Saunders Pre-Test Mode 75 Questions

The nurse is reviewing the health care provider's prescriptions for a client with Ménière's disease. Which diet would most likely be prescribed for the client? 1.Low-fat diet 2.Low-sodium diet 3.Low-cholesterol diet 4.Low-carbohydrate diet

2 Rationale: Dietary changes such as salt and fluid restrictions that reduce the amount of endolymphatic fluid are sometimes prescribed for a client with Ménière's disease. The diets in the remaining options are not specific to the client with Ménière's disease. Priority Concepts: Nutrition, Safety Test-Taking Strategy: Note the strategic words, most likely. Focus on the subject, the diet for the client with Ménière's disease. Recalling the pathophysiology related to Ménière's disease will direct you to option 2.

The nurse is preparing to give a bed bath to an immobilized client with tuberculosis. The nurse should wear which items when performing this care? 1.Surgical mask and gloves 2.Particulate respirator, gown, and gloves 3.Particulate respirator and protective eyewear 4.Surgical mask, gown, and protective eyewear

2 Rationale: The nurse who is in contact with a client with tuberculosis should wear an individually fitted particulate respirator. The nurse also would wear gloves as per standard precautions. The nurse wears a gown when the possibility exists that the clothing could become contaminated, such as when giving a bed bath. Priority Concepts: Infection, Safety Test-Taking Strategy: Focus on the subject, precautions when caring for the client with tuberculosis. Think about the nurse's task, a bed bath. Knowing that the nurse should wear a particulate respirator eliminates options 1 and 4. Knowledge of basic standard precautions directs you to the correct option

A nursing graduate is attending an agency orientation regarding the nursing model of practice implemented in the health care facility. The nurse is told that the nursing model is a team nursing approach. The nurse determines that which scenario is characteristic of the team-based model of nursing practice? 1.Each staff member is assigned a specific task for a group of clients. 2.A staff member is assigned to determine the client's needs at home and begin discharge planning. 3.A single registered nurse (RN) is responsible for providing care to a group of 6 clients with the aid of an unlicensed assistive personnel (UAP). 4.An RN leads 2 licensed practical nurses (LPNs) and 3 UAPs in providing care to a group of 12 clients.

4 Rationale: In team nursing, nursing personnel are led by a registered nurse leader in providing care to a group of clients. Option 1 identifies functional nursing. Option 2 identifies a component of case management. Option 3 identifies primary nursing (relationship-based practice). Priority Concepts: Care Coordination, Collaboration Test-Taking Strategy: Focus on the subject, team nursing. Keep this subject in mind and select the option that best describes a team approach. The correct option is the only one that identifies the concept of a team approach

The nurse assists a pregnant client with cardiac disease to identify resources to help her care for her 18-month-old child during the last trimester of pregnancy. The nurse encourages the pregnant client to use these resources primarily for which reason? 1.Reduce excessive maternal stress and fatigue. 2.Help the mother prepare for labor and delivery. 3.Avoid exposure to potential pathogens and resulting infections. 4.Prepare the 18-month-old child for maternal separation during hospitalization.

1 Rationale: A variety of factors can cause increased emotional stress during pregnancy, resulting in further cardiac complications. The client with known cardiac disease is at greater risk for such complications. The use of resources will assist the client to avoid emotional stress, thus reducing additional cardiac compromise during the last trimester. These resources are not intended to minimize potential risk of maternal infection or prepare the client and family for the subsequent labor, delivery, and hospitalization. Priority Concepts: Perfusion, Stress Test-Taking Strategy: Focus on the subject, identifying resources for a pregnant client with cardiac disease. Focusing on the pathophysiology of the client's condition will assist in directing you to the correct option.

Allopurinol is prescribed for a client and the nurse provides medication instructions to the client. Which instruction should the nurse provide? 1.Drink 3000 mL of fluid a day. 2.Take the medication on an empty stomach. 3.The effect of the medication will occur immediately. 4.Any swelling of the lips is a normal expected response.

1 Rationale: Clients taking allopurinol are encouraged to drink 3000 mL of fluid a day, unless otherwise contraindicated. A full therapeutic effect may take 1 week or longer. Allopurinol is to be given with, or immediately after, meals or milk. A client who develops a rash, irritation of the eyes, or swelling of the lips or mouth should contact the health care provider because this may indicate hypersensitivity. Priority Concepts: Client Education, Safety Test-Taking Strategy: Focus on the subject, client instructions for allopurinol. Option 4 can be eliminated easily because it indicates hypersensitivity, which is not a normal expected response. From the remaining options, recalling that this medication is used to treat gout and recalling the pathophysiology of this disorder will direct you to the correct option.

The nurse is caring for a client after a craniotomy and monitors the client for signs of increased intracranial pressure (ICP). Which finding, if noted in the client, would indicate an early sign of increased ICP? 1.Confusion 2.Bradycardia 3.Sluggish pupils 4.A widened pulse pressure

1 Rationale: Early manifestations of increased ICP are subtle and often may be transient, lasting for only a few minutes in some cases. These early clinical manifestations include episodes of confusion, drowsiness, and slight pupillary and breathing changes. Later manifestations include a further decrease in the level of consciousness, a widened pulse pressure, and bradycardia. Cheyne-Stokes respiratory pattern, or a hyperventilation respiratory pattern, and pupillary sluggishness and dilatation appear in the late stages. Priority Concepts: Clinical Judgment, Intracranial Regulation Test-Taking Strategy: Note the strategic word, early. Recalling that the earliest indicator of increased ICP is changes in level of consciousness will direct you to the correct option.

The nurse is lecturing to a group of women who are at high risk for osteoporosis. The nurse should inform the women about which most important measure? 1.Limit caffeine intake. 2.Limit intake of vitamin D. 3.Limit participation in activities such as walking and swimming. 4.Limit protein in the diet because it contributes to the incidence of bone demineralization.

1 Rationale: Excessive caffeine intake can increase calcium loss in the urine. Protein deficiency may contribute to the incidence of bone demineralization. Activities such as walking and swimming may be beneficial and are appropriate to reduce the risk of fracture. Adequate vitamin D intake is necessary for the metabolism of calcium. Priority Concepts: Client Education, Health Promotion Test-Taking Strategy: Note the strategic words, most important. Vitamin D is essential for calcium metabolism and should not be limited, so this option can be eliminated. Exercise, particularly walking, is encouraged, so limiting activities can also be eliminated. Protein is necessary to prevent bone demineralization, so limiting protein is also eliminated. The remaining option is the correct answer.

A 2-year-old boy with a diagnosis of hemophilia is admitted to the hospital with bleeding into the joint of the right knee. Which intervention should the nurse plan to implement with this child? 1.Measure the injured knee joint every shift. 2.Take the temperature by rectal method only. 3.Administer acetylsalicylic acid for pain control. 4.Immobilize the joint and apply moist heat to the joint.

1 Rationale: Interventions for bleeding into the joint include measuring the injured joint to assess for progression of the bleeding. This provides objective rather than subjective data, which are needed to determine if the bleeding is increasing. Rectal temperatures can cause tissue trauma, causing further bleeding. The application of heat and the administration of acetylsalicylic acid will increase bleeding. Priority Concepts: Clotting, Safety Test-Taking Strategy: Focus on the subject, interventions for joint bleeding. Focus on the child's diagnosis. Options 3 and 4 should be eliminated because they both increase bleeding. Option 2 also should be eliminated because taking rectal temperatures can cause tissue trauma and further bleeding. Also note the closed-ended word only in this option

The nurse is performing an admission assessment on a child with a seizure disorder. The nurse is interviewing the child's parents to determine their adjustment to caring for their child, who has a chronic illness. Which statement, if made by the parents, would indicate a need for further teaching? 1."Our child sleeps in our bedroom at night." 2."We worry about injuries when our child has a seizure." 3."Our child is involved in a swim program with neighbors and friends." 4."Our babysitter just completed cardiopulmonary resuscitation training."

1 Rationale: Parents are especially concerned about seizures that might go undetected during the night. The nurse needs to decrease parental overprotection and should suggest the use of a baby monitor at night. Involvement in a swim program and knowing CPR identify parental understanding of the disorder. Worrying about injuries when a child has a seizure is a common concern. The parents need to be reminded that as the child grows, they cannot always observe their child, but their knowledge of seizure activity and care is appropriate to minimize complications Priority Concepts: Family Dynamics, Intracranial Regulation Test-Taking Strategy: Note the strategic words need for further teaching. These words indicate a negative event query and ask you to select an option that is an incorrect statement. Recall that parental overprotection needs to be discouraged. The correct option identifies a need to provide the parents with an alternate manner to monitor for night seizures.

