleeding should be of the greatest concern. Even though the other options indicate bleeding and would be a concern, they are not as acute or severe as someone who is vomiting blood.

The licensed practical nurse is caring for a client with advanced cirrhosis of the liver. Which finding should receive immediate follow-up by the charge nurse?

Hematemesis- Vomiting of blood may indicate hemorrhage, especially from esophageal varices. This condition can be life-threatening, requiring immediate intervention.

A child is admitted to the unit with findings of nasal congestion and cough with periods of cyanosis and dehydration. The suspected diagnosis is pertussis (whooping cough). What is the priority nursing intervention for this child?

Implement droplet precautions along with standard precautions- Although all the responses are correct actions, it is most important to implement strict droplet precautions in addition to standard precautions because pertussis is spread via close contact. Therapeutic management focuses on providing respiratory support and eradicating the bacterial infection (macrolides, such as erythromycin, are the drug of choice). Fluids are encouraged to help thin secretions. Monitoring heart rate and oxygen saturation, especially during coughing paroxysms, is indicated.

A nursing student asks the licensed practical nurse (LPN) to explain the forces that drive health care reform. When responding to the student's question, what information should the nurse emphasize?

Increase in health care spending that's growing faster than the economy- One of the most significant reasons for health reform is the need to control costs. Health care spending continues to grow at a faster rate than the economy. Other reasons contributing to increased health care spending includes a decrease in the number of people with health care insurance and decreased competition in both insurer and provider markets. End-of-life care is expensive, but it is too narrow a focus to be the correct response.

A nurse is caring for a client admitted with the diagnosis of suspected Legionnaire's disease. Which finding would require the nurse's immediate attention?

Increased use of accessory muscles of breathing

A 6 year-old child is hospitalized with findings of moderate edema, gross hematuria and mild hypertension associated with the diagnosis of acute glomerulonephritis (AGN). Which nursing intervention would be appropriate for this client?

Institute seizure precautions- If AGN is untreated, renal failure, seizures and heart failure may result. Clients with AGN should restrict salt intake during the acute phase to control edema and volume-related hypertension. A protein-restricted diet may also be indicated. Underlying infections would be treated with antibiotics. Nursing care would include frequent monitoring of blood pressure, daily weights, intake and output, and seizure precautions.

The client with coronary artery disease has a prescription for nitroglycerin transdermal patches. What is the best reason the client should not wear a patch for more than 12 to 14 hours each day?

It may no longer work as well

A client is admitted with newly diagnosed hypothyroidism. A nurse would expect the client to exhibit which finding until the client achieves a euthyroid state with therapy?

Lethargy- Euthyroid is the state of having normal thyroid gland function. Hypothyroidism produces manifestations of a slowed metabolism, including lethargy. Heat intolerance, diarrhea and tachycardia are manifestations of increased metabolism, hyperthyroidism. The key words in this question are "hypothyroidism" and "antated findings." As you read each answer option, ask yourself if it sounds like a "hypo" function of the body - only one option is related to "slowing down."

A young adult seeks treatment in an outpatient mental health center. The client tells a nurse, "I am a government official and spies are following me." Upon further questioning, the client reveals that warnings must be heeded to prevent nuclear war. What is the initial therapeutic approach that the nurse should use?

Listen quietly without comment- The client's comments demonstrate grandiose ideas. The most therapeutic response is to listen and avoid being drawn into the delusions. Security should be contacted if a client with delusions of grandeur poses a threat to the nurse or to other health care team members.

The nurse is caring for a client who is experiencing a panic attack. Which action would be the nurse's primary intervention for the client?

Maintain safety for the client

The nurse is collecting data on a group of clients in a long-term health care facility. Which client is at a highest risk for the development of pressure ulcers?

Malnourished older adult client who is on bed rest

The client is diagnosed with heart failure and oral digoxin is prescribed. What is the priority nursing assessment for this medication?

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

The client has an order for intermittent gastrostomy tube (G-tube) feedings. What is the priority action by the nurse to accurately assess correct placement of the G-tube?

Measure the pH of stomach content aspirate

A client has an indwelling catheter with continuous bladder irrigation after undergoing a transurethral resection of the prostate (TURP) 12 hours ago. Which finding at this time should be reported to the registered nurse (RN) charge nurse?

