366 HESI Study Set 366

A client who was admitted with rapid atrial flutter is receiving amiodarone 1 mg/minute via a peripheral IV infusion in the left hand. The unlicensed assistive personal (UAP) reports to the nurse that the client's heart rate is 90 beats/minute and blood pressure is 110/50 mm Hg. Which intervention should the nurse implement? A Evaluate rhythm of client's heat rate. B Tell the UAP to turn off the amiodarone. C Restart the IV infusion in another site. D Determine regularity of peripheral pulses.

A - Evaluate rhythm of client's heart rate Rationale: Correct (A): Assessing rhythm is crucial to determine if the medication is effective. Incorrect: B) UAP shouldn't turn off medication. C) Restarting IV isn't necessary based on given information. D) Peripheral pulses are less important than cardiac rhythm.

The nurse is wearing personal protective equipment (PPE) while caring for a client. When exiting the room, which PPE should be removed first? A Gloves B mask C eyewear D gown

A - Gloves - Gloves are most contaminated and removed first to prevent contamination of other PPE during removal. Don PPE from the bottom up: 1. Gown - 2. Mask - 3. Goggles - 4. Gloves (with hands above head) Doff PPE in alphabetical order: 5. Gloves - 6. Goggles - 7. Gown - 8. Mask

When performing suctioning for a client with a tracheostomy, which action should the nurse include? A Wear protective goggles while performing the procedure. B Apply a water soluble lubricant to the catheter. C Instill 3mL of 0.9% sodium chloride before suctioning. D instruct the client to cough as the suction tip is removed.

A - Protective goggle with protect the eyes from potential splashes or aerosolized secretions. Suctioning can generate forceful, coughing, gagging, or sneezing which may cause secretions or mucus to be expelled forcefully, and potentially come into contact with the nurse's eyes.

An older client is admitted for repair of a broken hip. To reduce the risk for infection in the postoperative period, which nursing care intervention(s) should the nurse include in the client's plan of care? Select all that apply. A Remove urinary catheter as soon as possible and encourage voiding. B Teach client to use incentive spirometer every 2 hours while awake. C Maintain sequential compression devices while in bed. D Administer low molecular weight heparin as prescribed. E Assess pain level and medicate PRN as prescribed.

A - Removing urinary catheters as soon as possible is recommended to reduce the risk of catheter-associated urinary tract infections (CAUTIs), which are a common source of postoperative infections. Encouraging early voiding after catheter removal can help prevent urinary retention and the need for re-catheterization, further reducing the risk of CAUTIs. B - Deep breathing exercises with the incentive spirometer help expand the lungs, improve oxygenation, and mobilize secretions, reducing the risk of respiratory infections.

An adult client who is admitted to the mental health unit for treatment of bipolar disorder has a slightly slurred speech pattern and an unsteady gait. Which assessment finding is most important for the nurse to report to the healthcare provider? Reference Range: Blood alcohol level 0 to 0.05% (0 to 10.9 mmol/L] Lithium /0.8 to 1.2 mEq/L (0.8 to 1.2 mmol/L)] A Serum lithium level of 1.6 mEq/L (1.6 mmol/L). B Weight loss of 10 lb (4.5 kg) in past month. C Six hours of sleep in the past three days. D Blood alcohol level of 0.09% (19.5 mol/L).

A - Serum lithium level of 1.6 mEq/L (1.6 mmol/L) Rationale: Correct (A): This indicates lithium toxicity, which can cause the symptoms described. Incorrect: B, C) While concerning, not as urgent as lithium toxicity. D) While elevated, not as immediately concerning as lithium level.

The nurse working in the psychiatric clinic has phone messages from several clients. Which call should the nurse return fist? A A family member of a client with dementia who has been missing for five hours. B The mother of a child who was involved in a physical fight at school today. C A young man with schizophrenia who wants to stop taking his medications. D A client diagnosed with depression who is experiencing sexual dysfunction.

A A family member of a client with dementia who has been missing for five hours. - This is considered emergency since client with dementia may be confused, disoriented, have problems in communicating and have memory loss. Moreover, dementia is a major neurocognitive disorder that affects memory, thinking and social abilities of an individual.

A client with a history of unstable angina presents to the emergency department with constant chest pressure that is unrelieved with rest. The client appears anxious, pale, and diaphoretic. After obtaining the client's vital signs, which action should the nurse take next? A Administer four 81 mg aspirin tablets providing instructions to chew before swallowing. B Place an indwelling urinary catheter and institute strict intake and output measurements. C Evaluate upper and lower extremities for perfusion, pulse volume, and pitting edema. D Secure client consent for coronary angiography and percutaneous coronary intervention.

A Administer four 81 mg aspirin tablets providing instructions to chew before swallowing. - Given the client's symptoms of constant chest pressure that is unrelieved with rest, along with the client's appearance of anxiety, pallor, and diaphoresis, it indicates a high likelihood of an acute coronary event, such as a MI. In this situation, the nurse should prioritize immediate actions that address the potential cardiac emergency. Aspirin is essential in the initial management of acute coronary syndrome, including unstable angina and MI. It helps inhibit platelet aggregation and reduce the risk of clot formation in coronary arteries. The chewable form of aspirin allows for more rapid absorption.The other options are Incorrect, because the focus should be on addressing the potential acute coronary event and ensuring the client's cardiac stability.

A client with Crohn's disease is preparing for discharge from the hospital following treatment for an exacerbation of diarrhea, abdominal pain, and rectal bleeding. Which dietary recommendation(s) should the nurse discuss with the client? Select all that apply. A Avoid eating fried, fatty foods and large meals. B Limit high fiber foods, such as beans, popcorn, seeds. C Enjoy fast food restaurants only if dining with friends. D Take a vitamin supplement daily with a meal. E Drink dairy and effervescent sodas for hydration.

A Avoid eating fried, fatty foods and large meals. - These can exacerbate symptoms like diarrhea and abdominal pain during Crohn's flares. Large meals can also be difficult to digest and trigger symptoms. B Limit high fiber foods, such as beans, popcorn, seeds. - These can be difficult to tolerate during active Crohn's disease flares due to their roughage content. D Take a vitamin supplement daily with a meal. - Crohn's disease and the associated inflammation can lead to malabsorption of nutrients. Taking a daily vitamin supplement helps replenish any deficiencies and meet nutritional needs.The other options would exacerbate the disease.

A male client is admitted for the removal of an internal fixation device that was inserted for a fractured ankle. During the client's admission history, he tells the nurse that he recently received vancomycin for a methicillin-resistant Staphylococcus aureus (MRSA) wound infection. Which action(s) should the nurse take? (Select all that apply.) A Collect multiple site screening cultures for MRSA. B Place the client on contact transmission precautions. C Call healthcare provider for a prescription for linezolid. D Obtain a sputum specimen for culture and sensitivity. E Continue to monitor the client for signs of an infection.

A Collect multiple site screening cultures for MRSA. B Place the client on contact transmission precautions. E Continue to monitor the client for signs of an infection. Correct answers: A, B, E Rationale: Correct: (A) Screening for MRSA is standard. (B) Contact precautions prevent spread. (E) Monitoring for infection signs is essential. Incorrect: (C) Linezolid isn't necessary without specific indication. (D) Sputum culture isn't indicated without respiratory symptoms.

A client presents at the emergency department reporting a raspy voice, cold intolerance, and fatigue. Laboratory tests indicate an elevated thyroid stimulating hormone (TSH) and low triiodothyronine (T3) and thyroxine (T4) levels. After the client is admitted to the telemetry unit, which intervention is most important for the nurse to implement? A Administer prescribed dose of levothyroxine. B Assess for presence of non-pitting edema. C Note client's most recent hemoglobin level. D Offer additional blankets and a warm drink.

