review 16

The nurse instructs a student nurse about the correct way to prepare a sterile field. Place the following instructions by the nurse to the student nurse in the correct order from the FIRST action to the LAST. All options must be used.

**** Strategy: Think about each answer. (1) Assemble the necessary equipment: prevents breaks in technique (2) Place sterile drape on the work surface: hold drape away from body; lay bottom half of drape on work surface and then the top half of the drape (3) Open wrapper of sterile item: appropriate after assembling necessary equipment and placing sterile drape on work surface (4) Dispose of outer wrapper: prevents accidental contamination of sterile field

A newborn is transferred to the neonatal intensive care unit with a heart rate of 200 beats per minute. At delivery the child's weight is 3675 grams. The physician orders an initial dose of digoxin (Lanoxin) 0.03 mg/kg in 3 doses over 24 hours. The syringe is labeled digoxin 100 micrograms/mL. How many mL will the nurse administer to deliver one dose? Do not round. Type the correct answer to the hundredths place in the blank.

0.36 mL ****

The nurse is feeding a woman resident in the dining room of a long-term care facility. Suddenly, the resident starts to choke and becomes cyanotic. Which of the following is the BEST action for the nurse to take? 1. Start behind the resident and deliver a quick blow to the middle of her back with the palm of the hand. 2. Embrace the resident from behind and with a fist quickly thrust upward into her abdomen. 3. Check the resident's mouth and throat for food, and perform a finger sweep. 4. Lay the resident on the floor and prepare to initiate cardiopulmonary resuscitation.

1) implementation; should do Heimlich maneuver 2) CORRECT— implementation; description of Heimlich maneuver, expels remaining air in victim's lungs, along with foreign body 3) assessment; need to clear airway; will not be able to reach obstruction 4) implementation; need to clear airway immediately

The nurse has a 20 mL multi-dose vial of heparin labeled 10,000 units per mL. The ordered concentration is to mix 25,000 units of heparin per 250 mL of normal saline. How many mL will the nurse add to the 250 mL bag of normal saline? Type the correct answer to the tenths place in the blank.

2.5 ****

The nurse cares for a client receiving cimetidine (Tagamet) by continuous IV infusion. The physician has ordered 900 mg infused over 24 hours. The medication is mixed in 500 cc of D 5 W and the IV unit delivers 60 drops per ml. The nurse should adjust the flow rate to deliver how many drops per minute? Type the correct answer into the blank.

21 ****

The nurse cares for an elderly client 24 hours after an abdominal hysterectomy. The nurse asks the client if she is experiencing any pain. The client states, "No, I am just fine." Which of the following responses by the nurse is BEST? 1. "That's good. Please let me know if your abdomen starts hurting." 2. "I see that you have not used your PCA pump. Are you sure that you aren't in pain?" 3. "You are doing such a good job. If it were me, I would be using the pain medication." 4. "Look at this faces pain scale. Point to the picture that shows how you feel now."

Strategy: "BEST" indicates priority. 1) should validate client's statement; client may be denying pain 2) second best answer; nurse is making observation about client's use of PCA pump, but validates by asking a yes/no question 3) focus is on nurse and not client 4) CORRECT— allows nurse to assess client's perception of pain and validate client's denial of pain

The nurse cares for an elderly client who screams constantly. The nurse plans a behavior modification program to deal with the screaming. Which of the following actions should the nurse take FIRST? 1. Monitor client's ability to perform ADLs. 2. Assess the client's level of pain. 3. Observe the client's behavior at regular intervals. 4. Ask the client why he is screaming.

Strategy: "FIRST" indicates priority 1) would not give information about why client is screaming 2) assumes that pain is causing the client to scream 3) CORRECT— to design an effective behavior modification program, accurate baseline data about the behavior in relation to frequency, amount, time, and precipitating factors must first be collected 4) better to observe client's behavior

The nurse cares for clients in the outpatient surgical center. Four clients scheduled for surgery present to the surgical center at the same time. Which of the following clients should the nurse see FIRST? 1. A 19-year-old scheduled for a tonsillectomy. 2. A 25-year-old scheduled for an inguinal hernia repair. 3. A 32-year-old scheduled for a mastoidectomy. 4. A 39-year-old scheduled for removal of nasal polyps.

Strategy: "FIRST" indicates priority. 1) not the priority client 2) stable client; not the priority 3) CORRECT— chronic ear infections often cause vertigo, priority client due to safety 4) stable client

The nurse performs a physical assessment on a patient diagnosed with bulimia nervosa. Which of the following findings warrant an IMMEDIATE referral to the physician? 1. Bilateral parotid gland enlargement. 2. A hoarse voice that is barely audible. 3. Grey to black eroded teeth with foul odor. 4. Multiple papulopustular skin eruptions on face, chest, and back.

Strategy: "IMMEDIATE referral" indicates a complication. (1.) hallmark sign of chronic vomiting; glands become clogged with foreign matter; not priority (2.) CORRECT—at high risk for tracheoesophageal fistula from esophageal tear; laryngitis is danger sign (3.) sign of chronic vomiting; gastric acid erodes teeth; needs eventual dental referral (4.) sign of acne vulgaris related to bingeing on junk foods

A patient with a history of assault is admitted involuntarily to the locked psychiatric unit. As the nurse begins the admission interview, the patient angrily yells, "Get away from me, you racist bigot!" Which of the following actions by the nurse is MOST appropriate? 1. Inform the patient that the nurse will return in 30 minutes. 2. Ask another nurse of the same ethnic background as the patient to complete the interview. 3. Remain sitting quietly with the patient until the patient is ready to cooperate. 4. Ignore the patient's comment and continue the interview.

Strategy: "MOST appropriate" indicates discrimination is required to answer the question. (1.) CORRECT—history of assault makes this patient potentially violent, nurse's safety always comes first; give patient space and time to calm down (2.) inappropriate; will only validate patient's remark and set the stage for staff splitting (3.) inappropriate at this time; patient needs time alone to grasp situation (4.) may intensify patient's anger and make the nurse the target of violence

The nurse admits an elderly woman to the unit. The client demonstrates decreased ability to problem-solve, psychomotor retardation, and social isolation. Which of the following nursing actions is MOST appropriate? 1. Prepare a schedule of activities and monitor the client's participation in the activities. 2. Encourage the client to choose her own activities. 3. Allow the client time to get acclimated to the milieu before scheduling activities. 4. Allow the client to rest quietly to restore her energy level.

Strategy: "MOST appropriate" indicates discrimination is required to answer the question. 1) CORRECT— client displays symptoms of depression; a regular daily routine of scheduled activities provides structure and decreases the problem solving; participating in activities will increase self-esteem 2) client having difficulty making decisions; will increase social isolation, increase impairment, and decrease self-esteem 3) will increase social isolation 4) client having difficulty making decisions; will increase social isolation, increase impairment, and decrease self-esteem

The charge nurse implements a change in the nursing assistant's job description. The change increases the nursing assistants' responsibilities and independence. A nurse with 15 years of service on the unit verbally agrees to the change, but her behaviors indicate that she does not agree with the new job description. Which of the following actions by the charge nurse is MOST appropriate? 1. Inform the nurse that there is a conflict between her verbal statements and behaviors. 2. Schedule an appointment with the nurse. 3. Ask the nursing assistants to accommodate the nurse. 4. Facilitate an open discussion during a prescheduled meeting.

