QUESTION BANKS 31-45

lab value for PT INR??

.9-1.2 CRITICAL IF OVER 5!!!

The nurse collects data on several postpartum women in the clinic. Which woman is at highest risk for PUERPERAL INFECTION?

3 DAYS POSTPARTUM TEMP IS 100.8 F(38.2C) PAST TWO DAYS A temperature of 100.4 F (38 C) or higher on two successive days, not counting the initial 24 hours after birth, indicates a postpartum infection. The other women are not at risk for infection because their temperatures are within the expected normal findings for the time period.

The nurse works in a well-child clinic and examines many children every day. Which toddler requires further follow up?

30 MONTH OLD DRINKING ONLY FROM A SIPPY CUP A 30 month-old should be able to drink from a cup without a cover. The key to this question is to recognize that the question being asked is about what would be abnormal for a toddler ("what would require follow-up"). Read the answer options carefully and ask after each option: Is this normal for a toddler?

The charge nurse is making client room assignments. In order to minimize the risk of a hospital acquired infection, which of these children would be the most appropriate roommate for a 3 year-old diagnosed with minimal change disease?

5 YR OLD WITH BILATERAL INGUINAL HERNIA REPAIR Minimal change disease is a KIDNEY DISORDER that can lead to nephrotic syndrome. Corticosteroids can cure the disease in most children but cytotoxic therapy and other drugs may be needed, but this treatment can reduce the child's ability to fight infection. The charge nurse must select a roommate who does not have an infection, which is the child who just had surgery.

A primigravida's membranes spontaneously rupture and her vital signs are: T 99.8 F (37.6 C), P 84, R 20, BP 130/78, and fetal heart tones 148 beats/min. Four hours later the LPN reassesses the vital signs and FHT. Which finding should the licensed practical nurse immediately report to the registered nurse?

A FHR OF 168 BPM An increase in FHT may indicate fetal compromise, possibly due to the beginning of a maternal infection. The other assessment findings are within normal parameters.

WHAT IS MINIMAL CHANGE DISEASE?

A KIDNEY DISORDER THAT CAN LEAD TO NEPHROTIC SYNDROME CORTICOSTEROIDS CAN CURE THE DISEASE FOR most kids but can reduce ability to fight off infection ( STAY AWAY FROM PPL INFECTED!!)

The nurse is reinforcing information to a 10 year-old child who will be undergoing heart surgery. Which approach would be best for the nurse to use?

A MODEL OF THE HEART TO EXPLAIN THE SURGERY The nurse is reinforcing information to a 10 year-old child who will be undergoing heart surgery. Which approach would be best for the nurse to use?

What should the nurse remember about the reason why toddlers have a tendency to say "no" to almost everything?

ASSERTION OF CONTROL NEGATIVISM is a normal behavior in toddlers. The nurse must be aware that this behavior is an important sign of the child's progress from dependency to autonomy and independence.

A nurse is preparing to perform parts of a physical examination on an 8 month-old infant who is sitting contentedly on the mother's lap. Which action should the nurse perform first?

AUSCULTATE THE LUNG SOUNDS The nurse should auscultate the lung sounds during the first quiet moment with the infant in order to hear the sounds clearly. Other actions may follow in any order.

A client with moderate persistent asthma is admitted for a minor surgical procedure. On admission, the peak flow meter is measured at 480 liters/minute. Postoperatively the client is reports having chest tightness. The peak flow is now 200 liters/minute. What should the nurse do first?

ADMINISTER THE PRN DOSE OF ALBUTEROL Peak flow monitoring during exacerbations of asthma is recommended for clients with moderate-to-severe persistent asthma. This will help determine the severity of the exacerbation and guide the treatment. A peak flow reading of less than 50% of the client's baseline reading is a medical alert condition and a SHORT ACTING BETA AGONIST (such as albuterol) should be taken immediately.

The parents of a 7 year-old client tell the nurse their child has started to "tattle" on siblings. The nurse should respond with the knowledge that children of this age group act in this manner for what reason?

AN ETHICAL SENSE AND FEELINGS OF JUSTICE ARE EXPECTED DEVELOPMENTAL PROCESSES The child is developing a SENSE OF JUSTICE and a desire to do what is right. At 7 years old, children are increasingly AWARE OF FAMILY ROLES AND RESPONSIBILITIES. They also do what is right because of parental direction or to avoid punishment.

The client is an asthmatic who has recently developed gastroesophageal reflux disease (GERD). Which prescribed medication may aggravate GERD?

ANTICHOLINERGICS An anticholinergic medication will DEACREASE GASTRIC EMPTYING BY DEACREASING PERASTALSIS. It also relaxes the lower esophageal sphincter, which allows acid to "reflux" into the esophagus. Because the content of this question is GERD, and not asthma, corticosteroids and histamine blockers can be eliminated right away. There is nothing in the question that would indicate the need for an antibiotic.

A very active toddler pulls out a tunneled central venous catheter. What initial nursing intervention is appropriate?

APPLY PRESSURE TO THE INSERTION SITE inTO THE VEIN If a central venous catheter is accidentally removed, pressure should be applied to the vein entry site. You will note that the correct option is the only one that contains the word "vein," which is related to the content of the question about pulling out a central "venous" catheter. Also, regardless of the type of intravenous catheter, pulling out an IV always means that there will be bleeding.

A nurse is caring for a 75 year-old client diagnosed with colorectal cancer. Because the client's pain is no longer being controlled with a non-opioid analgesic, the health care provider has ordered a narcotic analgesic. What should the nurse recognize about the appropriateness of the order?