The nurse is preparing to care for a client who will be weaned from a cuffed tracheostomy tube. The nurse is planning to use a tracheostomy plug and plans to insert it into the opening in the outer cannula. Which nursing action is required before plugging the tube? 1.Deflate the cuff on the tube. 2.Place the inner cannula into the tube. 3.Ensure that the client is able to speak. 4.Ensure that the client is able to swallow

1 Rationale: Plugging a tracheostomy tube is usually done by inserting the tracheostomy plug (decannulation stopper) into the opening of the outer cannula. This closes off the tracheostomy, and airflow and respiration occur normally through the nose and mouth. When plugging a cuffed tracheostomy tube, the cuff must be deflated. If it remains inflated, ventilation cannot occur, and respiratory arrest could result. A tracheostomy plug could not be placed in a tracheostomy if an inner cannula was in place. The ability to swallow or speak is unrelated to weaning and plugging the tube. Priority Concepts: Gas Exchange, Safety Test-Taking Strategy: Focus on the subject, care of the client with a tracheostomy, and note the word required in the question. Think about the structure and function of a tracheostomy tube. Recalling that an inflated cuff would cause airway obstruction will assist in directing you to the option that addresses a priority physiological need.

The nurse is changing the central line dressing of a client receiving parenteral nutrition (PN) and notes that the catheter insertion site appears reddened. The nurse should next assess which item? 1.Client's temperature 2.Expiration date on the bag 3.Time of last dressing change 4.Tightness of tubing connections

1 Rationale: Redness at the catheter insertion site is a possible indication of infection. The nurse would next assess for other signs of infection. Of the options given, the temperature is the next item to assess. The tightness of tubing connections should be assessed each time the PN is checked; loose connections would result in leakage, not skin redness. The expiration date on the bag is a viable option, but this also should be checked at the time the solution is hung and with each shift change. The time of the last dressing change should be checked with each shift change. Priority Concepts: Clinical Judgment, Infection Test-Taking Strategy: Note the strategic word, next. This question requires that you prioritize based on the information provided in the question. Also note the relationship between site appears reddened in the question and the word temperature in the correct option. Focusing on the subject of infection will direct you to the correct option

A client has a cerebellar lesion. The nurse should plan to obtain which item for use by the client? 1.Walker 2.Slider board 3.Raised toilet seat 4.Adaptive eating utensils

1 Rationale: The cerebellum is responsible for balance and coordination. A walker would provide stability for the client during ambulation. A slider board would be used in transferring a client with weak or paralyzed legs from a bed to a stretcher or wheelchair. A raised toilet seat would be useful if the client did not have sufficient mobility or ability to flex the hips. Adaptive eating utensils would be beneficial if the client had partial paralysis of the hand. Priority Concepts: Functional Ability, Intracranial Regulation Test-Taking Strategy: Focus on the subject, the function of the cerebellum. Recalling that the cerebellum controls balance and coordination will assist in eliminating options 2 and 3. Regarding the remaining choices, recall that adaptive eating utensils are useful with loss of fine motor coordination, such as after a stroke. The walker would help the client maintain balance

A client involved in a motor vehicle crash presents to the emergency department with severe internal bleeding. The client is severely hypotensive and unresponsive. The nurse anticipates that which intravenous (IV) solution will most likely be prescribed? 1.5% dextrose in lactated Ringer's 2.0.33% sodium chloride (⅓ normal saline) 3.0.225% sodium chloride (¼ normal saline) 4.0.45% sodium chloride (½ normal saline)

1 Rationale: The goal of therapy with this client is to expand intravascular volume as quickly as possible. The 5% dextrose in lactated Ringer's solution (hypertonic solution) would increase intravascular volume and immediately replace lost fluid volume until a transfusion could be administered, resulting in an increase in the client's blood pressure. The solutions in the remaining options would not be given to this client because they are hypotonic solutions and, instead of increasing intravascular space, would move into the cells via osmosis. Priority Concepts: Fluid and Electrolyte Balance, Perfusion Test-Taking Strategy: Focus on the subject, that the client requires increased intravascular volume. Also, note the strategic words, most likely. Recalling IV fluid types and how hypotonic and hypertonic solutions function within the intravascular space will direct you to the correct option.

The home care nurse is providing safety instructions to the mother of a child with hemophilia. Which instruction should the nurse include to promote a safe environment for the child? 1.Eliminate any toys with sharp edges from the child's play area. 2.Allow the child to use play equipment only when a parent is present. 3.Allow the child to play indoors only, and avoid any outdoor play or playgrounds. 4.Place a helmet and elbow pads on the child every day as soon as the child awakens.

1 Rationale: The nurse should instruct the mother to remove toys with sharp edges that may cause injury from the child's play area. It is not necessary to restrict play if safety measures have been implemented. It is not necessary that the child be restricted from outdoor play activity, but the activities that the child participates in should be monitored. Requiring that the child wear a helmet and elbow pads immediately on awakening and throughout the day is not necessary; however, these items should be worn during activities that could cause injury. Priority Concepts: Clinical Judgment, Clotting Test-Taking Strategy: Eliminate options 2 and 3 first because of the closed-ended word only. Next, eliminate option 4 because of the closed-ended word every.

The nurse provides home care instructions to a client with systemic lupus erythematosus and tells the client about methods to manage fatigue. Which statement by the client indicates a need for further instruction? 1."I should take hot baths because they are relaxing." 2."I should sit whenever possible to conserve my energy." 3."I should avoid long periods of rest because it causes joint stiffness." 4."I should do some exercises, such as walking, when I am not fatigued."

1 Rationale: To help reduce fatigue in the client with systemic lupus erythematosus, the nurse should instruct the client to sit whenever possible, avoid hot baths (because they exacerbate fatigue), schedule moderate low-impact exercises when not fatigued, and maintain a balanced diet. The client is instructed to avoid long periods of rest because it promotes joint stiffness. Priority Concepts: Client Education, Immunity Test-Taking Strategy: Note the strategic words, need for further instruction. These words indicate a negative event query and the need to select the incorrect client statement. Also, focus on the subject, fatigue. This will assist in directing you to the correct option as the action that would exacerbate fatigue.

The nurse is conducting an interview of an older client and is concerned about the possibility of benign prostatic hyperplasia (BPH). Which are characteristics of this disorder? Select all that apply. 1.Nocturia 2.Incontinence 3.Enlarged prostate 4.Nocturnal emissions 5.Decreased desire for sexual intercourse

1,2,3 Rationale: Nocturia, incontinence, and an enlarged prostate are characteristics of BPH and need to be assessed for in all male clients over 50 years of age. Nocturnal emissions are commonly associated with prepubescent males. Low testosterone levels (not BPH) may be associated with a decreased desire for sexual intercourse. Priority Concepts: Clinical Judgment, Elimination Test-Taking Strategy: Focus on the subject, characteristics of BPH. Thinking about the pathophysiology associated with this disorder will assist you in answering correctly.

A girl who is playing in the playroom experiences a tonic-clonic seizure. During the seizure, the nurse should take which actions? Select all that apply. 1.Remain calm. 2.Time the seizure. 3.Ease the child to the floor. 4.Loosen restrictive clothing. 5.Keep the child on her back.

1,2,3,4 Rationale: When a child is having a seizure, the nurse should remain calm, time the seizure, ease the child to the floor if the child is standing or seated, keep the child on the side (to prevent aspiration), and loosen restrictive clothing. Priority Concepts: Intracranial Regulation, Safety Test-Taking Strategy: Focus on the subject, interventions if the client is having a seizure. Visualize each of the actions in the options. Eliminate option 5 because the child should be kept on her side during a seizure to prevent aspiration

The nurse recognizes which assessment and diagnostic data as being associated with a newly diagnosed schizophrenic client? Select all that apply. 1.A birthday of March 30 2.A loss of interest in hobbies 3.A suicide attempt 6 months ago 4.Adopted by family at age 14 months 5.Brain scan shows increased blood flow to the frontal lobes 6.Magnetic resonance imaging shows temporal lobe atrophy

1,2,3,6 Rationale: A late winter, early spring birthday (viral theory); apathy and anhedonia (the inability to experience pleasure from activities usually found enjoyable); suicidal ideations; and atrophy of brain tissue are all common to individuals exhibiting symptomatology of schizophrenia. Blood flow within the brain is generally decreased; no data support that adoption itself increases the risk for schizophrenia. Priority Concepts: Clinical Judgment, Psychosis Test-Taking Strategy: Focus on the subject, assessment and diagnostic data associated with schizophrenia. Thinking about the pathophysiology and current theories regarding causes associated with schizophrenia will assist in answering this item correctly.

The nurse is monitoring a client diagnosed with schizophrenia who demonstrates a dysfunctional affect. Which situation is congruent with inappropriate affect? 1.When told that a beloved pet has died, the client responds, "OK." 2.The client giggled while describing being physically abused as a child. 3.The client's facial expressions are unchanged during the entire admission process. 4.When staff members attempt to engage the client in conversation, the client only mumbles.

2 Rationale: An inappropriate affect refers to an emotional response to a situation that is incongruent with the tone of the situation. A flat affect is manifested as an immobile facial expression or blank look. A bizarre affect such as grimacing, laughing, and self-directed mumbling is marked when the client is unable to relate logically to the environment. A blunted affect is a minimal emotional response or outward affect that typically does not coincide with the client's inner emotions. Priority Concepts: Mood and Affect, Psychosis Test-Taking Strategy: Focus on the subject, dysfunctional affect. Select the option that demonstrates that the client's responses are inappropriate and incongruent with the situation.