A Correct- The client's symptoms (raspy voice, cold intolerance, fatigue) along with an elevated TSH and low T3 and T4 levels suggest hypothyroidism. Levothyroxine is a synthetic thyroid hormone used to treat hypothyroidism. Administering the prescribed dose of levothyroxine is crucial to address the thyroid hormone imbalance and alleviate the symptoms. Incorrect- While providing comfort measures like blankets and warm drinks can help the client feel more comfortable, they do not address the underlying thyroid hormone imbalance. Incorrect- Hemoglobin level is not directly related to the client's symptoms or the thyroid hormone imbalance. Monitoring hemoglobin is important in assessing anemia but is not the priority in this case. Incorrect- Non-pitting edema is not a common symptom of hypothyroidism. The client's symptoms and lab results are more indicative of hypothyroidism, and addressing the thyroid hormone imbalance is the priority.

A client exposed to tuberculosis is scheduled to begin prophylactic treatment with isoniazid. Which information is most important for the nurse to note before administering the initial dose? A Current diagnosis of hepatitis B. B History of intravenous drug abuse. C Length of time of the exposure to tuberculosis. D Conversion of the client's PPD test from negative to positive.

A Current diagnosis of hepatitis B. Rationale: Isoniazid can cause hepatotoxicity. A current diagnosis of hepatitis B is crucial information as it indicates pre-existing liver disease, which significantly increases the risk of severe hepatotoxicity from isoniazid. Incorrect: (B) History of intravenous drug abuse: While important, it's not as critical as current liver disease for isoniazid administration. (C) Length of time of exposure to tuberculosis: Important for treatment decisions but not as crucial for immediate medication administration. (D) Conversion of PPD test: Indicates TB infection but doesn't directly impact the safety of isoniazid administration.

An unlicensed assistive personnel (UAP) is assigned to provide personal care for a client whose prescribed activity is bedrest with bedside commode use. The UAP reports to the nurse that the client is so obese that the UAP feels unable to safely assist the client in transferring from the bed to the bedside commode. How should the nurse respond? A Determine the client's level of mobility and need for assistance. B Instruct the UAP that all clients deserve equal care. C Advise the client to maintain bedrest so that safety can be ensured. D Assign another UAP to care for the client.

A Determine the client's level of mobility and need for assistance. Rationale: Correct (A): Assessing the client's mobility and assistance needs is crucial for safe care planning. Incorrect: (B) Instructing equal care doesn't address safety concerns. (C) Advising bedrest isn't appropriate without assessment. (D) Reassigning doesn't solve the underlying issue.

While completing an admission assessment for a client with unstable angina, which closed questions should the nurse ask about the client's pain? A Does your pain occur when walking short distances? B How would you describe the location of your pain? C Can you tell me about your family history of heart disease? D What do you typically eat for breakfast?

A Does your pain occur when walking short distances? Unstable angina is characterized by chest pain or discomfort that occurs at rest or with minimal exertion; therefore, asking about pain while walking short distances can help determine the severity and frequency of the client's symptoms and complete the admission assessment.

When assessing a newborn girl with salt-wasting congenital adrenal hyperplasia due to 21 hydroxylase deficiency, the nurse notes that the infant has an enlarged clitoris. Which intervention should the nurse implement? A Explain to mother that the finding is due to increased androgen. B Review transcutaneous bilirubin levels with a bilirubinometer. C Assess for signs of fluid retention and bilateral pedal edema. D Observe and palpate newborn's breast tissue for enlargement.

A Explain to mother that the finding is due to increased androgen. - In classic salt-wasting CAH caused by 21-hydroxylase deficiency, there is an excess production of androgen hormones like testosterone due to the enzymatic defect. Explaining to the mother that the enlarged clitoris (clitoromegaly) is a result of increased androgen exposure helps provide education and understanding about this characteristic finding in female infants with CAH.

The nurse identifies several nursing problems for a client with paraplegia who has been having fecal incontinence and diarrhea. The client's parent is the primary caregiver. In planning care, the nurse should determine which problem is the highest priority? A Fluid volume deficit. B Bowel incontinence. C Caregiver role strain. D Impaired bed mobility.

A Fluid volume deficit. This is correct because fluid volume deficit is a life-threatening condition that can result from diarrhea and fecal incontinence. The nurse should monitor the client's fluid intake and output, electrolytes, weight, urine specific gravity, and skin turgor.

The nurse assesses a client being treated for Herpes zoster (shingles). Which assessments should the nurse include when evaluating the effectiveness of the treatment? Select all that apply. A Functional ability B Skin integrity C Pain scale D Bowel movement E Heart sounds

A Functional ability - Shingles can significantly impact a person's ability to perform daily activities due to pain and discomfort. B Skin integrity - Herpes Zoster causes painful skin rashes and blisters. Assessing skin integrity helps determine if the lesions are healing, if there are signs of infection, or if new lesions are forming. C Pain scale - Pain is a primary symptom of shingles and a major factor in the client's quality of life. Incorrect: D, E) Not directly related to shingles treatment.

The nurse is caring for a client who receives a prescription for parenteral lidocaine. Prior to administering the medication, the nurse should review the medical record for which condition? A Heart block. B Glaucoma. C Gastric ulcers. D Diabetes mellitus.

A Heart block. - Lidocaine is as a local anesthetic and an as an antiarrhythmic. It is contraindicated and clients with heart block. When used as an antiarrhythmic, Lidocaine works by blocking certain electrical signals in the heart that can cause an irregular heartbeat, like acute ventricular tachydysrhythmias. However, in patients with heart block, a condition where the electrical signals in the heart are partially or completely blocked, Lidocaine can worsen the condition. The other conditions are not directly related to the use of Lidocaine.

A client receives a prescription for itraconazole. Which statement made by the client requires additional instruction by the nurse? A I should take the medication with antacids. B If I experience any difficulty with breathing will report it. C Monitoring for changes in stool color is important. D Drinking grapefruit juice will reduce the effects of the medication.

A I should take the medication with antacids. By providing additional instruction to avoid taking antacids within 2 hours of itraconazole, the nurse can ensure the client understands the proper administration and maximizes the effectiveness of this antifungal medication.

A client is receiving IV heparin and oral warfarin after a pulmonary embolism (PE). The nurse determines the client's activated partial prothromboplastin time (aPPT) value is two times the control value; the prothrombin time (PT) level is the same as the control, and the international normalized ratio (INR) is 1. Which protocol prescription should the nurse implement? Reference Range: Activated Partial Prothromboplastin Time (aPTT) [Anticoagulant therapy: 1.5 to 2 times the control value in seconds]. Prothromboplastin Time (PT) [Anticoagulant therapy: greater than 1.5 to 2 times the control value.) International Normalized Ratio (INR) [0.8 to 1.1] A Increase the warfarin dose. B Increase the heparin dose and decrease the warfarin dose. C Withhold the heparin and continue the same dose of warfarin. D Decrease the heparin dose.

A Increase the warfarin dose. - The client's aPTT is two times the control value, which falls within the therapeutic range for anticoagulant therapy (1.5 to 2 times the control value). - Prothrombin Time (PT): The PT level is the same as the control, which is below the therapeutic range for anticoagulant therapy (greater than 1.5 to 2 times the control value). - International Normalized Ratio (INR): The INR is 1, which is within the normal range (0.8 to 1.1) but below the therapeutic range for patients on warfarin, which is typically between 2 and 3 for most indications including PE. - Since the aPTT is therapeutic, the heparin dose appears to be appropriate. However, the PT and INR values indicate that the warfarin dose is not yet therapeutic.

When admitting a client with a diagnosis of transient ischemic attack (TIA), which intervention is most important for the nurse to include in this client's plan of care? A Initiate neurological monitoring every 2 hours. B Palpate suprapubic region for urinary retention. C Assess bilateral breath sounds. D Review client's daily medications.

A Initiate neurological monitoring every 2 hours. - A TIA is a warning sign of a potential impending stroke, with the highest risk occurring in the first few days after the TIA event. - Close neurological monitoring is crucial during this period to detect any neurological changes or deterioration that could indicate a progressing stroke, like weakness, speech changes, or altered mental status, which may signal the onset of an ischemic stroke.