Strategy: "MOST appropriate" indicates discrimination is required to answer the question. 1) nurse is probably aware of actions; may make the nurse defensive 2) confrontation inappropriate when emotions are high 3) nursing assistant cannot perform under two different job descriptions 4) CORRECT— indirect approach; nurse not confronted directly about behaviors; peer pressure can be effective in dealing with situation

A nurse returns to work in an inpatient environment after not practicing for 5 years. The returning nurse reports to the employee health nurse that she established hepatitis B immunity with a previous employer. Which of the following responses by the employee health nurse is MOST appropriate? 1. "You must repeat the hepatitis immunity screen." 2. "Would you like to verify your immunity to hepatitis B with a blood test?" 3. "Do you have a copy of the results of your hepatitis screening?" 4. "Did you receive the hepatitis vaccine in the deltoid?"

Strategy: "MOST appropriate" indicates discrimination is required to answer the question. 1) once hepatitis immunity has been established, there is no need to reconfirm it 2) no reason to verify immunity 3) CORRECT— confirms immunity 4) dorsal gluteal site is avoided because it is associated with low antibody rates; more important to ask nurse for copy of the record

A nurse notes a significant increase in client falls causing injury. To help resolve this problem, which of the following actions by the nurse is MOST appropriate? 1. Schedule an inservice about client safety. 2. Inform staff that pay raises will be withheld until incidents decrease. 3. Convey to the staff the nurse's confidence in their abilities to provide safe care. 4. Form a group to design and implement a plan to prevent further incidents.

Strategy: "MOST appropriate" indicates discrimination is required to answer the question. 1) presumes that education is the solution 2) coercive techniques usually have temporary outcomes 3) charismatic power does little to address a safety problem; lacks problem solving 4) CORRECT— involvement of staff is likely to have more permanent effect; nurses have firsthand knowledge of why the problems are occurring

While working at a local welding plant, a piece of metal penetrates an employee's right eye. The nurse admits the client to the emergency department. Which of the following responses by the nurse is MOST appropriate? 1. "Can you tell me exactly what happened?" 2. "I thought the Occupational and Health Safety Act (OSHA) required you to wear eye protection." 3. "Did the plant have safety guidelines in place?" 4. "Do you know what type of material entered your eye?"

Strategy: "MOST appropriate" indicates priority. 1) does need to be documented, but not necessary to determine the client's immediate need 2) priority is determining client's immediate needs; safety discussion can happen at a later time 3) yes/no question that is not relevant to assessing the client's current condition 4) CORRECT— some materials (copper, iron, steel) can result in intense inflammatory reaction; information assists the staff to determine the extent of the injury

An 8-year-old with a history of asthma is brought to the emergency department by his mother. The child tells the nurse that he was wheezing earlier and now feels worse. The nurse should be MOST concerned with which of the following findings? 1. The child states that his chest feels tight. 2. The nurse auscultates wheezing at the end of each expiration. 3. The nurse auscultates decreasing breath sounds. 4. The child coughs while lying on the stretcher.

Strategy: "MOST concerned" indicates a complication 1) common complaint with asthma, but does not necessarily indicate severe respiratory impairment 2) indicates mild respiratory impairment; asthma attack produces dyspnea, audible wheezing, coughing, chest tightness, feeling of suffocation 3) CORRECT— with severe spasm or obstruction, breath sounds and crackles may become inaudible 4) indicates ability to breathe in the recumbent position

The psychiatric home health nurse makes a follow-up telephone call to the home of an 18- year-old male college student living at home with his mother and younger sister. The student was discharged 2 weeks ago from an inpatient psychiatric unit after being treated for depression and suicidal ideation. Which of the following statements by the mother MOST concerns the nurse? 1. "He rarely gets up the first time the alarm goes off. He must hit that snooze button three or four times before he is up and out of bed." 2. "He is like a changed person. He used to be rather selfish, but lately he has been actually giving away things he has treasured that he knows other people like." 3. "He is still quiet and keeps to himself a lot, but when friends invite him to a party with people, he goes out with them." 4. "He is not eating much, but asked me to stock carrot and celery sticks and other quick, healthy foods in the refrigerator so he can try substituting them for cigarettes."

Strategy: "MOST concerns the nurse" indicates a complication. (1.) indicates patient able to sleep well, which indicates improvement in depression; if sleeping too much, can indicate continued depression; not most concerning (2.) CORRECT—giving away possessions, especially cherished ones, can be a warning sign of suicide (3.) is responding to invitations of friends; needs further assessment, including of baseline socialization patterns prior to illness; not most concerning (4.) lack of appetite may reflect depression; wanting to decrease cigarette use is health-promoting behavior

The nurse in the prenatal clinic monitors the condition of a pregnant woman at 30 weeks' gestation who is diagnosed with gestational diabetes mellitus (GDM). Which of the following testing results MOST concerns the nurse? 1. Hemoglobin (Hgb) 11.5 mg/dL and hematocrit (Hct) 33%. 2. Glycosylated hemoglobin (HbA1c) 7%. 3. Urine dipstick testing is positive for ketones. 4. One-hour glucose tolerance test (GTT) result is 140 mg/dL.

Strategy: "MOST concerns" indicates a complication. (1.) probably reflects physiologic anemia of pregnancy, a normal response that occurs because of plasma volume expansion to a volume 3 times more than the RBC mass (2.) glycosylated Hgb reflects blood sugar control over the preceding 120 days; 7% is within normal range (3.) CORRECT—ketones result from fatty acid metabolism, and usually are completely metabolized by the liver; ketone bodies in the urine (ketonuria) are a sign of ketoacidosis which, in pregnancy, is a major factor contributing to intrauterine death (4.) result of 140 mg/dL or over is seen as abnormal and requires further evaluation with a 3-hour GTT

The clinic nurse examines the fingernails of a new patient who presents with pallor and complaints of fatigue, weakness, and dyspnea on exertion. Which of the following findings MOST concerns the nurse? 1. There are multiple small pits in the nail plate. 2. There are 1-mm-wide horizontal depressions in the nail plates. 3. The nail plate is concave, curving up from the nailbed and appearing spoon-shaped. 4. The angle between the nail plate and the proximal nail fold is straightened to 180 degrees.

Strategy: "MOST concerns" indicates a complication. (1.) seen in psoriasis (2.) not of most concern; these are Beau's lines; might occur singly or in multiples; reflect temporary disturbance of nail growth related to acute severe illness, such as infection, to isolated periods of severe malnutrition, or to direct nail root injury (3.) not of most concern; spoon nails are usually indicative of iron deficiency anemia; can also indicate use of strong detergents or other chemicals; formal name for these nails is koilonychias (4.) CORRECT—indicates early clubbing, a sign of hypoxia; with early clubbing, the nail base is also spongy upon palpation; there is normally a 160-degree angle between nail plate and proximal nail fold, and nail shape is normally convex; straightening or flattening beyond 180 degrees indicates late clubbing

For the past 3 days, an 8-year-old child has come to the school nurse's office complaining of "stomachaches." The school nurse notes that the abdominal pain subside when the child overhears the nurse contact the child's parent at work. It is MOST important for the nurse to take which of the following actions? 1. Ask the child what the child eats for breakfast and dinner 2. Ask the child to describe life at home. 3. Report this event to social services. 4. Ask the parents how the child behaves prior to school.

