Trends exam 2

The 11-year-old child falls off a bicycle and sustains a minor head injury. The injury is treated at the outpatient clinic. The nurse instructs the child's parent about care at home. The nurse determines further teaching is needed if the parent makes which statement? 1. "My child may have dizziness for 24 hours." 2. "My child can drink carbonated beverages if vomiting occurs." 3. "My child may report feeling nauseated." 4. "My child will probably have a headache."

"My child can drink carbonated beverages if vomiting occurs."

The older client is hospitalized with a fractured left hip. While awaiting surgery, the client is placed in Buck's traction with a 7-pound weight. Which instruction about moving does the nurse give to encourage the client to participate in care? 1. "Pull up on the overhead trapeze while you push down on your right foot to lift your body." 2. "With your right arm, grasp the bedside rail on the opposite side and pull yourself over gently." 3. "I'll raise the head of the bed 45 degrees, and then you'll lean forward and rotate your hips to the left." 4. "Swing your right leg over your left leg and turn from your waist down, keeping your legs straight."

"Pull up on the overhead trapeze while you push down on your right foot to lift your body."

The parents of a child diagnosed with hemophilia asks the nurse to explain the cause of the disease. Which response by the nurse is best?

"The mother transmits the gene to her son"-> HEMOPHILIA IS A SEX-LINKED DISORDER.

The office nurse reinforces the healthcare provider's explanation for a myelogram. Which statement correctly describes a pyelogram for the client? 1. "The test involves x-ray examination of the entire spinal column to determine the extent of myelin breakdown." 2. "The test injection of a contrast medium into a suspected ruptured vertebral disk, allowing radiographic visualization of the disk." 3. "The test involves a lumbar puncture with injection of contrast medium, allowing x-ray visualization of the vertebral canal." 4. "The test involves x-ray examination of the vertebral column following injection of air into the subarachnoid space."

"The test involves a lumbar puncture with injection of contrast medium, allowing x-ray visualization of the vertebral canal."

The client is scheduled for electromyography (EMG). Which information does the nurse tell the client about the procedure? 1. "Your hair will be carefully washed prior to the procedure." 2. "This is a noninvasive procedure that takes about 30 minutes." 3. "A sedative will be given to you shortly before the procedure." 4. "You will not be allowed to eat 4 to 6 hours before the procedure."

"This is a noninvasive procedure that takes about 30 minutes."

The nurse cares for the client diagnosed with a recurrent urinary tract infection. The health care provider prescribes ciprofloxacin. The nurse instructs the client to limit intake of which fluid? 1. Milk. 2. Cranberry juice. 3. Water. 4. Tea.

1) CORRECT — should limit intake of alkaline foods and fluids 2) can be increased to acidify urine 3) does not need to be restricted 4) does not need to be restricted

The client is admitted to the emergency department in acute respiratory distress. The client is very anxious, edematous, and cyanotic. The client receives morphine sulfate. Which finding does the nurse recognize as the desired response to the medication? 1. Increase in pulse pressure. 2. Decrease in anxiety. 3. Depression of the sympathetic nervous system. 4. Enhanced ventilation and decreased cyanosis.

1) is not affected by morphine sulfate 2) CORRECT — morphine sulfate is administered to minimize anxiety associated with respiratory distress from pulmonary edema 3) is not the action of the medication 4) medication does not improve ventilation

The nurse assesses the client diagnosed with a spinal cord injury. Which findings suggests the complication of autonomic dysreflexia? Select all that apply. 1. Urinary bladder spasm pain. 2. Severe pounding headache. 3. Profuse sweating. 4. Tachycardia. 5. Severe hypotension. 6. Nasal congestion.

1) may be the cause of autonomic dysreflexia due to overfilling of the bladder, but pain is not perceived 2) CORRECT — severe headache results from rapid onset of hypertension 3) CORRECT — especially of forehead 4) pulse will slow 5) BP will increase 6) CORRECT — also causes piloerection (goose flesh)

The nurse receives report from the previous shift. In which order should the nurse see these clients? 1. The client 1 day postop with an epidural catheter in place 2. The client diagnosed with type 1 diabetes scheduled for a cardiac catheterization at 1400 3. The client post coronary artery bypass graft having the atrioventricular wires removed at 1500 4. The client diagnosed with cardiomyopathy being evaluated for a heart transplant

1, 4, 2, 3

During a prenatal visit, the client states, "I have been very nauseated during my first trimester, and I don't understand the reason." Which response by the nurse is best? 1. "You are nauseated because of the fatigue you are feeling." 2. "The nausea is due to an increase in the basal metabolic rate." 3. "The nausea is caused by an elevation in the hormones." 4. "If you eat different kinds of foods, you won't be nauseated."

1) describes an erroneous rationale for the nausea 2) describes an erroneous rationale for the nausea 3) CORRECT — during the first trimester, nausea and vomiting are related to elevation in estrogen, progesterone, and hCG from the endocrine system 4) describes an erroneous rationale for the nausea

The nurse discusses changes due to aging with a group at the senior citizen center. The nurse knows which change in the pattern of urinary elimination occurs normally with aging? 1. Decreased frequency. 2. Nocturia. 3. Incontinence. 4. Hematuria.

1) frequency increases because bladder capacity decreases 2) CORRECT — decreased ability to concentrate urine increases urine formation and increased nocturnal urine production leads to need to awaken to void 3) ureters, bladder, and urethra lose muscle tone; results in stress and urge incontinence 4) blood in urine may be a sign of cancer, infection, or trauma of urinary tract, glomerular disease, urinary tract calculi, bleeding disorders

The 6-month-old is brought to the clinic for a well-baby check-up. During the exam, the nurse expects to observe which assessment findings?

2. Sitting with support. 5. Playing peek-a-boo. 6. Rolling from back to abdomen.

The nurse cares for the newborn infant diagnosed with fetal alcohol syndrome. The nurse expects to see which characteristics?

An infant with a small head circumference, low birth weight, and undeveloped cheekbones.

The nurse identifies which finding would have the greatest impact on the elderly client's ability to complete activities of daily living (ADLs)?

Apraxia-> APRAXIA IS LOSS OF PURPOSEFUL MOVEMENT IN THE ABSENCE OF MOTOR OR SENSORY IMPAIRMENT; WHEN IT AFFECTS AN ADL, SUCH AS DRESSING, THE CLIENT MAY NOT BE ABLE TO PUT CLOTHES ON PROPERLY.

The infant is admitted with vomiting and diarrhea. The infant's anterior fontanelle is depressed and the temperature is 103.2° F (39.5° C). Which nursing action is most appropriate? 1. Obtain daily weights and evaluate weight loss 2. Observe the infant's ability to take in fluids 3. Place a full bottle of pediatric electrolyte solution at the bedside 4. Start an intravenous infusion

Observe the infant's ability to take in fluids

The adult client is preparing for a plasma cholesterol screening. Which instruction does the nurse give to the client?

Only take sips of water for 12 hours before the test. -> ONLY SIPS OF WATER ARE PERMITTED FOR 12 HOURS BEFORE PLASMA CHOLESTEROL SCREENING TO ACHIEVE ACCURATE RESULTS.

The nurse is discussing growth and development with the parents of a 4-year child. The nurse identifies which type of play as characteristic of this age group?

Associative play -> Associative play is a form of play in which a group of children participate in similar or identical activities without formal organization, group direction, group interaction, or a definite goal.

The client is diagnosed with an obsessive-compulsive ritual. The nurse recognizes the client is attempting to achieve with psychological status? 1. Control of other people 2. Increased self-esteem 3. Avoid severe levels of anxiety 4. Express and manage anxiety

Avoid severe levels of anxiety

The client is admitted to the trauma intensive care unit (ICU) with a gunshot wound of the neck. The client is diagnosed with a spinal cord injury at the level of C4. The client is tearful, constantly reports discomfort, and requests to be suctioned. The nurse understands the client's attention-seeking behaviors may be due to which feelings? 1. Anger and frustration 2. Awareness of vulnerability 3. Increased social isolation 4. Increased sensory stimulation

Awareness of vulnerability

The parent brings a 9-month-old infant to the pediatric office with a fever of 102.2° F (39° C) and frequent vomiting. The nurse expects to find which reflex? 1. Babinski reflex 2. Moro reflex 3. Tonic neck reflex 4. Grasp reflex

Babinski reflex

The nurse cares for the client after an electroconvulsive therapy (ECT) treatment. The nurse reports which observation to the healthcare provider? 1. Headache 2. Disruption in short- and long-term memory 3. Transient confusional state 4. Backache

Backache

The client receives aminophylline IV. The client has clear lung sounds and unlabored breathing. Which is the MOST important nursing action if the client's IV infiltrates? 1. Apply warm soaks to the infiltration site, start a new IV, and continue IV medications 2. Wait 2 hours, reassess the client, and restart the IV if the client has wheezing or labored breathing 3. Restart the IV and continue the previous medication schedule 4. Call the healthcare provider and recommend the IV medication be changed to PO

Call the healthcare provider and recommend the IV medication be changed to PO

The nurse cares for clients in a drug rehabilitation facility. Which complication of IV drug abuse is the nurse most likely to observe?

Cellulitis->MOST NARCOTIC ADDICTS DO NOT INFECT STERILE PURIFIED MATERIAL WITH ASEPTIC TECHNIQUES; CELLULITIS. COMPLICATION BECAUSE OF SKIN POPPING OR USING AN INFECTED DRUG APPARATUS.

The home care nurse visits a new parent and a 2-week-old infant. The client asks the nurse which solid foods should be given to the child first. the nurse's response should be based on which statement?

Rice cereal is usually the first solid food and is started around 4-5 months.-> INFANTS ARE LESS LIKELY TO BE ALLERGIC TO RICE CEREAL THAN TO ANY OTHER SOLID FOOD; USUALLY STARTED BETWEEN 4-5 MONTHS OF AGE; BREASTFED INFANTS MAY BE STARTED ON SOLIDS EVEN LATER.

The nurse cares for a client admitted with a diagnosis of a stroke and facial paralysis. Nursing care should be planned to prevent which complication?

Corneal abrasion-> CLIENT WILL BE UNABLE TO CLOSE EYE VOLUNTARILY; WHEN FACIAL NERVE (CRANIAL NERVE VII) IS AFFECTED, THE LACRIMAL GLAND WILL NO LONGER SUPPLY SECRETIONS THAT PROTECT EYE.

The parent of the 7-year-old child is dying. The nurse anticipates the child will have which concept of death? 1. Death is punishment for the child's actions 2. Death is inevitable and irreversible 3. Death is temporary and gradual 4. Death as a concept based on past experience

Death is punishment for the child's actions

The nurse cares for the elderly client receiving IV fluids of 0.9% NaCl at 125 mL/h into the left arm. During a routine assessment, the nurse finds the client has distended neck veins, shortness of breath, and crackles in both lung bases. Which action does the nurse take FIRST? 1. Decrease the IV rate to 20 mL/h and notifies the healthcare provider 2. Decreases the IV rate to 100 mL/h and continues to monitor the client 3. Discontinues the IV and starts oxygen at 6 L/min 4. Assesses for infiltration of the IV solution

Decreases the IV rate to 20 mL/h and notifies the healthcare provider

The client is returned to the unit after surgery with a cuffed tracheostomy tube in place. The nurse knows the purpose of the cuff on the tracheostomy tube includes which reason? 1. Guarantees secure placement of the tracheostomy in the airway 2. Prevents ischemia of the tracheal wall by distributing the pressure applied to it 3. Decreases the chance of aspiration into the trachea 4. Protects the trachea from ischemia and edema

Decreases the chance of aspiration into the trachea

The nurse assesses the client with severe bilateral peripheral edema. Which is the BEST way for the nurse to determine the degree of edema in a limb? 1. Measure both limbs with the tape measure and compare 2. Depress the skin and rank the degree of pitting 3. Describe the swelling in the affected area 4. Pinch the skin and note how quickly it returns to normal

Depress the skin and rank the degree of pitting

The parent brings 10-year-old and 3-year-old children to the pediatric office. The young child reports dysuria. The healthcare provider orders a catheterized urine specimen. The nurse takes which action? 1. Describes the procedure to the child in short, concrete terms while taking calmly. 2. Allows the child to play with the equipment during the procedure 3. Involves the older sibling in explaining the procedure 4. Shows the child a diagram of the urinary system

Describes the procedure to the child in short, concrete terms while taking calmly

The nurse teaches a health class to a group of senior citizens. Which behavior does the nurse emphasize to facilitate regular bowel elimination? 1. Avoid strenuous activity 2. Eat more foods with increased bulk 3. Decrease fluid intake to decrease urinary losses 4. Use oral laxatives so a bowel pattern emerges

Eat more foods with increased bulk

The nurse in the outpatient clinic assists with the application of a cast to the left arm of the preschool-aged child. After the cast is applied, the nurse takes which action FIRST? 1. Petals the edges of the cast to prevent irrigation 2. Elevates the child's left arm on two pillows 3. Applies cool, humidified air to dry the cast 4. Asks the client to move the fingers to maintain mobility

Elevates the child's left arm on two pillows

The nurse cares for a client receiving chlorpromazine. The nurse notes the client is restless, unable to sit still, and reports insomnia and fine tremors of the hands. Which does the nurse identify as the best explanation for these symptoms occurring?

Extrapyramidal side effects resulting from this medication. -> SIDE EFFECTS INCLUDE AKATHISIA (MOTOR RESTLESSNESS), DYSTONIAS (PROTRUSION OF TONGUE, ABNORMAL POSTURING), PSEUDOPARKINSONIM (TREMORS, RIGIDITY), AND DYSKINESIA (STIFF NECK, DIFFICULTY SWALLOWING.