A child newly diagnosed with sickle cell anemia (SCA) is being discharged from the hospital which information is the most important for the nurse to provide to parents prior to discharge? A Instructions about how much fluid the child should drink daily B signs of addiction to opioid pain medication C information about non pharmaceutical pain relief measures D referral to social service for the child and family

A Instructions about how much fluid the child should drink daily Rationale: Hydration is crucial to prevent sickle cell crises. Incorrect: B) Addiction signs: Less immediate concern. C) Non-pharmaceutical pain relief: Important but secondary. D) Social services referral: Important but secondary.

A client experiencing an acute dystonic reaction presents with a laryngeal spasm. Which treatment should the nurse prepare? A Intravenous administration of benztropine. B Oral administration of divalproex. C Intravenous administration of isotonic crystalloid fluid. D Oral administration of lorazepam.

A Intravenous administration of benztropine. A) Correct - Acute dystonic reactions are involuntary muscle spasms caused by certain medications, including antipsychotic drugs. These reactions can sometimes affect the muscles of the face and neck, including the larynx. Benztropine is an anticholinergic medication commonly used to treat acute dystonic reactions. It works by blocking certain neurotransmitters that contribute to muscle spasms, helping to relieve the symptoms.

The home health nurse is assessing an older client who lives alone. The client reports being troubled by constipation. Which additional information should the nurse obtain to formulate a plan of care? Select all that apply. A Level of physical activity and exercise. B Methods currently used to treat constipation. C Current prescribed and over-the-counter medications. D Daily food and fluid intake. E Next scheduled visit with healthcare provider.

A Level of physical activity and exercise. B Methods currently used to treat constipation. C Current prescribed and over-the-counter medications. D Daily food and fluid intake.ABCD are all factors that can affect constipation. E is wrong because it is not directly relevant to formulating an immediate plan of care for managing the client's constipation at home.

When caring for a client with full-thickness burns to both lower extremities, which assessment finding(s) warrant immediate intervention by the nurse? Select all that apply. A Loss of sensation to the left lower extremity. B Change in the quality of the peripheral pulses. C Complaint of increased pain and pressure. D Sloughing tissue around wound edges. E Weeping serosanguineous fluid from wounds.

A Loss of sensation to the left lower extremity.- Loss of sensation could indicate nerve damage or compromised blood flow, both of which require immediate attention. B Change in the quality of the peripheral pulses. - Changes in peripheral pulses can indicate compromised circulation, which is a medical emergency. This could lead to tissue necrosis if not addressed promptly. C Complaint of increased pain and pressure. - Increased pain and pressure could indicate compartment syndrome, a serious condition that can lead to muscle and nerve damage if not treated immediately.

While assessing a client who is admitted with heart failure and pulmonary edema, the nurse identifies dependent peripheral edema, an irregular heart rate, and a persistent cough that produces pink blood-tinged sputum. After initiating continuous telemetry and positioning the client, which intervention should the nurse implement? A Obtain sputum sample. B Document degree of edema. C Initiate hourly urine output measurement. D Administer IV diuretics.

A Obtaining a sputum sample can help identify the cause of the blood-tinged sputum, such as an infection or other pathology. Incorrect: B. Document degree of edema - It is not the most immediate intervention needed to address the client's acute symptoms. C. Initiate hourly urine output measurement - while useful for monitoring fluid balance, especially after administering diuretics, but it is not the first immediate action. D. Administer IV diuretics: This is a critical intervention for heart failure and pulmonary edema, but it should be done after confirming the diagnosis and ensuring there are no contraindications.

The family of an older woman reports that they are no longer capable of caring for her at home. While performing the admission assessment at a long-term care facility, the nurse determines that the client is incontinent of urine, has dry mucous membranes, and has a large bruise on the coccyx. What intervention(s) should the nurse include in the plan of care? Select all that apply. A Offer beverages at frequent intervals. B Report suspicion of abuse. C Implement toileting program. D Apply a barrier cream to perianal areas. E Thicken liquids and provide pureed foods.

A Offer beverages at frequent intervals. B Report suspicion of abuse. C Implement toileting program. D Apply a barrier cream to perianal areas. Rationale: A) Offering beverages frequently helps prevent dehydration. B) Reporting suspicion of abuse is mandatory and necessary for the client's safety. C) Implementing a toileting program helps manage incontinence. D) Applying a barrier cream protects the skin from breakdown and irritation. Incorrect: E) Thicken liquids and provide pureed foods are not indicated unless the client has swallowing difficulties or other specific dietary needs.

In evaluating the effectiveness of a postoperative client's intermittent pneumatic compression devices, which assessment is most important for the nurse to complete? A Palpate all peripheral pulse points for volume and strength. B Monitor the amount of drainage from the client's incision. C Observe both lower extremities for redness and swelling. D Evaluate the client's ability to use an incentive spirometer.

A Palpate all peripheral pulse points for volume and strength. A. Correct- Intermittent pneumatic compression devices are used to prevent deep vein thrombosis (DVT) by promoting venous blood flow. Ensuring that peripheral pulse points are present and have adequate volume and strength is crucial. If pulses are weak or absent, it could indicate compromised circulation, potentially due to clot formation. B. Incorrect- Monitoring incision drainage is important for wound healing but is not directly related to evaluating the effectiveness of compression devices. C. Incorrect- Observing for redness and swelling is important for assessing potential wound infections but is not directly related to evaluating the effectiveness of compression devices. D. Incorrect- Evaluating the client's ability to use an incentive spirometer is relevant for respiratory care but not specifically for assessing the effectiveness of compression devices.

The nurse is providing care to a client having surgery to repair a retinal detachment to the left eye. Which intervention should the nurse implement during the postoperative period? A Provide an eye shield to be worn while sleeping. B Encourage deep breathing and coughing exercises. C Teach a family member to administer eye drops. D Obtain vital signs every 2 hours during hospitalization.

A Provide an eye shield to be worn while sleeping. - After retinal detachment surgery, it is crucial to protect the eye and the surgical repair site from accidental trauma or pressure. Providing an eye shield helps to shield the eye during sleep when the client may not have conscious control over their movements.

The nurse is preparing a 50 mL dose of 50% Dextrose IV for a client with insulin shock. How should the nurse administer the medication? A Push the undiluted Dextrose slowly through the currently infusing IV. B Dilute the Dextrose in one liter of 0.9% Normal Saline solution. C Mix the Dextrose in a 50 mL piggyback for a total volume of 100 mL. D Ask the pharmacist to add the Dextrose to a TPN solution.

A Push the undiluted Dextrose slowly through the currently infusing IV. Correct answer: A - Push the undiluted Dextrose slowly through the currently infusing IV. Rationale: Correct (A): Dextrose 50% is given as a rapid IV push in cases of severe hypoglycemia. Incorrect: (B, C, D) These methods are inappropriate for the urgent treatment of hypoglycemia.

A client with a history of type 1 diabetes mellitus (DM) and asthma is readmitted to the unit for the third time in two months with a current fasting blood sugar (FBS) of 325 mg/dl (18 mmol/L). The client describes to the nurse of not understanding why the blood glucose level continues to be out of control. What intervention(s) should the nurse implement? Select all that apply. Reference Range Blood Glucose [74 to 106 mg/dL (4.1 to 5.9 mmol/L)] A Determine if the client is using a new insulin needle each administration. B Have the client describe a typical day at work, home, and social activities. C Evaluate the client's asthma medications that can elevate the blood glucose. D Have the client demonstrate technique used to monitor blood glucose levels. E Ask the client if they want a different manufacturer's glucose monitoring device.

A Reusing insulin needles can reduce insulin efficacy and can also damage the needles, which can prevent optimal insulin delivery. B Lifestyle factors like stress, lack of physical activity, or irregular eating habits can all affect blood glucose control. C Some asthma medications, particularly corticosteroids, can increase blood glucose levels. D Incorrect technique can lead to inaccurate readings, which can result in inappropriate insulin dosing. Incorrect: E Changing the device isn't necessary if technique is correct.

The nurse is assessing an older client who is having difficulty remembering events from earlier in the day and concentrating on the questions being asked. A family member shares that the client's home was recently sold and the client has just moved in with them. Which nursing response best promotes effective communication with the family? A The client's delirium may be due to depression and is possibly reversible. B The client is exhibiting symptoms of dementia and because of age, it may be permanent. C If the dementia is a result of Alzheimer's disease, it is often reversible even in the late stages. D Delirium is often a sign of underlying mental illness and institutionalization is often necessary.