The mother of a child with cystic fibrosis (CF) asks the clinic nurse about the disease. What should the nurse tell the mother about CF? 1.Transmitted as an autosomal dominant trait 2.A chronic multisystem disorder affecting the exocrine glands 3.A disease that causes the formation of multiple cysts in the lungs 4.A disease that causes dilation of the passageways of many organs

2 Rationale: CF is a chronic multisystem disorder that affects the exocrine glands. The mucus produced by these glands (particularly those of the bronchioles, small intestine, and pancreatic and bile ducts) is abnormally thick, causing obstruction of the small passageways of these organs. It is transmitted as an autosomal recessive trait. It does not cause the formation of multiple cysts in the lungs. Options 1, 3, and 4 are incorrect. Priority Concepts: Client Education, Gas Exchange Test-Taking Strategy: Focus on the subject, the characteristics of cystic fibrosis. Recalling that CF is a multisystem disorder will direct you to the correct option. Additionally, the correct option is the umbrella option.

The nurse has completed 5 cycles of compressions after beginning cardiopulmonary resuscitation (CPR) on a hospitalized adult client who experienced unmonitored cardiac arrest. What should the nurse plan to do next? 1.Prepare epinephrine. 2.Charge the defibrillator. 3.Check the client's heart rhythm. 4.Pause CPR for 20 seconds and reassess.

2 Rationale: For witnessed adult cardiac arrest when a defibrillator is immediately available, it is reasonable that the defibrillator be used as soon as possible. For adults with unmonitored cardiac arrest or for whom a defibrillator is not immediately available, it is reasonable that CPR be initiated while the defibrillator equipment is being retrieved and applied and that defibrillation, if indicated, be attempted as soon as the device is ready for use. After completing 5 cycles of compressions and ventilations, the nurse should reassess the client by checking the heart rhythm. Defibrillation may be warranted depending on the assessed rhythm. Epinephrine may be prepared depending on the rhythm, but this would be prescribed by a health care provider (HCP). Chest compressions should not be interrupted for more than 10 seconds. Priority Concepts: Clinical Judgment, Perfusion Test-Taking Strategy: Note the strategic word, next. Note first that the client is hospitalized. This tells you that support personnel and the HCP are available. Use knowledge of adult CPR procedures to make your selection. The nurse should continue CPR measures unless directed by the HCP to take a different intervention.

The nurse is preparing an intravenous (IV) infusion of phenytoin as prescribed by the health care provider for the client with seizures. Which solution should the nurse plan to use to dilute this medication? 1.Dextrose 5% 2.Normal saline solution 3.Lactated Ringer's solution 4.Dextrose 5% and half-normal saline (0.45%)

2 Rationale: IV infusion of phenytoin should be administered by injection into a large vein. The medication may be diluted in normal saline solution; however, dextrose solution should be avoided because of medication precipitation. The medication is administered as intermittent doses. Continuous IV infusions should not be used. Infusion rates of more than 50 mg/minute may cause hypotension or cardiac dysrhythmias, especially in older and debilitated clients. Priority Concepts: Clinical Judgment, Safety Test-Taking Strategy: Note the subject, safe and proper preparation of phenytoin. In most but not all situations, medications can be diluted in normal saline, so this would be the best option to select if you are unfamiliar with the IV administration of this medication.

A quantitative 72-hour fecal fat collection is prescribed by the health care provider. How should the nurse instruct the client to prepare for the specimen collection? 1.Use a wax container for the collection. 2.Consume a high-fat diet for 3 days before the test. 3.Avoid refrigeration of the specimen during the collection. 4.Take laxatives starting 2 days before the test for collection of an adequate specimen.

2 Rationale: In a qualitative test, a random stool specimen is collected for examination. In a quantitative test, all stools for a 72-hour period are collected and refrigerated. The presence of large amounts of fecal fat is suggestive of inadequate bile and pancreatic secretions. Wax containers should not be used for collection. Preparation for the test includes a high-fat diet for 3 days and avoidance of alcohol, castor oil, and other laxatives. Priority Concepts: Client Education, Elimination Test-Taking Strategy: Focus on the subject, client preparation for this laboratory test. Note the words quantitative and fecal in the question. Note the relationship between fecal fat in the question and high-fat diet in the correct option.

A child with sickle cell anemia who is in vaso-occlusive crisis is admitted to the hospital. Which health care provider prescription would assist in reversing the vaso-occlusive crisis? 1.Monitor pulse oximetry. 2.Begin intravenous fluids. 3.Administer oxygen by face mask. 4.Monitor vital signs and respiratory status.

2 Rationale: Increased fluid volume reduces the viscosity of the blood, preventing further vascular occlusion and further sickling caused by dehydration. Pulse oximetry and vital sign monitoring may be components of care, but they are actions that relate to monitoring the client versus treating. The intravenous fluids, however, will treat the condition. Vaso-occlusive crisis treatment includes analgesic and fluid administration. Oxygen may help relieve symptoms of respiratory distress, but analgesics and fluids treat the condition. Priority Concepts: Clinical Judgment, Fluid and Electrolyte Balance Test-Taking Strategy: Focus on the subject, reversing the vaso-occlusive crisis. Options 1, 3, and 4 can be eliminated because they all relate to the respiratory system and are monitoring actions rather than treatment options.

The nurse is caring for a client after pulmonary angiography with catheter insertion via the left groin. Which assessment finding is related to an allergic reaction to the contrast medium? 1.Hypothermia 2.Decreased blood pressure 3.Hematoma in the left groin 4.Discomfort in the left groin

2 Rationale: Signs of allergic reaction to the contrast dye include early signs such as localized itching and edema, which are followed by more severe symptoms such as respiratory distress, stridor, and decreased blood pressure. Hypothermia, discomfort in the left groin, and hematoma in the left groin are abnormal assessment findings but are not related to allergic reaction to the contrast medium. Priority Concepts: Clinical Judgment, Immunity Test-Taking Strategy: Focus on the subject, an allergic reaction. Hypothermia is an unrelated event and is eliminated first. Discomfort is expected and is eliminated next. Hematoma formation is a complication of the procedure but does not indicate allergic reaction and is therefore eliminated. The remaining option is decreased blood pressure, which is a sign of an allergic reaction.

A client with a diagnosis of anorexia nervosa, who is in a state of starvation, is in a 2-bed room. A newly admitted client will be assigned to this client's room. Which client would be the best choice as a roommate for the client with anorexia nervosa? 1.A client with pneumonia 2.A client undergoing diagnostic tests 3.A client who thrives on managing others 4.A client who could benefit from the client's assistance at mealtime

2 Rationale: The client undergoing diagnostic tests is an acceptable roommate. The client with anorexia nervosa is most likely experiencing hematological complications, such as leukopenia. Having a roommate with pneumonia would place the client with anorexia nervosa at risk for infection. The client with anorexia nervosa should not be put in a situation in which the client can focus on the nutritional needs of others or be managed by others because this may contribute to sublimation and suppression of personal hunger. Priority Concepts: Care Coordination, Safety Test-Taking Strategy: Note the strategic word, best, and note the words in a state of starvation in the question. Recalling the characteristics of anorexia nervosa and that the client is immunocompromised as a result of starvation will direct you to the correct option.

The home care nurse is making a visit to a client who requires use of a wheelchair after a spinal cord injury sustained 4 months earlier. Just before leaving the home, the nurse ensures that which intervention has been done to prevent an episode of autonomic dysreflexia (hyperreflexia)? 1.Updating the home safety sheet 2.Leaving the client in an unchilled area of the room 3.Noting a bowel movement on the client progress note 4.Recording the amount of urine obtained with catheterization

2 Rationale: The most common cause of autonomic dysreflexia is visceral stimuli, such as with blockage of urinary drainage or with constipation. Barring these, other causes include noxious mechanical and thermal stimuli, particularly pressure and overchilling. For this reason, the nurse ensures that the client is positioned with no pinching or pressure on paralyzed body parts and that the client will be sufficiently warm. Priority Concepts: Intracranial Regulation, Safety Test-Taking Strategy: Note the subject, preventing an episode of autonomic dysreflexia. This implies an action orientation on the part of the nurse. Each of the incorrect options contains an item related to documentation rather than an action to be taken by the nurse just before leaving

The client diagnosed with mild depression says to the nurse, "I haven't had an appetite at all for the last few weeks." Which response by the nurse best assesses the client's nutritional issue? 1."The last few weeks?" 2."You haven't had an appetite at all?" 3."Have patience, it will take time for your appetite to improve." 4."When the medication begins to work, your appetite will return."