A client suspects she is pregnant because the last menstrual period began May 8 and ended May 12. Which estimated date of birth will the nurse calculate for this client? 1. February 1 2. February 15 3. February 19 4. March 14

February 15

The client is receiving imipramine. It is important for the nurse to instruct the client to immediately report which symptoms? 1. Fever 2. Dry mouth 3. Increased fatigue 4. Vomiting and diarrhea 5. Staggering gait 6. Sore throat

Fever, dry mouth, increased fatigue, vomiting and diarrhea, & sore throat

The health care provider orders naproxen sodium for an elderly client. The nurse should assess the client for which symptoms?

Fluid retention and dizziness. -> NSAID USED AS ANALGESIC; SIDE EFFECTS: HA, DIZZINESS, GI DISTRESS, PRURITUS, AND RASH

Which type of foods should the nurse encourage for a client diagnosed with hypoparathyroidism?

Foods high in calcium-> DIET FOR THE CLIENT SHOULD PROVIDE HIGH CALCIUM AND LOW PHOSPHORUS BECAUSE THE PARATHYROID CONTROLS CALCIUM BALANCE.

The nurse knows that according to Erikson's stages of psychosocial development, which best represents a 50-year-old client?

Generativity versus stagnation -> STAGE OF DEVELOPMENT IS APPROPRIATE FOR AGES 45 TO 64.

The client has a neurological disorder. Which nursing assessment is MOST helpful to determine subtle changes in the client's level of consciousness? 1. Client posturing 2. Glasgow coma scale 3. Client thinking pattern 4. Occurrence of hallucinations

Glasgo coma scale

The client is diagnosed with obsessive-compulsive disorder manifested by the compulsion of hand-washing. The nurse knows which behavior BEST describes the client's need for repetitive acts of hand-washing? 1. Hand-washing represents an attempt to manipulate the environment to make it more comfortable. 2. Hand-washing externalizes the anxiety from a source within the body to an acceptable substitute outside the body 3. Hand-washing helps the client avoid undesirable thoughts and maintain some control over guilt and anxiety 4. Hand-washing helps maintain the client in an active state to resist the effects of depression

Hand-washing helps the client avoid undesirable thoughts and maintain some control over guilt and anxiety

The client has orders for cefoxitin 2 g IV piggyback in 100 mL 5% dextrose in water. The primary IV is 5% dextrose in lactated Ringer's and is infusing by gravity. It is most important for the nurse to take which action? 1. Administer the medication slowly, at 20 to 25 mL/h. 2. Change the primary IV solution 3. Hang the piggyback infusion bag higher than the primary infusion bag 4. Obtain an infusion pump prior to administration

Hang the piggyback infusion bag higher than the primary infusion bag

The nurse assesses the client's neurosensory cerebella functioning. Which assessment technique is correct? 1. Test the client's deep tendon reflexes to observe for weakness 2. Check the client's pupils with a penlight and observe for constriction 3. Have the client's stand with eyes closed and observe for swaying 4. Ask the client to show the teeth and stick out the tongue

Have the client's stand with eyes closed and observe for swaying

The nurse reviews procedures with the health care team. The nurse intervenes if the RN staff member makes which statement? 1. "It is my responsibility to ensure the consent form has been signed and is attached to the client's record." 2. "It is my responsibility to witness the signature of the client before surgery is performed." 3. "It is my responsibility to explain the surgery and ask the client to sign the consent form." 4. "It is my responsibility to answer questions the client may have before surgery."

Strategy: "Nurse intervenes" indicates an incorrect statement is required. Question is unstated. Read answer choices for clues. 1) describes the nurse's responsibility in obtaining consent 2) signature indicates the nurse saw the client sign the form 3) CORRECT — health care provider should provide explanation and obtain client's signature 4) the nurse should answer questions after the health care provider has obtained consent

The nurse plans a diet for a child diagnosed with cystic fibrosis (CF). Which dietary requirements should be considered by the nurse? 1. High-protein 2. Low-sodium 3. High-calorie 4. Low-protein 5. Low-carbohydrate 6. High-sodium

High-protein & high-calorie

The client is treated in the telemetry unit for cardiac disease. The client receives propranolol hydrochloride 20 mg PO at 09:00. When the nurse enters the room to give the medication to the client, the nurse finds the client wheezing with a nonproductive cough and shortness of breath. Initially the nurse takes which action? 1. Holds the medication and counts the respirations 2. Holds the medication and calls the healthcare provider 3. Takes an apical pulse and then gives the medication 4. Gives the medication as ordered

Holds the medication and counts the respirations

The neonate weighing 7 lb 4 oz with Apgar scores of 7 and 8 at 1 and 5 minutes, respectively. Because the infant's mother is diagnosed with type 1 diabetes, the nurse knows the infant is at greatest risk for developing which problem? 1. Hypovolemia 2. Hypoglycemia 3. Hyperglycemia 4. Cold stress

Hypoglycemia

The health care provider order hydromorphone 15 mg IM for a client. The nurse should observe for which side effect?

Hypotension and respiratory depression.-> NARCOTIC ANALGESIC USED FOR MODERATE TO SEVERE PAIN, MONITOR VITALS FREQUENTLY.

Which action is the best way for the nurse to assess the fluid balance of the elderly client?

Maintain an accurate intake and output. ->BEST INDICATOR OF FLUID STATUS.

An adolescent is brought to the hospital for treatment of deep partial thickness and full thickness burns sustained in a house fire. An IV infusion is started in the client's left forearm. The nurse identifies which reason as the primary purpose for the IV?

Maintain fluid balance. -> LOSS OF FLUID OCCURS FROM OPEN BURN SURFACES; MAINTAINING CIRCULATION IS LIFE-SAVING REQUIREMENT.

The client is admitted to the hospital for a hemiglossectomy with lymph node dissection. The client's preoperative care includes frequent oral hygiene with normal saline. The nurse knows the purpose of this treatment includes which reason? 1. Minimizes the bacterial count in the mouth 2. Softens the mucous membranes of the tongue before surgery 3. Stimulates the microcirculation of the mouth 4. Hydrates the tissues of the gums

Minimizes the bacterial count in the mouth

The nurse cares for the elderly client diagnosed with dementia. Which nursing action is BEST? 1. Place the client in soft hand restraints or chair restraints 2. Monitor wandering behaviors during a 7-day period 3. Keep the lounge's television volume on a low level 4. Encourage a diet high in protein, iron, and vitamins

Monitor wandering behaviors during a 7-day period

The parent of a child with chickenpox asks the clinic nurse why the child will not come down with chickenpox again if exposed to the virus at school at a later date. which explanation does the nurse give?

Natural active immunity occurs because the child's body actively makes antibodies against the chickenpox virus. -> antigen enters the body without human assistance; body responds by actively making antibodies.

The client takes phenelzine. The nurse observes the client eat another client's lunch. After a few minutes, the client reports headache, nausea, and rapid heartbeat, and begins to vomit. The nurse anticipates administering which medication? 1. Buspirone 2. Fluoxetine 3. Prochlorperazine 4. Nifedipine

Nifedipine

The nurse cares for the child who is in Buck's traction. The nurse notes the foot of the uninjured leg feels warmer to touch than that of the broken leg. The nurse takes which action? 1. Records the observation 2. Encourages the child to move the foot 3. Covers the colder foot with a sock 4. Notifies the healthcare provider

Notifies the healthcare provider

The client has an irregular pulse rate of 81 and a potassium level of 3.0 mEq/L (3.0 mmol/L). The client has digoxin ordered. Which nursing action is BEST? 1. Give the digoxin 2. Hold the digoxin 3. Notify the healthcare provider 4. Recheck the pulse

Notify the healthcare provider

The client is learning to self-administer insulin. Which observation indicates to the nurse the client needs further teaching? 1. The client draws up the short-acting insulin first, then the intermediate-acting insulin 2. The client gently rotates the insulin bottle before withdrawing the dose 3. The client rotates injection sites following the guide on the printed diagram 4. The client administers the insulin while it is still cold from the refrigerator

The client administers the insulin while it is still cold from the refrigerator

The charge nurse makes client assignments on the maternity unit. The RN has been reassigned to the maternity unit from outpatient surgery. Which client does the charge nurse assign to the RN? 1. The client at 16 weeks gestation admitted with hyperemsis and receiving IV fluids 2. The client at 26 weeks in premature labor and receiving terbutaline 3. The client at 32 weeks gestation with a placenta prevue and ruptured membranes 4. The client at 37 weeks gestation with severe preeclampsia and epigastric pain

The client at 16 weeks gestation admitted with hyperemesis and receiving IV fluids

The nurse reviews client assignments on a medical surgical unit. The nurse determines the assignment is appropriate if the nurse assistive personnel provides care for which client? 1. The client diagnosed with AIDS dementia complex and who requires a urine specimen 2. The client reporting postop pain after repair of a torn rotator cuff 3. The client diagnosed with GI bleeding due to a duodenal ulcer and who is receiving packed cells 4. The client diagnosed with type 1 diabetes and who is receiving prednisone for a herniated disk

The client diagnosed with AIDS dementia complex and who requires a urine specimen

The nurse cares for the client after right cataract surgery. The nurse intervene if which observation is made? 1. Client is in the supine position 2. The head of the bed is elevated 30 degrees 3. The client is lying on the right side 4. An eye shield is over the right eye

The client is lying on the right side

The client is diagnosed with right-sided weakness. The nurse instructs the client how to walk down stairs using a cane. Which client behavior indicates the teaching is successful? 1. The client puts the right leg on the step, then the cane, followed by the left leg. 2. The client leads with the cane, followed by the right leg and then the left leg. 3. The client advances the right leg, followed by the left leg and the cane. 4. The client puts the cane on the step and advances the left leg, followed by the right leg.

The client leads with the cane, followed by the right leg and then the left leg

The nurse administers oral verapamil to a client. Which assessment does the nurse make before the nurse make before administering the medication?

The client's heart rate.-> VERAPAMIL IS INDICATED FOR THE TREATMENT OF SUPRAVENTRICULAR TACHYCARDIA, SO THE CLIENT'S HEART RATE SHOULD BE CHECKED PRIOR TO ADMINISTRATION.

The healthcare provider orders morphine sulfate 8mg IM Q3 to 3 hours for pain PRN. In which situation does the nurse consider withholding the medication until further assessment is completed? 1. The client's reports acute pain from a partial-thickness burn affecting the lower left leg 2. The client's BP is 140/90, pulse is 90, and respiration is 28 3. The client's level of consciousness fluctuates from alert to lethargic 4. The client exhibits restlessness, anxiety, and cold and clammy skin

The client's level of consciousness fluctuates from alert to lethargic

Which would be most important for the rehabilitation nurse to assess during a new client's admission?

The client's personal goals for rehabilitation-> IT IS IMPORTANT FOR THE NURSE TO UNDERSTAND WHAT THE CLIENT EXPECTS FROM THE REHABILITATION PROGRAM FOR FUTURE SUCCESS.

The nurse checks the incision of the client 48 hours after surgery for a hernia repair. Which finding indicates a possible complication? 1. There is swelling under the sutures 2. There is crusting around the incision line 3. The incision line is red 4. The incision line is approximated

The incision line is red

The nurse administers Rho(D) immune globulin to prevent complications in which client situation? 1. The baby is Rh-negative, the mother is Rh-negative, and the father is Rh-positive. 2. The mother is Rh-negative, the baby is Rh-positive, and there is a negative direct Coombs. 3. The mother is Rh-positive and previously sensitized, and the baby is Rh-negative. 4. The mother is Rh-positive, the baby is Rh-negative, and there is a history of one incomplete pregnancy.

The mother is Rh-negative, the baby is Rh-positive, and there is a negative direct Coombs.

The outpatient clinic nurse cares for an elderly client diagnosed with type 1 diabetes. Because the client is unwilling to perform blood glucose monitoring, the client tests urine for sugar and acetone. The nurse knows that blood glucose monitoring is preferred over urine testing for glucose because of which reason?

The renal threshold for glucose is elevated in the elderly.-> THE LEVEL AT WHICH GLUCOSE STARTS TO APPEAR IN THE URINE INCREASES, LEADING TO FALSE-NEGATIVE READINGS; RESULTS IN ELEVATED GLUCOSE LEVELS

The nurse performs the Rinne test on a client. Which is an accurate statement of how this test should be started?

The stem of a vibrating tuning fork is held against the mastoid bone until the client indicates sound can no longer be heard. -> CLIENT SHOULD HEAR SOUND AGAIN WHEN TUNING FORK IS REMOVED FROM MASTOID BONE TO THE FRONT OF THE AUDITORY CANAL BECAUSE AIR CONDUCTION IS BETTER THAN BONE CONDUCTION.

The health care provider orders mannitol for a client with a closed head injury. Which should the nurse recognize as the desired response to this medication?

Urinary output increases to 175 mL/hour. -> MANNITOL IS AN OSMOTIC DIURETIC; INCREASES URINARY OUTPUT AND DECREASES INTRACRANIAL PRESSURE.