Strategy: "MOST important" indicates discrimination is required to answer the question. (1.) incorrect assessment, frequent stomach upset in children is suggestive of anxiety (2.) question too broad, child still thinks in concrete terms (3.) need further assessment data before taking this action (4.) CORRECT—need to validate anxiety, especially separation anxiety; child may be worrying about parents and is relieved when nurse talks to the parent

The nurse cares for a patient who is complaining of pain at the IV site. Upon assessment, the nurse notes tenderness and redness at the IV insertion site and redness proximally along the vein. It is MOST important for the nurse to take which of the following actions? 1. Slow the infusion rate and monitor patient's response. 2. Stop the infusion and notify the physician. 3. Remove the IV and apply a pressure dressing. 4. Remove the IV and apply warm soaks.

Strategy: "MOST important" indicates discrimination is required to answer the question. (1.) symptoms are likely caused by phlebitis and will only progress with continued infusion (2.) catheter should be removed and warm soaks applied; notify physician if the signs and symptoms are severe, if they persist, or as indicated by the facility's policy; otherwise, nurse should document patient's chart appropriately and monitor the site (3.) warm soak required (4.) CORRECT—IV catheter should be removed to prevent further damage to the vein; warm soaks decrease inflammation, swelling, and discomfort

The nurse obtains a history from a client scheduled for a permanent pacemaker insertion. It is MOST important for the nurse to convey which information to the physician? 1. The client is diagnosed with obsessive-compulsive disorder. 2. The client wears a hearing aid in the left ear. 3. The client works as a computer programmer. 4. The client lives in a two-story house.

Strategy: "MOST important" indicates discrimination is required to answer the question. 1) not most important; may impact teaching about pacemaker management, specific directions likely to be followed, especially if written, but anxieties about pacemaker function and safety may be intense 2) CORRECT— hearing aid battery may affect placement of pacemaker; should not be placed under the left clavicle in this client 3) equipment that is grounded and well maintained is not a problem 4) clients with pacemakers do not require stair-climbing restrictions unless heart rhythm shows marked variation in response to this activity

The nurse cares for a client who is in Buck's traction due to a fractured right hip. It is MOST important for the nurse to take which of the following actions? 1. Assess for pain at regular intervals. 2. Encourage the client to move from side to side. 3. Allow the weights to hang freely at all times. 4. Remove weights if client complains of pain.

Strategy: "MOST important" indicates discrimination is required to answer the question. 1) pain is considered the fifth vital sign and it is important to assess; client may be given analgesics, anti-inflammatories, and/or muscle relaxants 2) should not twist from side to side; encourage client to move unaffected areas 3) CORRECT— weights need to hang freely in order to maintain traction; reposition client frequently to maintain the proper reduction of the fracture 4) do not remove the weights unless ordered by the physician

The nurse cares for clients on the urology unit. After assessing the clients, it is MOST important for the nurse to instruct the support staff to monitor which of the following clients? 1. A client diagnosed with diabetic retinopathy and hypertension. 2. A client with a blood urea nitrogen (BUN) of 35 mg/dL and serum creatinine of 2.5 mg/dL. 3. A client with urinary albumin of 30 mg/24 h. 4. A client with a urinary output of 3,000 mL/24 h.

Strategy: "MOST important" indicates priority. 1) although diabetic retinopathy with hypertension may indicate renal failure, these are not definitive diagnostic tools 2) CORRECT— indicates renal failure 3) normal >30 mg/24 h 4) may or may not indicate renal failure; composition of urine would determine client status

The nurse cares for a 4-year-old child diagnosed with epiglottitis. It is MOST important for the nurse to take which of the following actions? 1. Instruct a nursing assistant to take the child to the x-ray department. 2. Use a padded tongue blade to assess the child's gag reflex. 3. Obtain a blood culture and arterial blood gases (ABGs) as ordered. 4. Apply a pulse oximeter and start an IV.

Strategy: "MOST important" indicates priority. 1) epiglottitis is inflammation of the epiglottis and can be life-threatening; a professional should be with the child at all times 2) Never insert a tongue blade into the mouth of a child diagnosed with epiglottitis; gag reflex can cause complete obstruction of the airway 3) crying can cause obstruction of airway 4) CORRECT— treatment includes moist air and IV antibiotics to decrease epiglottal swelling; pulse oximeter measures oxygen saturation to determine the need for supplemental oxygen

The nurse cares for clients on the medical/surgical unit. The nurse learns that a client admitted for r/o myocardial infarction has a history of alcoholism. It is MOST important for the nurse to ask which of the following questions? 1. "What over-the-counter medication do you take?" 2. "How much alcohol do you consume each day?" 3. "When did you have your last drink?" 4. "Have you ever had symptoms of withdrawal?"

Strategy: "MOST important" indicates priority. 1) important question; more important to determine when client had last drink 2) will impact the severity of the withdrawal symptoms, more important for the nurse to anticipate when withdrawal might occur 3) CORRECT— symptoms of withdrawal occur from 48 to 72 hours after the last drink 4) appropriate question; priority is determining when withdrawal might occur

The nurse in the postanesthesia care unit (PACU) assesses the motor/sensory function of a client recovering from spinal anesthesia. The nurse notes that the client can feel the lower extremities and is able to wiggle the toes and move the legs. Which of the following actions should the nurse take NEXT? 1. Obtain the client's blood pressure. 2. Auscultate for bowel sounds. 3. Assess the client's skin temperature and color. 4. Auscultate breath sounds.

Strategy: "NEXT" indicates priority. (1.) CORRECT—ability to feel and move toes and legs indicates motor blockade from anesthetic is wearing off; blockage of autonomic nervous system may still be present and cause hypotension; monitor for hypotension, gradually elevate head of client's bed (2.) important to assess but priority is blood pressure due to spinal anesthesia (3.) not related to neurological functioning (4.) important action but priority is to determine if client is hypotensive due to spinal anesthesia

A patient diagnosed with type 2 diabetes mellitus is treated for hypertension with propanolol (Inderal). History reveals that the patient is diagnosed with glaucoma and is allergic to sulfa. The nurse is MOST concerned if an order was written for which of the following medications? 1. Glycerin (Osmoglyn). 2. Pilocarpine (Isopto-Carpine). 3. Acetazolamide (Diamox). 4. Timolol maleate (Timoptic).

Strategy: "Nurse is MOST concerned" indicates a complication. (1.) should be questioned but not of most concern; osmotic agent; diuretic; increases osmolarity of the blood, extracting fluid from extracellular space into the bloodstream, including aqueous humor and vitreous humor from the anterior chamber of the eye, thus decreasing intraocular pressure; glycerin needs to be used with caution in diabetics because it can cause hyperglycemia (2.) no need to question this order; direct-acting parasympathetic function causing miosis (3.) CORRECT—contraindicated; cross-sensitivity can occur due to allergy to antibacterial sulfonamides and sulfonamide derivatives (4.) should be questioned, but not priority; beta blockers given for systemic use, such as propanolol and atenolol, can enhance the therapeutic and toxic effects of beta blockers prescribed for ophthalmic use

The nurse is caring for a patient with a pulse oximeter probe in place. Which of the following situations requires an intervention by the nurse? 1. The probe is in place on the woman's ring finger, which has clear polish on the nail. 2. The emitting and receiving sensors of the probe are directly opposite each other. 3. The hand with the probe attached is directly beneath a procedure light to prevent chilling. 4. The SaO 2 alarm for the pulse oximeter is set at 95%.