Minimal drainage into the urinary collection bag- The LPN should report minimal drainage in the urinary collection bag because this puts the client at risk for bladder rupture. The flow rate of the continuous irrigation would need to be slowed until the health care provider is notified. If an order to irrigate the system is written, sterile technique would be used. The other options are all expected findings after this procedure Incorrect

A hospitalized infant is receiving gentamicin. Which nursing intervention should receive priority in the plan of care?

Monitor the infant's urine output- Toxicity from aminoglycoside results in increased serum creatinine levels. Decreased urine output is one of the first findings of nephrotoxicity and renal failure. You will note that two of the options focus on "output." Remember that a priority intervention typically begins with data gathering; the word "monitor" is a "data collecting" word.

A client has completed a renal biopsy. Which nursing intervention is appropriate after a renal biopsy?

Monitor vital signs using post-op protocols- The potential complication of this procedure is internal hemorrhage. Monitoring vital signs is critical to detect early indications of bleeding. The dressing should have no drainage, nor should it become saturated. No reason exists to keep the client NPO for 24 hours or to walk within four hours.

A 14 month-old child ingests a half a bottle of baby aspirin (81 mg) tablets. Which finding should a nurse expect to see in the child?

Nausea and vomiting- Some of the earliest signs of salicylate toxicity include nausea, vomiting, diaphoresis and tinnitus. Other findings include hyperventilation, tachycardia and hyperactivity. As toxicity progresses, there may be agitation, delirium, hallucinations, convulsions, lethargy and stupor. With the large ingestion of the aspirin, which is an acid, the temperature may rise from the severe acidosis that increases metabolic rate. Hyperventilation may be present from the attempt of the body to rid the acid via carbon dioxide.

An 80 year-old client is hospitalized for a chronic condition. The client informs family members that a living will has been prepared and the client wants no life-prolonging measures performed. The client's condition deteriorates and the client becomes unresponsive. Which of the following nursing actions is most appropriate?

Notify the attending physician- Lithium is a fast-acting mood stabilizer and quite effective in controlling mania soon after starting the medication. But it may take several weeks for it to reach maximum effectiveness.

The nurse is caring for a postoperative client following a closed reduction of distal tibia and mid-femur fractures. The client has a long leg plaster cast. Thirty-six hours after surgery, the client suddenly becomes confused, short of breath and spikes a temperature of 103 F (39.4 C). What should be the first action by the nurse?

Obtain the pulse oximetry reading

A nurse is caring for a client with a sigmoid colostomy. The client requests assistance in removing the flatus from a one-piece drainable ostomy pouch. Which intervention should the nurse use?

Open the bottom of the pouch to allow the flatus to be expelled

When a client returns from surgery after an open reduction with cast application for a femur fracture, a small blood stain is noted on the cast by the nurse. Four hours later, the nurse observes that the stain has doubled in size. What is the initial action for the nurse to take at this time?

Outline the spot with a pen and note the time and date on the cast- Marking the outline of the drainage is a good way to assess the amount of bleeding over a period of time. The bleeding does not appear to be excessive; some bleeding is expected with open reduction surgeries. The nurse should inform the RN and then record the finding.

A nurse is assigned to care for a 10 month-old infant with the new diagnosis of anemia. Which of these findings should the nurse anticipate?

Pale mucosa inside the mouth- In iron-deficiency anemia, the physical exam reveals a pale, tired-appearing child with mild to severe tachycardia. The skin may have a waxy appearance. Anemia that is severe can cause a lack oxygen to the body, causing the skin color to become an ashen, dusky gray instead of the classic skin color of cyanosis with oxygen deficiency. The hemoglobin level would be low rather than high in anemia.

A nurse is monitoring the client's initial postoperative condition after a total thyroidectomy. Which findings should the nurse expect as complications and report immediately to the registered nurse (RN)?

Paresthesia and muscle cramping- Because the parathyroid gland may be damaged in this surgery, secondary acute hypocalcemia may occur. Findings of hypoparathyroidism include tetany, paresthesia, muscle cramps and seizures. Mild dysphagia and hoarseness is an expected postoperative finding and may last for six to eight weeks after surgery.