A The client's delirium may be due to depression and is possibly reversible. - This response is empathetic and informative. It provides a potential explanation for the client's symptoms and suggests a course of action that could improve the client's condition. Delirium is an acute state of confusion that can be caused by various factors, including physical illness, medication side effects, and emotional stressors. It is often reversible when the underlying cause is identified and treated.

Which information should the nurse include in the discharge teaching plan of a client with low back pain who is taking cyclobenzaprine to control muscle spasms? A Use cold and allergy medications only as directed by a healthcare provider. B Avoid using heat or ice on injured muscles while taking this medication. C Discontinue all nonsteroidal anti-inflammatory medications. D Take this medication on an empty stomach.

A Use cold and allergy medications only as directed by a healthcare provider. Correct answer: A - Use cold and allergy medications only as directed by a healthcare provider. Rationale: Correct (A): Cyclobenzaprine can interact with other medications, including those for colds and allergies, potentially causing increased sedation or other side effects. Incorrect: B) Heat or ice can be beneficial for muscle injuries and is not contraindicated with cyclobenzaprine. C) NSAIDs can be used concurrently with cyclobenzaprine unless contraindicated for other reasons. D) Cyclobenzaprine should be taken with food to minimize gastrointestinal upset.

The nurse is developing an educational program for older adults who are being discharge with new antihypertensive medications. The nurse should ensure that the educational materials include which characteristics? Select all that apply. A Uses common words with view syllables B Printed using a 12-point type font C Uses pictures to help illustrate complex ideas D Contains a list with definitions of unfamiliar terms E Written at a twelfth-grade reading level.

A Uses common words with few syllables - Using common words with few syllables makes the information more accessible and easier to understand. C Uses pictures to help illustrate complex ideas - Visual aids can significantly enhance understanding, especially for complex medical concepts. Pictures can help bridge gaps in comprehension and make the material more engaging. D Contains a list with definitions of unfamiliar terms - Including definitions of unfamiliar terms helps ensure that patients fully understand the information being provided. This is crucial for effective medication management and adherence. Incorrect: B - While 12-point font is standard, it may not be large enough for older adults, who often have visual impairments. A larger font, such as 14-point or 16-point, is typically recommended to enhance readability. E - Educational materials for older adults should generally be written at a lower reading level, such as the fifth to eighth grade, to ensure comprehension across a broader audience. A twelfth-grade reading level is too advanced for many older adults, particularly those with lower health literacy.

When teaching a group of school-aged children how to reduce the risk for Lyme disease, which Instruction should the camp nurse include? A Wear long sleeves and pants. B Avoid drinking lake water. C Wash hands frequently. D Do not share personal products.

A Wear long sleeves and pants. - Lyme disease is transmitted through tick bites, and sleeves and pants can prevent tick bites.Typical symptoms include fever, headache, fatigue, and a characteristic skin rash called erythema migrans.

The nurse administers an antibiotic to a client with a respiratory tract infection. To evaluate the medication's effectiveness, which laboratory values should the nurse monitor? Select all that apply. A White blood cell (WBC) count. B Red blood cell (RBC) count. C Sputum culture and sensitivity. D Urinalysis. E Blood urea nitrogen (BUN). F Serum potassium.

A White blood cell (WBC) count. - A high WBC count can signify an infection or inflammation. If the treatment is effective, the WBC count should start to normalize as the infection is controlled. C Sputum culture and sensitivity. - This test identifies the specific bacteria causing the respiratory tract infection and determines which antibiotics are effective against it. Monitoring the results of sputum culture and sensitivity tests can help evaluate if the prescribed antibiotic is effective against the identified pathogen. Adjustments to the antibiotic regimen may be necessary based on these results.

In assessing a client at 34-weeks gestation, the nurse notes that she has a slightly elevated total T4 with a slightly enlarged thyroid, a hematocrit of 28% (0.28 volume fraction), a heart rate of 92 beats per minute, and a systolic murmur. Which finding requires follow-up? Reference Range: Hematocrit [37% to 47% (0.37 to 0.47 volume fraction)] A Heart rate of 92 beats per minute. B Hematocrit of 28% (0.28 volume fraction). C Elevated thyroid hormone level. D Systolic murmur.

A) Correct- Hematocrit values below the reference range during pregnancy could indicate anemia, which requires further evaluation and intervention. The other findings can be attributed to normal physiological changes during pregnancy (elevated total T4, heart rate increase) or can be common findings (systolic murmur). B) Incorrect - A heart rate of 92 beats per minute is within the normal range for pregnancy due to increased blood volume and hormonal changes. C) Incorrect - A systolic murmur can be a common finding during pregnancy due to increased cardiac output. D)Incorrect - An elevated total T4 can be a normal finding during pregnancy due to hormonal changes.

A 3-year-old client was successfully toilet trained prior to admission to the hospital for injuries sustained from a fall. The client's parents are very concerned that the child has regressed in toileting behaviors. Which information should the nurse provide to the parents? A A retraining program will need to be initiated when the child returns home. B A potty chair should be brought from home to maintain the current level of toileting skills. C Diapering will be provided since hospitalization is stressful to preschoolers. D Children usually resume their toileting behaviors when they leave the hospital.

A) Correct- Hospitalization and changes in routine can cause regression in toilet training, especially in young children. The nurse should educate the parents that initiating a retraining program when the child returns home is a practical approach. This response acknowledges the parents' concern and provides a solution for addressing the regression in toileting behaviors. B) Incorrect - Diapering is not a recommended approach for a previously toilet-trained child as it might reinforce regressive behavior. C) Incorrect - Bringing a potty chair from home might not necessarily address the issue of regression due to hospitalization. D)Incorrect - Although children often resume their previous behaviors upon returning home, it's important to provide parents with practical advice for managing the regression.

A client with obstructive sleep apnea (OSA) ambulates in the hallway with the nurse prior to bedtime and intervention is most important for the nurse to implement before leaving the client? A. Apply the client's positive airway pressure device. B Elevate the head of the bed to a 45 degree angle. C Lift and lock the side rails in place. D Remove dentures or other oral appliance.

A. Apply the client's positive airway pressure device. Rationale: Correct (A): For clients with obstructive sleep apnea, applying the positive airway pressure device before sleep is crucial to maintain airway patency and prevent apneic episodes during sleep. Incorrect: (B) Elevate the head of the bed: While helpful, it's not as effective as PAP therapy. (C) Lift and lock side rails: A safety measure but not directly addressing OSA. (D) Remove dentures: May be necessary but not the most important intervention for OSA.

A client develops urticaria on the trunk and neck shortly after a secondary infusion of piperacillin is initiated. In which order should the nurse implement these interventions? (Arrange the actions in order of priority, with the highest priority first, and least priority last or at the bottom.) Document reaction to the drug. Stop the infusion. Assess vital signs. Contact the healthcare provider. Initiate an adverse event report.

A. Stop the Infusion. B. Assess vital signs C. Contact the healthcare provider. D. Initiate an adverse event report. E. Document reaction to the drug. A) This is because the client is experiencing an allergic reaction to piperacillin, which can be life-threatening. The nurse should stop the infusion immediately to prevent further exposure to the drug and assess vital signs to monitor for signs of anaphylaxis, such as hypotension, tachycardia, wheezes, or stridor. B) Assessing vital signs is a priority to determine the severity of the reaction and the client's overall condition. C) The nurse should contact the healthcare provider to report the situation and obtain orders for treatment, such as antihistamines, corticosteroids, or epinephrine. D) The nurse should initiate an adverse event report to document the incident and follow the facility's protocol for reporting medication errors. E) The nurse should also document the reaction to the drug in the client's chart and notify the pharmacy to avoid future administration of piperacillin or related antibiotics

The nurse is caring for a group of clients with the help of a practical nurse (PN). Which nursing action should the nurse assign to the PN? (Select all that apply). A administer a dose of insulin per sliding scale for a client with type 2 diabetes mellitus. B start the second blood transfusion for a client 12 hours following below knee amputation. C initiate patient-controlled analgesia (PCA) pumps for two clients immediately postoperatively. D perform daily surgical dressing change for a client who had an abdominal hysterectomy. E obtain postoperative vital signs for a client one day following unilateral knee arthropathy.