Strategy: "Requires an intervention" indicates a complication. 1) equipment includes wave of infrared light and sensor placed on finger, nose, toe, earlobe, or forehead; no intervention needed; measures oxygen saturation through the skin 2) correct placement of equipment 3) CORRECT— don't expose the probe to direct sunlight or strong light, gives inaccurate results, cover with dry washcloths; rotate site every 4 h to prevent skin irritation 4) normal SaO 2 is 95-100%; measures reserve oxygen attached to hemoglobin; results below 86-91% considered emergency, below 70% life-threatening

The nurse instructs a patient receiving olanzapine (Zyprexa). Which of the following statements, if made by the patient to the nurse, requires further teaching? 1. "This medication will help my thoughts and behavior." 2. "I must report to my physician if I feel restless and have trouble sitting still." 3. "I will tell the physician if I am planning to get pregnant." 4. "Stiffness and tremors are expected for the first 2 weeks."

Strategy: "Requires further teaching" indicates incorrect information 1) atypical antipsychotic; client will have improved thought processes 2) describes akathisia: must report to physician; will decrease dosage 3) category C: risk to fetus; contraindicated during pregnancy 4) CORRECT— describes extrapyramidal symptoms; contact physician immediately; olanzapine is an antipsychotic medication; side effects include neuroleptic malignant syndrome, muscle rigidity, constipation, increased appetite, tardive dyskinesia, akathisia, suicide, tachycardia and hypotension, significant weight gain; patient teaching includes report suicidal ideation, abnormal bleeding, sudden muscle pain/weakness and irregular heartbeat

The nurse should question the order if propanolol (Inderal) is ordered for which of the following patients? 1. A 39-year-old woman with type 1 diabetes. 2. A 45-year-old woman with peptic ulcer disease. 3. A 49-year-old man with a history of bronchial asthma. 4. A 60-year-old man with atrial tachycardia.

Strategy: "Should question" indicates a contraindication. 1) propanolol given with caution to Type 1 diabetic clients; may mask tachycardia and client should be instructed to recognize other signs of hypoglycemia; propanolol is a beta-adrenergic blocker used as antihypertensive 2) propanolol use not contraindicated for this patient 3) CORRECT—may cause bronchospasm; other side effects include bradycardia and depression; nursing care includes taking pulse before administering medication; dosage should be gradually reduced before discontinued 4) propanolol use not contraindicated for this patient

The nurse counsels a client diagnosed with iron deficiency anemia. The nurse determines that teaching is effective if the client selects which of the following menus? 1. Roast beef, brown rice, green beans, carrot and raisin salad, and milk. 2. Cheese pizza, tossed green salad, oatmeal-raisin cookie, and lemonade. 3. Two scrambled eggs, bacon, white toast with strawberry jam, and coffee. 4. Corn flakes with milk, whole wheat toast, and orange juice.

Strategy: "Teaching is effective" indicates correct information. 1) CORRECT— beef is good source of organic iron, brown rice and raisins are good sources of inorganic iron; green beans also contain inorganic iron; total iron, 8.4 mg 2) cheese pizza contains small amount of iron, oatmeal-raisin cookie is best source of iron in this selection (2.7 mg); total iron, 4.8 mg 3) total iron, 2.5 mg (1.4 mg from scrambled eggs); coffee contains tannin, which combines with nonheme iron and prevents it from being absorbed; nonheme iron comes from inorganic sources 4) total iron, 4 mg from nonorganic sources; vitamin C enhances the absorption of inorganic iron

The nurse cares for a client receiving aluminum hydroxide gel (Amphojel). The nurse determines that teaching is effective if the client states which of the following? 1. I will only take this medication before bedtime. 2. I will decrease side effects by taking this medication before meals. 3. I will take the medication 1 hour after meals. 4. I will take the medication when I feel epigastric pain.

Strategy: "Teaching is effective" indicates correct information. 1) antacids are taken several times per day to be effective 2) most effective when taken after digestion has begun but before the stomach has emptied 3) CORRECT— antacids neutralize gastric acids, increase gastric pH, and inactivate pepsin; contains sodium, check if patient is on sodium-restricted diet 4) take medication to prevent epigastric pain

The nurse assists a patient who is diagnosed with oral candidiasis (moniliasis, thrush) secondary to antibiotic treatment in preparing for discharge to home. Which of the following statements, if made by the patient to the nurse, indicates that teaching is successful? 1. "I will stop on the way home to get some mouthwash at the store." 2. "I will swish the Mycostatin around in my mouth thoroughly before I spit it out." 3. "I think I will take it easy for a while by reading some books." 4. "I will start cooking with some strong spices that I know have healing properties."

Strategy: "Teaching is successful" indicates correct information. (1.) commercial mouthwash should be avoided because of high alcohol level that causes a burning feeling in the irritated oral mucosa; warm saline or hydrogen peroxide are mouthwashes that can be used instead (2.) nystatin (Mycostatin) is an antifungal agent in oral suspension; should be swished around in the mouth and then swallowed (3.) CORRECT—relaxation can help immune system repair itself, and engaging in an enjoyable activity can be a distraction from the pain of the stomatitis (4.) soft, bland, nonacidic, and cool liquids and foods will help eating process be more comfortable; spicy foods, hot liquids, and citrus juices cause mucosal irritation

The nurse obtains a history from a client scheduled to undergo electroconvulsive therapy. It is MOST important for the nurse to report which of the following findings to the physician? 1. The client takes alendronate (Fosamax) once a day. 2. The client complains of lethargy and fatigue. 3. The client has received electroconvulsive therapy in the past. 4. The client walks for 30 minutes three times per week.

Strategy: "report finding to physician" indicates a contraindication to the procedure. 1) CORRECT— Fosamax is used to treat osteoporosis, which places the client at risk for ECT; should be reported to the physician 2) symptoms of depression; ECT used to treat depression 3) not a contraindication 4) appropriate to prevent osteoporosis

A 10-year-old girl is receiving Amoxicillin 250 mg PO. Which of the following statements, if made by the nurse, is MOST likely to elicit cooperation from the child? 1. "Amoxicillin is an antibiotic to help you get well." 2. "This medicine tastes good. Would you like some?" 3. "Would you like to take this medicine with milk or juice?" 4. "Do you want to go play after you take your medicine?"

Strategy: All answers are implementation. Determine the outcome of each answer. Is it desired? 1) CORRECT— discussion of facts is appropriate with school-age child 2) don't compare medication to food 3) offers child a choice, gives some control over behavior, suitable for younger child 4) bargaining, not based on Erikson's developmental tasks

The nurse in the outpatient clinic receives a phone call from a client diagnosed with type 1 diabetes. The client reports that the blood sugar at 0700 am was 200 mg/dL. The nurse should include which action in the client's plan of care? 1. Increase the evening dose of NPH insulin. 2. Increase the morning dose of regular insulin. 3. Instruct the client to obtain a blood sugar at 0300. 4. Decrease the evening dose of NPH insulin.