The client receives tetracycline. The nurse indicates which information in the teaching plan? 1. Take the medication with milk or antacids to decrease GI problems 2. The medication should always be taken with meals 3. Use a maximum-protection sunscreen when outdoors. 4. Crackers and juice will help decrease gastric irritation

Use a maximum-protection sunscreen when outdoors

The client asks what the difference is between a gastric ulcer and duodenal ulcer. Which response does the nurse give? 1. "Gastric ulcers have an increased association with clients who experience greater psychological pressures." 2. "The pain of a duodenal ulcer usually occurs 2 to 4 hours after meals." 3. "Client with gastric ulcers often gain weight, as food alleviates the pain." 4. "Antacids are seldom prescribed for clients with duodenal ulcers."

"The pain of a duodenal ulcer usually occurs 2 to 4 hours after meals."

At 32 weeks gestation, a client has an order for an ultrasound. "the nurse determines the client understands the procedure if the client makes which statement?

"The results will inform us of the gestational age."-> ULTRASOUND DETECTS THE GESTATIONAL AGE.

The client has a nasogastric tube connected to intermittent low suction. At 07:00, the nurse documents 235 mL of greenish drainage in the suction container. At 15:00, there is 445 mL of greenish drainage in the suction container. Twice during the shift, the nurse irrigates the tube with 30 mL of normal saline. Which is the actual amount of drainage from the nasogastric tube for 07:00 to 15:00? 1. 150 mL. 2. 210 mL. 3. 295 mL. 4. 385 mL.

1) CORRECT - 445 − 235 = 210 − 60 = 150 2) does not subtract 60 mL of fluid used to irrigate tube 3) does not take into account solution added to container during day shift; does not subtract for fluids used to irrigate tube 4) does not subtract 235 mL that was in container from previous shift

The parent tells the nurse about having had difficulty forming relationships. The parent is worried the 7-year-old child will have the same problem. Which statement by the nurse is best? 1. "Children develop trust from birth to 18 months of age." 2. "Children develop trust from 18 months to three years of age." 3. "Children develop trust from three to six years of age." 4. "Children develop trust from six to twelve years of age."

1) CORRECT — Erikson states that trust results from interaction with dependable, predictable primary caretaker 2) toddler stage concerns autonomy verses shame and doubt 3) preschool stage concerns initiative versus guilt 4) latency or school age stage concerns industry versus inferiority

The health care provider prescribes lithium carbonate 300 mg PO QID for the adult client. The nurse in the outpatient clinic instructs the client about the medication. The nurse encourages the client to maintain an adequate intake of which substance? 1. Sodium. 2. Protein. 3. Potassium. 4. Iron.

1) CORRECT — alkali metal salt acts like sodium ions in the body; excretion of lithium depends on normal sodium levels; sodium reduction causes marked lithium retention, leading to toxicity 2) doesn't interact with lithium 3) doesn't interact with lithium 4) doesn't interact with lithium

The client reports a severe headache, nausea, and photophobia. The health care provider orders a complete blood count (CBC) and a lumbar puncture (LP). A diagnosis of bacterial meningitis is made. Which laboratory result does the nurse expect? 1. Cerebrospinal fluid (CSF) cloudy, hemoglobin (Hgb) 13 g/dL (130 g/L), hematocrit (HCT) 38%, white blood cell count (WBC) 18,000/mm3. 2. CSF with red blood cells (RBCs) present, Hgb 10 g/dL (100 g/L), HCT 37%, WBC 8,000/mm3. 3. CSF cloudy, Hgb 12 g/dL (120 g/L), HCT 37%, WBC 7,000/mm3. 4. CSF clear, Hgb 15 g/dL (150 g/L), HCT 40%, WBC 11,000/mm3.

1) CORRECT — cerebrospinal fluid (CSF) normally clear, colorless; normal white blood cell count (WBC) 5,000 to 10,000 per mm3, normal hemoglobin (Hgb) (male 13 to 18 g/dL (130-180 g/L), female 12 to 16 g/dL)(120-160 g/L), normal hematocrit (HCT) (male 42 to 52%, female 35 to 47%); CSF is cloudy indicating inflammation/infection; Hgb and HCT are within the normal ranges; WBC is elevated indicating infection 2) indicates trauma or hemorrhage 3) WBC too low, not typical of bacterial meningitis 4) indicates viral meningitis; clear CSF, increase in WBC not as significant as bacterial meningitis

The 7-year-old child is having some difficulty adjusting to the parents' impending divorce. The health care provider suggests play therapy. The nurse identifies which reason this is effective for this age group? 1. Young children have difficulty verbalizing emotions. 2. Children hesitate to confide in anyone but their parents. 3. Play is an enjoyable form of therapy for children. 4. Play therapy is helpful in preventing regression.

1) CORRECT — children have difficulty putting feelings into words; play is how they express themselves 2) somewhat true, but not best reason for play therapy 3) not reason play therapy is used; is used because it is the best way for children to express themselves 4) may encourage child to act out earlier developmental stage to reveal underlying conflicts

The client is diagnosed with an adjustment disorder with depressed mood. The client has the greatest chance of success in activities that require psychic and physical energy if the nurse schedules activities at which time? 1. During the morning hours. 2. During the middle of the day. 3. During the afternoon hours. 4. During the evening hours.

1) CORRECT — client with reactive depression has the highest level of physical and psychic energy in the morning 2) as the day progresses, energy level declines 3) as the day progresses, energy level declines 4) as the day progresses, energy level declines

The client diagnosed with Addison's disease comes to the health clinic. When assessing the client's skin, the nurse expects to make which observation? 1. Darker skin that is more pigmented. 2. Skin that is ruddy and oily. 3. Skin that is puffy and scaly. 4. Skin that is pale and dry.

1) CORRECT — increase in melanocyte-stimulating hormone results in "eternal tan" 2) not seen with Addison's disease 3) not seen with Addison's disease 4) not seen with Addison's disease

The nurse cares for the client receiving haloperidol. The nurse anticipates which adverse effects? 1. Blood dyscrasia and extrapyramidal symptoms. 2. Hearing loss and unsteady gait. 3. Nystagmus and vertical gaze palsy. 4. Alteration in level of consciousness and increased confusion.

1) CORRECT — major adverse effects of haloperidol include hematologic problems, primarily blood dyscrasia and extrapyramidal symptoms (EPS) 2) not seen with haloperidol 3) not seen with haloperidol 4) not seen with haloperidol

The health care provider orders chlorpromazine to control the alcoholic client's restlessness, agitation, and irritability following surgery. The nurse checks the order with the health care provider because of which rationale? 1. The nurse believes the client's symptoms reflect alcohol withdrawal. 2. The nurse does not know if the client is allergic to this medication. 3. The nurse knows the client is not psychotic. 4. The nurse routinely checks on the health care provider's orders.

1) CORRECT — medication is contraindicated for the treatment of alcohol withdrawal symptoms; medication will lower client's seizure threshold and BP, causing potentially serious medical consequences 2) not best rationale for checking with health care provider about this order 3) not best rationale for checking with health care provider about this order 4) not best rationale for checking with health care provider about this order

The nurse prepares the client for an IV pyelogram (IVP) scheduled in 2 hours. The nurse contacts the health care provider if the client makes which statement? 1. "I take metformin for type 2 diabetes." 2. "I completed the bowel prep last evening." 3. "I ate a light meal last evening." 4. "I had an IVP 3 years ago."

1) CORRECT — should discontinue 48 hours prior to procedure, contrast media can cause life-threatening lactic acidosis 2) appropriate action; removes feces, fluid, and air from bowel so kidneys, ureters, and bladder will not be obscured 3) appropriate action 4) no reason to contact the health care provider

Correct steps of a dressing change

1) First Use clean gloves to remove old dressing to protect nurse. 2) Second Prepare the cotton swabs with providone-iodine. 3) Third Use circular motion going from center to outside area; clean to dirty. 4) Fourth Apply dressing to area. 5) Last Tape dressing in place.

The client returns from surgery after a right mastectomy. There is an IV of 0.9% NaCl infusing at 100 mL/h into the left forearm. The IV infiltrates several hours later. The nurse supervises the student nurse preparing to insert a new peripheral intravenous catheter. The nurse intervenes in which situation? 1. The student nurse selects a site where the veins are soft and elastic. 2. The student nurse selects a site on the distal portion of the left arm. 3. The student nurse selects a site close to the wrist joint. 4. The student nurse holds the skin taut prior to insertion of the catheter.

1) acceptable site selection 2) acceptable site selection; insertion site proximal to the infiltrated area may be used if same extremity must be used; right extremity avoided with mastectomy 3) CORRECT - inappropriate; movement in area could cause displacement 4) acceptable procedure

The client has a history of hypertension and angle-closure glaucoma. Which medication order does the nurse question? 1. Propranolol 80 mg PO QID. 2. Verapamil 40 mg PO TID. 3. Tetrahydrozoline 2 drops in each eye TID. 4. Timolol 1 drop in each eye once daily.

1) antihypertensive, beta-blocker used as an antianginal, reduces cardiac oxygen demand, no effect on glaucoma 2) calcium channel blocker used as antianginal; not contraindicated 3) CORRECT — contraindicated; ophthalmic vasoconstrictor, contraindicated with angle-closure glaucoma; use cautiously with hypertension 4) reduces aqueous formation and increases outflow, used for glaucoma

The nurse cares for the client with a radium implant. During the removal of the implant, it is most important for the nurse to take which action? 1. Clean the radium implant carefully with a disinfectant (alcohol or bleach) using long forceps. 2. Handle the radium carefully using forceps and rubber latex gloves. 3. Document the date and time of removal together with the total time of implant treatment. 4. Double-bag the radium implant before the person from radiology removes it from the room.

1) at no time should the nurse or client handle the radium; radiology department is responsible for handling implant 2) at no time should the nurse or client handle the radium; radiology department is responsible for handling implant 3) CORRECT — important that accurate documentation be maintained on the internal radium implant 4) at no time should the nurse or client handle the radium; radiology department is responsible for handling implant

The nurse recognizes which symptoms as characteristic of a panic attack? Select all that apply. 1. Decreased blood pressure. 2. Palpitations. 3. Decreased perceptual field 4. Bradycardia 5. Diaphoresis 6. Fear of going crazy

1) blood pressure increases. 2) CORRECT - the heart rate increases and palpitations occur. 3) CORRECT - the visual field narrows; part of the fight or flight reaction. 4) tachycardia occurs. 5) CORRECT - neurological changes cause diaphoresis. 6) CORRECT- clients fear they are going crazy; part of the neurological changes

The client comes to the clinic to have a hemoglobin A1c performed. Which client statement indicates to the nurse an understanding of the procedure? 1. "This test is performed by using a first voided urine specimen." 2. "This test needs to be performed in the morning before I eat breakfast." 3. "This test indicates how well my blood sugar has been controlled the past 2-3 months." 4. "I must follow my diet carefully for several days before the test."

1) blood sample is needed; can be obtained from a finger stick or a venapuncture 2) timing of test is not important 3) CORRECT — when RBCs are being formed, glucose is attached (glycosylated) and remains attached throughout the life of the RBC; normal 2.5 to 6% 4) current blood glucose doesn't affect test

The nurse observes the student nurse auscultate the right middle lobe (RML) lung of the client. The nurse knows the student nurse is auscultating correctly if the stethoscope is placed in which position? 1. Posterior and anterior base of right side. 2. Right anterior chest between the fourth and sixth intercostal spaces. 3. Left of the sternum, midclavicular, at right fifth intercostal space. 4. Posterior chest wall, midaxillary, right side.

1) cannot auscultate the RML from the posterior 2) CORRECT — RML is found in the right anterior chest between the fourth and sixth intercostal spaces 3) point of maximum impulse or apical pulse 4) cannot auscultate the RML from the posterior

The client at 16 weeks gestation has an amniocentesis. The client asks what will be learned from this procedure. The nurse responds that which condition can be detected? 1. Tetralogy of Fallot. 2. Talipes equinovarus. 3. Hemolytic disease of the newborn. 4. Cleft lip and palate.

1) cardiac abnormality detected at birth; pulmonary stenosis, ventricular septal defect, overriding aorta, hypertrophy of right ventricle 2) congenital deformity detected at birth; foot twisted out of normal position, clubfoot 3) CORRECT — maternal antibodies destroy fetal RBCs; bilirubin secreted because of hemolysis 4) congenital deformity detected at birth, midline fissure or opening into lip and/or palate

The nurse cares for the client diagnosed with Ménière's syndrome. The nurse stands directly in front of the client when speaking. Which best describes the rationale for the nurse's position? 1. This enables the client to read the nurse's lips. 2. The client does not have to turn the head to see the nurse. 3. The nurse will have the client's undivided attention. 4. There is a decrease in client's peripheral visual field.

1) client is not hard of hearing 2) CORRECT — by decreasing movement of client's head, vertigo attacks may be decreased 3) not the reason 4) there is no problem with visual fields

The nurse obtains a specimen from the client for sputum culture and sensitivity (C and S). Which instruction is best? 1. After pursed lip breathing, cough into a container. 2. Upon awakening, cough deeply and expectorate into a container. 3. Save all sputum for three days in a covered container. 4. After respiratory treatment, expectorate into a container.

1) coughing into a container is indicated, but not pursed-lip breathing 2) CORRECT — specimens should be obtained in the early morning because secretions develop during the night 3) appropriate for acid-fast stain for TB 4) earliest specimen is most desirable

The client is brought to the emergency department after being raped in the home. The client asks the nurse to call the spouse to come to the emergency department. The nurse knows the most common reaction of the significant other to a rape victim is reflected in which behavior? 1. Supportive and helpful to the victim. 2. Disconnected from and apathetic toward the victim. 3. Frustrated and feeling vulnerable, but denying the need for help. 4. Emotionally distressed and needing assistance.