2 Rationale: The therapeutic communication technique is restatement. Although it is a technique that has a prompting component to it, it repeats the client's major theme, which helps the nurse obtain a more specific perception of the problem from the client. The length of time is not as relevant as defining what the nutritional issue actually involves. The other options minimize the client's concerns about eating. Eliminate options that fails to focus on the nutritional issue or blocks the communication process by minimizing the client's concern. Priority Concepts: Communication, Mood and Affect Test-Taking Strategy: Note the strategic word best and focus on the subject, nutrition. Use the therapeutic communication techniques to answer the question. Eliminate any option that fails to focus on the nutritional issue or blocks the communication process by minimizing the client's concern

After initial assessment the nurse determines the need to place a restraint on a client. The client refuses application of the restraint. What is the best nursing action for this client? 1.Apply the restraint anyway. 2.Contact the health care provider (HCP). 3.Compromise with the client and then apply the restraint. 4.Medicate the client with a sedative and then apply the restraint.

2 Rationale: The use of restraints needs to be avoided if possible. If the nurse determines that a restraint is necessary, this should be discussed with the family and a prescription needs to be obtained from the HCP. The HCP's prescription protects the nurse from liability. The nurse should explain to the client and family the reasons why the restraint is necessary, the type of restraint selected, and the anticipated duration of restraint. If the nurse applied the restraint on a client who was refusing, the nurse could be charged with battery. Compromising with the client is unethical. Priority Concepts: Health Care Law, Health Care Quality Test-Taking Strategy: Use knowledge of principles and concepts related to ethical and legal issues. Note the strategic word, best. Eliminate options 1 and 4 first because they are comparable or alike. From the remaining options, eliminate option 3 because it is unethical.

The emergency department nurse is assessing a client who has sustained a blunt injury to the chest wall. Which finding indicates the presence of a pneumothorax in this client? 1.A low respiratory rate 2.Diminished breath sounds 3.The presence of a barrel chest 4.A sucking sound at the site of injury

2 Rationale: This client has sustained a blunt or closed-chest injury. Basic symptoms of a closed pneumothorax are shortness of breath and chest pain. A larger pneumothorax may cause tachypnea, cyanosis, diminished breath sounds, and subcutaneous emphysema. Hyperresonance also may occur on the affected side. A sucking sound at the site of injury would be noted with an open chest injury. Priority Concepts: Gas Exchange, Perfusion Test-Taking Strategy: Focus on the subject, a blunt chest injury. Noting the word blunt will assist in eliminating option 4, which describes a sucking chest wound injury. Knowing that in a respiratory injury increased respirations will occur will assist you in eliminating option 1. Option 3 can be eliminated because a barrel chest is a characteristic finding in a client with chronic obstructive pulmonary disease.

A home care nurse is assigned to visit a Hispanic American client to perform an admission assessment. On the initial meeting with the client, the nurse should plan to incorporate which social custom? 1.Avoid touching the client. 2.Greet the client with a handshake. 3.Smile and use humor throughout the entire admission assessment. 4.Avoid using affirmative nods during the conversations with the client.

2 Rationale: To demonstrate respect, compassion, and understanding, health care providers (HCPs) should greet Hispanic American clients with a handshake. On establishing rapport, providers may further demonstrate approval and respect through touch, smiling, and affirmative nods of the head. Because of the diversity of dialects and the nuances of language, use of culturally congruent use of humor is difficult to accomplish and therefore should be avoided. Priority Concepts: Communication, Culture Test-Taking Strategy: Focus on the subject, cultural communication patterns of Hispanic Americans. Remember that to demonstrate respect, compassion, and understanding, HCPs should greet Hispanic American clients with a handshake.

The nurse has a routine prescription to administer an injection of phytonadione (Vitamin K) to the newborn. Which statement made by the new mother indicates that teaching on this medication was effective? 1."I know that this medication is used to stimulate the liver to produce vitamin K." 2."I know that this medication is used to prevent clotting abnormalities in the newborn." 3."I know that this medication is used to prevent vitamin deficiency of fat-soluble vitamins." 4."I know that this medication is used to supplement my baby, because breast milk and formula are low in vitamin K."

2 Rationale: Vitamin K is given to the newborn to prevent clotting abnormalities. Vitamin K is usually produced by bacteria in the gastrointestinal tract, which is sterile in the newborn. The other options are incorrect reasons for administering this medication to a newborn Test-Taking Strategy: Note the strategic word, effective. Focus on the subject, the purpose of a vitamin K injection in a newborn. Thinking about the action and purpose of vitamin K will assist you in answering correctly

A postoperative client receives a dose of naloxone hydrochloride for respiratory depression shortly after transfer to the nursing unit from the postanesthesia care unit. After administration of the medication, the nurse should assess the client for which change? 1.Pupillary changes 2.Scattered lung wheezes 3.Sudden increase in pain 4.Sudden episodes of vomiting

3 Rationale: Naloxone hydrochloride is an antidote to opioids, and it also may be given to postoperative clients to treat respiratory depression. When given postoperatively for respiratory depression, it may reverse the effects of analgesics. Therefore, the nurse must assess the client for a sudden increase in level of postoperative pain. The remaining options are unrelated to the administration of naloxone. Priority Concepts: Clinical Judgment, Gas Exchange Test-Taking Strategy: Focus on the subject, naloxone hydrochloride. Recall that this medication is an antidote to opioid analgesics. Therefore, a sudden increase in pain in the postoperative client or a return of pain in the client who has received an opioid analgesic is likely

A nurse has provided dietary instructions to a client with Addison's disease. Which statement made by the client indicates that the client understands instructions? 1."I will decrease my carbohydrate intake." 2."High fat intake is essential with this disease." 3."I will maintain a normal sodium intake in my diet." 4."I will need to restrict the amount of protein in my diet."

3 Rationale: A high-complex carbohydrate, high-protein diet will be prescribed for the client with Addison's disease. To prevent excess fluid and sodium loss, the client is instructed to maintain a normal salt intake daily (3 g) and to increase salt intake during hot weather, before strenuous exercise, and in response to fever, vomiting, or diarrhea. A high-fat diet is not prescribed. Priority Concepts: Fluid and Electrolyte Balance, Nutrition Test-Taking Strategy: Focus on the subject, understanding of dietary teaching for the client with Addison's disease. Recall specific knowledge regarding the pathophysiology associated with Addison's disease to answer this question. Remember that a high-complex carbohydrate, high-protein diet with normal sodium intake is prescribed for the client with Addison's disease.

The nurse educator is conducting an in-service education session for the nurses employed in the eye and ear surgical unit of a large trauma center. In discussing the topic of cochlear implants, the educator notes that this surgical procedure is contraindicated in which client? 1.A client with bilateral profound hearing loss 2.A client who communicates primarily by speech 3.A client who became deaf before learning to speak 4.A client who received no benefit from conventional hearing aids

3 Rationale: Adults who were born deaf or became deaf before learning to speak usually are not candidates for this type of surgery. Criteria for a cochlear implant procedure are bilateral profound hearing loss, use of speech as the primary mode of communication, lack of benefit from conventional hearing aids, evidence of strong family and social support, and realistic client expectations for the outcome of the implant procedure. Priority Concepts: Communication, Sensory Perception Test-Taking Strategy: Focus on the subject, the surgical procedure, noting the word contraindicated. Recalling the purpose of a cochlear implant will direct you to the correct option.

A client with trigeminal neuralgia is being treated with carbamazepine, 400 mg orally daily. Which value indicates that the client is experiencing an adverse effect to the medication? 1.Sodium level, 140 mEq/L (140 mmol/L) 2.Uric acid level, 4.0 mg/dL (0.24 mmol/L) 3.White blood cell count, 3000 mm3 (3.0 × 109/L) 4.Blood urea nitrogen level, 10 mg/dL (3.6 mmol/L)

3 Rationale: Adverse effects of carbamazepine appear as blood dyscrasias, including aplastic anemia, agranulocytosis, thrombocytopenia, and leukopenia; cardiovascular disturbances, including thrombophlebitis and dysrhythmias; and dermatological effects. The low white blood cell count reflects agranulocytosis. The laboratory values in options 1, 2, and 4 are normal values. Priority Concepts: Clinical Judgment, Cellular Regulation Test-Taking Strategy: Focus on the subject, an adverse effect of carbamazepine. If you are familiar with normal laboratory values, you will note that the only option that indicates an abnormal value is the correct option

A client seen in the health care clinic for follow-up care is taking atorvastatin. The nurse should assess the client for which adverse effect of the medication? 1.Earache 2.Hearing loss 3.Photosensitivity 4.Lung congestion

3 Rationale: Atorvastatin is a reductase inhibitor (HMG-CoA reductase inhibitor) that is used to treat hypercholesterolemia and hypertriglyceridemia. Adverse effects include photosensitivity and the potential for developing cataracts. The symptoms in the remaining options are not side and adverse effects of this medication. Priority Concepts: Clinical Judgment, Safety Test-Taking Strategy: Focus on the subject, side and adverse effects of atorvastatin. It is necessary to know these side and adverse effects to answer correctly. Remember that adverse effects of this medication include photosensitivity and the potential for developing cataracts.