Strategy: Assess before implementing. 1) assess before implementing 2) assess before implementing 3) CORRECT— assess the blood sugar to determine if hyperglycemia is caused by Somogyi effect, normal or elevated blood glucose at bedtime, hypoglycemia at 0200-0300, and a rebound hyperglycemia in the morning 4) appropriate action if Somogyi effect identified; must rule out insulin waning and dawn phenomenon before taking action

The nursing team at the home care agency consists of an RN, an LPN, and a nursing assistant. The RN should assign the LPN/LVN to which of the following clients? 1. A client just discharged from the hospital with a diagnosis of hypertension and hypothyroidism. 2. A client recovering from a kidney transplant complaining of fever and tenderness over the transplant site. 3. A client diagnosed with regional enteritis requiring a dressing change for an abdominal abscess. 4. A client recovering from a hip fracture requiring assistance with a bath and hair washing.

Strategy: Assign stable clients with expected outcomes. 1) requires the assessment and teaching skills of the RN 2) could indicate rejection or infection; requires the assessment skills of the RN 3) CORRECT— LPN/LVN recognizes normal from abnormal and can perform dressing change 4) standard, unchanging procedure; assign to nursing assistant

An elderly man is admitted to the hospital from a nursing home. The nurse establishes a nursing diagnosis of fluid volume deficit related to decreased intake and fever. Which of the following symptoms substantiates this nursing diagnosis? 1. The patient's temperature is 102°F (38.4°C), pulse is 120, BP 90/60, and respirations 22 and deep. 2. The patient has difficulty breathing in the supine position or with minimal activity. 3. The patient's skin is pale and cool to touch with pitting edema in dependent areas. 4. There is a decrease in the patient's level of consciousness and ascites.

Strategy: Determine how each answer relates to fluid volume. 1) CORRECT— will see increased pulse rate with thready quality, decreased BP, fever, and increased rate and depth of respirations 2) seen with fluid volume excess 3) indicates fluid volume excess 4) seen with overhydration

The nurse who is caring for patients in the outpatient clinic receives four phone calls. Which of the following calls should the nurse return FIRST? 1. A patient reports a headache that is unrelieved by medications. The patient reports taking two propoxyphene napsylate acetaminophen (Darvocet-N) and two acetaminophen (Tylenol) every 4 hours for 3 days. 2. A patient complains of left ankle pain and swelling that is reddened and warm to the touch. The patient states the redness and swelling occurred spontaneously and denies injury to the ankle. 3. The mother of a toddler calls to report that her child has a rash and a sore throat. 4. The father of a toddler calls to report that his child swallowed a dime.

Strategy: Determine the MOST unstable patient. (1.) both contain acetaminophen which is 90 to 95% metabolized by the liver; at risk for damage to the liver as a result of overdose (2.) the possibility of an infectious process requiring evaluation and treatment exists; an overdose takes precedence (3.) probably Streptococcus A infection; not emergent unless patient is having respiratory difficulty (4.) CORRECT—nurse should immediately evaluate to determine if the toddler is having respiratory difficulty

The nurse on the medical unit reviews laboratory results on four patients. The nurse should notify the physician about which of the following results? 1. Theophylline (Theobid) level 15 mcg/mL. 2. Digoxin (Lanoxin) level 2.5 ng/mL. 3. Intermational Normalized Ratio (INR) 2.5 for a client who takes warfarin (Coumadin) 4. Lithium (Lithobid) level of 1.2 mEq/L for a client with bipolar disorder

Strategy: Determine the abnormal lab results. (1.) therapeutic range 10-20 mcg/mL; toxicity occurs with levels over 20 mcg/mL; theophylline is xanthine-derivative bronchodilator (2.) CORRECT—toxic levels for digoxin are over 2 ng/mL; normal therapeutic level of digoxin in the blood is between 0.5 and 2 ng/mL (3.) optimal dose of Coumadin prolongs the PT and maintains the INR at 2 to 3 (4.) should read: within normal limits, lithium dosage is adjusted to maintain a serum lithium level of 1.0 - 1.5 mEq/L, particularly in acute mania

The nurse on the surgical unit administers an incorrect dose of medication to the client. The nurse should take which of the following actions? Select all that apply: 1. Record the dose of medication administered. 2. Photocopy the incident report for the nurse's personal files. 3. Perform an assessment of the client. 4. Contact the physician. 5. Chart any adverse reaction the client experienced. 6. Submit the report to the risk manager within 48 hours.

Strategy: Determine the outcome of each answer 1) CORRECT— record the dose of medication administered and dose of medication ordered 2) do not make a copy because can be subpoenaed in court; nurse should keep a written account of incident for personal files 3) CORRECT— assess and factually record client's response 4) CORRECT— record any action taken by physician 5) CORRECT— record factually; also record staff's response to adverse reaction 6) submit as soon as possible (within 24 hours)

Which of the following actions, if performed by a nurse, would be considered negligence? 1. The nurse does not aspirate before injecting heparin SQ into a patient's abdomen. 2. The nurse removes wrist restraints hourly and puts the patient's arm through passive range of motion. 3. The nurse checks the pedal pulses 2 hours after a patient returns from a cardiac catheterization. 4. The nurse administers a preoperative injection to a patient before removing the patient's dentures.

Strategy: Determine the outcome of each answer choice. 1) unnecessary to aspirate before giving the medication to prevent bruising; negligence is the unintentional failure of nurse to perform an act that a reasonable person would or would not perform in similar circumstances; can be act of commission or omission 2) acceptable procedure to maintain range of motion while a patient is in restraints; re-evaluate the need for restraints 3) CORRECT— checking the pedal pulses after a cardiac catheterization should be done immediately after the procedure and repeated every 15 minutes for several hours to detect changes in circulation; act of omission 4) acceptable procedure to prepare a patient for surgery; standards of care are the actions that other nurses would do in the same or similar circumstances that provide for quality client care

An adult client is to receive heparin sodium (Heparin) 5,000 units subcutaneously. Which of the following techniques should be used by the nurse to administer this medication? 1. Gently massage the injection site. 2. Do not aspirate after inserting the needle. 3. Use a 1-inch, 18- to 20-gauge needle. 4. Administer the medication in the deltoid muscle.

Strategy: Determine the outcome of each answer choice. Is it desired? 1) site should not be massaged; causes bruising 2) CORRECT— aspirating the syringe with a subcutaneous heparin solution can cause bruising 3) incorrect needle size for subcutaneous injection; should use 25- to 27-gauge 3/8- to 5/8-inch needle 4) should be given in abdomen

The nurse cares for clients on the psychiatric unit. A patient yells that nobody cares for her and throws her lunch tray at a group of patients. Which of the following actions should the nurse take FIRST? 1. Instruct the client to stop yelling and throwing things. 2. Remove the client from the lunchroom. 3. Ask the client why she is upset. 4. Administer a PRN sedative.

Strategy: Determine the outcome of each answer. 1) is important to set limits, but priority is to remove client so no one will be hurt 2) CORRECT— when client becomes violent, intercede early; nurse should continue nonthreatening behavior, get help, tell client that you will not permit the client to harm herself or others 3) do not ask why questions 4) use least restrictive methods available to control client

The nurse discovers a visitor on the floor of the waiting room in the outpatient clinic. The elderly woman is unconscious and not breathing. Which of the following actions should the nurse take FIRST? 1. Lift the back of the woman's neck and check her airway. 2. Move the lower jaw backward and push the tongue to the side. 3. Turn the woman's head to one side and shake her firmly. 4. Tilt the woman's head back and lift her chin.