APPROPRIATE PAIN MANAGEMENT AROUND THE CLOCK Older adult clients with cancer pain are frequently under-medicated. Ordering an opioid analgesic to manage cancer pain is appropriate and should be offered around-the-clock. The importance of assessing and treating pain appropriately is critical for anyone experiencing pain.

A client, diagnosed with active tuberculosis (TB), has a history of medication noncompliance. Which action by the nurse indicates an understanding of the appropriate care needed for this client?

ASK A FEMILY MEMBER TO SUPERVISE DAILY MEDICATION COMPLIANCE Direct-observed therapy is a recognized method for ensuring client compliance to any medication regimen. The program can be set up to directly observe the client taking the medication in the clinic, home, workplace or other convenient location. Notice the word "compliance" the correct option, which matches the content in the question. Remember that contacting a health care provider would not normally be considered a correct option unless the information in the question is life-threatening, potentially life-threatening, or if a health care provider's order is needed.

A 75 year-old Catholic Latino client with prostate cancer adamantly refuses pain medication because of the belief that "suffering is part of life" and that life is in God's hands. What action should the nurse take in response to this situation?

ASK IF THE PT WOULD LIKE TO SPEAK TO A PRIEST Beliefs regarding pain are one of the oldest culturally related research areas in health care. Astute observations and careful assessments must be completed to determine the level of pain a person can tolerate. Health care practitioners must investigate the meaning of pain to each person within a cultural explanatory framework. Associate the option using the word "priest" with the words in the stem of the question (Catholic and in God's hand). Also note that this is the only response that is most directly associated with the problem - life.

An 80 year-old client with prostate cancer rates his pain as a 6, using a 10-point scale. The client refuses all pain medication other than ibuprofen (Motrin), which does not relieve the pain. What approach should the nurse take?

ASK THE PT FOR MORE INFO ABOUT THE REFUSAL Astute observations and careful assessments must be completed to determine the level of pain a person can tolerate. Health care practitioners must investigate the meaning of pain with each person. Remember, when asked for the action of the nurse, think "data collection." Only one option involves data collection ("ask for more information"). You can eliminate the one option where the information source is the family and not the client. The other two options are interventions, not data collection.

There is an order to discontinue the client's nasogastric (NG) tube. The nurse should take which action when removing the NG tube?

ASK THE PT TO HOLD THEIR BREATH Holding the breath closes the epiglottis, which will help prevent aspiration. When inserting the NG tube it may advance easier if the client swallows sips of water during the process. Emptying the tube by suction does not prevent aspiration and suction will irritate the mucosa if left on during removal. There should be no need for the crash cart.

The nurse is reinforcing discharge teaching to a client with asthma. During the discussion, a warning should be given about the use of which over-the-counter medication?

ASPIRIN PRODUCTS FOR PAIN RELIEF Aspirin is known to induce asthma attacks and can also cause nasal polyps and rhinitis. Notice that two of the (incorrect) options are respiratory answers; these are the distractors. Now, left with two responses, you should ask yourself if an ointment or an oral medication creates a systemic response.

A client has an order for 1000 mL of D5W to run over an eight-hour period. The nurse discovers that 800 mL has been infused after only four hours. What is the priority nursing action at this time?

AUSCULTATE THE LUNGS All of the options are correct actions and would be part of the treatment plan following too rapid administration of a large amount of fluid. However, the most serious consequence could be heart failure with lung congestion, which makes auscultation of the lungs the priority action. The sequence of actions would be: auscultate the lungs, ask the client about breathing problems, check vital signs, encourage the client to void as much/as often as possible, and then notify the charge nurse.

LAB VALUES FOR aPTT ??

Aptt-25-35 secs PARTIAL THROMBOPLASTIN TIME CRITICAL IF OVER 60 (>60)

The nurse is preparing to administer diltiazem (Cardizem) to a client. Which data should the nurse collect prior to giving the medication?

BLOOD PRESSURE Diltiazem (Cardizem) is a calcium channel blocker that causes systemic vasodilation, resulting in decreased blood pressure. Clients will need the BP checked lying and standing for postural (or orthostatic) hypotension. A drop of 20 mm Hg or more systolic upon standing requires the nurse to hold the medication and notify the registered nurse (RN).

A client takes digoxin (Lanoxin) for heart failure. A nurse should report which side effects to the charge nurse?

BRADYCARDIA / HYPOTENSION Bradycardia, low blood pressure, and other arrhythmias can be life threatening and must be reported immediately.

A client with multiple sclerosis plans to begin an exercise program. In addition to discussing the benefits of regular exercise, the nurse should caution the client to avoid activities that have which effect?

CAN CAUSE DEHYDRATION The client must take in adequate fluids before and during exercise periods to prevent dehydration. Dehydration stresses the body, which can contribute to MS symptoms. An increase in heart rate is normal during exercise. Exercise is naturally aerobic. Competitive exercise such as tennis is not contraindicated as long as the client does not become dehydrated. The correct option is the only answer that would not be a benefit of regular exercise.

The nurse is preparing to administer an enteral feeding to a client via a nasogastric feeding tube. What should the initial action of the nurse be?

CHECK THAT THE FEEDING SOLUTION MATCHES THE ORDER Tube feedings are similar to medications and verification of correct feeding is the first action. The other options are correct and should be done prior to starting the feeding solution. Take care when answering questions like this. Because this is a priority question (which means all responses are probably correct), you need to focus on the correct sequence of actions. Recall that gathering data is the first step in the care giving process and then ask yourself if the correct solution or correct temperature of the solution is more important.

The nurse is caring for a child diagnosed with Reye's syndrome. The nurse should give which of these interventions the highest priority?