A 4-year-old child with acute glomerulonephritis is admitted to the hospital. The nurse identifies which client problem in the plan of care as the priority? 1.Infection related to hypertension 2.Injury related to loss of blood in urine 3.Excessive fluid volume related to decreased plasma filtration 4.Retarded growth and development related to a chronic disease

3 Rationale: Glomerulonephritis is a term that refers to a group of kidney disorders characterized by inflammatory injury in the glomerulus. The child with acute glomerulonephritis will have an excessive accumulation of water and retention of sodium, leading to circulatory congestion and edema. Excessive fluid volume would be a focus for this disease process. No risk for infection is associated with this disease; it is a postinfectious process, usually from a pneumococcal, streptococcal, or viral infection. Hematuria is present, but the loss of blood is not enough to constitute a risk for injury. The disease is acute as opposed to chronic, and almost all children recover completely. Priority Concepts: Clinical Judgment, Fluid and Electrolyte Balance Test-Taking Strategy: Note the strategic word, priority. Focus on the child's diagnosis. Recalling that the child with acute glomerulonephritis will have an excessive accumulation of water and retention of sodium will direct you to the correct option.

The nurse is developing a plan of care for a client who was experiencing anxiety after the loss of a job. The client is now verbalizing concerns regarding the ability to meet role expectations and financial obligations. What is the priority nursing problem for this client? 1.Anxiety 2.Unrealistic outlook 3.Lack of ability to cope effectively 4.Disturbances in thoughts and ideas

3 Rationale: Lack of ability to cope effectively may be evidenced by a client's inability to meet basic needs, inability to meet role expectations, alteration in social participation, use of inappropriate defense mechanisms, or impairment of usual patterns of communication. Anxiety is a broad description and can occur as a result of many triggers; although the client was experiencing anxiety, the client's concern now is the ability to meet role expectations and financial obligations. There is no information in the question that indicates an unrealistic outlook or disturbances in thoughts and ideas. Priority Concepts: Anxiety, Coping Test-Taking Strategy: Note the strategic word, priority. Focus on the subject, concerns regarding the ability to meet role expectations and financial obligations. Option 1 can be eliminated because the client was previously experiencing anxiety. Eliminate options 2 and 4 because there are no data in the question that address these problems.

A client with a history of myasthenia gravis presents at a clinic with bilateral ptosis and is drooling, and myasthenic crisis is suspected. The nurse assesses the client for which precipitating factor? 1.Getting too little exercise 2.Taking excess medication 3.Omitting doses of medication 4.Increasing intake of fatty foods

3 Rationale: Myasthenic crisis often is caused by undermedication and responds to the administration of cholinergic medications. Cholinergic crisis (the opposite problem) is caused by excess medication and responds to withholding of medications. Too little exercise and excessive fatty food intake are incorrect. Overexertion and overeating possibly could trigger myasthenic crisis Priority Concepts: Clinical Judgment, Safety Test-Taking Strategy: Focus on the subject, a precipitating factor for myasthenic crisis. Think about the pathophysiology associated with myasthenia gravis and myasthenic crisis. Recalling that myasthenia gravis is treated with medication will assist you in determining that undermedication is a common cause of myasthenic crisis. This will direct you to option 3.

The nurse is assessing a client's muscle strength. The nurse asks the client to hold the arms up and supinated, as if holding a tray, and then asks the client to close the eyes. The client's left hand turns and moves downward slightly. The nurse interprets this to mean that the client has which condition? 1.Ataxia 2.Nystagmus 3.Pronator drift 4.Hyperreflexia

3 Rationale: Pronator drift occurs when a client cannot maintain the hands in a supinated position with the arms extended and the eyes closed. This assessment may be done to detect small changes in muscle strength that might not otherwise be noted. Ataxia is a disturbance in gait. Nystagmus is characterized by fine, involuntary eye movements. Hyperreflexia is an excessive reflex action. Priority Concepts: Clinical Judgment, Functional Ability Test-Taking Strategy: Focus on the subject, techniques for assessing muscle strength. Looking at everyday meanings of words is a useful strategy that may help you with this question. The word drift means to move slightly or without effort; knowing this will assist in directing you to the correct option.

A client has been started on long-term therapy with rifampin. The nurse should provide which information to the client about the medication? 1.Should always be taken with food or antacids 2.Should be double-dosed if 1 dose is forgotten 3.Causes orange discoloration of sweat, tears, urine, and feces 4.May be discontinued independently if symptoms are gone in 3 months

3 Rationale: Rifampin causes orange-red discoloration of body secretions and will stain soft contact lenses permanently. Rifampin should be taken exactly as directed. Doses should not be doubled or skipped. The client should not stop therapy until directed to do so by a health care provider. It is best to administer the medication on an empty stomach unless it causes gastrointestinal upset, and then it may be taken with food. Antacids, if prescribed, should be taken at least 1 hour before the medication. Priority Concepts: Client Education, Safety Test-Taking Strategy: Options 2 and 4 are comparable or alike and are inaccurate, based on general guidelines for medication administration; the client should not double-dose or discontinue medication independently. Eliminate option 1 next because of the closed-ended word always.

The nurse is caring for a client in active labor. Which nursing intervention would be the best method to prevent fetal heart rate (FHR) decelerations? 1.Prepare the client for a cesarean delivery. 2.Monitor the FHR every 30 minutes. 3.Encourage an upright or side-lying maternal position. 4.Increase the rate of the oxytocin infusion every 10 minutes.

3 Rationale: Side-lying and upright positions such as walking, standing, and squatting can improve venous return and encourage effective uterine activity. Many nursing actions are available to prevent FHR decelerations, without necessitating surgical intervention. Monitoring the FHR every 30 minutes will not prevent FHR decelerations. The nurse should discontinue an oxytocin infusion in the presence of FHR decelerations, thereby reducing uterine activity and increasing uteroplacental perfusion. Priority Concepts: Perfusion, Reproduction Test-Taking Strategy: Note the strategic word, best. Focus on the subject, nursing intervention for preventing FHR decelerations. Options 1, 2, and 4 will not accomplish this goal. Side-lying and upright positions will encourage effective uterine activity.

A new registered nurse (RN) prepares to administer sodium polystyrene sulfonate to a client. Before administering the medication, the nurse reviews the action of the medication with another RN. Which statement by the new RN indicates that the teaching has been effective? 1."Bicarbonate is exchanged for primarily sodium ions." 2."Potassium ions are exchanged for primarily sodium ions." 3."Sodium ions are exchanged for primarily potassium ions." 4."Sodium ions are exchanged for primarily bicarbonate ions."

3 Rationale: Sodium polystyrene sulfonate is a cation exchange resin used for the treatment of hyperkalemia. The resin passes through the intestine or is retained in the colon. It releases sodium ions primarily in exchange for potassium ions. The therapeutic effect occurs 2 to 12 hours after oral administration and longer after rectal administration. Therefore, the remaining options are incorrect. Priority Concepts: Clinical Judgment, Fluid and Electrolyte Balance Test-Taking Strategy: Note the strategic word, effective. Focus on the subject, the action of sodium polystyrene sulfonate. Looking closely at the name of the medication, which includes the word sodium, may provide you with assistance regarding its action in that sodium and potassium exchange for each other

The nurse is reviewing the record of a pregnant woman and notes that the health care provider has documented the presence of Chadwick's sign. Which assessment finding supports the presence of Chadwick's sign? 1.Darkening of the areola 2.Softening of the uterine isthmus 3.Bluish discoloration of cervix and vagina 4.Palpation of the uterus above the level of the symphysis pubis

3 Rationale: The cervix undergoes significant changes after conception. The most obvious changes occur in color and consistency. In response to the increasing levels of estrogen, the cervix becomes congested with blood, resulting in the characteristic bluish color that extends to include the vagina and labia. This discoloration, referred to as Chadwick's sign, is one of the earliest signs of pregnancy. Darkening of the areola occurs during pregnancy but is not related to Chadwick's sign. Softening of the uterine isthmus is known as Hegar's sign. The presence of the uterus (fundal height) just above the symphysis pubis dates the pregnancy to be about 13 weeks' gestation. Priority Concepts: Cellular Regulation, Reproduction Test-Taking Strategy: Note the subject, Chadwick's sign. Knowledge of physiological changes and the hormones responsible for these changes is required to answer this question. Remember that the cervix and vagina become congested with blood, which is observed as a bluish discoloration

The nurse working in a detoxification unit is admitting a client for alcohol withdrawal. The client's spouse states, "I don't know why I don't get out of this rotten situation." Which response by the nurse addresses the spouse's concerns? 1."This is not a good time to make that decision." 2."What would your spouse think about your decision?" 3."What aspects of this situation are the most difficult for you?" 4."You seem to have a good grip on this situation. You probably should get out."