1) significant others may want to be helpful; however, they generally do not have the immediate coping strategies to do so 2) rarely feel disconnected 3) usually family members will need and respond well to psychological intervention 4) CORRECT — sexual assault by rape is a crisis situation for victim and family members and friends

Which is the best method for the nurse to use when evaluating the effectiveness of tracheal suctioning? 1. Notes subjective data, such as "My breathing is much improved now." 2. Notes objective findings, such as decreased respiratory rate and pulse. 3. Consults with the respiratory therapist to determine effectiveness. 4. Auscultates the chest for change or clearing of adventitious breath sounds.

1) subjective data and not as conclusive 2) correct but not as effective 3) not appropriate 4) CORRECT — to assess the effectiveness of suctioning, auscultate the client's chest to determine if adventitious sounds are cleared and to ensure that the airway is clear of secretions

The client diagnosed with metastatic lung cancer is admitted to the hospital. The client's orders include do not resuscitate (DNR) and morphine 2 mg/h by continuous IV infusion. The client's BP is 86/50, respirations are 8, and the client is nonresponsive. Naloxone hydrochloride 0.4 mg IV is ordered stat. It is important for the nurse to consider which action? 1. The BP and respirations will need to increase before a second dose of naloxone can be given. 2. Naloxone should not be given to the client because of the DNR status. 3. A dose of naloxone may need to be repeated in 2 to 3 minutes. 4. Naloxone is effective in treating respiratory changes caused by opiates, barbiturates, and sedatives.

1) will not change without naloxone, respirations increase within 2 min 2) DNR indicates no resuscitation should be done if heart stops; does not preclude administration of medications to correct iatrogenic problems 3) CORRECT — half-life of naloxone is short; may go back into respiratory depression; may need to be repeated 4) used for respiratory depression of opiates, not used with barbiturates or sedatives

The nurse cares for clients on a psychiatric unit and is suddenly faced with multiple issues. In which order does the nurse address these situations? 1. The client diagnosed with depression says to the nurse, "My plan is complete, and I'm ready to go." 2. The client diagnosed with bipolar disorder walks into he day room wearing only underwear. 3. The client with substance abuse reports harassment by another client. 4. The client diagnosed with schizophrenia tells the nurse the TV should be destroyed.

1, 3, 4, 2

The nurse cares for clients in the outpatient clinic. In which order will the nurse return the messages?

1. The "soft spot" on the heard of the 4-day-old feel slightly elevated when asleep. -> BULGING FONTANELLE MAY INDICATE INCREASED INTRACRANIAL PRESSURE AND IS MOST SERIOUS. 2. The circumcision site of the 3-day-old is slightly swollen.-> CIRCUMCISION SHOULD HAVE YELLOWISH EXUDATE AT THIS TIME, BUT SWELLING IS NOT NORMAL AND MAY INTERFERE WITH URINATION. 3. The umbilical cord of the 5-day-old is soft and draining exudate-> UMBILICAL CORD SHOULD BE DRY AND HARD; DRAINING INDICATES A POSSIBLE INFECTION AND NEEDS TO BE ASSESSED. 4. When bed is bumped, a 2-day-old rapidly extends the extremities-> DESCRIBES THE MORO REFLEX AND IS NORMAL.

The nurse cares for a client during an acute manic episode. The nurse identifies which client behaviors as most characteristic of mania? Select all that apply. 1. Paranoia. 2. Grandiose delusions. 3. Somatic difficulties. 4. Difficulty concentrating. 5. Agitation. 6. Distorted perceptions.

Strategy: Think about mania and how it is manifested. 1) related to schizophrenia. 2) CORRECT - delusions of grandeur are common during mania. 3) related to personality disorders. 4) CORRECT - due to excessive activity. 5) CORRECT - clients are constantly in motion. 6) related to depression.

The client develops a low intestinal obstruction. The nurse anticipates which findings? Select all that apply. 1. Nausea. 2. Vomiting. 3. Explosive diarrhea. 4. Tarry stool 5. Abdominal distention. 6. Rectal bleeding.

Strategy: Think of intestinal anatomy. 1) CORRECT - nothing moving in the intestine causes nausea. 2) CORRECT - nothing moving in the intestine causes vomiting. 3) blockage causes no stool. 4) blockage results in no stool. 5) CORRECT - as stool backs up, abdominal distention occurs. 6) blockage results in no stool and no bleeding is associated.

The nurse cares for a client diagnosed with a pneumothorax resulting from a motor vehicle accident 3 days ago. The client has a chest tube connected to a 3-chamber water-seal drainage system (Pleur-evac) with 20 cm suction. The nurse determines the ling has re-expanded if which observation is made?

The fluid in the water-seal chamber does not fluctuate with respirations. -> INDICATES NO MORE AIR LEAKING INTO PLEURAL SPACE. .

The nurse cares for the elderly client admitted with a possible fractured Right hip. During the initial nursing assessment, which observation of the Right leg and validates this diagnosis?

The leg appears to be shortened and is adducted and externally rotated.-> ACCURATE ASSESSMENTS OF THE POSITION OF A FRACTURED HIP PRIOR TO REPAIR.

The nurse supervises care given to clients a medical surgical unit. The nurse intervene if which activity is observed? 1. The nurse and client wear masks during a dressing change for the central catheter used for total parenteral nutrition 2. The nurse injects insulin through a single-lumen percutaneous central catheter for the client receiving total parenteral nutrition 3. The nurse applies lip balm to the lips immediately after performing a blood draw to obtain a specimen 4. The nurse wears a disposable particulate respiratory when administering rifampin to the client with TB

The nurse applies lip balm to the lips immediately after performing a blood draw to obtain a specimen

The 6-month-old infant has had all of the required immunizations for that age. The nurse knows this includes which immunizations? 1. Three doses of diphtheria, tetanus, and pertussis vaccine 2. Measles, mumps, and rubella vaccine 3. One dose of rotavirus 4. Varicella vaccine

Three of diphtheria, tetanus, and pertussis vaccine

The client has a total laryngectomy with a permanent tracheostomy. The nurse plans nutritional intake for the next 3 days. Which action is necessary for the nurse to consider regarding the client's nutrition? 1. To facilitate healing of the surgical area, a nasogastric tube may be utilized and tube feedings may be implemented. 2. The client will be unable to maintain any oral intake as long as the tracheostomy is in place. 3. Nutritional and/or gastric feedings will not be attempted for approximately 3 weeks to decrease the incidence of aspiration. 4. Because the client is dependent on the ventilator, nutritional intake will be delayed.

To facilitate healing of the surgical area, a nasogastric tube may be utilized and tube feedings may be implemented.

A client in labor is monitored with an internal fetal monitor. The nurse knows which is the most important reason for the fetal monitor?

To monitor the oxygen status of the fetus during labor.-> GOAL IS EARLY DETECTION OF MILD FETAL HYPOXIA.

The nurse cares for the client admitted with a diagnosis of acute hypoparathyroidism. It is MOST important for the nurse to have which items available? 1. Tracheostomy set 2. Cardiac monitor 3. IV monitor 4. Heating pad

Tracheostomy set

The nurse cares for the elderly client who is admitted with confusion, mood lability, impaired communication, and lethargy. Which order from the healthcare provider does the nurse question? 1. Dexamethasone suppression test 2. Thyroid studies 3. Drug toxicology screen 4. Trendelenburg test

Trendelenburg test

The nurse leads a parenting class for a group of expectant clients. How many extra calories a day does the nurse advise the clients to consume to support breastfeeding?

500-> MILK PRODUCTION REQUIRES AN INCREASE OF 500 CALORIES PER DAY.

The nurse cares for the postop client diagnosed with type 2 diabetes controlled with oral antihyperglycemic agents. The client asks why the health care provider ordered subcutaneous insulin injections after surgery. The nurse's response is based on knowing which physiological process?

Being NPO inhibits normal blood glucose control. -> TEMPORARY CONTROL BY INSULIN IS NEEDED DUE TO INABILITY TO CONTROL DIABETES MELLITUS BY DIET AND ORAL AGENTS, SURGICALLY INDUCED METABOLIC CHANGES, BEING NPO BOTH BEFORE AND AFTER SURGERY, AND THE INFUSION OF IV FLUIDS.

The client has a three-way indwelling urinary catheter following a transurethral resection. Which finding causes the nurse to infuse the irrigating solution rapidly? 1. The urinary output is increased 2. Bright-red drainage or clots are present 3. Dark-brown drainage is present 4. The client reports pain

Bright-red drainage or clots are present

The nurse provides care for a 2-day-old client. The neonate will not take formula from the parent or the nurse. Which is the priority nursing diagnosis? 1. Swallowing difficulty 2. Failure to thrive 3. Dehydration 4. Altered bonding

Dehydration

The middle-aged client is admitted to an inpatient psychiatric unit. The client reports a family member is trying to steal the client's property. The client is diagnosed with paranoid disorder. The nurse suspects that the client is demonstrating which symptom?

Delusions of persecution->CLIENT HAS DELUSION OF PERSECUTION; DELUSION IS A STRONGLY HELD BELIEF THAT IS NOT VALIDATED BY REALITY; THE IDEA THAT A FAMILY MEMBER IS TRYING TO STEAL PROPERTY IS A BELIEF NOT VALIDATED BY REALITY.

The nurse prepares the adult client diagnosed with intellectual delay for discharge. The health care provider ordered warfarin sodium, 5 mg each day. To maintain client safety, which action should the nurse take first?

Determine the client's comprehension of the medication administration. -> ASSESSMENT; INTELLECTUALLY DELAYED CLIENT SHOULD BE CAREFULLY EVALUATED TO ENSURE COMPLETE COMPREHENSION OF THE DOSAGE REGIMEN TO PREVENT OVERDOSAGE AND UNDERDOSAGE.

The nurse prepares a dopamine infusion for the client. Which action does the nurse take FIRST? 1. Evaluates the urine output 2. Obtains the client's weight 3. Determines the patency of the IV line 4. Measures pulmonary artery pressures

Determines the patency of the IV line

The client receives a blood transfusion and experiences a hemolytic reaction. The nurse anticipates which assessment findings? Select all that apply. 1. Hypotension. 2. Low back pain. 3. Wet breath sounds. 4. Fever. 5. Urticaria. 6. Severe shortness of breath.

Did you identify the topic correctly? Signs and symptoms of hemolytic blood reaction. Note: The topic is not what you are worried about if you see it; it is very specific to hemolytic reaction. Use the words. Is (the answer) a finding for hemolytic reaction? This will help keep you focused. 1) CORRECT — blood pressure drops 2) CORRECT — classic symptom related to hemolytic reaction 3) related to circulatory overload 4) CORRECT — fever is an expected symptom 5) related to an allergic reaction 6) related to circulatory overload

The toddler diagnosed with lead poisoning is admitted to the pediatric unit. The health care provider writes an order to encourage fluids. Which fluids is best for the nurse to offer to the toddler?

Milk-> MILK CONTAINS CALCIUM; CALCIUM BINDS TO LEAD AND INHIBITS ITS ABSORPTION.

The nursing team consists of one RN, two LPNs/LVNs, and three nursing assistive personnel (NAP). The RN cares for which client? 1. The client with a chest tube who is ambulating in the hall. 2. The client with a colostomy requiring assistance with an irrigation. 3. The client with a right-sided stroke requiring assistance with bathing. 4. The client declining medication to treat cancer of the colon.

Strategy: Determine the skill level involved with each client's care. The RN cares for clients who require assessment, teaching, and nursing judgment. 1) stable client with an expected outcome; assign to the LPN/LVN 2) stable client with an expected outcome; assign to the LPN/LVN 3) standard, unchanging procedure; assign to the NAP 4) CORRECT — requires assessment skills of the RN

The client is admitted with a tentative diagnosis of late stage AIDS dementia complex. The nursing assessment is most likely to reveal which finding? 1. Hyperactive deep tendon reflexes. 2. Peripheral neuropathy affecting the hands. 3. Disorientation to person, place, and time. 4. Impaired concentration and memory loss.

Strategy: Think about each answer and how it relates to AIDS-related dementia. 1) not relevant to this condition 2) not relevant to this condition 3) CORRECT — approximately 65% of AIDS clients demonstrate a progressive dementia staged according to severity of debilitation; late stage is typified by cognitive confusion and disorientation 4) is a sign of early-onset dementia

The nurse identifies that the primary reason elderly adults have problems with constipation is because of which process?

elderly adults engage in less exercise and have decreased muscle tone of the GI tract. -> REDUCED GI MOTILITY DUE TO DECREASED MUSCLE TONE, DECREASED EXERCISE; OTHER FACTORS INCLUDE PROLONGED USE OF LAXATIVES, IGNORING URGE TO DEFECATE, SIDE EFFECT OF MEDICATIONS, EMOTIONAL PROBLEMS, INSUFFICIENT FLUID INTAKE, AND EXCESSIVE DIETARY FAT.

A client, gravida 2 para 1, is admitted with hypertension. The client reports her wedding band is tight. The nurse should assess for which indications of mild pre-eclampsia?

facial swelling and proteinuria -> REPRESENTS 2 OF THE 3 SYMPTOMS SEEN WITH PRE-ECLAMPISA; ALSO INCLUDE HYPERTENSION.

The nurse cares for a patient client at 8 weeks gestation with a positive VDRL. When the nurse prepares the teaching plan, it is most important for the nurse to include which information?

instruct the client about the importance of taking all of the medication.-> PHYSICAL, VITALLY IMPORTANT TO COMPLETE ALL THE MEDICATION

Prior to sending a client for a cardiac catheterization, it is most important for the nurse to report which information?

the client has an allergy to shellfish.-> ALLERGIES TO IODINE AND/OR SEAFOOD MUST BE REPORTED IMMEDIATELY BEFORE CARDIAC CATH TO AVOID ANAPHYLACTIC SHOCK DURING THE PROCEDURE.