CHECK THE LEVEL OF CONCIOUSNESS Decreased level of consciousness suggests increased intracranial pressure related to cerebral edema and encephalopathy.

A client is admitted to an inpatient mental health unit for SEVERE DEPRESSSION. After several days, the client continues to withdraw from staff and other clients. In order to promote interaction with other clients, which statement by the nurse would be most appropriate?

COME PLAY CHINESE CHECKERS WITH GLORIA AND ME Requesting the client to engage in an simple activity with the nurse and with one other client will assist the client to gradually engage in interactions with others. This activity also allows the nurse to directly observe the interaction between the client and another person in a positive, less stressful manner.

A client who reports drinking for many years states: "I drink when I get upset about things, such as being unemployed or feeling like life is not leading anywhere." What does the nurse understand about the reasons why this client is using alcohol?

COPE WITH LIFES STRESSORS When people are under stress, particularly for an extended period of time, they tend to exhibit more unhealthy behaviors than people who report being less stressed. Alcohol is often used by some people to manage anxiety and stress. The overall intent of this behavior is to decrease the negative and increase the positive feelings.

The nurse suspects that the client is in cardiogenic shock. Which of the following findings supports this information?

DECREASED OR MUFFFLED HEART SOIUNDS Cardiogenic shock involves DECREASED CARDIAC OUTPUT and evidence of tissue hypoxia in the presence of adequate intravascular volume; it is the leading cause of death in acute MI. Findings of cardiogenic shock include hypotension, rapid and faint peripheral pulses, distant-sounding heart sounds, cool and mottled skin, oliguria and altered mental status.

A 15 year-old client is diagnosed with a lengthy confining illness. This client is at risk for altered growth and development related to which issue?

DEPENDANCE The client role in any long-term illness fosters dependency. Adolescents may react to dependency with rejection, uncooperativeness or withdrawal. Notice that two of the options are the only "developmental options" given (dependence and lack of trust). Decide on which option is more closely related to adolescence. According to Erikson, infancy is when a person learns about trust and mistrust. The major developmental stage in adolescence is identify versus role confusion.

The nurse is preparing to insert an indwelling urinary catheter into a male client. What is the purpose of lubricating the tip of the catheter prior to insertion?

DIMINISH FRICTION Lubrication diminishes friction and eases insertion. Due to the nature of the male urethra, lubrication also reduces potential trauma to the mucosa.

A client has developed a DEEP VEIN THROMBOSIS(DVT) of the left leg. Which intervention on the plan of care should be given the highest priority?

ELEVATE THE LEG ON TWO PILLOWS The first goal of non-pharmacologic interventions in DVT is to minimize edema and venous stasis of the affected extremity by leg elevation. Support stockings are used for prevention of venous thrombosis, not treatment. Clients may be able to go to the bathroom or use a bedside commode, but this is not the highest priority. Warm compresses will enhance arterial circulation to the site and provide comfort, but the problem is with venous circulation.

A male client with benign prostatic hypertrophy is admitted with a distended bladder due to acute urinary retention. There is an order to insert an indwelling urinary catheter (IUC). What should the nurse understand about catheter insertion and care for this client?

EMPTY THE BLADDER QUICKLY AND COMPLETELY With acute urinary retention, treatment begins with catheterization. It's best to use the smallest catheter size (14 to 16 Fr); a coude-tipped catheter is often used in men with an enlarged prostate or urethral stricture. Evidence-based practice supports complete and rapid emptying of the bladder. The client may need to have an IUC for several days. Bladder irrigation is performed to maintain patency of a retention catheter by removing sediment or clots, usually following a surgical procedure involving the urinary system.

The nurse is providing care for an 18 month-old toddler. What information should be used when assisting with developing the care plan for this child?

ENCOURAGE THE HILD TO EAT FINGER FOODSAccording to Erikson, the toddler is in the stage of autonomy versus shame and doubt. The nurse should encourage increasingly independent activities of daily living, especially feeding and dressing self. It is unsafe to allow the toddler to walk on the unit. Holding and cuddling is more appropriate for infants. Playing games with other children would be associated with the developmental stage of the school-aged child.

The nurse checks a client diagnosed with chronic obstructive pulmonary disease (COPD). The client is using oxygen per nasal cannula. Which action would be a priority for the nurse?

EVALUATE SA02 LEVELS The best method for the nurse to use in evaluating a client's oxygenation is to evaluate the SaO2 using a pulse oximeter. This is an effective alternative to arterial blood gases to evaluate the oxygenation; it is also less traumatic and less expensive.

The nurse recognizes fluid sounds during the auscultation of a client's lung. What is the best way to document these sounds?

LOW PITCHED AND RUMBLING Crackles, which indicate moisture or fluid in the lung, are described as discontinuous, low-pitched rumbling sounds that are hyper-resonant. They are more commonly heard during inspiration.

A client admitted with a diagnosis of a fractured tibia has been placed in skeletal traction. Which nursing intervention on the plan of care should receive priority?

FREQUENT NEUROVASCULAR CHECKS OF THE AFFECTED LEG The most important activity for the nurse is to assess neurovascular status at this time. Compartment syndrome, compression of the nerves and vessels from swelling, is a serious complication that occurs from trauma such as a car accident or crush injury or surgery. Prompt recognition of this neurovascular problem and early intervention may prevent permanent limb damage. The other options are correct but the priority intervention is regular neurovascular assessment.

"Dry and grating" would best describe a ?? either of the pericardial sac or the pleural lining.

FRICTION RUB

A 15 year-old client recently attempted suicide. When discussing suicide prevention with the parents, what behavioral cue or signal should the nurse be sure to include in the discussion?