3 Rationale: The most helpful response is one that encourages the spouse to explore the problem and problem-solve. The correct response should not disregard or redirect focus away from the spouse's concern. The nurse should appear neither to disagree nor agree with the spouse. Giving advice implies that the nurse knows what is best and can also foster dependency. Priority Concepts: Addiction, Communication Test-Taking Strategy: Focus on the subject, a therapeutic response. Determine the client in this situation, which is the spouse of the individual being admitted. Eliminate options 1 and 4 because they focus on the nurse's opinion instead of on the client. Eliminate option 2 because it ignores the client's concerns and focus instead on the alcoholic spouse.

The nurse is supervising the postmortem care of a client. Which action by the unlicensed assistive personnel (UAP) performing the care is appropriate? 1.Keeps the client's body in a flat, supine position 2.Closes the client's eyes by taping the eyelids shut 3.Elevates the head of the bed 30 degrees as soon as possible after death 4.Removes the client's dentures and places them in a denture cup with the client's name on the lid

3 Rationale: The nurse may delegate postmortem care to UAPs, but the nurse must supervise the postmortem care. The care given must protect the client's body from damage or disfigurement. Elevating the head of bed immediately after the client's death can help reduce facial discoloring from livor mortis. Using tape may damage the delicate eyelid tissues; dentures should be placed inside the client's mouth during postmortem care to maintain facial structure. Priority Concepts: Caregiving, Leadership Test-Taking Strategy: Focus on the subject, procedure for postmortem care. Note that options 1 and 3 are opposite, indicating that one of these options may be correct. Recalling that the care given must protect the client's body from damage or disfigurement will direct you to option 3.

The nurse provides an educational session on client rights. Which statement by a member of the session demonstrates the best understanding of the nurse's role regarding ensuring that each client's rights are respected? 1."Autonomy is the fundamental right of each and every client." 2."A client's rights are guaranteed by both state and federal laws." 3."Being respectful and concerned will ensure that I'm attentive to my clients' rights." 4."Regardless of the client's condition, all nurses have the duty to value client rights."

3 Rationale: The nurse needs to respect and have concern for the client; this is vital to protecting the client's rights. While it is true that autonomy is a basic client right, there are other rights that must also be both respected and facilitated. State and federal laws do protect a client's rights, but it is sensitivity to those rights that will ensure that the nurse secures these rights for the client. It is a fact that safeguarding a client's rights is a nursing responsibility, but stating that fact does not show understanding or respect for the concept. Priority Concepts: Caregiving, Ethics Test-Taking Strategy: Note the strategic word, best. Focus on the broad issue of client rights and how the nurse will respect and preserve these rights. This is the umbrella option. Also note the word respected in the question and respectful in the correct option

The nurse is conducting an initial assessment of a client in crisis. When assessing the client's perception of the precipitating event that led to the crisis, which is the most appropriate question? 1."With whom do you live?" 2."Who is available to help you?" 3."What leads you to seek help now?" 4."What do you usually do to feel better?"

3 Rationale: The nurse's initial task when assessing a client in crisis is to assess the individual or family and the problem. The more clearly the problem can be defined, the better the chance a solution can be found. The correct option would assist in determining data related to the precipitating event that led to the crisis. Options 1 and 2 assess situational supports. Option 4 assesses personal coping skills. Priority Concepts: Anxiety, Coping Test-Taking Strategy: Note the strategic words, most appropriate. Also note the subject, assessment techniques for the client in crisis, and note the words precipitating event and led to the crisis. Eliminate options 1 and 2 because these data would determine support systems. Eliminate option 4 because this question would be asked when determining coping skills.

The nurse is assigned to care for a client who has chosen to formula-feed her infant. The nurse should plan to provide which instruction to the client? 1.Apply a heating pad to breasts for comfort. 2.Wear a breast shield to correct nipple inversion. 3.Wear a supportive brassiere continuously for 72 hours. 4.Use the manual breast pump provided to express milk.

3 Rationale: Wearing a supportive brassiere continuously for 72 hours postpartum will minimize breast engorgement. Any stimulation of the breasts (expression of milk, infant sucking) or increase in circulation (heating pad) will increase milk production or cause the blood vessels and lymphatics to engorge. Correction of nipple inversion will not be necessary if the mother chooses not to breast-feed her infant. Priority Concepts: Client Education, Reproduction Test-Taking Strategy: Focus on the subject, client instructions about formula-feeding. Knowledge of the lactation process will allow you to eliminate applying a heating pad and manually pumping the breasts because these actions are breast stimulants. The correction of nipple inversion is not necessary if the client is formula-feeding her infant

Vasopressin is prescribed for a client with diabetes insipidus. The nurse should be particularly cautious in monitoring a client receiving this medication if the client has which preexisting condition? 1.Depression 2.Endometriosis 3.Pheochromocytoma 4.Coronary artery disease

4 Rationale: Because of its powerful vasoconstrictor actions, vasopressin can cause adverse cardiovascular effects. By constricting arteries of the heart, vasopressin can cause angina pectoris and even myocardial infarction, especially if administered to clients with coronary artery disease. In addition, vasopressin may cause vascular problems by decreasing blood flow in the periphery. The remaining options are not conditions of concern with the use of this medication. Priority Concepts: Clinical Judgment, Safety Test-Taking Strategy: Focus on the subject, a concern related to the administration of vasopressin. Recall that this medication has powerful vasoconstrictor actions to assist you in answering correctly. Also, note the relationship between the name of the medication, vasopressin, and coronary artery disease, the correct option.

The home health nurse visits an agoraphobic client who experiences panic attacks. Which statement by the client would indicate a therapeutic response to behavioral and pharmacological treatment? 1."I took an extra pill for anxiety and got through the funeral fairly well." 2."I worry that if I don't take my anxiety pill on time, I'll have one of those attacks." 3."Taking my anxiety pills before I leave has helped me to cross the bridge and go to work every morning." 4."I went to the movies with my family and stayed through the whole film by sitting in a seat along the aisle."

4 Rationale: Generalizing fears to a specific place or situation is the hallmark of agoraphobia. Improvement is observed when the client is able to demonstrate appropriate coping behaviors for anxiety reduction. Taking extra anxiety medication would not indicate improvement. "Clock-watching" with regard to the medication schedule is also not a sign that the client is responding well to the treatment. Priority Concepts: Anxiety, Coping Test-Taking Strategy: Focus on the subject, therapeutic response to treatment and appropriate coping. The correct option is the only one that demonstrates the client's use of an appropriate coping mechanism. Also note that the remaining options are comparable or alike in that the client relies on antianxiety medications.

A health care provider prescribes an intravenous (IV) solution of 5% dextrose and half-normal saline (0.45%) with 40 mEq of potassium chloride for a child with hypotonic dehydration. The nurse performs which priority assessment before administering this IV prescription? 1.Obtains a weight 2.Takes the temperature 3.Takes the blood pressure 4.Checks the amount of urine output

4 Rationale: In hypotonic dehydration, electrolyte loss exceeds water loss. The priority assessment before administering potassium chloride intravenously would be to assess the status of the urine output. Potassium chloride should never be administered in the presence of oliguria or anuria. If the urine output is less than 1 to 2 mL/kg/hour, potassium chloride should not be administered. Although options 1, 2, and 3 are appropriate assessments for a child with dehydration, these assessments are not related specifically to the IV administration of potassium chloride. Priority Concepts: Clinical Judgment, Fluid and Electrolyte Balance Test-Taking Strategy: Note the strategic word, priority. Focus on the IV prescription. Recalling that the kidneys play a key role in the excretion and reabsorption of potassium will direct you to the correct option.

The nurse is planning care for a child with acute bacterial meningitis. Based on the mode of transmission of this infection, which precautionary intervention should be included in the plan of care? 1.Maintain enteric precautions. 2.Maintain neutropenic precautions. 3.No precautions are required as long as antibiotics have been started. 4.Maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics.

4 Rationale: Meningitis is an infectious process of the central nervous system caused by bacteria and viruses; it may be acquired as a primary disease or as a result of complications of neurosurgery, trauma, infection of the sinus or ears, or systemic infections. A major priority of nursing care for a child suspected to have meningitis is to administer the antibiotic as soon as it is prescribed. The child also is placed on respiratory isolation precautions for at least 24 hours while culture results are obtained and the antibiotic is having an effect. Enteric precautions and neutropenic precautions are not associated with the mode of transmission of meningitis. Enteric precautions are instituted when the mode of transmission is through the gastrointestinal tract. Neutropenic precautions are instituted when a child has a low neutrophil count. Priority Concepts: Infection, Safety Test-Taking Strategy: Focus on the subject, the mode of transmission of meningitis. Eliminate options 1 and 2 first because they are comparable or alike, and are unrelated to the mode of transmission. Recalling that it takes about 24 hours for antibiotics to reach a therapeutic blood level will assist in directing you to the correct option

A client has a new prescription for metoclopramide. On review of the chart, the nurse identifies that this medication can be safely administered with which condition? 1.Intestinal obstruction 2.Peptic ulcer with melena 3.Diverticulitis with perforation 4.Vomiting following cancer chemotherapy

4 Rationale: Metoclopramide is a gastrointestinal stimulant and antiemetic. Because it is a gastrointestinal stimulant, it is contraindicated with gastrointestinal obstruction, hemorrhage, or perforation. It is used in the treatment of vomiting after surgery, chemotherapy, or radiation. Priority Concepts: Clinical Judgment, Safety Test-Taking Strategy: Focus on the subject, safe use of metoclopramide. Recalling the classification and action of this medication and that it is an antiemetic will direct you to the correct option.