The client is diagnosed with asthma. What information should the nurse reinforce that the client should monitor on a daily basis?

Peak air flow volume

A 3 year-old child is brought to the health clinic. The grandmother reports that the child is always "scratching his bottom" and is "extremely irritable." Based on this information, which health issue would the nurse assess for initially?

Pinworm- Findings of pinworm infection include intense perianal itching. The itching is usually worse at night, which is why the child will also exhibit poor sleep patterns, general irritability, restlessness, bedwetting, distractibility and a short attention span. The eggs will stick to a piece of clear cellophane tape placed against the rectum and the eggs can be seen under a microscope. The nurse can also take some samples from under the child's fingernails to look for eggs. Recall tip: the "P in worms" are found where the "pooh" comes out - the anal/rectal area. Scabies is an itchy skin condition caused by a tiny mite that burrows under the skin, causing small, itchy bumps or blisters; the most commonly affected areas of the body are the hands and feet. Ringworm is a fungus with characteristic round, itchy irritations on the skin.

A school nurse monitors a child with a history of tonic-clonic seizures. The school nurse should inform teachers that if the child falls to the floor and experiences a seizure while in the classroom, which of the following would be the most important action to take during the seizure?

Place the hands or a folded blanket under the head of the child

A client diagnosed with autism begins to eat with both hands. The nurse can best handle the behavior by using which approach?

Placing the spoon in the client's hand and stating "Use the spoon to eat your food."- By placing the spoon in the client's hand while giving basic instructions to the client identifies a need for adaptive behavior with instruction and a verbal expectation. This response is the most client-centered and therapeutic for the autistic child. Punitive responses should always be eliminated ("I believe you know better than to eat with your hands" and "You can't have any more food until...").

A Native American chief visits his newborn son and performs a traditional ceremony that involves feathers and chanting. The nurse comments to a colleague: "I wonder if he has any idea how ridiculous he looks - he's a grown man!" The nurse's comment is an example of what type of attitude?

Prejudice- Prejudice is a hostile attitude toward individuals simply because they belong to a particular group presumed to have objectionable qualities. Prejudice refers to preconceived ideas, beliefs or opinions about an individual, group or culture that limit a full and accurate understanding of the individual, culture, gender, race, event or situation. If you are not sure of the correct answer, look at the words in quotation in the question and ask yourself: Does this nurse's statement sound like discrimination (a behavior or action) or prejudice (attitude)?

The nurse is caring for a postmature infant in the newborn nursery. What factor should the nurse recognize as being the primary reason associated with complications of being post-term?

Progressive placental insufficiency- A post-term pregnancy is defined as extending 42 weeks and beyond. The placenta functions less efficiently as pregnancy continues beyond 42 weeks. If the fetus does not receive adequate nutrition, it will utilize its subcutaneous fat stores for energy. Consequently, post-term infants are susceptible to hypoglycemia because of the rapid use of glycogen stores. Also, the risk of meconium aspiration and umbilical cord compression increases past 41 weeks, predisposing the newborn to hypoxia. Chronic intrauterine hypoxia causes increased fetal erythropoietin and red blood cell production, resulting in polycythemia.

A nurse discusses the healthy use of both conscious and unconscious defense mechanisms with a group of clients. An appropriate goal for these clients would be to use these mechanisms for which purpose?

Protect the ego and diminish anxiety- Ego defense mechanisms are unconscious proactive barriers that are used to manage instinct and affect the presence of stressful situations. Healthy reactions that use both types of defense mechanisms are those in which clients admit that they are feeling various emotions.

A newborn has hyperbilirubinemia and is being treated with a biliblanket. Which intervention is indicated during this therapy?

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

A client is admitted to the mental health inpatient unit with a diagnosis of major depression after a suicide attempt. In addition to expressions of sadness and hopelessness, the nurse anticipates observing which characteristics?

Psychomotor retardation, agitation- Somatic or physiologic findings of depression include fatigue, psychomotor retardation or psychomotor agitation, chronic generalized or local pain, sleep disturbances, disturbances in appetite, gastrointestinal complaints and impaired libido. Notice the data given in the stem relates to feelings and the question is asking: what findings other than feelings might be observed? Because two of the options deal with feelings or emotions, these can be eliminated. Compare the remaining options and determine which behavior is most likely to occur with a diagnosis of depression - attention to grooming and hygiene or psychomotor retardation and agitation.