Strategy: Determine the outcome of each answer. 1) not best way to position client to open airway 2) will not open airway 3) need to open airway 4) CORRECT— provides for airway; place hand on forehead, applying backward pressure, place fingers of other hand under chin and lift forward

The nurse develops a plan of care for a client diagnosed with dementia. It is MOST important for the nurse to include which of the following? 1. Reinforce the client's thought patterns. 2. Use simple, short phrases when speaking with the client. 3. Administer antianxiety medication. 4. Plan a regular exercise program.

Strategy: Determine the outcome of each answer. 1) reality orientation is important, don't reinforce client's altered thought processes 2) CORRECT— enhance client's ability to process information 3) may increase confusion 4) appropriate strategy to decrease anxiety

An RN arrives at work stating, "My throat hurts and I have a temperature of 99.5°F (38°C)." This RN is one of two RNs scheduled to work the shift with no additional support staff. Which of the following actions by the healthy nurse is MOST appropriate? 1. Refuse to work with the RN with the sore throat. 2. Recommend to the RN with the sore throat to obtain a throat culture before accepting an assignment. 3. Ask the charge nurse from the previous shift to send home the RN with the sore throat. 4. Arrange for coverage for the RN with the sore throat while a throat culture is obtained.

Strategy: Determine the outcome of each answer. 1) safety of patients is primary concern 2) RN with until group A Streptococcus cannot care for clients until 24 hours after receiving appropriate antibiotic therapy; recommendation allows nurse to assent or refuse; does not protect the patients 3) assess before implementing 4) CORRECT— protects the patients while a diagnosis is made; results of rapid test can be obtained in 10 minutes; if results are negative, RN can care for clients

The parents of a baby born with cleft lip and palate are struggling with shock, grief, and feelings of inadequacy and frustration. Which of the following statements is BEST for the nurse to make to the parents at this time? 1. "You should focus on your baby's personality, not appearance." 2. "Let me show you pictures of some babies before and after surgery." 3. "There are other problems with this condition that go beyond surgical correction." 4. "Has anyone else in either of your families had cleft lip or palate?"

Strategy: Determine the outcome of each answer. Is it desired? (1.) commanding in nature, and judgmental; does not allow for parents' expression of feelings and concerns; facial anomalies in a child are very visible and a severe shock to the parents when first seen (2.) CORRECT—addresses the immediate fears and concerns of the parents, who are in a state of crisis; offers concrete pictorial evidence of a brighter future for their child than they might otherwise have expected (3.) is a true statement, but could be frightening and discouraging to the parents at this time, particularly without having given them the reassurance that surgery can help deal with their immediate concern, the cosmetic situation (4.) genetic factors might be etiologic factor; family history of a cleft increases the risk of other children having a cleft; however, this is a history-taking question, information-based and not helpful at this point

The nurse receives report on a patient admitted to the unit with a new diagnosis of abdominal aortic aneurysm (AAA). When teaching the patient measures to reduce the risk of complications associated with AAA, the nurse should include which of the following? 1. Elevate the lower extremities above the level of the heart. 2. Encourage the patient to increase fluid intake and dietary fiber. 3. Teach the patient to utilize proper lifting techniques. 4. Advise the patient not to wear a seatbelt while driving.

Strategy: Determine the outcome of each answer. Is it desired? (1.) contraindicated; increases pressure in the aortic artery, which may increase the risk of rupture (2.) CORRECT—prevents constipation and the need for straining with bowel movements that may cause increased intra-abdominal pressure and risk of rupture (3.) instruct to not lift heavy objects which may increase intra-abdominal pressure and lead to rupture of the aneurysm (4.) never instruct a patient not to wear a seatbelt; increases likelihood of a fatality should the patient be involved in a motor vehicle collision

The nurse cares for a patient just returned from surgery after a right total knee replacement. It is MOST important for the nurse to take which of the following actions? 1. Change the surgical dressing immediately. 2. Assist the patient to ambulate in the room. 3. Encourage the patient to use the incentive spirometer three times per day. 4. Apply a sequential compression device to the patient's lower extremities.

Strategy: Determine the outcome of each answer. Is it desired? (1.) dressing is usually not changed for 24 to 48 hours; if becomes saturated or loosens during this time, it should simply be reinforced (2.) placed on bedrest initially and then activity will be increased as ordered by physician and tolerated by patient (3.) instruct to use the incentive spirometer every 1 to 2 hours (4.) CORRECT—improves circulation and prevents clot formation

The nurse on the psychiatric inpatient unit is notified in report of four admissions expected on that shift. There is only one private room available. Which of the following patients should the nurse admit to the private room? 1. A patient diagnosed with chronic undifferentiated schizophrenia. 2. A patient diagnosed with bipolar disorder in the manic phase. 3. A patient diagnosed with obsessive-compulsive disorder. 4. A patient diagnosed with major depression and suicidal ideation.

Strategy: Determine the outcome of each answer. Is it desired? (1.) patient does not need a private room; odd, disorganized, and restless behaviors, careless dress and appearance, and fragmented thought processes are not likely to harm patient or others and do not require intense monitoring or withdrawal from others (2.) CORRECT—patients experiencing mania need a quiet environment with decreased stimuli; a private room provides this as a refuge (and a staff time-out limit-setting opportunity) from the stimuli of other patients and from the unit as a whole (3.) does not need a private room; these patients' behavior is usually focused on themselves; it is unlikely to affect a roommate unless there were issues related to focus of the obsessive-compulsive disorder, such as cleanliness concerns with a shared bathroom (4.) does not need a private room; if anything, having a roommate could help patient feel less alone and also be safer should self-destructive behavior or suicidal thought be expressed at a time staff were not present

A patient came to the emergency department after witnessing a friend shot to death on her front balcony. The patient is shaking, crying, and states she feels very nervous. The nurse observes the patient to be severely anxious. The nurse's plan of care should include which of the following? Select all that apply: 1. Remain with the patient. 2. Contact the police to interview the patient. 3. Administer lorazepam (Ativan) 1 mg IM. 4. Encourage patient to describe the incident. 5. Provide privacy for the patient. 6. Write down important information.

Strategy: Determine the outcome of each answer. Is it desired? 1) CORRECT— always remain with the patient; assist patient to clarify thoughts and feelings 2) would escalate anxiety; assess and provide for patient's needs first; may provide physical care if necessary 3) CORRECT— antianxiety to assist client to cope with anxiety; side effects include drowsiness, light-headedness, hypotension 4) may escalate anxiety; acknowledge client's distress and concerns about the problem 5) CORRECT— especially important if activities around the patient are overstimulating the patient 6) CORRECT— may have difficulty listening to and understanding information if anxiety is severe

The nurse performs teaching for a patient receiving amitriptyline hydrochloride (Elavil). The nurse should intervene if the patient makes which of the following statements? Select all that apply: 1. "I will take Elavil at bedtime." 2. "I always forget to wear sunscreen." 3. "I will stop eating cheese and yogurt." 4. "It may be 3 to 4 weeks before I feel better." 5. "When I start to feel better, I can adjust the dosage of Elavil." 6. "I can exercise as soon as I wake up in the morning."