ADE Rationale: A) Administer insulin: Within PN scope. D) Perform surgical dressing change: Within PN scope. E) Obtain postoperative vital signs: Within PN scope. Incorrect: B) Start blood transfusion: Requires RN. C) Initiate PCA pump: Requires RN.

Following a fractured left tibia, which necessitated placement of long leg cast, a client is using crutches to ambulate. During an orthopedic follow-up visit, a client reports to the nurse having difficulty managing the crutches. Which assessment should the nurse perform? A Palpate for dependent edema. B Measure capillary refill time. C Determine degree of skin elasticity. D Note hand and forearm strength.

Answer D. Note hand and forearm strength. Explanation This question is related to the assessment a nurse should perform when a client reports difficulty managing crutches following a fractured left tibia and placement of a long leg cast. The use of crutches requires good upper body strength, particularly in the hands and forearms, to support the body's weight during ambulation. Therefore, it is important for the nurse to assess the client's hand and forearm strength. - Palpating for dependent edema (option A) and measuring capillary refill time (option B) are assessments related to circulation, not the ability to manage crutches. - Determining the degree of skin elasticity (option C) is typically done to assess hydration status or aging, not the ability to manage crutches.

A client diagnosed with calcium kidney stones has a history of gout. A new prescription for aluminum hydroxide is scheduled to begin at 0730. Which client medication should the nurse bring to the healthcare provider's attention? A Furosemide. B. Aspirin, low dose. C. Allopurinol. D. Enalapril.

Answer Allopurinol A) Incorrect- Furosemide is a loop diuretic used to treat conditions such as edema and hypertension. It does not directly relate to the client's history of gout or the risk of calcium kidney stones. B) Incorrect- Low-dose aspirin is often used for its antiplatelet effects to prevent cardiovascular events. It does not directly relate to the client's history of gout or the risk of calcium kidney stones. C) Correct- Allopurinol is a medication used to treat gout by reducing the production of uric acid in the body. However, allopurinol can also increase the risk of forming calcium oxalate kidney stones, which is the type of kidney stone mentioned in the client's history. Calcium oxalate stones are the most common type of kidney stone, and they are composed primarily of calcium and oxalate. In this case, the client has a history of gout and is prescribed allopurinol. The nurse should bring the client's prescription for allopurinol to the healthcare provider's attention because it has the potential to contribute to the formation of kidney stones, which could exacerbate the client's existing condition. D) Incorrect- Enalapril is an angiotensin-converting enzyme (ACE) inhibitor used to treat hypertension and heart failure. It does not directly relate to the client's history of gout or the risk of calcium kidney stones.

A client with metastatic bone cancer is requesting pain medication. Which approach should the nurse use to assess the quality of the client's pain? A Provide a numeric pain scale B Asked the client to describe the pain C Observe body language and movement D Identify effective pain relief measure

B - Ask the client to describe the pain Rationale: Correct (B): Client's description provides the most comprehensive pain assessment. Incorrect: A, C, D) These provide limited information compared to client description.

The nurse enters a client's room to administer oral medications and finds an unlicensed assistive personnel (UAP) providing personal care to the client, whose condition has obviously deteriorated. The client is lying in a supine position and is weak, pale, and diaphoretic. Which is the priority nursing action? A Explain to the UAP that changes in a client's condition should be reported immediately. B Advise the UAP to stop providing care so the nurse can assess the client's condition. C Ask the UAP to position the client so the oral medications can be administered. D Determine why the UAP did not notify the nurse of the change in the client's condition.

B Advise the UAP to stop providing care so the nurse can assess the client's condition. Correct- In this situation, the priority is to ensure the safety and well-being of the client. The client's deteriorated condition needs to be assessed promptly by a licensed nurse to determine the appropriate interventions. Stopping the care being provided by the unlicensed assistive personnel (UAP) allows the nurse to focus on the client's immediate needs. Incorrect- A - While it's important for UAPs to report changes in a client's condition, the immediate priority is to assess and address the deteriorating condition of the client. The nurse's first action should be to stop the current care being provided and assess the client. Incorrect- C - Administering oral medications is not the immediate priority in this situation. The client's deteriorating condition takes precedence over administering medications. Incorrect- D - While investigating the situation and addressing communication gaps is important, the first priority is to assess and address the client's current condition. The nurse needs to take immediate action to ensure the client's safety and well-being.

Which condition(s) are most likely to respond to treatment with antihistamines? Select all that apply. A Otitis media. B Allergic rhinitis. C Myocarditis. D Contact dermatitis. E Bronchitis.

B Allergic rhinitis. D Contact dermatitis. Antihistamines block the effects of histamine, which causes nasal congestion, runny nose, itchy/watery eyes, skin rashes or hives, etc. Antihistamines can provide relief from allergy symptoms associated with conditions like allergic rhinitis and contact dermatitis. The other options are not primarily caused by allergic reactions or histamine release.

A client with a hip fracture is requesting pain medication prior to being repositioned in the bed. To assess the quality of the client's pain, which approach should the nurse use? A Identify effective pain relief measures. B Ask the client to describe the pain. C Observe body language and movement. D Provide a numeric pain scale.

B Ask the client to describe the pain. - This approach allows the nurse to gather information about the characteristics of the pain, such as its location, intensity, duration, and nature (sharp, dull, throbbing, etc.), which can help in tailoring the pain management strategy to the client's specific needs.

A client presents to the emergency department (ED) with complaints of abdominal pain. The nurse observes the client's right cheek and eye are bruised and suspects possible domestic violence. Which approach is best for the nurse to use when interviewing the client? A Ask questions in a vague, non-specific format. B Begin with questions that are less sensitive in nature. C Get the most difficult questions over with fist. D Share personal values to put the client at ease.

B Begin with questions that are less sensitive in nature. - By beginning with less sensitive, open-ended questions, the nurse can gradually build rapport, identify potential domestic violence issues, and create a supportive environment for the client to share their experiences, ultimately enabling more effective screening and intervention.

Which information is most important for the nurse to obtain when determining a client's risk for obstructive sleep apnea syndrome (OSAS)? A Level of consciousness. B Body mass index. C Self-description of pain. D Breath sounds.

B Body mass index. B. Body mass index (BMI) is a significant risk factor for OSAS, as higher BMI is strongly associated with increased risk of sleep apnea. A. Level of consciousness is not directly related to the risk of OSAS. C. Self-description of pain does not relate to the risk factors for OSAS. D. Breath sounds might be relevant in assessing respiratory status but do not directly indicate the risk for OSAS.

A client with chronic kidney disease reports to the nurse of feeling increasingly tired. The client receives injections for epoetin alfa three times a week. Which laboratory value should the nurse review? A Liver enzymes. B Complete blood count. C Serum electrolytes. D Platelet count.

B Complete blood count. B) Correct- Epoetin alfa is a medication that stimulates the production of red blood cells and is often used to treat anemia associated with chronic kidney disease. A complete blood count (CBC) would provide information about red blood cell levels, hemoglobin, and hematocrit, which are essential for assessing the effectiveness of the treatment. A) Incorrect- Liver enzymes are important for assessing liver function, but they are not the primary concern when a client with chronic kidney disease is feeling increasingly tired. Epoetin alfa injections are used to stimulate red blood cell production, so the nurse should review a laboratory value related to anemia. C) Incorrect- Serum electrolytes are important for assessing overall kidney function and electrolyte balance, but the primary concern here is the client's increasing fatigue. Reviewing a value related to anemia and red blood cell production would be more appropriate. D) Incorrect- Platelet count is important for assessing blood clotting function, but it's not directly related to the client's increasing fatigue. Anemia-related laboratory values should be the focus.