GIVING AWAY VALUED PERSONAL ITEMS Eighty percent of all potential suicide victims give some type of clue or signal with behavior and verbal actions. Common behavioral cues to suicide include a change in behavior (increased withdrawal or isolation from friends and family, giving away prized possessions), multiple physical complaints or self-destructive behaviors. These clues might lead one to suspect that a client is having suicidal thoughts and/or is developing a plan.

A client diagnosed with bipolar disorder has been taking lithium (Eskalith, Lithobid) for the past two weeks. During a regularly scheduled appointment, what information should the nurse reinforce with the client?

HAVE THE SERUM LITHIUM LEVELS DRAWN MORE FREQUENTLY DURING THE SUMMER MONTHS When lithium is first prescribed, there are frequent blood tests to measure and monitor the amount of lithium in the blood. But once the therapeutic range has been achieved, then lithium can be monitored at regular intervals (and not necessarily every one to three months). Clients taking lithium NEED TO BE AWARE THAT HOT WEATHER MAY CAUSE EXCESSIVE PERSPIRATION, LOSS OF NA, AND CONSEQUENTLY AND INCREASE INN SERUM LITHIUM CONCENTRATION THEREFORE MORE FREQUENT BLOOD TESTS TAKEN DURING SUMMER MONTHS . Lithium should be taken WITH FOOD and nto to change the intake of sodium

The nurse is assisting in the discharge of a 68 year-old male client diagnosed with benign prostatic hypertrophy (BPH). Which statement by the client demonstrates an understanding of this condition?

I WILL CONTINUE TO URINATE FREELY Clients with benign prostatic hypertrophy have overflow incontinence with frequent urination in small amounts day and night. Urination is not painful, just frequent, with difficulty initiating the flow of urine. The client should continue to drink plenty of fluids, not restrict fluids.

The nurse, in a direct observation unit, is caring for a client who is being diagnosed with a myocardial infarction (MI). It is noted that the hourly urinary output has dropped significantly. What observation should the nurse expect to make more frequently?

HEART RATE Following a MI, a significant decline in urine output indicates decreased cardiac output. This will be best observed by heart rate changes. With a drop in urine output, there is no expected change in body temperature. Compensatory rise in heart rate and respiratory rate are initial findings of acute heart failure (which is a complication of heart attack); a later finding is a drop in the systolic blood pressure. Notice that the correct response is the only "heart" answer. Associate "heart rate" with influencing "cardiac output" or "blood pressure." So heart rate would be first monitored more frequently to identify early changes. Remember, if cardiac output is low, urine output may also be low.

A hospitalized infant is receiving digoxin (Lanoxin) for the treatment of cardiac problems. Prior to administering the next dose of medication, the infant's parent reports that the baby has vomited once, just after the morning feeding. The heart rate is 94. What should be the initial response by the nurse?

HOLD THE MEDICATION Toxic side effects of digoxin include bradycardia, dysrhythmia, nausea, vomiting, poor feeding, dizziness, headache, weakness and fatigue. In infants and young children, only one episode of vomiting, associated with mealtime, does not usually warrant withholding the medication. However, bradycardia (normal rate in this age child is 120 - 160 BPM in the awake stage) is sufficient reason to hold the medication and notify the health care provider.

The nurse is working on a medical-surgical unit. The nurse understands that contact precautions, in addition to standard precautions, should be implemented for a client with which of these health concerns?

HSV -HERPES SIMPLEX VIRUS Contact precautions are required to protect against either DIRECT OR INDIRECT TRANSMISSION of an illness. Clients with the viral infection HSV should be placed on contact precautions UNTIL THE LESIONS HAVE CRUSTED OVER Mononucleosis and viral pneumonia require only standard precautions. Clients diagnosed with scarlet fever will be placed on droplet precautions for about 24 hours.

A 6 year-old child, who is diagnosed with acute glomerulonephritis, experiences anorexia, moderate edema and elevated blood urea nitrogen (BUN) levels. The child requests a peanut butter sandwich for lunch. What would be the nurse's best response to this request?

I KNOW THAT THAT IS YOUR FAVORITE BUT LET ME HELP YOU PICK A DIFFERENT LUNCH Consider the health condition of the child. If the child cannot have peanut butter, then look at the remaining options. Of those options, two of them give no choice to the child. Usually, the option that offers a choice for the client, no matter what age group, is more likely to be the correct answer.

Which action should a nurse recommend be included in a plan of care for clients diagnosed with schizophrenia and who are taking an antipsychotic medication?

LIMIT CALORIC AND FAT INTAKE TO MINIMIZE WEIGHT GAIN

The nurse is discussing with a new mother the proper techniques for breastfeeding an infant. Which statement made by the mother indicates incorrect information and the need for additional instruction?

I WILL GIVE THE BABY A PACIFIER IN BETWEEN NURSING Babies adapt more quickly to the breast when they aren't confused about what is put into their mouths and its purpose. Artificial nipples do not lengthen and compress the way the human nipples (areola) do.

A nurse is speaking with a woman who is planning a pregnancy. Which statement suggests that the client understands the connection between alcohol consumption and fetal alcohol syndrome?

IF I DRINK MYT BABY MAY BE HARMED BEFORE I EVEN KNOW THAT I AM PREGNANT Alcohol has the greatest teratogenic effect during organogenesis, which occurs within the first weeks of pregnancy. Therefore, women considering a pregnancy should not drink any alcoholic beverages. When comparing the options, you will note that three of the (incorrect) options indicate that it may be okay to drink under certain circumstances. The correct option states that alcohol consumption may harm a developing fetus.

The nurse is caring for a client diagnosed with a venous stasis ulcers on one leg. Which nursing intervention would be most effective to promote healing?