The 8-year-old has been receiving chemotherapy for 6 months. The child asks, "Am I going to die?" Which response by the nurse is BEST? 1. "Are you afraid of dying?" 2. "Why do you ask that question?" 3. "Only God knows that answer." 4. "We won't leave you alone."

"Are you afraid of dying?"

Several days after the delivery of a stillborn, the parents says, "we wish we could talk other couples who have gone through this trauma." which response be the nurse is best?

"SHARE will provide you with this opportunity." -> SHARE IS A SUPPORT GROUP FOR PARENTS WHO HAVE LOST A NEWBORN OR HAVE EXPERIENCED A MISCARRIAGE.

Which statement should be documented by the nurse to reflect a client's emotional adjustment to being hospitalized in the ICU?

"The client constantly calls for nurses and cries uncontrollably."-> GIVES AN OBJECTIVE DESCRIPTION OF THE CLIENT'S BEHAVIOR AND AFFECT.

The nurse supervises care given to a group of clients on the unit. The nurse observes a staff member entering a client's room wearing gown and gloves. The nurse knows the staff member is caring for which client? 1. An 18-month-old with respiratory syncytial virus. 2. A 4-year-old with Kawasaki disease. 3. A 10-year-old with Lyme disease. 4. A 16-year-old with infectious mononucleosis.

(1) correct—acute viral infection; requires contact precautions; assign to private room or with other RSV-infected children (2) acute systemic vasculitis in children under 5; standard precautions (3) connective tissue disease; standard precautions (4) standard precautions

The nurse evaluates the desired client response to diuretic therapy. Which action is the most reliable client measure for the nurse to use? 1. Obtain daily weights. 2. Obtain urinalysis. 3. Monitor Na+ and K+ levels. 4. Measure intake.

1) CORRECT — effectiveness of diuretic therapy is demonstrated by decreased edema and is measured by daily weights 2) does not relate to the effects of diuretic therapy 3) important to consider, but is not a priority 4) important to consider, but is not a priority

The nurse plans care for the 20-year-old client. Which psychosocial stage does the nurse identify as the priority to consider? 1. Identity versus identity diffusion. 2. Intimacy versus isolation. 3. Integrity versus despair and disgust. 4. Industry versus inferiority

1) appropriate for adolescents 2) CORRECT — this is the stage for 19- to 35-year-olds 3) for 65 years and older 4) for 6 to 12 years of age

The adult client is admitted to the hospital unit diagnosed with hepatitis A. Which precautions does the nurse include in the client's overall care during hospitalization? 1. Contact precautions. 2. Airborne precautions. 3. Standard precautions. 4. Droplet precautions.

1) required with client care activities that require physical skin-to-skin contact, or occurs by contact with contaminated inanimate objects in the client's environment 2) unnecessary; used with pathogens transmitted by airborne route 3) CORRECT— standard precautions should be used on everyone; sources for this virus are saliva, feces, and blood; use contact isolation if fecal incontinence 4) unnecessary; used when pathogens transmitted by infectious droplets

The nurse responds to a train derailment. After making initial assessments, in what order should the nurse see these clients? 1. The young client with blood pulsating from a cut on the right leg 2. The pregnant client who states clothing is wet 3. The unconscious client with the right leg shorter than the left leg 4. The preschool child who is screaming and crying uncontrollably

1, 3, 2, 4

The nurse recognizes which symptoms are early signs of lithium toxicity?

1. Fine motor tremors. 4. Nausea and vomiting. 6. Diarrhea.

Which symptoms might alert the nurse to consider an alcohol problem in a client hopsitalized for a physical illness?

1. Tremors. 2. Elevated temperature. 4. Nocturnal leg cramps.

The nurse in the pediatric office observes the child in the waiting room. The child can walk up and down steps, has a steady gait, can stand on one foot momentarily, and jumps with both feet. Which does the nurse identify as the child's chronological age? 1. 1 year old 2. 2 years old 3. 3 years old 4. 5 years old

3 years old

Which is the MOST appropriate nursing action to take before administering captopril? 1. Check the client's apical pulse for 60 seconds 2. Check the client's BP 3. Check the client's urine output 4. Check the client's temperature

Check the client's BP

The nurse knows that cortisol is responsible for which action?

Converting proteins and fat into glucose.-> action of cortisol; is also an anti-inflammatory agent.

A 7-year-old child is seen in the clinic with a diagnosis of pituitary dwarfism. Which clinical manifestation is the nurse most likely to observe?

Delicate features-> APPEAR YOUNGER THAN CHRONOLOGICAL AGE.

The nurse cares for a 3-month old infant scheduled for a barium swallow in the morning. Prior to the procedure, it is most appropriate for the nurse to take which action?

Make the infant NPO for 3 hours

The nurse should caution the client with hypothyroidism to avoid which implementation?

Narcotic sedative.-> CLIENT IS VERY SENSITIVE TO NARCOTICS, BARBITURATES, AND ANESTHETICS.

During the client's fourth stage of labor, the nurse should palpate the client's fundus in which location?

Palpable at the umbilicus

The nurse performs ROM exercises for an elderly client recently immobilized. the nurse identifies which statement is correct about ROM?

ROM assists the elderly to carry out activities of ADLs-> EMPHASIS SHOULD BE ON ROMS THAT SUPPORT ADLS

The client is diagnosed with a hiatal hernia. Which information is the nursing assessment MOST likely to reveal? 1. A bulge in the lower right quadrant 2. Pain at the umbilicus radiating down into the groin 3. A burning sensation in the midepigastric area each day before lunch 4. Reports of awakening at night with heartburn

Reports of awakening at night with heartburn

If the nurse cares for a client with ataxia, which action is most important?

Supervise-ambulation-> CLIENT'S COORDINATION IS POOR, THE ONLY RELEVANT NURSING ACTION IS TO SUPERVISE AMBULATION.

The nurse cares for an older client scheduled for a colon resection this morning. The nurse notes the client had polyerthylene glycol-electrolyte solution and a soapsuds enema the previous evening. This morning the client passes a medium amount of soft brown stool. Which conclusion by the nurse is most accurate?

The bowel preparation is incomplete-> COLON SHOULD NOT HAVE REMAINING SOFT STOOL.

The nurse prepares an older client for an Intravenous pyelogram (IVP). The client asks the nurse to explain the reason why the procedure is performed. The nurse's response should be based on which explanation?

The health care provider is able to examine the urinary tract by x-ray. -> X-RAYS OF ENTIRE URINARY TRACT TAKEN, EVALUATES KIDNEY FUNCTION.

The nurse obtains a history from the parent of the 6-year-old child with a history of epilepsy. The child was admitted with uncontrolled seizures. It is MOST important for the nurse to ask which question? 1. "What part of the body was affected by the seizure?" 2. "What is the family history of seizure disorders?" 3. "What was your child doing before the seizure?" 4. "How long has it been since the last episode of seizures?"

"What was your child doing before the seizure?"

The client experiences inflammation due to rheumatoid arthritis. Which nursing statement is correct? 1. "If you are having a 'bad' day, postpone your exercises until the next day." 2. "Passive exercises are better for you than active exercises." 3. "When inflammation is severe, decrease the number of repetitions of the exercise." 4. "You can substitute your normal household tasks for your exercises to provide variety."

"When inflammation is severe, decrease the number of repetitions of the exercise."

The nurse cares for a client diagnosed with gastric reflux due to a hiatal hernia. The client asks the nurse why food and fluids should be withheld just before going to bed. Which response by the nurse is most appropriate?

"You are less likely to awaken during the night with heartburn if the stomach is empty."-> FULL STOMACH IS MORE LIKELY TO SLIDE (REFLUX) THROUGH THE HERNIA, CAUSING REGURGITATION AND HEARTBURN.

The client is diagnosed with Cushing syndrome. Which assessment finding does the nurse recognize as pertinent to this diagnosis? 1. Low blood pressure and weight loss. 2. Thin extremities with easy bruising. 3. Decreased urinary output and decreased serum potassium. 4. Tachycardia with reports of night sweats..

1) BP increases and client gains weight 2) CORRECT — clients with Cushing syndrome tend to lose weight in their legs and have petechiae and bruising 3) no correlation with urinary output; potassium decreases 4) no correlation with Cushing syndrome

The nurse cares for the homebound client with a urinary catheter. The client's spouse states the catheter is obstructed. Which observation by the nurse confirms this suspicion? 1. The nurse notes that the bladder is distended. 2. The client reports a constant urge to void. 3. The nurse notes that the urine is concentrated. 4. The client reports a burning sensation.

1) CORRECT — bladder distention is one of the earliest signs of obstructed drainage tubing 2) seen with a urinary tract infection 3) seen with dehydration 4) seen with a urinary tract infection

The health care provider prescribes estrogen 0.625 mg daily for the 43-year-old woman. The nurse identifies which symptom as a common initial adverse effect of this medication? 1. Nausea. 2. Visual disturbances. 3. Tinnitus. 4. Ataxia.

1) CORRECT — common at breakfast time; will subside after weeks of medication use; take after eating to reduce incidence 2) seen with long-term use 3) ringing in the ears is seen with long-term use 4) unsteady gait rarely seen

The nurse plans care for the client diagnosed with paranoid schizophrenia. The nurse knows that questioning the client about the client's false ideas will elicit which response? 1. Cause the client to defend the idea. 2. Help the client clarify thoughts. 3. Facilitate better communication. 4. Lead to a breakdown of the defense.

1) CORRECT — contraindicated; encourages client to engage in further distortion of reality 2) needs reality testing from nurse, not questioning 3) questioning is nontherapeutic; may cause client to avoid nurse physically 4) needs defense; questioning will further distort reality or elaborate on delusion

The nurse prepares discharge teaching for the parents of the newborn. Which information does the nurse provide regarding the accuracy of a PKU (phenylketonuria) test? 1. The initial specimen should be collected as close to discharge as possible but not later than 7 days. 2. The infant can have water but should not have formula for 6 hours before the test. 3. The test will need to be repeated at 6 weeks and at the 3-month check-up. 4. Blood will be drawn at three 1-hour intervals; there is no specific preparation.

1) CORRECT — if initial specimen is collected before newborn is 24 hours old, a repeat test should be performed by 2 weeks of age 2) no restriction on formula intake 3) test may be repeated within 2 weeks to ensure accuracy 4) only one blood sample is needed

The adolescent is scheduled for a below-knee (BK) amputation following a motorcycle accident. The nurse includes which information in the preoperative teaching session? 1. Explain that the client will walk with a prosthesis soon after surgery. 2. Encourage the client to share feelings and fears about the surgery. 3. Take the informed consent form to the client and ask the client to sign it. 4. Evaluate how the client plans to complete schoolwork during hospitalization.

1) fails to recognize client's immediate concerns 2) CORRECT — discussing client's feelings and fears is important in dealing with anxiety due to a change in body image and functioning 3) client is underage; parents will need to sign the permit 4) is more appropriate for the postoperative period of time than for the preoperative period

The client is diagnosed with a gastric ulcer. The nurse anticipates the client will experience pain at which time? 1. Two to three hours after a meal. 2. During the night. 3. Prior to the ingestion of food. 4. One-half to 1 hour after a meal.

1) feature of a duodenal ulcer 2) feature of a duodenal ulcer 3) feature of a duodenal ulcer 4) CORRECT — pain related to a gastric ulcer occurs about 0.5 to 1 hour after a meal and rarely at night; is not helped by ingestion of food

The client with type 1 diabetes asks the nurse why the health care provider prescribed short-acting insulin instead of intermediate-acting insulin. Which response by the nurse is best? 1. "More injections are required with intermediate-acting insulin than with short-acting insulin." 2. "Hypoglycemia and hyperglycemia are more common with intermediate-acting insulin." 3. "Development of eye and kidney damage is less likely with short-acting insulin." 4. "Blood glucose levels can be controlled more accurately with short-acting insulin."

1) fewer injections are required with intermediate-acting insulin 2) no change in incidence of hypoglycemia or hyperglycemia 3) complications are caused by blood vessel damage from sugar and fat deposits, not type of insulin used 4) CORRECT — tighter blood glucose control occurs with short-acting insulin, especially initially

Identify the most unstable clients to see first.

1) first: the client with pink tinged mucus; symptoms of pulmonary edema; requires immediate attention 2) second: the client on heparin; still potential for problems related to heparin; assess for bleeding gums, hematuria 3) third: the client with pneumonia; potential for relapse; assess breath sounds, encourage fluids, cough and deep breathe 4) fourth: breastfeeding client; stable client, least critical/priority

The geriatric residents of a long-term care facility participate in a reminiscing group. The nurse identifies which goal as the primary goal of this type of group activity? 1. Provides psychosocial educational opportunities for stress and coping. 2. Provides an avenue for physical exercise. 3. Provides an environment for social interaction and companionship. 4. Reorients and provides a reality test for confused clients.

1) is not primary goal of a reminiscing group 2) is not primary goal of a reminiscing group 3) CORRECT — primary goal of a reminiscing group for geriatric clients is to review and share their life experiences with the group members (4) groups that facilitate orientation to time, person, place, and current events are called reality orientation groups

The client is newly diagnosed with Buerger's disease. The clinic nurse obtains a health history. The nurse expects the client's history to include which symptom? 1. Heart palpitations. 2. Dizziness when walking. 3. Blurred vision. 4. Digital sensitivity to cold.