Strategy: Determine the outcome of each answer. Is it desired? 1) appropriate action; has a sedative effect; other side effects include blurred vision, dry mouth, diaphoresis, postural hypotension, palpitations, constipation, urinary retention, increased appetite 2) CORRECT— sunblock required 3) CORRECT— true of MAO inhibitors (Nardil, Marplan); foods containing tyramine may cause hypertension 4) true statement; takes 3-4 weeks to achieve therapeutic level and see changes in mood 5) CORRECT— patient should never adjust dosage of medication without consulting a physician 6) CORRECT— may cause orthostatic hypotension; instruct client to sit on side of bed before arising in the morning

The nurse evaluates care provided by the staff on the medical/surgical unit. The nurse determines that care of a patient diagnosed with HIV is appropriate if which of the following is observed? 1. The LPN wears a protective gown when entering the patient's room. 2. The nursing assistant uses sterile sheets to make the patient's bed. 3. The nursing staff wears gloves when exposed to the patient's secretions. 4. The family wears gown, gloves, and mask when entering the patient's room.

Strategy: Determine the outcome of each answer. Is it desired? 1) not necessary to wear gown into room; use nonsterile gowns if patient care activities are likely to generate splashes and sprays 2) no reason to use sterile sheets 3) CORRECT— use standard precautions when caring for client 4) not necessary

The home care nurse visits a client diagnosed with dementia. The client lives with a son and his family. The nurse identifies which stressor is MOST critical to the family? 1. The client is unwilling to eat with the family. 2. The client does not recognize family members. 3. The family is not aware of community resources available to them. 4. The client is incontinent.

Strategy: Discrimination is required to answer the question. 1) offer finger foods that client can walk with 2) CORRECT— confirms a deteriorating condition and increases the feelings of loss among the family members 3) making family aware of community resources is important, but dealing with a parent who does not recognize family members is more stressful 4) adds to the stress; toilet early in morning, after meals and snack, and before bedtime

The nurse learns that a client recovering from a rhinoplasty is being transferred from recovery to the medical/surgical unit. The nurse determines that the client's room assignment is appropriate if the client is placed in a room with which of the following clients? 1. A client with infected decubitus ulcers. 2. A client diagnosed with pneumonia. 3. A client with wired jaws because of a mandibular fracture. 4. A client diagnosed with osteomyelitis.

Strategy: Place noninfected clients with noninfected clients. 1) not appropriate because the surgical client is considered "clean" 2) not appropriate because of infection 3) CORRECT— place "clean" client with "clean" client 4) infection of bone; not an appropriate placement

The nurse cares for a teenager admitted for burns to 50% of her body. Which of the following actions by the nurse has highest priority? 1. Counsel patient regarding body image changes. 2. Maintain airborne precautions. 3. Maintain aseptic technique during procedures. 4. Encourage the teen's friends to visit regularly.

Strategy: Remember Maslow. 1) physical needs take priority over psychosocial needs 2) cap, gown, mask, and gloves worn by nurse to protect patient 3) CORRECT— patient is at high risk for infection; use careful sterile technique when performing wound care 4) important for an adolescent but more important to maintain aseptic technique

The nurse plans care for an adult woman admitted with toxic shock syndrome. The nurse is MOST concerned if the client states which of the following? 1. "I am very frightened of doctors and hospitals." 2. "I vomited 12 times in the past 24 hours." 3. "I have abdominal pain and pressure." 4. "I use extra-absorbent tampons."

Strategy: Remember Maslow. 1) psychosocial need; not most important 2) CORRECT— physical need; would lead to fluid volume deficit; fluids lost due to vomiting and diarrhea; symptoms of toxic shock syndrome include fever of sudden onset, hypotension, rash 3) psychosocial need; not most important; fluid volume deficit priority 4) teaching need; not most important; instruct about prevention: change tampon every 3-6 hours, don't use extra-absorbent tampons, use sanitary napkins at night; fluid volume deficit takes priority

The nurse finds a visitor slumped to the floor of a patient's room during visiting hours at the hospital. INITIALLY, the nurse should take which of the following actions? 1. Start rescue breathing and chest compressions. 2. Call for help. 3. Shake the patient and shout, "Are you all right?" 4. Listen for breath sounds.

Strategy: Remember the nursing process. 1) implementation; need to assess first 2) implementation; need to assess first 3) CORRECT— assess unconsciousness; open airway with head tilt of chin lift (jaw thrust if neck injury is suspected); look, listen, and feel for signs of breathing 4) assessment, but should not be done first

A client diagnosed with acute streptococcal glomerulonephritis (ASGN) visits the nurse at the university health center. The client is receiving captopril (Capoten) 25 mg PO and is concerned about side effects. Which of the following responses by the nurse is BEST? 1. "Where did you get this information?" 2. "What are your concerns?" 3. "You need to continue with the medication." 4. "This is the best medication for you."

Strategy: Remember therapeutic communication. 1) important to determine if client is making decisions based on valid information; not the priority response 2) CORRECT— allows client to verbalize concerns so that nurse can give client appropriate information to make an informed decision 3) client has the right to refuse treatment but should be given appropriate information 4) may be a true statement but nurse should further assess client's concerns

A client has a neurogenic bladder following a spinal cord injury. In planning a bladder training program, the nurse anticipates the physician will prescribe which of the following medications? 1. Diphenhydramine (Benadryl). 2. Diazepam (Valium). 3. Dicyclomine (Bentyl). 4. Bethanechol (Urecholine).

Strategy: Think about the action of each drug. 1) antihistamine; promotes urinary retention 2) antianxiety medication; may cause nausea, but no change to urinary system 3) anticholinergic; promotes urinary retention 4) CORRECT— cholinergic or parasympathomimetic used to treat functional urinary retention; mimics action of acetylcholine

The clinic nurse anticipates the arrival of a Navajo Native American client for follow-up care regarding type 2 diabetes. When planning care for the client, the nurse should expect which behavior? 1. The client may not arrive at the appointed time. 2. The client may be noncompliant with medication. 3. The client may complain about dietary restrictions. 4. The client may offer a firm handshake.

Strategy: Think about each answer. (1.) CORRECT—Native Americans are present oriented and do not live by the clock (2.) do accept Western medicine along with traditional remedies (3.) silent and reserved, more attuned to listening and observing body language (4.) handshaking is considered aggressive; instead, a passing of the hands may occur

A patient comes to the emergency room with a possible pneumothorax. The nurse should assess for which of the following? 1. Rapid respirations. 2. Deep, rapid respirations. 3. Respiratory depression. 4. Periods of hyperpnea alternating with periods of apnea.

Strategy: Think about each answer. 1) CORRECT— describes tachypnea 2) hyperpnea; causes include metabolic acidosis, diabetic ketoacidosis 3) occurs with drug overdose 4) Cheyne-Stokes respirations; crescendo breathing; cause is cerebral lesion

When providing care for a client over the age of 65 years, the nurse knows that which of the following is the MOST reliable sign of infection? 1. Fever. 2. Hypotension. 3. Leukocytosis. 4. Tachypnea.