IMPROVE THE PTS NUTRITIONAL STATUS The goal of clinical management in a client diagnosed with venous stasis ulcers is to promote healing. This can only be accomplished with proper nutrition. The other interventions are appropriate, but without proper nutrition, they would be of little help. Venous ulcers take a long time to heal so proper nutritional therapy is the most important intervention.

A toddler is hospitalized with croup. Which finding indicates an early respiratory problem?

INABILITY OF THE FAMILY TO CALM THE CHILD If family members cannot calm a child, this may be indicative of escalating respiratory problems. Other subtle findings in toddlers include increased restlessness and increased respiratory effort. Remember, restlessness is one of the first findings of hypoxia, regardless of age. The other options are later findings of respiratory problems. When collecting data about a child with croup, the nurse should check for inspiratory stridor, retractions, air entry, cyanosis and level of consciousness.

According to Erikson, ? is when a person learns about trust and mistrust

INFANCY

A client who received chemotherapy through a central line is admitted to the hospital with a diagnosis of sepsis. Which nursing intervention should receive priority?

INSPECT ALL SITES THAT MAY SERVE AS ENTRY PORTS FOR BACTERIA Prompt recognition of the source of infection and subsequent initiation of therapy will reduce morbidity and mortality in sepsis. This should be the nurse's first action. Central line infections are common causes of sepsis that can be avoided through appropriate central line care. Pay attention to the word "priority" and remember that gathering data comes before any other action.

A client is receiving oxygen therapy via a nasal cannula. When providing nursing care, which intervention would be most appropriate?

INSPECT THE NARES AND EARS FOR SKIN BRAKEDOWN Oxygen therapy can cause drying of the nasal mucosa. Also, pressure from the tubing can cause skin irritation. When you read the answer options, you will notice that the only answer that addresses the nose is the correct response. Two of the other options address the cannula and not the client. There should be no mist with oxygen administration through a nasal cannula.

The nurse providing care in an assisted living facility is reviewing diet and nutrition. Due to age-related changes, the nurse knows that older adult clients should follow which of the following types of diets?

LOW FAT Due to age-related changes in body composition and physiology, and accompanying lifestyle, social, economic and medical condition, the diet of older clients should emphasize nutrient-dense foods. Older adults should eat a diet rich in fruits and vegetables, lean protein and vitamin B12, complex carbohydrates, whole grains and healthy fats. They should limit sodium and cholesterol intake.

A client who is diagnosed with pneumonia affecting two-thirds of the right lung is having difficulty bringing up secretions to clear the airway and has a low oxygen saturation level. What is the best position for a nurse to recommend to this client?

LYING ON THE LFT SIDE Positioning the client with the good lung down and the infected lung up is best in this situation. Gravity will draw the most blood flow to the dependent portion of the lung, the left lung, with an outcome of the best gas exchange for this client. This position also allows for the drainage of secretions from the affected right lung and will facilitate clearance of airway secretions, which will help the infection resolve more quickly.

The nurse is collecting data from a client, diagnosed with schizophrenia, who is being re-admitted to the mental health unit. The client's thought processes and behaviors have been managed for several months with fluphenazine (Prolixin). Which data should the nurse obtain first when taking the history?

MEDICATION COMPLIANCE Fluphenazine is a typical antipsychotic medication used to manage the findings associated with schizophrenia, including hallucinations, delusions and hostility. Compliance with daily doses is critical and requires initial investigation. The key words in this question are "re-admitted" and "schizophrenia

A nurse is caring for a newborn diagnosed with a neural tube defect (myelomeningocele). What would be the best covering for the lesion?

MOIST/ STERILE/ NON ADHESANT DRESSING

The nurse is participating in the plan of care for a school-aged child diagnosed with a vasoocclusive crisis of the elbow. Which intervention should be selected as the priority?

MONITOR THE PATIENCT CONTROLLED ANALGESIA (PCA) Vasoocclusive crisis involves SEVERE PAIN due to infarctions. It is an acute condition SEEN IN SICKLE CELL ANEMIA. Management of a crisis is directed towards supportive and symptomatic treatment; the priority of care is pain relief. In a school-aged child, patient controlled analgesia (PCA) promotes maximum comfort. Oxygenation and hydration would be the next focuses.

Following a thoracotomy, the client has two chest tubes connected to one chest drain. The nurse observes bubbling in the water seal chamber when the client coughs. What is the appropriate nursing action?

MONITOR TO SEE IF THE BUBBLING INCREASES Bubbling associated with coughing after lung surgery is to be expected as small amounts of air escape the pleural space when pressures inside the chest increase with coughing. Monitoring is the only nursing action required at this time.

The nurse is caring for a client who is on mechanical ventilation. What is the best evidence that the client needs endotracheal suctioning?

RHONCHI THROUHGHOUT THE LUNGS Rhonchi occur from mucous in the airways and suggests the need for suctioning

BREATH SOUNDS HEARD BILATERALLY: NORMAL OR ABNORMAL FOR A PT WITH AN ENDO TRACHE TUBE>

NORMAL

A toddler comes to the pediatric clinic after the sudden onset of these findings: irritability, thick muffled voice, croaking on inspiration, hot to touch, sitting leaning forward, tongue protruding, drooling and suprasternal retractions. What is the appropriate initial intervention by the nurse?

NOTIY THE HEALTH CARE PROVIDER OF THE CHILDS STATUS AND FEEDINGS These findings suggest a medical emergency related to EPIGLOTTIS. Immediate notification of the provider is indicated so that the child can receive emergency care to prevent complete airway obstruction. Any child with an acute onset of an inflammatory response in the mouth and throat should receive immediate attention in a facility equipped to perform intubation or a tracheostomy in the event of further or complete airway obstruction. If epiglottitis is suspected, the back of the throat should not be examined because laryngospasm may occur, followed by respiratory arrest.