The nurse is setting up the equipment to assist with a sigmoidoscopy while the practical nurse (PN) positions the client in a flat prone position. Which action should the nurse implement? A Assume care of the client and assign the PN to the care of a different client. B Demonstrate to the PN how to position the client more effectively for the procedure. C Acknowledge that the PN has positioned the client safely and correctly. D Arrange for unlicensed assistive personnel to assist the PN during the procedure.

B Demonstrate to the PN how to position the client more effectively for the procedure.- Per Saunders, "Colonoscopy is performed with the client lying on the left side with the knees drawn up to the chest; position may be changed during the test to facilitate passing of the scope." One of the primary sigmoidoscopy vs colonoscopy differences is how far the doctor can see during the procedure. While sigmoidoscopy is used for investigating only the lower part of the colon, colonoscopy allows a doctor to view the colon's full length.

A client with persistent low back pain has received a prescription for an electronic stimulator (TENS) unit. After the nurse applies the electrodes and turns on the power, the client reports feeling a tingling sensation. How should the nurse respond? A Check the amount of gel coating on the electrodes. B Determine if the sensation feels uncomfortable. C Remove electrodes and observe for skin redness. D Decrease the strength of the electrical signals.

B Determine if the sensation feels uncomfortable. B - Correct- A tingling sensation is normal and expected when using a TENS unit, and it does not indicate any harm or damage to the skin or nerves. However, the sensation should not be painful or unpleasant for the client, and the nurse should adjust the intensity of the electrical signals accordingly. A Incorrect - The amount of gel coating on the electrodes might not be the primary issue if the client is feeling a tingling sensation. C - Incorrect - Skin redness might indicate irritation, but the initial focus should be on the client's sensation. D - Incorrect - Decreasing the strength of the electrical signals might be premature if the sensation is normal.

A client arrives for an annual physical exam and complains of having calf pain. The client's health history reveals peripheral arterial disease. Which question should the nurse ask the client about expected findings related to chronic arterial symptoms? A Were your legs ever suddenly swollen, red, warm, and painful? B Does the calf pain occur when walking short distances? C Did you receive treatment for weeping ulcers on lower legs? D Have you experienced ankle edema and varicose veins?

B Does the calf pain occur when walking short distances? - Intermittent claudication, calf pain while moving, is a symptom of peripheral artery disease.

A client is receiving continuous ambulatory peritoneal dialysis since the arteriovenous (AV) graft in the right arm is no longer available to use for hemodialysis. The client has lost weight, has increasing peripheral edema, and has a serum albumin level of 1.5 g/dL (15 g/L). Which intervention is the priority for the nurse to implement? Reference Range: Serum Albumin [Reference Range: 3.5 to 5.5 g/dL (35 to 55 g/L)l. A Evaluate patency of the AV graft for resumption of hemodialysis. B Ensure the client receives frequent small meals containing complete proteins. C Instruct the client to continue to follow the prescribed rigid fluid restriction amounts. D Recommend the use of support stockings to enhance venous return.

B Ensure the client receives frequent small meals containing complete proteins. Rationale: Correct (B): Low albumin indicates malnutrition; protein-rich meals are essential. Incorrect: (A) AV graft patency isn't the priority given nutritional issues. (C) Rigid fluid restriction may worsen nutritional status. (D) Support stockings don't address the underlying nutritional problem.

Which instruction regarding skin care should the nurse provide to a client who is receiving radiation therapy for metastatic breast cancer? A Frequently apply moisturizers to prevent dry skin. B Gently pat the skin dry after rinsing with water. C Use a sponge to debride the affected area. D Protect the site from getting wet during bathing.

B Gently pat the skin dry after rinsing with water. - Radiation therapy can cause skin reactions like dryness, redness, and irritation in the treated area. Gentle skin care is crucial to avoid further trauma and promote healing.

A 10-year-old child arrives to the clinic accompanied by a parent three days following a right ankle fracture that required internal fixation with screws. The parent reports the child is doing well but asks for pain medication about every 4 to 6 hours. The parent is concerned about addiction and has been trying to administer the pain medication sparingly. Which information is best for the nurse to provide the parent regarding pain management for the child? A Provide time for the child to rest when experiencing pain can be helpful. B Giving pain medication around the clock helps control the pain. C Encourage quiet activities as a pain distractor such as watching television. D The use of hot baths can be used as an alternative for pain medication.

B Giving pain medication around the clock helps control the pain. - It is important to manage the child's pain effectively to promote healing and comfort, and that it is unlikely for a child to develop addiction to pain medication when used appropriately for acute pain.

A client with arthritis has been receiving treatment with naproxen and now reports ongoing stomach pain, increasing weakness, and fatigue. Which laboratory test should the nurse monitor? A Serum calcium. B Hemoglobin. C Osmolality. D Erythrocyte sedimentation rate.

B Hemoglobin. Rationale: Naproxen is a nonsteroidal anti-inflammatory drug (NSAID) that can cause gastrointestinal bleeding as a side effect. The reported stomach pain, weakness, and fatigue could indicate potential GI bleeding. Monitoring hemoglobin levels is crucial to detect anemia resulting from blood loss. Incorrect: (A) Serum calcium: Not directly related to NSAID side effects or the symptoms described. (C) Osmolality: Not specifically relevant to NSAID side effects or the symptoms described. (D) Erythrocyte sedimentation rate: While this can indicate inflammation, it's not the most direct indicator of potential GI bleeding from NSAIDs.

A male client with schizophrenia tells the nurse that the hospital has installed cameras that watch him and listening devices that record what everyone says. Which nursing problem should the nurse document for this client? A Noncompliance with medication related to thought broadcasting. B Impaired environmental interpretation related to paranoid delusions. C Disturbed sensory perception related to auditory hallucinations. D Situational self-esteem disturbance secondary to schizophrenia.

B Impaired environmental interpretation related to paranoid delusions. - this delusional belief demonstrates an impaired ability to accurately interpret the environment and reality. A. Noncompliance with medication is not directly indicated by the client's statement. C. Disturbed sensory perception relates more to hallucinations (auditory, visual, etc.). D. Situational self-esteem disturbance centers on the client's paranoid delusion rather than self-esteem issues.

A 5-week-old infant who developed projectile vomiting over the last two weeks is diagnosed with hypertrophic pyloric stenosis. Which intervention should the nurse plan to implement? A Instruct the mother to give the child sugar water only. B Maintain IV fluid rehydration therapy per prescription. C Offer the infant oral rehydration solution every 2 hours. D Provide electrolyte replacement via the nasogastric tube.

B Maintain IV fluid rehydration therapy per prescription. - Intravenous fluid replacement therapy is a crucial initial treatment to correct fluid and electrolyte deficits in infants with HPSWrong:A. Sugar water would worsen dehydration and provide inadequate nutrition and electrolyte replacement. C. Oral rehydration solutions may not be tolerated due to the pyloric obstruction causing projectile vomiting. D. Nasogastric tube feedings are generally avoided in HPS due to the risk of worsening vomiting and aspiration.

The nurse is caring for a client with pneumonia who now develops initial signs of septic shock and multi-organ failure. The healthcare provider prescribes a sepsis protocol. Which intervention is most important for the nurse to include in the plan of care? A Monitor blood glucose level. B Maintain strict intake and output. C Assess warmth of extremities. D Keep head of bed raised 45 degrees.

B Maintain strict intake and output: Monitoring fluid balance is crucial in managing septic shock as fluid resuscitation is a key part of treatment. However, it's not the most important intervention at this stage. Incorrect: A Monitor blood glucose level: While it's important to monitor blood glucose levels in critically ill patients, this is not the most critical intervention in the early stages of septic shock. C Assess warmth of extremities: This can indicate peripheral perfusion and may be useful in assessing the patient's response to treatment. But again, it's not the most critical intervention at this stage. D Keep head of bed raised 45 degrees: This intervention is primarily used to prevent aspiration pneumonia in patients who are intubated or have difficulty swallowing. It doesn't directly address the management of septic shock.

An older adult client arrives to the clinic describing a new onset of urinary incontinence. Which intervention should the nurse implement? A Provide protective undergarments for the client. B Obtain a clean, voided urine specimen for analysis. C Evaluate the client's response to bladder training efforts. D Encourage increased fluid intake for 24 hours.