Strategy: Think about each answer. 1) absent in 25 to 30% of clients 2) is not a sign of infection 3) more than 20% of elderly clients with infection may present without leukocytosis 4) CORRECT— tachycardia, tachypnea, and confusion may be signs of infection in elderly patients

The nurse evaluates care for an elderly client diagnosed with disseminated herpes zoster. The nurse should intervene if which of the following is observed? 1. A nursing assistant wears an N-95 mask when entering the room. 2. The phlebotomist leaves the door open when leaving the room. 3. The client is placed in a room with negative air pressure. 4. The LPN/LVN removes the gown before leaving the client's room.

Strategy: Think about each answer. 1) appropriate action; disseminated herpes zoster requires both airborne and contact precautions 2) CORRECT— keep door closed at all times 3) appropriate action for airborne precautions 4) appropriate action

A client at 16 weeks' gestation asks the clinic nurse what her baby looks like at this point in the pregnancy. Which of the following responses by the nurse is BEST? 1. "Your baby has a heart beat and its arms and legs are just starting to form." 2. "Your baby can hear and breathe at this point." 3. "Your baby likes to suck his or her thumb and weighs about 1/2 pound." 4. "We can tell if you are having a boy or a girl and the heart has formed."

Strategy: Think about each answer. 1) describes fetal development at 8 weeks 2) able to hear at 38 weeks; lungs acquire definitive shape at 12 weeks 3) at 20 weeks the fetus can suck and weighs approximately 11+ ounces 4) CORRECT— intestines begin to collect meconium, lanugo present on body, transparent skin with visible blood vessels

The nurse administers carbamazepine (Tegretol) to a client for trigeminal neuralgia (tic douloureux). The nurse knows that the therapeutic effect of this medication is to 1. relieve accompanying depression. 2. reduce the possibility of grand mal seizures. 3. relieve the agonizing pain. 4. provide sedation effects.

Strategy: Think about each answer. 1) may occur as a result of the diminished pain, but is not the primary purpose of giving Tegretol 2) grand mal seizures are not associated with tic douloureux 3) CORRECT— agonizing pain of tic douloureux may result in severe depression and suicide; Tegretol inhibits nerve impulses and reduces the pain of the condition 4) may occur as a result of the diminished pain, but is not the primary purpose of giving Tegretol

The nurse cares for a client diagnosed with Korsakoff's psychosis. The nurse should assess for which of the following? 1. Seizures. 2. Diplopia. 3. Nystagmus. 4. Confabulation.

Strategy: Think about each answer. 1) not seen with Korsakoff's psychosis 2) symptom of Wernicke's syndrome, form of dementia that results from thiamine deficiency 3) indicates Wernicke's syndrome 4) CORRECT— in order to fill memory gaps, client invents elaborate, improbable happenings

The nurse assesses a client during the client's first prenatal visit. The nurse determines that the client is at 6 weeks' gestation. The nurse identifies which of the following as a probable sign of pregnancy? 1. Amenorrhea. 2. Positive urine pregnancy test. 3. Urinary frequency. 4. Fetal heart tone auscultated by Doppler.

Strategy: Think about each answer. 1) presumptive sign of pregnancy; presumptive signs are felt by the woman, such as nausea/vomiting, breast sensitivity, fatigue, quickening 2) CORRECT— probable signs are observed by the examiner; uterine enlargement, souffle and contractions, positive urine pregnancy test, Hegar's sign, Chadwick's sign 3) presumptive sign; can also be caused by UTI 4) positive sign of pregnancy; palpation of fetal movement; sonogram of fetus

Which of the following behaviors should the nurse be alert for if a client has been taking fluoxetine (Prozac) for 4 weeks? 1. Anger and sarcasm. 2. Suicidal behavior. 3. Withdrawal from reality. 4. Waking early in the morning.

Strategy: Think about each answer. 1) seen in clients with elation or mania 2) CORRECT— Prozac is a selective serotonin reuptake inhibitor (SSRI), which takes about 4 weeks for full effect; be aware of suicidal tendencies 3) occurs with psychosis; Prozac is an antidepressant 4) causes drowsiness or insomnia

A nurse cares for children in the pediatric clinic. A mother tells the nurse that she thinks her 8 year-old son has attention deficit hyperactivity disorder (ADHD). Which of the following behaviors, if identified by the nurse, supports a diagnosis of ADHD? Select all that apply: 1. When asked to sit in the waiting room, the child wanders in the hallway. 2. The child quietly looks at a book while his mother talks to the nurse. 3. The child looks out the window when the nurse is talking to him. 4. During the visit with the nurse, the child repeatedly demands to leave. 5. The mother reports that her son independently completes his homework 6. The mother states that her son was "always on the go as a toddler."

Strategy: Think about each behavior and how it relates to ADHD. 1) CORRECT— not following directions and leaving seat when remaining seated is expected is indicative of ADHD 2) indicates that child is able to attend and follow directions 3) CORRECT— child with ADHD often does not seem to listen when someone speaks directly to him/her 4) CORRECT— often interrupts or intrudes on others 5) child with ADHD has difficulty following through on instructions or finishing schoolwork 6) CORRECT— parents report that child is often on the go or acts as if driven by a motor

The charge nurse on the psychiatric unit observes that when a client is admitted with a history of sexual abuse, a certain nurse subtly, and sometimes overtly, verbally attacks the client. The charge nurse learns that the nurse was sexually abused as a child. When making assignments, the charge nurse should consider which of the following? 1. Assign the nurse to clients who have been sexually abused to promote therapeutic feedback to the client. 2. Assign the nurse to clients who have been sexually abused and request that the nurse begin therapy. 3. Assign the nurse to clients who do not have a history of sexual abuse because the nurse is able to interact therapeutically with these other clients. 4. Inform the nurse that she can no longer care for clients on the psychiatric unit because she has a history of being sexually abused.

Strategy: Think about the outcome of each answer 1) charge nurse should consider the abilities of each staff member; should not assign nurse to clients that the nurse is having difficulty caring for in a therapeutic way 2) nurse should receive counseling to deal with unresolved issues of the past 3) CORRECT— assign nurse to clients that she is able to deal with in a therapeutic way 4) not an appropriate action

The home care nurse assesses a client diagnosed with hypertension. The client's blood pressure is 180/100 mm Hg. The nurse questions the client about compliance with medication. Which of the following responses by the client indicates to the nurse that the client is taking the prescribed medication? 1. "I take my medication every morning. If my blood pressure is high, I take another dose in the evening." 2. "I take my medication every day at the same time regardless of how I feel. I have not missed any doses." 3. "I take my medication every day and make sure that I drink a large amount of liquid with each dose." 4. "If I miss the morning dose of medication, I take two pills in the evening."

Strategy: Think about what the words mean. 1) client should not add extra doses of medication 2) CORRECT— describes how antihypertensives should be taken; because the client is taking medication appropriately, health care provider should be notified 3) important to monitor fluid balance 4) should take medication as prescribed

The nurse cares for a 17-year-old girl diagnosed with cancer receiving chemotherapy. Which of the following statements indicates to the nurse that the client has a realistic perception of her health status? 1. "I will be cured after my therapy is complete." 2. "I have started buying scarves of different colors." 3. "I will be carrying a full load of classes this semester." 4. "I must have done something to cause this illness."

Strategy: Think about what the words mean. 1) may or may not happen 2) CORRECT— indicates the client is realistic about what may happen because of chemotherapy; obtains wig, scarves, or hats before losing hair 3) not realistic; weakness and fatigue are common side effects of chemotherapy 4) indicates blame and guilt