1) no cardiac involvement 2) dizziness not seen; intermittent claudication (pain with exercise) seen 3) optic nerve not affected 4) CORRECT — vasculitis of blood vessels in upper and lower extremities

The client is admitted to the outpatient oncology unit for routine chemotherapy transfusion. The client's current lab report is WBC 2,500 mm3, RBC 5.1 million/mm3, total serum calcium 9.3 mg/dL (2.3 mmol/L). Based on the lab values, the nurse determines which is the priority nursing diagnosis? 1. Risk for Activity Intolerance related to decrease in red cells. 2. Risk for Infection related to low white cell count. 3. Risk for Anxiety secondary to hypoparathyroid disease. 4. Risk for Fluid Volume Deficit due to decreased fluid intake.

1) not a priority 2) CORRECT — clients with a low WBC count are susceptible to infection 3) not correctly stated as a nursing diagnosis and is not appropriate 4) not a priority for this client

The school nurse conducts a class on childcare at the local high school. During the class, one of the participants asks the nurse what age is best to start toilet training a child. Which is the best response by the nurse? 1. 11 months of age. 2. 14 months of age. 3. 17 months of age. 4. 20 months of age.

1) not able to physiologically control sphincters until 18 months of age 2) not able to physiologically control sphincters until 18 months of age 3) not able to physiologically control sphincters until 18 months of age 4) CORRECT — average of training begins at 20 months; by 24 months may be able to achieve daytime bladder control

The newborn is diagnosed with fetal alcohol syndrome. The nurse knows which action is an important consideration for this newborn? 1. Prevent iron deficiency anemia. 2. Decrease touch to prevent over stimulation. 3. Provide feedings via gavage to decrease energy expenditure. 4. Replace vitamins depleted as a result of poor maternal diet.

1) not highest priority 2) infant needs to be held and cuddled due to a poorly developed CNS 3) usually unnecessary 4) CORRECT — frequently, maternal diet is poor and infant is malnourished; adequate intake of B complex vitamins is necessary for normal CNS function

The nurse cares for the client diagnosed with hypoparathyroidism. Which nursing action has the highest priority for this client? 1. Develop a teaching plan. 2. Plan measures to deal with cardiac dysrhythmias. 3. Take measures to prevent a respiratory infection. 4. Assess laboratory results.

1) not highest priority action related to the diagnosis 2) CORRECT — cardiac dysrhythmias related to low serum calcium would be the highest priority 3) potential for respiratory infection is not a major threat 4) not highest priority action related to the diagnosis

The nurse develops care plans for these four clients. The nurse plans to use a restraint for which client? 1. The infant with septicemia. 2. The child after a tonsillectomy. 3. The infant after a cleft lip repair. 4. The child with meningitis.

1) not in need of restraints 2) not in need of restraints 3) CORRECT — arm restraints are necessary to prevent infant from rubbing or otherwise disturbing suture line 4) not in need of restraints

The nursing assistive personnel (NAP) reports to the RN that the client with anemia reports weakness. Which nursing response is best? 1. "Listen to the client's breath sounds and report back to me." 2. "Set up the client's lunch tray." 3. "Obtain a diet history from the client ." 4. "Instruct the client to balance rest and activity."

1) requires assessment; should be performed by the RN 2) CORRECT — standard, unchanging procedure; decreases cardiac workload 3) involves assessment; should be performed by the RN 4) assessment and teaching required; performed by the RN

Which assessment information indicates to the nurse the client has hypocalcemia? 1. Constipation. 2. Depressed reflexes. 3. Decreased muscle strength. 4. Positive Trousseau's sign.

1) symptom associated with hypercalcemia 2) symptom associated with hypercalcemia 3) symptom associated with hypercalcemia 4) CORRECT — positive Trousseau's sign is indicative of neuromuscular hyperreflexia associated with hypocalcemia

The 4-year-old child is admitted with drooling and an inflamed epiglottis. The nurse identifies which symptom as indicative of an increase in respiratory distress? 1. Bradycardia. 2. Tachypnea. 3. General pallor. 4. Irritability.

1) tachycardia occurs early in hypoxia 2) CORRECT — increase in the respiratory rate is an early sign of hypoxia, also for tachycardia 3) pallor is not specific for hypoxia 4) client may be anxious and restless, but is generally not described as irritable

The nurse develops a comprehensive care plan for the young client diagnosed with anorexia nervosa. The client is referred to assertiveness skills classes. This is an appropriate intervention because the client may exhibit which problem? 1. Aggressive behaviors and angry feelings. 2. Self-identity and self-esteem issues. 3. An intense focus on reality. 4. Family boundary intrusions.

1) these clients do have problems with feelings of anger; family therapy sessions can be helpful in identifying some of these feelings and difficulties with family boundaries 2) CORRECT — clients with eating disorders experience difficulty with self-identity and self-esteem, which inhibits their abilities to act assertively; some assertiveness techniques that are taught include giving and receiving criticism, giving and accepting compliments, accepting apologies, being able to say no, and setting limits on what they can realistically do rather than just doing what others want them to do 3) do not have problems with reality 4) these clients do have problems with family boundary intrusion; family therapy sessions can be helpful in identifying some of these feelings and difficulties with family boundaries

A Miller-Abbott tube is ordered for the client. The nurse knows this tube is inserted for which main reason? 1. Provides an avenue for nutrients to flow past an obstructed area. 2. Prevents fluid and gas accumulation in the stomach. 3. Administers medications that can be absorbed directly from the intestinal mucosa. 4. Removes fluid and gas from the small intestine.

1) tube would be placed in an area of reduced peristalsis and would slowly work past an obstruction 2) describes a tube such as a Levin or Salem Sump, which decompresses the stomach 3) tube provides for decompression instead of instillation of medications 4) CORRECT — Miller-Abbott tube provides for intestinal decompression; intestinal tube is often used for treatment of paralytic ileus

The health care provider diagnoses Graves' disease for the client. The nurse expects the client to exhibit which symptom? 1. Lethargy in the early morning. 2. Sensitivity to cold. 3. Weight loss of 10 lb in 3 weeks. 4. Reduced deep tendon reflexes.

1) will be restless 2) will have heat intolerance due to increased metabolic rate 3) CORRECT — increased metabolic rate causes weight loss even with increased appetite 4) reflexes will be hyperactive

The client returns from surgery. There is a fine, reddened rash around the area where providone iodine prep was applied prior to surgery. The nursing notation in the client's record includes which observation? 1. Time and circumstances under which the rash was noted. 2. Explanation given to the client and family of the reason for the rash. 3. Notation on an allergy list and notification of the health care provider. 4. The need for application of corticosteroid cream to decrease inflammation.

1) would be noted, but is not as high a priority 2) inappropriate 3) CORRECT — suspected reaction to substances should be reported to the health care provider and noted on list of possible allergies 4) inappropriate

The nurse receives report on these clients from the previous shift. In which order should the nurse see the clients? 1. The client scheduled to receive heparin and the aPTT is 70 seconds 2. The client receiving IV potassium infusion who reports burning at the IV site 3. The client receiving ciprofloxacin IV, reports a fine macular rash on the chest 4. The client receiving a blood transfusion who reports a dry mouth

3, 2, 1, 4

The nurse cares for a client receiving docusate 100mg through a gastric tube. The solution contains 150mg/15mL. The nurse should administer how many mL of the solution to the client?

ANSWER: 10 mL 100mg/X mL= 150mg/15mL 1500mg/mL=150mg/XmL 1500mg/mL / 150mg X= 10 mL

The nurse cares for the client receiving D5 0.45% NS 1,000 mL to run from 0900 to 1700. The drip factor on the delivery tubing is 20 gtt/mL. At what are does the nurse set the IV to drip?

ANSWER: 42 gtt/min 1000mL/8 hours=125 mL/hour 125mL/hour x 20 gtt/mL / 60 minutes= 42 gtt/min

The elderly client diagnosed with chronic schizophrenia is cared for in a partial hospitalization program. The client has been on long-term antipsychotic medication and recently developed symptoms of tardive dyskinesia. The nurse's documentation includes which finding? 1. Assessment of ADL ability 2. Mini-Mental Status Examination (MMSE) 3. Abnormal Involuntary Movement Scale (AIMS) 4. Modified Overt Aggression Scale (MOAS)

Abnormal Involuntary Movement Scale (AIMS)

The nurse on a psychiatric unit of the hospital declines a client's request to organize a party on the unit for the client's friends. The client becomes angry and uses abusive language toward the nurse. Which statement indicates the nurse has an understanding of the client's behavior?

Abusive language is one of the behaviors symptomatic of the client's illness. -> SYMPTOMS WILL RESPOND TO TREATMENT.

In planning diet teaching for a child in the early stages of nephrotic syndrome, the nurse should discuss with the parents which dietary change?

Adequate protein, low sodium intake.-> IF CHILD CAN TOLERATE THE PROTEIN INTAKE, THEN THIS DIET IS ENCOURAGED TO SPEED HEALING; SODIUM IS USUALLY RESTRICTED.

The nurse cares for the client with dementia. Which plan of care is MOST successful? 1. Teach new skills for adjusting to the aging process 2. Adjust the environment to meet the client's individual needs 3. Encourage competitive activities to keep the client physically strong 4. Provide unstructured activities with frequent changes to increase stimulation

Adjust the environment to meet the client's individual needs

The client diagnosed with bipolar disorder is in a manic phase with combative behavior. Which is the INITIAL PRIORITY nursing action? 1. Provide adequate hygiene and nutrition 2. Decrease environmental stimuli 3. Slowly involve the client in unit activities 4. Administer and monitor sedative and mood-stabilizing medications

Administer and monitor sedative and mood-stabilizing medications

The client with bipolar illness is extremely angry. The client tells the nurse, "I just found out my spouse has filed for divorce. I need to use the phone right now!" Which action by the nurse is most appropriate? 1. Allow the client to use the phone 2. Confront the client about the anger and inappropriate plan of action 3. Do not allow the client to use the phone because this is an involuntary admission 4. Set limits on the client's phone use because of the inability to control behavior

Allow the client to use the phone

The nurse provides care for a client in a psychiatric facility. The client describes seeing snakes on the walls of the room. Which is an accurate nursing diagnosis? 1. Altered sensory perception 2. Long-term confusion 3. Impaired coping 4. Altered interaction

Altered sensory perception

In the process of a normal adjustment to a terminal illness, the nurse knows that the client's initial denial and isolation will give way to the second stage. The second stage is characterized by which behavior?

Anger

The client is admitted for a series of tests to verify the diagnosis of Cushing's syndrome. Which nursing assessment finding supports this diagnosis? 1. Buffalo hump 2. Intolerance to heat 3. Hyperglycemia 4. Hypernatremia 5. Intolerance to cold 6. Irritability

Buffalo hump, hyperglycemia, & hypernatremia

The nurse obtains the client's temperature of 103° F (39.4° C). The nurse knows body compensatory mechanisms include which mechanism? 1. Decreased respiratory rate and bradycardia 2. Normal BP and pulse 3. Increased respiratory rate and tachycardia 4. Diaphoresis with cool, clammy skin

Increased respiratory rate and tachycardia

The health care provider inserts a temporary pacemaker following a MI. The nurse knows that which outcome is the primary purpose of the pacemaker?

Increases the cardiac output. -> ACTS TO REGULATE CARDIAC RHYTHM.

The nurse cares for a client with a tracheostomy. Which is the priority nursing diagnosis for this client?

Ineffective Airway Clearance related to increased trachobronchial secretions. -> INEFFECTIVE AIRWAY CLEARANCE IS THE TOP PRORITY FOR THE CLIENTS WITH A TRACHEOSTOMY BECAUSE LOSS OF THE UPPER AIRWAYS INCREASES THE AMOUNT AND VISCOSITY OF SECRETIONS.

The nurse collects the following data: anger directed by client toward staff in the form of frequent sarcastic or crude comments, increased wringing of hands, and purpseless pacing, particularly after the client has used the telephone. Based on these data, the should make which nursing diagnosis?

Ineffective individual coping related to recent anger and anxiety. -> CLIENT IS DISPLAYING EVIDENCE OF ANGER AND ANXIETY AND AN INABILITY TO DIRECTLY DEAL WITH CONCERNS, WHICH IS INEFFECTIVE COPING.

A client with an endotracheal tube requires suctioning. Which statement is an accurate description of how the nurse should perform the procedure?

Insert the suction catheter until resistance is met, and then withdraw it slightly. Apply suction intermittently as the catheter is withdrawn. -> INSERT SUCTION CATHETER UNTIL RESISTANCE IS MET WITHOUT APPLYING SUCTION, WITHDRAW 0.4-0.8 INCHES, AND APPLY INTERMITTENT SUCTION WITH TWIRLING MOTION.

the 18-month-old is admitted to the unit with a diagnosis of larynogtracheobronchitis (LTB). During the initial assessment, the nurse expects to find which early symptoms?

Inspiratory stridor and restlessness. -> THIS CONDITION IS CHARACTERIZED BY EDEMA AND INFLAMMATION OF UPPER AIRWAYS.

The nurse teaches nutrition classes at the community center. Which food does the nurse encourage the low-income client to eat to satisfy essential protein needs? 1. Legumes 2. Red meat 3. Seafood 4. Cheese

Legumes

The nurse knows which mood-altering drug is most often associated with an increased risk for HIV infection related to IV drug use?