A client experiences postpartum hemorrhage eight hours after the birth of twins. She is treated with IV fluids and whole blood and now her hemoglobin and hematocrit are within normal limits. The client asks if she should continue to breast-feed the twins. Which response by the nurse is best?

NURSING WILL HEL CONTRACT THE UTERUS AND REDUCE YOUR RISK OF BLEEDING Stimulation of the breast during breast-feeding releases oxytocin, which helps to contract the uterus. This contraction is especially important following an episode of hemorrhage. The other options are incorrect. Early breast milk contains colostrum and is rich in nutrients and antibodies for the babies. As long as the mother feels up to it, she should be encouraged to breast-feed.

An 80 year-old client diagnosed with chronic obstructive pulmonary disease (COPD) and acute respiratory difficulty is receiving oxygen per nasal cannula at two liters per minute. Which observation during nursing rounds should receive a nurse's immediate attention?

O2 SAT O 85% The highest priority in this situation is correcting the client's hypoxemia, which is demonstrated by the low oxygen saturation level. Clients with COPD should maintain an oxygen saturation level of 88 to 91%, and as much oxygen should be given as needed to maintain that goal, without raising the saturation level too high.

The nurse is assisting in the plan of care for a 10 month-old infant diagnosed with bacterial meningitis. The nurse would expect the plan of care to include which intervention?

OBSERVE FOR A DECREASE IN PLAY ACTIVITY When treating meningitis, the nurse should frequently assess for any neurological deterioration. In children, a decrease in play activity is equivalent to a decreased level of consciousness. Depending on the infective organism, the child may need to be on droplet precautions for 24 hours and then standard precautions, but not contact precautions. You should note that because the question involves a neurological issue, it will require a neurological answer.

While obtaining the history of a 2 week-old infant during the well-baby exam, the nurse finds that the neonatal screening for phenylketonuria (PKU) was done when the infant was less than 24 hours-old. Which action should the nurse take?

OBTAIN A REPEAT BLOOD TEST AT THIS POINT Testing for PKU is most reliable when protein has been ingested for at least 24 to 48 hours. A REPEAT BLOOD SPECIMEN MUST BE TAKEN IN THE 3RD WEEK of life if the initial specimen was taken from an infant less than 24 hours-old.

The nurse is assisting a client who reports having watery diarrhea. The client is asking for assistance with meal planning. Which menu choice should the nurse reinforce that the client should avoid?

ORANGE JUICE Orange juice is contraindicated for a client with diarrhea. Given the choices, it would have more tendency to increase the motility of the gastrointestinal tract. Bananas are bland and easily digested. Although dairy products should be avoided, yogurt is an exception because of its live or active cultures. Teas are a better choice than coffee, and especially the herbal, caffeine-free varieties that can help replace lost fluids.

A client receiving chemotherapy has developed sores in the mouth. The client asks, "Why has this happened?" The nurse should respond with which comment?

THE CELLS IN THE MOUTH ARE SENSITIVE TO CHEMOTHERAPY The epithelial cells in the mouth are very sensitive to chemotherapy due to their high rate of cell turnover. Chemotherapy mostly affects cells that grow rapidly, like hair and tissues in the mucous membranes. Although mouth sores often do occur with chemotherapy, providing this information does not answer the client's question.

A 9 year-old child is taken to the emergency department with right lower quadrant pain and vomiting. During preparation of the child for emergency surgery, the nurse should know that the child's greatest fear would be related to what issue?

PERCIEVED LOSS O CONTROL For school-age children, 6 to 12 years of age, major fears are associated with LOSS OF CONTROL AND SEPERATED FROM PEERS/FRIENDS Although the child would most likely be afraid of the unfamiliar environment, the greatest concern would be the loss of control.

A client is on a mechanical ventilator when the high pressure alarm goes off. What is the first action the nurse should perform?

PERFORM A QUICK CHECK ON THE PTS OVERALL CONDITION THEN CONTACT THE RN

A client is unconscious after a tonic-clonic seizure. What should the nurse do at this time?

PLACE THE PT IN A SIDE LYING POSITION Place the client in a side-lying position to maintain an open airway, drain secretions, and prevent aspiration if vomiting occurs. Nothing should be placed in the client's mouth

In response to a call for assistance by a client in labor, a nurse notes a loop of THE UMBILICAL CORD PROTRUDING from the vagina. What should be the nurse's next action?

PLACE THE PT IN TRANDELENBERG POSITION Umbilical cord prolapse is a life-threatening event for the fetus. Immediate action is needed to save the fetus because pressure on the cord results in a DECREASED BLOOD FLOW TO THE FETUS. Trendelenburg or knee chest position will accomplish this. The next action should be to immediately get help and start monitoring the fetal heart rate to determine the condition of the fetus. Additionally, the cord must be kept moist. If oxygen is not already running, it should be started at 8 L/min and the fetal heart rate should be continuously monitored as preparations are made to immediately deliver the fetus.

The nurse is working in a health clinic with an adolescent who is diagnosed with morbid obesity. The nurse should understand that obesity in adolescents is most often associated with which of the following factors?

POOR BODY IMAGE As the adolescent gains weight, there is a decreased sense of self-esteem and a poor body image. Morbid obesity is diagnosed by determining body mass index (BMI); normal BMI ranges from 20-25. Someone who is morbidly obese is 100 pounds over ideal body weight, with a BMI of 40.