B Obtain a clean, voided urine specimen for analysis. - Urinalysis can help identify whether there is a urinary tract infection (UTI), hematuria, or other abnormalities that may be contributing to the incontinence. The other options do not address the underlying cause.

The nurse is caring for a one-week-old infant who has a ventriculoperitoneal (VP) shunt that was placed 2 days after birth. Which finding(s) indicate a postoperative complication? Select all that apply. Reference Range: White blood cells (WBC) [9,000 to 30,000/mm3 (9 to 10 x 109/L) A Hyperactive bowel sounds. B Poor feeding and vomiting. C Leakage of cerebral spinal fluid from the incisional site. D WBC of 10,000/mm3 (10 x 109/L). E Abdominal distention.

B Poor feeding and vomiting. C Leakage of cerebral spinal fluid from the incisional site. E Abdominal distention. A ventriculoperitoneal (VP) shunt is a medical device that lessen and relieves the pressure in the brain that is an effect of fluid accumulation. This is a treatment to a condition called hydrocephalus and is more likely to occur in newborns. The risk of ventriculoperitoneal (VP) shunting can be serious and can lead to death however, postoperative complications can include poor feeding, vomiting, leakage of CSF from the incision site and abdominal distention.

A client who is one day postpartum tells the nurse that her baby cannot latch onto the breast. The nurse determines that the client's nipples are inverted. Which action should the nurse implement? A Offer supplemental formula feedings. B Recommend using a breast shield. C Encourage the use of ice on the areola. D Teach about the use of a breast pump.

B Recommend using a breast shield. - A breast shield can be recommended to help draw out the nipple and create a more optimal shape for latching. It can also provide a larger surface area for the baby to grasp onto, making breastfeeding more successful for both the mother and the baby.

The nurse is caring for a client with a binge eating disorder. Which goal should the nurse first establish with the client? A Institute an exercise plan. B Regulate food portions. C Obtain satisfaction with appearance. D Achieve a steady weight loss.

B Regulate food portions. - Regulating food portions is a crucial initial step in treating binge eating disorder. It helps the client develop a healthier relationship with food and break the cycle of binge eating episodes.The other answers are incorrect, because the priority is to develop healthy, eating habits.

A client who has been taking allopurinol prophylactically comes into the clinic with reoccurring gout attack episodes in left ankle. The healthcare provider changes the prescription to febuxostat. Which instruction should the nurse include in the discharge teaching? A Eat high protein foods to achieve ideal body weight. B Report experiencing right upper quadrant discomfort. C Use electric heating pad when pain is at its worse. D Replace dietary table salt with salt substitutes.

B Report experiencing right upper quadrant discomfort. Febuxostat is a medication used to manage hyperuricemia and prevent gout attacks. However, it has been associated with hepatotoxicity, including liver enzyme elevations and liver failure. Therefore, it is important for the nurse to instruct the client to report any signs or symptoms of liver dysfunction, such as right upper quadrant discomfort. This will allow for prompt evaluation and appropriate management if hepatotoxicity occurs.

Six weeks after the birth of a child with Trisomy 21, the parents return to the prenatal clinic for a follow-up visit. They have spoken with a genetic counselor but are still unsure about the risk of having another child with Trisomy 21. The couple brings literature from the counselor with them and asks the nurse to explain it. Which action should the nurse take? A Recommend a community support group for parents of children with Trisomy 21. B Review the literature and answer any questions the nurse is able to answer. C Tell the couple that it is best to call the counselor with their questions. D Determine their reasoning for seeking genetic counseling at this time.

B Review the literature and answer any questions the nurse is able to answer. - The nurse should make an effort to address the parents' concerns and provide accurate information based on the materials from the genetic counselor. This demonstrates support, a willingness to help, and a commitment to providing accurate information.

Which laboratory test result is most important for the nurse to report to the surgeon prior lo a client's scheduled hernia repair? Reference Ranges: Blood glucose [74 to 106 mg/dL (4.1 to 5.9 mmol/L)] Serum creatinine [0.5 to 1.1 mg/dL (44 to 97 µmol/L)] Potassium [3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)] Hemoglobin (Hgb) (12 to 16 g/dL (120 to 160 g/L)] A Blood glucose of 90 mg/dL (5 mmol/L). B Serum creatinine of 5 mg/d (442 µmol/L). C Potassium level of 4 mEq/L (4 mmol/L). D Hemoglobin level of 13 g/dL (130 g/L).

B Serum creatinine of 5 mg/d (442 µmol/L). - A serum creatinine of 5 mg/dl is indicative of severe kidney failure, which could possibly prompt a delay of the surgery.

A client with diabetes insipidus (DI) has an average urinary output of 500 ml of dilute urine every hour for the last 4 hours. Which laboratory test is most important for the nurse to monitor? A Urine specific gravity. B Serum sodium. C Capillary glucose. D White blood cell count.

B Serum sodium. B - Correct- Diabetes insipidus (DI) is a condition characterized by excessive thirst and urination due to the body's inability to regulate fluid balance. In DI, the body either lacks antidiuretic hormone (ADH), which regulates water reabsorption in the kidneys, or the kidneys are resistant to its effects. As a result, clients with DI can produce large volumes of dilute urine. The most significant concern in DI is the potential for electrolyte imbalances, particularly low serum sodium levels (hyponatremia). Excessive loss of water in the urine can lead to dehydration and concentration of the blood's sodium levels. This can result in neurological symptoms, such as confusion, seizures, and even coma. Monitoring the serum sodium level is crucial to ensure that it remains within a safe range. D - Incorrect- This test is used to assess for infection or inflammation and is not specifically related to monitoring diabetes insipidus. C - Incorrect- This test is used to monitor blood sugar levels in individuals with diabetes mellitus, not diabetes insipidus. A - Incorrect- While urine specific gravity can provide information about urine concentration, it is not the most important laboratory test to monitor in a client with diabetes insipidus. Serum sodium level is a more critical indicator of electrolyte balance and potential complications in DI.

A client with right-sided weakness calls for assistance with ambulating to the bathroom. Which action should the nurse implement? A Bring a bedside commode to the client. B Stand on the client's right side while walking. C Walk directly behind the client to prevent a fall. D Give the client a cane to hold in the right hand.

B Stand on the client's right side while walking. -By positioning themselves on the client's right (weaker) side during ambulation, the nurse can provide the necessary support, stability, and guidance to promote safe mobility and prevent falls or further injury.

The nurse is developing a plan of care for a client who reports chest pain on exertion and who is newly diagnosed with cardiovascular disease. Which outcome should the nurse include in the plan of care for this client? A The client will monitor blood glucose and blood pressure after each meal. B The client's daily blood pressure will be less than 140/80 mmHg this month. C The client's blood pressure readings will be less than 160/90 mmHg D The nurse will encourage the client to walk thirty minutes every day.

B The client's daily blood pressure will be less than 140/80 mmHg this month. - Achieving a blood pressure of 140/80 mmHg or lower helps reduce the risk of adverse cardiovascular events, target organ damage, and mortality in patients with cardiovascular disease. A blood pressure of 160/90 mmHg would be classified as Stage 2 HTN, which is above the recommended target for patients with cardiovascular disease and increases their risk of complications.

The nurse leading a care team on a medical surgical unit is assigning client care to a practical nurse (PN) and an unlicensed assistive personnel (UP). Which task should the nurse assign to the PN? A Determine the need for urinary catheterizations. B Titrate oxygen to prescribed parameters. C Evaluate and update plans of care for clients. D Receive a postoperative client and conduct the assessment.

B Titrate oxygen to prescribed parameters. Rationale: Correct (B): Titrating oxygen within prescribed parameters is within the scope of practice for a practical nurse (PN) and requires nursing judgment. Incorrect: (A) Determine need for catheterizations: Typically requires RN assessment. (C) Evaluate and update care plans: This is an RN responsibility. (D) Receive postoperative client and conduct assessment: This is an RN responsibility due to the complexity of postoperative assessment.