Narcotics-> NARCOTICS ARE MOST OFTEN USED IV.

The nurse cares for the multipara client who delivered an infant 1 hour ago. The nurse observes the client's breasts are soft, the uterus is boggy to the right of the midline and 2cm below the umbilicus, and there is moderate lochia rubra. It is MOST important for the nurse to take which action? 1. Perform a straight catheterization 2. Offer the client the bedpan 3. Put the baby to breast 4. Massage the uterine fundus

Offer the client the bedpan

The client has a diagnosis of a ruptured lumbar disc. The nurse anticipates which assessment finding? 1. Sensation loss in an upper extremity 2. Clonic jerks in the affected foot 3. Paresthesia in the affected leg 4. Chorea in the upper and lower extremities

Paresthesia in the affected leg

The client is admitted with irritable bowel syndrome. The nurse anticipates the client's history will reflect which information? 1. Pattern of alternating diarrhea and constipation 2. Chronic diarrhea stools occurring 10 to 12 times per day 3. Diarrhea and vomiting with severe abdominal distention 4. Bloody stools with increased cramping after eating

Pattern of alternating diarrhea and constipation

A client had a kidney transplant yesterday, and the client's adult child has come to visit. The nurse should instruct the adult child to do which action?

Perform good hand washing-> GOOD HAND WASHING IS THE MOST EFFECTIVE METHOD OF REDUCING INFECTION; VERY IMPORTANT WITH IMMUNOSUPPRESSED CLIENTS.

The client has been taking propranolol 40 mg bid and furosemide 40 mg daily for several months. Two weeks ago, the health care provider added verapamil 80 mg tid to the client's medication regimen. It is MOST important for the nurse to assess the client for which symptom? 1. Tachycardia 2. Diarrhea 3. Peripheral edema 4. Impotence

Peripheral edema

The postop cataract client is cautioned about not making sudden movements or bending over. The nurse identifies the rational for this recommendation is to prevent which complication?

Pressure on the ocular suture line. -> SUDDEN CHANGES IN POSITION, CONSTIPATION, VOMITING, STOOPING, OR BENDING OVER INCREASE THE INTRAOCULAR PRESSURE AND PUT PRESSURE ON THE SUTURE LINE.

A client comes to the outpatient psychiatric clinic for treatment of a fear of heights. the nurse knows that phobias involve which behaviors?

Projection and displacement-> PROJECTION (ATTRIBUTING ONE'S THOUGHTS OR IMPULSES TO ANOTHER) AND INTERNALIZATION (SITTING OF EMOTION CONCERNING PERSON OR OBJECT TO ANOTHER NEUTRAL OR LESS DANGEROUS PERSON OR OBJECTION).

The nurse provides care for a client who has had an above-knee amputation (AKA) with an immediate prosthetic fitting. It is IMPORTANT for the nurse to take which action? 1. Assess drainage from site drains 2. Observe dressings for signs of excessive bleeding 3. Elevate the residual limb for no less than 40 hours 4. Provide cast care on the affected extremity

Provide cast care on the affected extremity

The nurse cares for the client on suicide precautions. The client verbalizes other options besides suicide, appears to be responding to antidepressant medication, is sleeping and eating better, and has indicated a willingness to interact more with family members. Based on this data, which nursing action is MOST important? 1. Recommend the healthcare provider decrease the client's medication dosage. 2. Recommend the treatment team reevaluates the client's treatment plan. 3. Give the client privileges to walk around the hospital alone. 4. Ask the family to begin planning for the client's discharge.

Recommend the treatment team reevaluate the client's treatment plan.

The nurse cares for a child diagnosed with pediculosis capitis (Head lice) and is being treated with permethrin 1% cream rinse. The nurse should include which information when instructing the child's parents?

Repeat the application of the cream rinse in 7 days if nits still present. -> MAY BE REPEATED 7 DAYS AFTER FIRST APPLICATION.

The client has just indicated a wish to commit suicide. The client then asks the nurse not to tell anyone. Which action by the nurse is BEST? 1. Encourage the client not to do anything without thinking it through carefully. 2. Explain to the client that anything told to the nurse is kept strictly confidential 3. Reports this to staff members in order to protect the client. 4. Encourage the client to tell the nurse more about what is being felt.

Report this to staff members in order to protect the client

The nurse cares for a client with a diagnosis of Guillain-Barre syndrome. Which symptoms support this diagnosis? 1. Respiratory failure 2. Pulmonary congestion 3. Hypertension 4. Flaccid paralysis 5. Hemiplegia 6. Urinary retention

Respiratory failure, flaccid paralysis, & urinary retention

The nurse cares for a client receiving a blood transfusion. After 30 minutes, the nurse assesses the client. Which symptom indicates an allergic reaction is occurring?

Respiratory wheezing-> ALLERGIC REACTION IS CHARACTERIZED BY WHEEZING, URTICARIA (HIVES), FACIAL FLUSHING, AND ITCHING

Which observation suggests to the nurse that the client has developed an Addisonian Crisis?

Restlessness and rapid, weak pulse. -> MAY BE SIGNS OF SHOCK RELATED TO AN ADDISONIAN CRISIS.

Which information should the nurse recognize as being the most pertinent to the diagnosis of cholecystitis?

Right upper abdominal pain. -> will experience pain in the upper-right abdominal quadrant.

The nurse cares for the client receiving a continuous tube feeding. Which nursing action is MOST appropriate? 1. Rinse the bag and change the formula every 4 hours 2. Rinse the bag and change the formula every shift 3. Rinse the bag and change the formula every 12 hours 4. Rinse the bag and change the formula every 2 hours

Rinse then bag and change the formula every 4 hours

The young adult is immobilized for trauma to the spinal cord. The client has periods of diaphoresis, a draining abdominal wound, and diarrhea. On the basis of the nursing assessment, which is the MOST important nursing diagnosis? 1. Risk for constipation related to immobilization 2. Risk for impaired skin integrity related to immobilization and secretions 3. Risk for infection related to involuntary bowel secretions 4. Risk for fluid volume excess related to secretions

Risk for impaired skin integrity related to immobilization and secretions

The nurse cares for the client who has just had a prosthetic hip implant. The nurse places the client in which position? 1. With the affected hip internally rotated and flexed 2. With the affected hip adducted when turned 3. In the supine position with the knees elevated 90 degrees 4. Side-lying with the affected hip in a position of abduction

Side-lying with the affected hip in a position of abduction

The adult client receives dexamethasone for chronic lymphocytic leukemia. It is most important for the nurse to report which finding to the health care provider? 1. Prothrombin time (PT) 12 seconds and hemoglobin (Hgb) 15 g/dL (150 g/L). 2. Blood urea nitrogen(BUN) 18 mg/dL (6.4 mmol/L) and creatinine 1.0 mg/dL (88 µmol/L). 3. Serum potassium (K) 3.4 mEq/L (3.4 mmol/L) and serum calcium (Ca) 7.8 mg/dL (2 mmol/L) . 4. Aspartate aminotransferase (AST) 18 U/L and alanine aminotransferase (ALT) 12 U/L.

Strategy: "most important to report to the health care provider" indicates a complication. 1) normal PT 9.5 to 12 sec, normal Hgb male: 13 to 18 g/dL (130-180 g/L), female: 12 to 16 g/dL (120-160 g/L) 2) normal BUN 10 to 20 mg/dL (3.6-7.2 mmol/L) 60 years or younger, normal creatinine 0.7 to 1.4 mg/dL (62-124 µmol/L) 3) CORRECT — normal K 3.5 to 5.0 mEq/L, normal Ca 8.5 to 10.5 mg/dL (2.2-2.6 mmol/L), indicates hypokalemia and hypocalcemia 4) normal AST 8 to 40 units, normal ALT 8 to 40 units

The nurse prepares the client for a magnetic resonance imaging (MRI). Which client statement indicates the teaching is successful? 1. "The dye used in the test will turn my urine green for about 24 hours." 2. "I will be put to sleep for this procedure. I will return to my room in two hours." 3. "This procedure will take about 90 minutes to complete. There will be no discomfort." 4. "The wires that will be attached to my head and chest will not cause me any pain."

Strategy: All answers are implementation. Determine the outcome of each answer. Is it desired? 1) if contrast is used, it does not change the color of the urine 2) client is not anesthetized for this procedure 3) CORRECT — procedure takes approximately 90 minutes, not painful 4) indicates misunderstanding of MRI because no wires are used

The client is diagnosed with myasthenia gravis. It is most important for the nurse to consider which action? 1. Prevent accidents from falls as a result of vertigo. 2. Maintain fluid and electrolyte balance. 3. Control situations that could increase intracranial pressure and cerebral edema. 4. Assess muscle groups toward the end of the day.

Strategy: Answers are a mix of assessment and implementation. Is there an appropriate assessment? Yes. 1) does not experience vertigo 2) fluid and electrolytes usually not a problem for this client 3) increased intracranial pressure is not associated with myasthenia gravis 4) CORRECT — client has increased muscle fatigue, needs more assistance toward end of day

The client has a modified radical mastectomy and axillary dissection. Which nursing diagnosis is a correctly stated, priority nursing diagnosis for the client immediately after the procedure? 1. Anxiety related to the mastectomy. 2. Impaired Skin Integrity related to the mastectomy. 3. Pain related to surgical incision. 4. Deficient Self-care related to dressing changes.

Strategy: Think about each answer. 1) is stated incorrectly with "related to the mastectomy" 2) is stated incorrectly with "related to the mastectomy" 3) CORRECT — immediately after surgery the priority is optimizing the client's comfort 4) is not an immediate priority

The nurse cares for a client admitted 2 days ago with a diagnosis of closed head injury. If the client develops diabetes insipidus, the nurse will observe which symptoms? Select all that apply. 1. Glucosuria. 2. Cracked lips. 3. Weight gain of 5 lb. 4. BP 160/100, pulse 56. 5. Urinary output of 4 L/24 hours. 6. Urine specific gravity of 1.004.

Strategy: Think of water loss with diabetes insipidus. 1) occurs with diabetes mellitus. 2) CORRECT- due to dehydration caused by excessive water loss. 3) weight loss occurs; symptom of SIADH (syndrome of inappropriate antidiuretic hormone) opposite of diabetes insipidus. 4) late signs of increased intracranial pressure or brain damage. 5) CORRECT - excessive fluid loss is major occurrence of diabetes insipidus. 6) CORRECT - specific gravity very low as urine is not concentrated in the kidney.

The client has partial-thickness and full-thickness burns over 75% of the body. The nurse is most concerned if which symptom is observed? 1. Epigastric pain 2. Restlessness 3. Tachypnea 4. Lethargy

Tachypnea

The older client diagnosed with pneumonia is admitted to the medical/surgical unit. Which other client does the nurse place with the older client? 1. The 20-year-old in traction for multiple fractures of the left lower leg 2. The 35-year-old with recurrent fever of unknown origin 3. The 50-year-old recovering alcoholic with cellulitis of the right foot 4. The 89-year-old with Alzheimer's disease awaiting long term care facility placement

The 50-year-old recovering alcoholic with cellulitis of the right foot

The nurse supervises an LPN/LVN administering an enema to a client. The nurse determines the LPN/LVN's actions are appropriate if which action is observed?

The LPN/LVN positions the client in the left side-lying with knee flexed.-> ALLOWS SOLUTION TO FLOW DOWNWARD ALONG THE NATURAL CURVE OF THE SIGMOID COLON AND RECTUM, WHICH IMPROVES RETENTION OF SOLUTION.

The nurse assists a nursing assistive personnel (NAP) in providing a bed bath to the comatose client with incontinence. The nurse intervenes if which action is noted? 1. The NAP answers the phone while wearing gloves 2. The NAP log rolls the client to provide back care 3. The NAP places an incontinence pad under the client 4. The NAP positions the client on the left side, head elevated

The NAP answers the phone while wearing gloves

The school nurse observes a group of preschool children in the playroom. The nurse recognizes which activity as appropriate behavior for the 5-year-old client? 1. The child plays with a large truck with another child 2. The child talks on a toy telephone and imitates same-sex parent 3. The child works on a puzzle with several other children 4. The child holds and cuddles a large stuffed animal

The child talks on a toy telephone and imitates same-sex parent

The nursing team consists of an RN who has been practicing for 6 months, an LPN/LVN who has been practicing for 15 years, and a nursing assistive personnel who has been caring for client for 3 years. The RN should care for which client?

The client ordered to receive 2 units of packed cells. -> REQUIRES THE ASSESSMENT AND TEACHING SKILLS OF THE RN.

The nurse cares for the client several days after an above-knee amputation (AKA). Which symptom is characteristic of an infected residual limb wound? 1. The client is anxious and restless 2. There is a small amount of dark drainage on the dressing 3. The client reports persistent pain at the operative site 4. The skin is cool above the operative site

The client reports persistent pain at the operative site

The nurse cares for a client diagnosed with type 1 diabetes reporting decreased vision. The client asks the nurse what caused the visual changes. The nurse's response is based on which statement?

The client's decreased vision is caused by gradual destruction and degeneration of the retina. -> GRADUAL DESTRUCTION OCCURS BECAUSE OF DETERIORATION OF THE RETINAL VESSESLS.

In preparing a teaching plan regarding colostomy irrigations, the nurse should include which information?

The colostomy needs to be irrigated at the same time every day-> COLOSTOMY IRRIGATION SHOULD BE DONE AT SAME TIME EACH DAY TO ASSIST IN ESTABLISHING A NORMAL PATTERN OF ELIMINATION.