A client with type 1 diabetes mellitus is having trouble remembering the types, duration, and onset of the action of insulin. The client tells the nurse that family members have not been supportive. Which response by the nurse is best? 1."What is it that you don't understand?" 2."You can't always depend on your family to help." 3."It's not really necessary for you to remember this." 4."Let me go over the types of insulins with you again."

4 Rationale: Reinforcement of knowledge and behaviors is vital to the success of the client's self-care. All of the other options do not address the need for client instructions and are not therapeutic responses. Priority Concepts: Communication, Glucose Regulation Test-Taking Strategy: Note the strategic word, best. Use therapeutic communication techniques. Asking the client what he or she does not understand requests an explanation from the client. Telling a client that he or she cannot depend on family members devalues a client's family. Telling a client that he or she does not have to remember this places the client's concern on hold. The correct option validates and clarifies previous information

A test for the presence of rheumatoid factor is performed in a client with a diagnosis of rheumatoid arthritis (RA). What result should the nurse anticipate in the presence of this disease? 1.Neutropenia 2.Hyperglycemia 3.Antigens of immunoglobulin A (IgA) 4.Unusual antibodies of the IgG and IgM type

4 Rationale: Rheumatoid arthritis is a chronic, progressive, systemic inflammatory autoimmune disease process that affects primarily the synovial joints. The test for rheumatoid factor detects the presence of unusual antibodies of the IgG and IgM type, which develop in a number of connective tissue diseases. The other options are incorrect. Priority Concepts: Cellular Regulation, Immunity Test-Taking Strategy: Focus on the subject, the purpose of the rheumatoid factor test. Knowledge of the rheumatoid factor test is required to answer the question. Remember that the test for rheumatoid factor detects the presence of unusual antibodies of the IgG and IgM type

What is the appropriate nursing intervention for a client diagnosed with posttraumatic stress disorder and paranoid tendencies who begins to pace and fidget? 1.Escort the client to a private, low-stimulus room. 2.Engage the client in a nonthreatening conversation. 3.Allow the client to pace unless the behavior becomes aggressive. 4.Share the observation with the client so the behavior can be recognized.

4 Rationale: Sharing observations with the client may help the client recognize and acknowledge feelings. Allowing the client to pace may also allow the client to get out of control. Moving to a quiet room or changing the subject will not help the client to recognize his behaviors and feelings. Priority Concepts: Mood and Affect, Safety Test-Taking Strategy: Use knowledge regarding therapeutic communication techniques to assist in answering the question. The correct option is the only one that directly addresses the client's feelings.

A client is seen in the clinic complaining of anorexia and nausea. The health care provider (HCP) suspects that the client may be experiencing digoxin toxicity. While waiting for test results to become available, the nurse should assess the client for which sign or symptom that would support a diagnosis of digoxin toxicity? 1.Edema 2.Chest pain 3.Constipation 4.Photophobia

4 Rationale: The most common early manifestations of digoxin toxicity are gastrointestinal disturbances such as anorexia, nausea, and vomiting and neurological disturbances such as fatigue, headache, weakness, drowsiness, confusion, and nightmares. Visual disturbances such as photophobia, light flashes, halos around bright objects, and yellow or green color perception also may occur. Priority Concepts: Clinical Judgment, Safety Test-Taking Strategy: Focus on the subject, the signs and symptoms of digoxin toxicity. Recalling that visual disturbances occur in digoxin toxicity will direct you to the correct option.

A nursing student is preparing to instruct a pregnant client in performing Kegel exercises. The nursing instructor asks the student the purpose of Kegel exercises. Which response made by the student indicates an understanding of the purpose? Select all that apply. 1."The exercises will help reduce backaches." 2."The exercises will help prevent ankle edema." 3."The exercises will help prevent urinary tract infections." 4."The exercises will help strengthen the pelvic floor in preparation for delivery." 5."The exercises will help strengthen the muscles that support the bladder and urethra."

4,5 Rationale: Kegel exercises will assist in strengthening the pelvic floor as well as the muscles that support the bladder and urethra. Pelvic tilt exercises will help to reduce backaches. Leg elevation will assist in preventing ankle edema. Instructing a client to drink 8 oz of fluids 6 times a day will help to prevent urinary tract infections. Test-Taking Strategy: Focus on the subject, the purpose of Kegel exercises. Think about the action that the client takes to perform these exercises. Also, recalling that these exercises will help to strengthen the perineal floor muscles will assist in directing you to the correct options.

A health care provider prescribes morphine sulfate 4 mg, intravenously (IV) stat, for a postoperative client in pain. The medication label states morphine sulfate 2 mg/mL. How many milliliters will the nurse prepare to administer to the client? Fill in the blank.

2ml

The nurse has provided home care instructions to a client with a history of cardiac disease who has just been told that she is pregnant. Which statement, if made by the client, indicates a need for further instruction? 1."It is best that I rest lying on my side to promote blood return to the heart." 2."I need to avoid excessive weight gain to prevent increased demands on my heart." 3."I need to try to avoid stressful situations because stress increases the workload on the heart." 4."During the pregnancy, I need to avoid contact with other individuals as much as possible to prevent infection."

4 Rationale: To avoid infections, visitors with active infections should not be allowed to visit the client; otherwise, restrictions are not required. Resting should be done by lying on the side to promote blood return. Too much weight gain can place further demands on the heart. Stress causes increased heart workload, and the client should be instructed to avoid stress. Priority Concepts: Client Education, Health Promotion Test-Taking Strategy: Note the strategic words, need for further instruction. These words indicate a negative event query and ask you to select an option that is an incorrect statement. Using principles related to the therapeutic management of cardiac disease in general will assist in directing you to the correct option.

The nurse is giving medication instructions to a client who has been prescribed acetylsalicylic acid. Which client statement indicates that education was effective? 1."I may develop heartburn." 2."I should monitor for the muscle aches." 3."I may experience burning on urination." 4."I should take measures to prevent constipation."

1 Rationale Acetylsalicylic acid is a nonsteroidal agent that is prescribed for its antiinflammatory, antipyretic, and anticoagulant properties. Occasional side/adverse effects include gastrointestinal distress such as cramping, mild nausea, heartburn, and abdominal distention. The client also should self-monitor for evidence of allergic reaction such as pruritus, urticaria, and difficulty breathing. Acetylsalicylic acid may be used to treat muscle aches. Constipation and burning on urination are not side effects of this medication. Priority Concepts: Client Education, Safety Test-Taking Strategy Note the strategic word, effective. Next, focus on the subject, side effects of acetylsalicylic acid. Focusing on the name of the medication, acetylsalicylic acid, will assist in determining that gastrointestinal side effects can occur.

The nurse is providing instructions to a client regarding food items that are high in vitamin D. The client demonstrates understanding of the instructions by stating the need to include which food item in the diet? 1.Milk 2.Meat 3.Oranges 4.Broccoli

1 Rationale: Milk provides the highest amount of vitamin D. Broccoli and oranges are high in vitamin C, and meat is high in vitamin B complex

The nurse is caring for a client with respiratory failure related to Guillain-Barré syndrome. The nurse plans care knowing that what other extrapulmonary causes can lead to respiratory failure? Select all that apply. 1.Stroke 2.Pneumonia 3.Sleep apnea 4.Myasthenia gravis 5.Obstructive lung disease 6.Opioid analgesics, sedatives, anesthetics

1,3,4,6 Rationale: Extrapulmonary causes of respiratory failure include the following: stroke, sleep apnea, myasthenia gravis, and opioid analgesics, sedatives, and anesthetics. Both obstructive lung disease and pneumonia are intrapulmonary causes of respiratory failure. Priority Concepts: Acid-Base Balance, Gas Exchange Test-Taking Strategy: Focus on the subject, extrapulmonary causes of respiratory failure. Apply knowledge that extrapulmonary causes are related to neurologic, cardiac, and neuromuscular disorders and are not related to intrapulmonary or respiratory conditions. Recalling this information will help you to eliminate options 2 and 5.