LAB VALUE FOR PT:

PROTHROMBIN TIME: 11-15 SECS CRITICAL IF OVER 30 (>30)

The nurse is collecting data on a client with an endotracheal tube. Which finding would call for an immediate action by the nurse?

PULSE O2 AT 86% SATURATION Pulse oximetry should not be lower than 90%. The other findings are expected observations after endotracheal tube insertion.

A nurse is caring for a 69 year-old client diagnosed with acute heart failure. Which of these findings requires the nurse's immediate attention?

PULSE OXIMETRY OF 89% While all of the findings are common in acute heart failure, a LOW O2 IS THE HGIHEST PRIORITY that needs immediate intervention through the administration of oxygen. An oxygen saturation (SpO2) of greater than 95% is generally considered normal (92% or greater is normal in older adults). An SpO2 of 92% or less (at sea level) suggests hypoxemia.

A nurse checks a 2 day-old infant and notices that the breasts are enlarged bilaterally with a white, thin discharge. What is the appropriate action by the nurse?

RECORD THE FINDINGS ON THE NURSES NOTES BECAUSE THESE ARE NORMAL FINDINGS Newborn infants of both sexes may have engorged breasts and may secrete milk during the first few days to few weeks after birth. This is an expected normal finding and would be noted on the nurses' notes.

A nurse on the eating disorder unit instructs a new staff member that each client must be weighed wearing only a hospital gown. What is the rationale for this intervention?

REDUCE THE TENDANCY OF THE PT TO HIDE OBJECTS UNDER CLOTHING The client may conceal something on his or her body to increase the reading when weighed, which would indicate false improvement.

A client has just undergone electroconvulsive therapy (ECT). What is a post-procedure nursing intervention following this procedure?

REMAIN WITH THE PT TILL THE PT IS ORIENTED Clients commonly awaken 20 to 30 minutes after treatment and are groggy and confused. Therefore, the nurse should remain with the client until the client is oriented and able to engage in self care. Memory loss after ECT is typically short-term. Once home, the client may sleep longer than six hours. To select an answer to this question, you should determine which of the options is a nursing

The nurse observes a coworker removing a narcotic from the electronic medication dispensing machine and self-medicating. Which action is required for the nurse who observes this behavior?

REPORT THE COWOORKER TO THE NURSING SUPERVISOR Nurses who divert drugs pose a threat to client safety and are a legal liability for the facility, which is why the behavior must first be reported to the unit manager or other nursing supervisor.

A nurse is planning care for a client who is diagnosed with a cerebral vascular accident (CVA). Which intervention would be most effective for this client to prevent skin breakdown?

REPOSITION Q 1-2 HOURS IN OR OUT OF BED Clients who are at risk for skin breakdown develop fewer pressure ulcers when turned every one to two hours, whether sitting or lying. By relieving the pressure over bony prominences at frequently scheduled intervals, blood flow is maintained to areas of potential injury

The CNA informs the nurse that a client's condition has changed. Which assessment finding is the earliest indication of inadequate oxygen transport?

RESTLESSNESS Neurological changes are early findings of inadequate oxygenation that should prompt immediate intervention. Restlessness is one of the earliest findings of inadequate oxygenation. Next, the nurse would expect to find confusion. Somnolence is a more terminal finding.

The licensed practical nurse (LPN) is caring for a client diagnosed with chronic obstructive lung disease (COPD). Which of these findings should the (LPN) immediately report to the registered nurse (RN)?

RESTLESSNESS AND CONFUSION Pursed-lip breathing is an expected finding with COPD and does not need to be reported immediately to the RN. Finally, fever and cough can have many different causes. When someone is restless or confused, one of your first thoughts should be hypoxia and this should be considered a priority.

The licensed practice nurse (LPN) and family members witness a hospitalized child having a grand mal seizure. The child vomits immediately after the seizure. What should be a priority nursing concern to discuss with the registered nurse (RN)?

RISK FOR ASPIRATION R/T LOSS OF CONSCIOUSNESS AND VOMITING The tonic-clonic or grand mal seizure appears suddenly and often leads to a brief loss of consciousness. The greatest risk for the child is from airway blockage and aspiration during vomiting. Notice that only the correct option addresses both the seizure and vomiting, which are found in the content of the question.

The nurse is participating in the plan of care for an infant. Which need does the nurse understand is the most important in order to develop a feeling of trust in a 6 month-old infant?

SECURITY While infants have many physical needs, they must be touched, loved and stimulated in order to develop security and trust. You will notice that three of the options involve physical needs. Because the question is asking about developing a "feeling of trust," you should look for the option that concerns the emotional aspect of development, which is "security."

The practical nurse understands that time management is important. Which action best describes the application of time management strategies for the nurse in a charge position?

SET DAILY GOALS TO PRIORITIZE SELF AND WORKLOAD OF THE HEALTH CARE TEAM Time management strategies must include setting priorities and meeting goals on a daily, weekly, monthly or yearly basis

A client is prescribed atenolol (Tenormin). The nurse should emphasize to the client to immediately report which finding?

SLOW BOUNDING PULSE Atenolol (Tenormin) is a beta blocker. Side effects of this medication include bradycardia and hypotension. Beta blockers should be used cautiously in clients diagnosed with asthma because they may stimulate bronchospasm as a side effect. The spelling of the generic name of beta blockers often end with "lol."

A client is being discharged with a prescription for CHLORPROMAZINE. Before the client leaves the hospital, the nurse should remind the client to report which findings within 24 hours after discharge?