The nurse checks for placement of a NG tube prior to initiating a tube feeding for the client. Which result indicates the tube feeding can begin? 1. A small amount of white mucus is aspirated from the NG tube 2. The contents aspirated from the NG tube have a pH of 3 3. No bubbles are seen when the nurse inverts the NG tube in water 4. The client says the NG tube can be felt in the back of the throat

The contents aspirated from the NG tube have a pH of 3

A client develops a postop infection and receives ceftriaxone sodium IV daily. It is most important for the nurse to monitor for which changes?

The surface of the tongue.-> CEPHALSOPORIN, LONG-TERM USE OF CEFTRIAXONE SODIUM CAN CAUSE OVERGROWTH OF ORGANISMS; MONITORING OF TONGUE AND ORAL CAVITY IS RECOMMENDED.

The health care provider writes an order for a stat dose of morphine 4 mg IV for pain. 3 hours later the client again reports pain, and the nurse administers a second injection of morphine. Which best describes the nurse's liability?

There is no order for a second dose of medication, the nurse is liable-> ORDER FOR A STAT DOSE IS A FOR A ONE TIME ADMINISTRATION; NURSE PRACTICE ACT ADDRESSES SCOPE OF PRACTICE; BY ADMINISTERING A SECOND DOSE THE NURSE WAS PRESCRIBING THE MEDICATION, SOMETHING ONLY A HEALTHCARE PROVIDER WITH PRESCRIPTIVE ABILITY CAN DO; NURSE WAS PRACTICING MEDICINE, NOT NURSING AND WAS OUTSIDE OF SCOPE OF PRACTICE.

The nurse cares for the male client diagnosed with urinary tract problems. A prostate-specific antigen (PSA) and acid phosphatase test are to be done. Which statement best describes the rationale for doing these tests? 1. These tests are valuable screening tests for prostatic cancer 2. The level of PSA is decreased in clients with renal calculi 3. The tests reflect the level of renal involvement in acid-base problems 4. The level of PSA is elevated in clients in early-stage kidney failure

These tests are valuable screening tests for prostatic cancer

The nurse conducts a physical examination of the client suspected to have bulimia. Which nursing observation MOST likely indicates bulimia? 1. Edema of the lower extremities 2. The presence of lanugo 3. Ulcerated oral mucous membranes 4. Dry, yellowish colored skin

Ulcerated oral mucous membranes

The teenage client diagnosed with anorexia nervosa is admitted to the hospital. Which behavior does the nurse expects the client to present? 1. View appearance as "skinny." 2. Be hypoactive and withdrawn 3. Want to discuss and plan meals 4. Have a close relationship with a parent

Want to discuss and plan meals

The client with newly diagnosed type 1 diabetes says to the nurse, "I know I have to take good care of my feet. When I buy new shoes, is there anything special I should do?" Which response by the nurse is best? 1. "It is best to buy new shoes in the morning." 2. "Have each foot measured every time you buy new shoes." 3. "Buy shoes a half-size larger than your foot size so the fit is roomy 4. "Buy vinyl shoes because they won't lose their shape easily."

"Have each foot measured every time you buy new shoes."

A client is admitted to the neurosurgery unit for the removal of a cerebellar tumor. The nurse expects the client to make which statement about symptoms? 1. "I have been having difficulty with my hearing." 2. "I lose my balance easily." 3. "I can't tell the difference between a sweet and sour taste." 4. "It is not easy for me to remember names and faces."

"I lose my balance easily."

Which client statement indicates to the nurse the client is using the defense mechanism of conversion? 1. "I love my family with all my heart, even though they don't love me." 2. "I was unable to take my final exams because I was unable to write." 3. "I don't believe I have diabetes. I feel perfectly fine." 4. "If my spouse was a better housekeeper I wouldn't have such a problem."

"I was unable to take my final exams because I was unable to write."

The elderly alcoholic client receives a long-acting benzodiazepine for 2 days for symptom management and reduction. The client states, "Get those bugs off of me and clean them out of here." The nurse knows the client is exhibiting symptoms of which problem? 1. A reaction to the sedative medication 2. A worsening course of the withdrawal syndrome 3. An exacerbation of the schizophrenia process 4. The process of aging and the effects of delirium

A worsening course of the withdrawal syndrome

A newborn client at 32 weeks' gestation weighs 4 lb 10 oz (2.12 kg) and has mottling of the skin and acrocyanosis with irregular respirations of 60 breaths per minute. Which newborn problem does the nurse suspect this client is experiencing? 1. Hypoglycemia 2. Cold stress 3. Birth asphyxia 4. Hypovolemia

Cold stress

The nurse observes the student nursing care for the client. The student nurse wears a gown and gloves in addition to following standard precautions. The nurse determines care is appropriate if the student nurse performs which activity? 1. Gives isoniazid to a client with TB 2. Administers an IM injection to a client with rubella 3. Delivers a food tray to a client with hepatitis 4. Changes the dressing for a client with a draining abscess

Changes the dressing for a client with a draining abscess

The child has a closed transverse fracture of the right ulna. Which nursing action before the application of a cast is most important? 1. Check the radial pulses bilaterally and compare 2. Evaluate the skin temperature and tissue turgor in the area 3. Assess sensation of each foot while the child closes the eyes 4. Apply baby powder to decrease skin irritation under the cast

Check the radial pulses bilaterally and compare

The parent of a toddler recovering from surgery is concerned because the client is restless and overactive. Which action will the nurse take? 1. Direct the LPN to obtain the client's vital signs 2. Ask the parent if the client's sutures are still intact 3. Telling nursing assistive personnel to take the client for a walk 4. Check to see when pain medication was last provided

Check to see when pain medication was last provided

The 25-year-old primigravida is diagnosed with type 1 diabetes mellitus. The nurse reviews the insulin regimen with the client. The nurse explains insulin needs will change in which way? 1. Increase during pregnancy and decrease after delivery 2. Decrease during pregnancy and increase after delivery 3. Increase during pregnancy and remain increased after delivery 4. Decrease during pregnancy and fluctuate after delivery

Increase during pregnancy and decrease after delivery

The nurse cares for the client one day after a thoracotomy. Nursing actions in the care plan include turn, cough, and deep breathe Q2H. Which does the nurse understand to be the purpose of this nursing action? 1. Promote ventilation and prevent respiratory alkalosis 2. Increase oxygenation and removal of secretions 3. Increase pH and facilitate and balance of bicarbonate 4. Prevent respiratory alkalosis by increasing oxygenation

Increase oxygenation and removal of secretions

The client is admitted for regulation of insulin dosage. The client takes 15 units of isophane insulin at 08:00 every day. At 16:00, which nursing observations indicate a complication from the insulin? 1. Acetone odor to the breath 2. Irritability 3. Polyuria 4. Tachycardia 5. Headache 6. Diaphoresis

Irritability, tachycardia, & diaphoresis

The nurse evaluates the nutritional intake of the adolescent girl attending camp. The adolescent eats all of the food provided. Each of the three meals contains foods from all areas of the "My Food Plate", averages about 900 calories, and has 3 mg of iron. The adolescent menstruates monthly and is of appropriate weight for height. Which best describes the adolescent's intake? 1. The diet is low in calories and high in iron. 2. The diet is low in calories and low in iron. 3. The diet is high in calories and low in iron. 4. The diet is high in calories and high in iron

1) diet is high in calories (only 1,200 to 1,500 kcal/day required); iron is acceptable for a 12-13 year old female adolescent and low for an adolescent 14-18 2) diet is not low in calories but is low in iron 3) CORRECT - 900 × 3 = 2,700 calories/day and females 12-18 years old need 2000 kcal/day (males 12-13 years old need 2200 kcal/day; males at 14 years old need 2400 kcal/day; males 15 years old need 2600 kcal/day; males 16-18 years old need 2800 kcal/day); 3 mg × 3 = 9 mg/day of iron and females 12-13 years old need 8 mg/day and females 14-18 years old need 15 mg/day of iron (males 12-13 years old need 8 mg/day and males 14-18 years old need 11 mg/day of iron); with pregnancy 30 mg/day is required 4) diet is high in calories but not in iron

The nurse plans discharge teaching for the client after a lumbar laminectomy. Which muscle or muscles does the nurse instruct the client to exercise regularly? 1. Anal sphincter. 2. Abdominal. 3. Trapezius. 4. Rectus femoris.

1) does not contribute to support of the lumbar spine 2) CORRECT — strengthening the abdominal muscles adds support for the muscles supporting the lumbar spine 3) does not contribute to support of the lumbar spine 4) does not contribute to support of the lumbar spine

The nurse assesses the client immediately after an exploratory laparotomy. Which nursing observation indicates the complication of intestinal obstruction? 1. Protruding soft abdomen with frequent diarrhea. 2. Distended abdomen with ascites. 3. Minimal bowel sounds in all four quadrants. 4. Distended abdomen with reports of pain.

1) does not support intestinal obstruction 2) does not support intestinal obstruction 3) immediately after postoperative abdominal surgery, bowel sounds are absent or decreased; would be no passage of stool; ascites not often seen 4) CORRECT — if an obstruction is present, the abdomen will become distended and painful

The client was just placed in physical restraints. Which nursing intervention is most important for the client's care? 1. Prepare PRN dose of psychotropic medication. 2. Check that the restraints have been applied correctly. 3. Review hospital policy regarding duration of restraints. 4. Monitor the client's needs for hydration and nutrition while restrained.

1) implementation; inappropriate for the client in restraints 2) CORRECT — assessment; while a client is restrained, physiological integrity is important; monitoring positioning, tightness, and peripheral circulation is essential; nurse documents the client's response and clinical status after being restrained 3) implementation; all staff members involved in a restraint event must be aware of hospital policy before using restraints 4) assessment; important to attend to client's nutrition and hydration after the client is safely restrained

Promethazine hydrochloride 25 mg IV push is ordered for the client. Prior to administering this medication, the nurse makes which assessment? 1. The color of the medication solution. 2. The client's pulse and temperature. 3. The time of the last analgesic dose the client received. 4. The patency of the client's vein.

1) is true, but not as high a priority as the IV patency 2) no relevance to the question asked 3) promethazine hydrochloride is used as an adjunct to analgesics but has no analgesic activity itself 4) CORRECT — is very important to determine absolute patency of the vein; extravasation will cause necrosis

The nurse assesses orientation to person, place, and time for the elderly hospitalized client. Which principle does the nurse understand? 1. Short-term memory is more efficient than long-term memory. 2. The stress of an unfamiliar environment may cause confusion. 3. A decline in mental status is a normal part of aging. 4. Learning ability is reduced during hospitalization of the elderly client.

1) just the opposite is true; long-term memory is more efficient than short-term memory 2) CORRECT — stress of an unfamiliar situation or environment may lead to confusion in elderly clients 3) mental status and learning ability are not affected by aging, although elderly clients may be slower at doing things 4) mental status and learning ability are not affected by aging, although elderly clients may be slower at doing things

The client receives parenteral nutrition (PN) for several weeks. If the PN is abruptly discontinued, the nurse expects the client to exhibit which signs and symptoms? 1. Tinnitus, vertigo, blurred vision. 2. Fever, malaise, anorexia. 3. Diaphoresis, confusion, tachycardia. 4. Hyperpnea, flushed face, diarrhea.

1) not seen 2) suggestive of infection 3) CORRECT — insulin levels remain high while glucose levels decline; results in hypoglycemia; will also see restlessness, headache, weakness, irritability, apprehension, lack of muscle coordination 4) not seen

The client is diagnosed with pneumonia secondary to chronic pulmonary disease. Which nursing goal is most appropriate? 1. Maintain and improve the quality of oxygenation. 2. Improve the status of ventilation. 3. Increase oxygenation of peripheral circulation. 4. Correct the bicarbonate deficit.

1) primary problem is not level of oxygenation, but the level of carbon dioxide contributing to an acidotic state 2) CORRECT — to improve the quality of ventilation refers to levels of carbon dioxide and oxygen 3) not appropriate for the situation 4) not appropriate for the situation

The nurse cares for the client the first day postoperative after a transurethral prostatectomy (TURP). The client has a continuous bladder irrigation (CBI). The client's spouse asks why the client has the CBI. Which response by the nurse is best? 1. "The CBI prevents urinary stasis and infection." 2. "The CBI dilutes the urine to prevent infection." 3. "The CBI enables urine to keep flowing." 4. "The CBI delivers medication to the bladder."

1) refers to a possible preoperative complication of infection due to the enlarged prostate 2) not the reason for the CBI 3) CORRECT — continuous bladder irrigation prevents formation of clots that can lead to obstruction and spasm in the postoperative TURP client 4) medication is not routinely administered via a CBI in a first-day postop TURP

The client is to have an intravenous pyelogram (IVP). Nursing management includes which action? 1. A fat-free meal the evening before the examination and radiopaque tablets at bedtime 2. Placement of a retention urinary catheter to facilitate dilation of the bladder sphincter 3. Cleansing enemas the evening before to provide for adequate visualization of the urinary tract 4. Explaining the importance of following directions regarding voiding during the test

Cleansing enemas the evening before to provide for adequate visualization of the urinary tract

A client is evaluated for infertility, us the health care provider prescribes clomiphene citrate 50 mg daily for 5 days. The client asks the nurse how the medication works. Which response by the nurse is best?

Clomiphene citrate induce ovulation by changing hormonal effects on the ovary. -> CLOMIPHENE CITRATE INDUCES OVULATION BY ALTERING ESTROGEN AND STIMULATING FOLLICULAR GROWTH TO PRODUCE A MATURE OVUM.