The family member tells an admitting nurse that the client values the practice of Chinese medicine. The nurse must understand that for this family and client a priority goal should take which focus?

Restore yin and yang- For followers of Chinese medicine, health is maintained through balance between the forces of yin and yang. The key here is the term "Chinese medicine." The word "restore" in correct option can be associated with the word "medicine" in the stem because medicine restores function.

A nurse is caring for a client with pneumococcal pneumonia. Which breath sounds would the nurse expect to disappear as the client responds to the antibiotic treatment?

Rhonchi- Pneumonia causes a marked increase in interstitial and alveolar fluid, producing secretions in the airway, or discolored sputum. Rhonchi are low-pitched, snore-like sounds caused by airway secretions. These abnormal sounds occur in pneumonia and, as the illness subsides, they should disappear, demonstrating the effectiveness of the antibiotic therapy. Friction rubs, diminished sounds, and wheezes are not typically associated with pneumonia. If the lung sounds and other findings were not improving or were getting worse after two to three days of antibiotic therapy, the provider should be notified, as an alternative antibiotic may be needed to treat the organism responsible for the infection.

A mother asks about expected motor skills for her 3 year-old child. Which activity should the nurse discuss as normal at this age?

Riding a tricycle- Coordination is gained through large muscle use. A 3 year-old child has the ability to ride a tricycle, hop and stand on one foot. The other activities would more typically be found in preschoolers.

A nurse is caring for a woman two hours after a vaginal delivery. Documentation indicates that the membranes ruptured 36 hours prior to delivery. Which of these nursing diagnoses should the nurse expect the charge nurse to list as a priority at this time?

Risk for infection

The nurse is caring for a client who has just been admitted to the inpatient mental health unit with severe depression. Which concern should be a priority of care?

Safety

A pregnant woman in the third trimester reports having severe heartburn. What action should a nurse remind the client to take?

Sleep with head propped on several pillows

A child has severe burns to the lower extremities. A diet high in protein and carbohydrates is recommended. The nurse should care for this client with the knowledge that the most important reason for such a diet is to achieve which result?

Spare protein catabolism to meet metabolic and healing needs- Because of the severe burn injury, the child has an increased metabolism and catabolism. By providing a high-carbohydrate diet, the breakdown of protein for energy is avoided. Proteins are then used to restore and aid in the healing of tissues. Notice that the correct response includes a word used in the question ("protein").

The LPN is assisting the RN to provide care for a client diagnosed with a traumatic brain injury. Using the Glasgow Coma Scale, when the client does not obey verbal commands to move, which technique will the RN use to evaluate motor function?

Squeeze the trapezius muscle firmly- If there is no spontaneous movement and the client does not obey verbal commands to move, the RN can provide central pain stimulation to assess motor function. The trapezius pinch is the preferred method. If there is no response to the trapezius pinch, and there are no facial fractures, the nurse can then apply pressure to the supraorbital notch to elicit a response. Using the Glasgow Coma Scale, the client's response on the motor scale is scored from 1 (no movement) to 6 (obeys 2-part verbal request). Rubbing the sternum with the knuckles is no longer used since it can easily bruise the soft tissue. Observing for pronation and drift is used in neurologic assessments to detect subtle arm movement in clients who can obey commands.

The client is diagnosed with infective endocarditis of the tricuspid valve. Which finding suggests a complication of this condition?

Sudden dyspnea- For the client with infective endocarditis, vegetation growing on the infected heart valves on the right side of the heart can break off and travel in the blood to lodge in a blood vessel in the lung. This is known as pulmonary embolism (PE). A significant piece of evidence of this is sudden dyspnea, as well as a sudden decrease in oxygen saturation. The breath sounds associated most with PEs are diminished or absent, not pronounced. A spike in temperature is more commonly from bacterial pneumonia, urinary tract infection, or otitis media than PE. Vegetation from the infected heart valves on the left side of the heart would lead to the complication of cerebral infarction or finding of a stroke, or ischemia of other peripheral blood vessels.

The client is prescribed alendronate (Fosamax). What information about medication administration should the nurse be sure to reinforce?