A health care provider is about to perform a paracentesis for a client with abdominal ascites. The nurse assisting with the procedure should help the client into which position? 1.Supine 2.Upright 3.Right side-lying 4.Left side-lying

2 Rationale: An upright position allows the intestine to float posteriorly and helps prevent intestinal laceration during catheter insertion. The client ideally sits upright in a chair, with the feet flat on the floor and with the bladder emptied before the procedure. Therefore, the remaining positions are incorrect. Priority Concepts: Clinical Judgment, Safety Test-Taking Strategy: Focus on the subject, position for paracentesis. Attempt to visualize this procedure to select the correct option. Knowing that fluid will be aspirated from the abdominal cavity will assist in directing you to the correct option

Trimethoprim-sulfamethoxazole is prescribed to be administered by intravenous infusion to a client with a recurrent urinary tract infection. How should the nurse administer this medication? 1. Over 30 minutes 2. Over 60 to 90 minutes 3. Piggybacked into the peripheral line containing parenteral nutrition 4. Piggybacked into the existing infusion of normal saline and potassium chloride

2 Rationale: Trimethoprim-sulfamethoxazole may be administered by intravenous infusion but should not be mixed with any other medications or solutions. Trimethoprim-sulfamethoxazole is infused over 60 to 90 minutes, and bolus infusions or rapid infusions must be avoided. Priority Concepts: Clinical Judgment, Safety Test-Taking Strategy: Focus on the subject, administering intravenous trimethoprim-sulfamethoxazole. Eliminate options 3 and 4, the piggybacking options, because they address mixing the trimethoprim-sulfamethoxazole with other solutions. From the remaining choices, the correct option identifies the longer time frame and is the safe and correct choice.

The ambulatory care nurse is providing discharge instructions to a female client who underwent cryosurgery with laser therapy because of a positive Papanicolaou test. Which statement by the client indicates an understanding of the instructions? 1."I should take sitz baths every 4 hours for the next week." 2."I should expect the vaginal discharge to be clear and watery." 3."Very strong pain medications will be needed to relieve any discomfort I may have." 4."If I note any odor to the vaginal discharge, I should call the health care provider immediately."

2 Rationale: Vaginal discharge should be clear and watery after cryosurgery with laser therapy. The client should be told that the vaginal discharge may be odorous as a result of the sloughing of dead cell debris. This vaginal odor takes about 8 weeks to resolve. The client should be instructed to avoid any sitz baths or tub baths while the area is healing, which takes approximately 10 weeks. Pain is mild after this procedure, and very strong pain medication will not be needed. Priority Concepts: Cellular Regulation, Client Education Test-Taking Strategy: Focus on the subject, expected findings following cryosurgery with laser therapy to the cervical region. Thinking about the anatomical location and the effects of the procedure will direct you to the correct option.

A client is being weaned from parenteral nutrition (PN) and is expected to begin taking solid food today. The ongoing solution rate has been 100 mL/hour. The nurse anticipates that which prescription regarding the PN solution will accompany the diet prescription? 1.Discontinue the PN. 2.Decrease PN rate to 50 mL/hour. 3.Start 0.9% normal saline at 25 mL/hour. 4.Continue current infusion rate prescriptions for PN.

2 Rationale: When a client begins eating a regular diet after a period of receiving PN, the PN is decreased gradually. PN that is discontinued abruptly can cause hypoglycemia. Clients often have anorexia after being without food for some time, and the digestive tract also is not used to producing the digestive enzymes that will be needed. Gradually decreasing the infusion rate allows the client to remain adequately nourished during the transition to a normal diet and prevents the occurrence of hypoglycemia. Even before clients are started on a solid diet, they are given clear liquids followed by full liquids to further ease the transition. A solution of normal saline does not provide the glucose needed during the transition of discontinuing the PN and could cause the client to experience hypoglycemia. Priority Concepts: Glucose Regulation, Nutrition

A pregnant client asks the nurse in the clinic, "When will I begin to feel fetal movement?" Which response should the nurse make? 1.Between 6 and 8 weeks 2.Between 8 and 10 weeks 3.Between 12 and 14 weeks 4.Between 16 and 20 weeks

4 Rationale: Fetal movement, called quickening, is not perceived until the second trimester. Between 16 and 20 weeks' gestation, the expectant client first notices subtle fetal movements that gradually increase in intensity. Therefore, the remaining options are incorrect. Priority Concepts: Development, Reproduction Test-Taking Strategy: Focus on the subject, when quickening occurs. Specific knowledge of quickening and the detection of fetal movement by the client is required to answer this question.

Oxybutynin chloride is prescribed for a client with urge incontinence. Which sign would indicate a possible toxic effect related to this medication? 1.Pallor 2.Drowsiness 3.Bradycardia 4.Restlessness

4 Rationale: Toxicity (overdosage) of oxybutynin produces central nervous system excitation, such as nervousness, restlessness, hallucinations, and irritability. Other signs of toxicity include hypotension or hypertension, confusion, tachycardia, flushed or red face, and signs of respiratory depression. Drowsiness is a frequent side effect of the medication but does not indicate overdosage. Priority Concepts: Clinical Judgment, Safety Test-Taking Strategy: Focus on the subject, signs of toxicity (overdosage) of oxybutynin. Remember that restlessness is a sign of toxicity.

The nurse is developing a plan of care for a hospitalized Asian American client. The nurse should include which measures in the client's plan of care? Select all that apply. 1.Limit eye contact. 2.Clarify responses to questions. 3.Use hand gestures to communicate. 4.Maintain physical space with the client. 5.Hold the client's hand to provide comfort.

1,2,4 Rationale: Avoiding physical closeness, limiting eye contact, avoiding hand gestures, and clarifying responses to questions are all components of the plan of care for an Asian American client. Therefore, options 1, 2, and 4 are appropriate interventions, whereas options 3 and 5 are inappropriate Priority Concepts: Communication, Culture Test-Taking Strategy: Focus on the subject, caring for an Asian American client. Select option 2 because it is a therapeutic communication techniques. For the remaining options, it is necessary to know the characteristics of the culture.

The nurse is performing an assessment on a client diagnosed with placenta previa. Which assessment findings should the nurse expect to note? Select all that apply. 1.Uterine rigidity 2.Uterine tenderness 3.Severe abdominal pain 4.Bright red vaginal bleeding 5.Soft, relaxed, nontender uterus 6.Fundal height may be greater than expected for gestational age

4,5,6, Rationale: Placenta previa is an improperly implanted placenta in the lower uterine segment near or over the internal cervical os. Painless, bright red vaginal bleeding in the second or third trimester of pregnancy is a sign of placenta previa. The client has a soft, relaxed, nontender uterus, and fundal height may be more than expected for gestational age. In abruptio placentae, severe abdominal pain is present. Uterine tenderness accompanies placental abruption. In addition, in abruptio placentae, the abdomen feels hard and boardlike on palpation as the blood penetrates the myometrium and causes uterine irritability. Priority Concepts: Clinical Judgment, Perfusion Test-Taking Strategy: First, eliminate options 1 and 2 because they are comparable or alike. Next, remember that the difference between placenta previa and abruptio placentae involves the presence of uterine pain and tenderness with abruptio placentae, as opposed to painless bright red bleeding with placenta previa.

A 2-year-old child is being transported to the trauma center from a local community hospital for treatment of a burn injury that is estimated as covering more than 40% of the body. The burns are both partial- and full-thickness burns. The nurse is asked to prepare for the arrival of the child and gathers supplies, anticipating that which treatment will be prescribed initially? 1.Insertion of a Foley catheter 2.Insertion of a nasogastric tube 3.Administration of an anesthetic agent for sedation 4.Application of an antimicrobial agent to the burns

1 Rationale: A Foley catheter is inserted into the child's bladder so that urine output can be accurately measured on an hourly basis. Although pain medication may be required, the child would not receive an anesthetic agent and should not be sedated. The burn wounds would be cleansed after assessment, but this would not be the initial action. Intravenous fluids are administered at a rate sufficient to keep the child's urine output at 1 to 2 mL/kg of body weight per hour for children weighing less than 30 kg, thus reflecting adequate tissue perfusion. A nasogastric tube may or may not be required but would not be the priority intervention. Priority Concepts: Clinical Judgment, Tissue Integrity Test-Taking Strategy: Note the strategic word, initially. Option 3 can be eliminated first because the child should not be sedated and an anesthetic agent would not be administered. Eliminate option 2 next, knowing that a nasogastric tube may or may not be required. From the remaining option, knowledge that fluid resuscitation and determining the adequacy of the amounts of fluid are essential will direct you to the correct option.

A child is placed in skeletal traction for treatment of a fractured femur. The nurse creates a plan of care and should include which intervention? 1.Ensure that all ropes are outside the pulleys. 2.Ensure that the weights are resting lightly on the floor. 3.Restrict diversional and play activities until the child is out of traction. 4.Check the health care provider's (HCP's) prescriptions for the amount of weight to be applied.

4 Rationale: When a child is in traction, the nurse would check the HCP's prescription to verify the prescribed amount of traction weight. The nurse would maintain the correct amount of weight as prescribed, ensure that the weights hang freely, check the ropes for fraying and ensure that they are on the pulleys appropriately, monitor the neurovascular status of the involved extremity, and monitor for signs and symptoms of immobilization. The nurse would provide therapeutic and diversional play activities for the child. Priority Concepts: Mobility, Safety Test-Taking Strategy: Focus on the subject, care of the child in traction. Eliminate option 3 first because of the word restrict. Next recall the general principles related to traction, recalling that weights should hang freely and ropes should remain in the pulleys.