SORE THROAT/ FEVER Chlorpromazine is used to treat the symptoms of schizophrenia and other psychotic disorders. A sore throat and fever may be findings of agranulocytosis, which a severe decrease in granulated white blood cells. This adverse effect would predispose the client to severe infections. Although findings such as change in libido and breast enlargement are associated with chlorpromazine, they would not occur in 24 hours. A stuffy nose is also a side effect of this medication, but it is not life-threatening.

A nurse is providing health care in a client's home. Which of these actions is most likely to ensure the safety of the nurse when making a visit to a client's home?

STAY ALERT AT ALL TIMES WITH PLANS TO LEAVE IF CUES SUGGEST THE HOME OR AREA IS NOT SAFE No person or equipment can guarantee safety, but the threat of violence can be minimized. Before making initial visits to new clients, review referral information carefully and have a plan to communicate with the agency staff. Schedule appointments with clients within specific time intervals. When driving into an area for the first time, note potential hazards and possible sources for assistance; become acquainted with neighbors. Be alert and confident while parking the car, walking to the client's door, making the visit, walking to the car, and driving away. Listen to the clients; if they tell a health care worker to leave, then the nurse should leave.

?? is the result of a larger, upper airway constriction; it sounds like intense continuous, monophonic wheezes.

STRIDOR

When reinforcing discharge instructions to a client who takes alprazolam (Xanax), the nurse should include which important piece of information

SUDDEN CESSATION OF XANAX CAN CAUSE REBOUND INSOMNIA NIGHTMARES Sudden cessation of alprazolam can cause rebound insomnia and nightmares. Other withdrawal findings include nervousness, irritability, sweating, lightheadedness, abdominal and muscle cramps, tremors and seizures. Before discontinuing any BENODIAZEPINE, the dosage should be gradually decreased.

A client is diagnosed with confusion and anemia. While caring for this client, which task should the practical nurse assign to an unlicensed assistive person (UAP)?

TEST STOOL FOR OCCULT BLOOD The UAP can do STANDARD UNCHANGING TASKS with predictable outcomes, like obtaining and testing stool for occult blood. The nursing functions of assessment, planning, evaluation and nursing judgment cannot be delegated.

A 2 year-old child is brought to the emergency department at 2:00 pm. The mother states that the child has not had a wet diaper all day. The child is pale and the heart rate is 132. What data should the nurse obtain next?

THE STATUS OF THE CHILDS PLAY ACTIVITY THAT DAY Clinical findings of acute dehydration in children include lethargy, decreased play activity, sunken eyes, increased pulse, and dry mucous membranes and skin. The normal pulse rate for a child this age is 70-110 BPM. The change in the child is acute, so looking at changes during the past day is more appropriate than changes over a longer period of time.

A client reports feeling nauseated, having a metallic taste in the mouth and experiencing fine hand tremors two hours after receiving the first dose of lithium (Eskalith, Lithobid). Which response by the nurse would be the best?

THESE SIDE EFECTS ARE COMON AND SHOULD GO AAWAY IN A FEW DAYS Lithium is commonly used to treat and prevent episodes of mania in people with bipolar disorder. Nausea, metallic taste and fine hand tremors are common and expected side effects that usually subside within a few days. When reading the answer options, there are two responses that address "side effects." This is when you will have to remember that lithium is a salt and the client should not alter his or her diet while taking lithium. Taking lithium with food can help reduce nausea, abdominal pain and diarrhea.

To whom should the measurement and documentation of vital signs in a long-term care facility be assigned?

UNLISCENCED ASSISTIVE PESONNEL (UAP)The measurement and documentation of vital signs which are routine tasks may be delegated to a UAP. Considerations for assigning care to UAPs would be: who is capable and is the least expensive worker to do tasks that are routine and have predictable outcomes?

During the two-month well-baby visit, the mother explains that baby formula seems to stick to her baby's mouth and tongue. Which action by a nurse would provide the most valuable information?

USE A SOFT CLOTH TO ATTEND TO REMOVE THE PATCHES Candidiasis can be distinguished from coagulated milk by trying to wipe the patches from the mouth and tongue. When attempts to remove the patches with a soft cloth are unsuccessful or THE TONGUE BLEEDS, THEN CANDIDIASIS IS SUSPECTED. Also known as oral thrush, this common infection is caused by the overgrowth of the yeast Candida albicans.

A nurse is discussing negativism with the parents of a toddler. The nurse should tell the parents that their best response to this behavior would be which action?

USE PATIENCE AND A SENSE OF HUMOR TO DEAL WITH THIS BEHAIVIOR The nurse should help the parents see the negativism as a normal growth of autonomy in the toddler. They can best handle this by using patience and humor. Toddlers say "no" because they can, not because they are trying to be difficult or mean. Although limit-setting and consistent boundaries for behavior is important for toddlers, asserting authority or punishment for saying "no" is not what is indicated.

?? can be described as high-pitched and musical; this sound indicates a narrowed lower airway such as the bronchials.

WHEEZING

The nurse is checking to see how a client is doing. Which statement by the nurse reflects the best use of a therapeutic interaction techniques?

YOU LOOK UPSET TELL ME WHATS HAPPENING Giving broad opening statements and making observations are examples of therapeutic communication. Closed-ended questions that require a "Yes" or "No" response often block further communication about concerns or issues. In certain situations yes/no questions are appropriate: severely depressed clients during admission, cognitively impaired clients and situations of respiratory distress. Only ask one question at a time.

The nurse checks lab results for an adult client with suspected cancer prior to a liver BIOPSY. Which finding requires immediate notification of the health care provider?

aPTT OF 50 SECONDS Because the liver is a vascular organ and a biopsy is an invasive procedure, bleeding is one of the risks. An elevated aPTT increases the risk of bleeding. ((NORMAL TIME ) 25 - 35 SECS