Take on an empty stomach- Fosamax should be taken first thing in the morning, with a full glass of water, and at least 30 minutes before other medication or food. Fosamax, a bone reabsorption inhibitor, is used for postmenopausal bone thinning osteoporosis and to treat Paget's disease. Clients should remain in an upright position for at least an hour after taking this medication.

The LPN is unsure about an assignment by the charge nurse to hang an intravenous (IV) infusion that contains potassium. What resource should the LPN check first to determine if LPNs can administer IV medications?

The nurse practice act of the state in which the practice takes place

The nurse is discussing an illness with a 10 year-old child. What should the nurse keep in mind about this child's ability to understand the information at this stage of development?

Thinks logically to organize facts- According to Piaget, the child is in the concrete operational stage and is capable of mature thought when allowed to manipulate and organize objects or thoughts. School-age children tend to focus on "rules," which helps to organize facts. The other options are either too advanced or not advanced enough.

A client has chronic renal failure and is being treated at home. During weekly home visits, which factor is the most accurate indicator of fluid balance?

Trends in daily weights

The nurse is caring for a postoperative client. What is the priority nursing intervention the nurse will reinforce for preventing atelectasis?

Turn, cough and breathe deeply

The nurse is reviewing the history of a pregnant woman. Which factor should the nurse recognize as a priority contraindication for breastfeeding?

Uses cocaine on weekends

A nurse is talking to parents about the side effects of routine immunizations. Which finding should the nurse reinforce about calling the health care provider if it occurs within 24 to 48 hours after a routine immunization?

Tympanic temperature of 104 F (40 C)- Another adverse reaction to report is inconsolable crying (sustained crying for more than three hours).

In checking a postpartum client, the nurse palpates a firm fundus. However, the nurse also observes a constant trickle of bright red blood from the vaginal opening. What should the nurse suspect?

Vaginal lacerations- Continuous bleeding in the absence of a boggy fundus indicates undetected vaginal tract lacerations. If you are not sure about the correct response, re-read the responses and you should note that three of the (incorrect) options would result in excessive bleeding, and not a "trickle."

A nurse is taking a health history from parents of a child admitted with possible Reye's syndrome. Which recent illness should the nurse recognize as being associated with an increased the risk for the development of Reye's syndrome?

Varicella- Varicella (chicken pox), influenza and the cold virus are viral illnesses that have been identified as increasing the risk for Reye's syndrome in children, particularly when aspirin has been used. Rubeola, meningitis, and hepatitis are not recognized as precursors to Reye's syndrome. The combination of a viral infection and the administration of aspirin to children from birth to 19 years of age can result in the development of Reye's syndrome; therefore, aspirin should be avoided during these ages.

A nurse is discussing with a client the precautions with warfarin. The nurse should tell the client to avoid foods with excessive amounts of what substance?

Vitamin K- Eating foods with excessive amounts of vitamin K (often contained in green leafy vegetables) may affect anticoagulant effects.

A client is diagnosed with a Salmonella infection. What is a primary nursing intervention to be taken to minimize the transmission of disease from this client?

Wash hands thoroughly before and after any client contact

A nurse is caring for a client diagnosed with obesity and osteoarthritis of the knees. During reinforcement of the teaching given by the registered nurse (RN), the practical nurse (PN) should know that which health practice should have the greatest benefit on the client's outcome?

Weight reduction- A major contributor to the development of osteoarthritis is excess body weight, due to the ongoing stress placed on joints. Weight reduction can play a key role in promoting the client's long-term health and mobility. Leg elevation is not indicated in osteoarthritis of knees. Joint braces are not a treatment for osteoarthritis. Anti-inflammatory medications play a role in reducing inflammation and pain, but they will not address the cause of the problem.

The nurse is giving a morning bath to a client who has a colostomy. While giving the bath, the nurse should reinforce that the collection pouch should be emptied at what time?

When it is one-third to one-half full

The nurse is caring for a client who is one-day postoperative with a T-tube following a cholecystectomy. What color would the nurse expect the drainage from the client's T-tube to be?

Yellowish-brown- Bile, which is yellowish-brown, is the expected drainage from a T-tube. Green is characteristic of normal gastric secretions.