The nurse is managing the care of a client with Cushing's syndrome. Which intervention(s) should the nurse delegate to the unlicensed assistive personnel (UAP)? Select all that apply. A Assess the client for weakness and fatigue. B Weigh the client and report any weight gain. C Evaluate the client for sleep disturbances. D Report any client mention of pain or discomfort. E Note and report the client's food and liquid intake during meals and snacks.

B Weigh the client and report any weight gain. D Report any client mention of pain or discomfort. E Note and report the client's food and liquid intake during meals and snacks. Correct- B - Weighing the client and reporting any weight gain is a routine measurement that can be safely performed by the UAP. Weight gain can be an important indicator of fluid retention, a common issue in Cushing's syndrome. Correct- D - Reporting any client complaints of pain or discomfort is important for monitoring the client's well-being and promptly addressing any potential issues. Correct- E - Noting and reporting the client's food and liquid intake during meals and snacks is part of monitoring the client's nutritional status, which is an appropriate task for the UAP.

A preschool-aged child who is being treated for Streptococcal pharyngitis returns to the clinic for signs of scarlet fever. Which assessment finding provides the earliest indication to the nurse that the child is experiencing a reaction to the toxins that are created by the Streptococcus bacteria? A Red bumps across chest. B White coating on tongue. C High, protracted fever. D Flaky, peeling skin.

B White coating on tongue. Correct answer: B - White coating on tongue. Rationale: Correct (B): White coating (strawberry tongue) is an early sign of scarlet fever. Incorrect: (A, C, D) These are later signs of scarlet fever.

When the parents of a 6-year-old boy with a brain tumor are told that his condition is terminal, the mother shouts at the father, "This is your fault! It never would have happened if we had sought treatment sooner!" Which intervention is best for the nurse to implement? A Refer the parents to the chaplain to provide grief counseling. B Assure the parents that a terminal diagnosis was inevitable: C Explain to the parents that anger is a common response to grief. D Tell the parents that blaming each other will not change the situation.

B) Assure the parents that a terminal diagnosis was inevitable. The parents are distressed by their child's terminal diagnosis, which is reflected in the mother's comment, attributing blame to the father for not seeking treatment earlier. This blame, however, might be more reflective of her fear and desperation, rather than a grounded belief. The mother's remark suggests a belief that seeking treatment sooner could have prevented the terminal diagnosis. This assumption maybe erroneous and possibly exacerbates the distress of the parents. As a nurse, the most constructive intervention can be to gently correct the mother's misassumption while also offering emotional support. Assuring the parents that the terminal diagnosis would have been inevitable, even if treatment had been sought earlier, can reflect both empathy and understanding.

When entering the room of a sedated postoperative client, which assessment requires immediate intervention by the nurse? A Oxygen is being administered via nasal cannula at 4 L/minute without humidification. B Low intermittent suction prescribed for the nasogastric tube is turned off. C The urinary catheter drainage bag is almost completely full of amber urine. D A Hemovac drain is partially full of serous drainage and is not compressed.

B. Low intermittent suction prescribed for the nasogastric tube is turned off. This is a serious issue that requires immediate intervention. If the suction is turned off, it could lead to aspiration, which can cause pneumonia or other serious complications. Not A. While humidification can help prevent dryness and irritation in the nasal passages, it's not typically a critical issue that requires immediate intervention. Not C. While it's important to empty the bag to prevent backflow and potential infection, it's not typically an immediate emergency. Not D. While the drain should be compressed to promote drainage, it's not typically an immediate emergency if it's not.

While providing a health history, a female client tells the clinic nurse that she frequently thinks about hurting herself. Which question is most important for the nurse to ask? a. "Do you often have feeling of sadness?" b. "Are you having problems concentrating?" c. "Have you though about taking your life?" d. "What problems are you facing right now?"

C "Have you thought about taking your life?" The problem involves a health history consultation where a female client reveals she frequently contemplates self-harm. As a nurse, it's important to ask the most important question to evaluate the severity of her thoughts. Identify the Appropriate Question Among the given options, we need to identify the question that best relates to the severity of self-harm thoughts and acts upon them effectively. Given the client's self-harming thoughts, option C - "Have you thought about taking your life?" - best addresses the severity of her situation. Questions about sadness (option A), concentration problems (option B), and current problems (option D) can be relevant, but they aren't as crucial to establishing immediate safety as option C.

The parent of a child born with a myelomeningocele asks the nurse, "What did I do to deserve this?" Which response is most helpful? A "You didn't do anything wrong." B "Is there any particular reason why you think this is your fault?" C "This must be a very difficult time for you." D "With surgery, your baby should have full recovery."

C "This must be a very difficult time for you." - this is the most helpful response because it acknowledges the parent's feelings and offers empathy. It doesn't place blame or make assumptions. Instead, it opens up a space for the parent to express their feelings and concerns.Choice B could potentially lead to a constructive conversation. However, it might also make the parent feel defensive or as if they need to justify their feelings. It's crucial to approach this situation with empathy and understanding, acknowledging the parent's feelings without making them feel judged. Choice A might seem comforting, but it doesn't address the parent's feelings of guilt or responsibility. D - never promise anything

After repositioning an immobile client, the nurse observes an area of hyperemia. To assess for blanching, which action should the nurse take? A Palpate the temperature of the area. B Measure the degree of indentation. C Apply light pressure over the area. D Note the skin color surrounding the area.

C - Applying light pressure over the reddened area, known as the "blanch response" or "finger press test", is the recommended method to differentiate between blanching and non-blanching erythema. Hyperemia is an increase in the amount of blood flow to a particular area or tissue in the body. Blanchable hyperemia is a normal response that resolves with pressure relief, while non-blanchable hyperemia is an early sign of pressure injury and requires immediate intervention to prevent further tissue damage.

A client with a traumatic brain injury becomes progressively less responsive to stimuli. The client has a "Do Not Resuscitate" prescription, and the nurse observes that the unlicensed assistive personnel (UP) has stopped turning the client from side to side as previously scheduled. What action should the nurse take? A Encourage the UP to provide comfort care measures only. B Assign a practical nurse to assist the UP in turning the client. C Advise the UP to resume positioning the client on schedule. D Assume total care of the client to monitor neurologic function.

C Advise the UP to resume positioning the client on schedule. - The DNR prescription does not mean the client should not receive routine care and interventions to maintain their comfort.

The nurse is assigned to care for four surgical clients. After receiving report, which client should the nurse see first? A An adult who is in Buck's traction and scheduled for hip arthroplasty within the next 12 hours. B An adult one day postoperative laparoscopic cholecystectomy requesting pain medication. C An older client who is receiving packed red blood cells on the third day postoperative for colon resection. D An older client with continuous bladder irrigation who is 2 days postoperative for bladder surgery.

C An older client who is receiving packed red blood cells on the third day postoperative for colon resection. Correct- Postoperative hemorrhage is a serious complication, and an older client receiving packed red blood cells may be experiencing active bleeding. This situation requires immediate assessment and intervention. Incorrect- Hip arthroplasty is a scheduled procedure, and there is no immediate indication of a critical condition that requires urgent attention. Incorrect- Pain management is important, but it is not as urgent as assessing a client who may be experiencing active bleeding. Incorrect- While continuous bladder irrigation requires monitoring, it is not as urgent as a potential postoperative hemorrhage.

An older client comes to the clinic with a family member. When the nurse attempts to take the client's health history, the client does not respond to questions in a clear manner. Which action should the nurse implement first? A Provide a printed health care assessment form. B Ask the family member to answer the questions. C Assess the surroundings for noise and distractions. D Defer the health history until the client is less anxious.

C Assess the surroundings for noise and distractions. - By assessing the surroundings, the nurse can identify and address any potential barriers to communication.

A client is admitted with the diagnosis of Wernicke's syndrome. Which assessment finding should the nurse use in planning the clients care? A Depression. B Peripheral neuropathy. C Confusion. D Right lower abdominal pain.

C Confusion. - Wernicke's syndrome, part of Wernicke-Korsakoff syndrome, is primarily characterized by confusion due to brain damage, particularly in the lower parts of the brain such as the thalamus and hypothalamus, caused by a lack of vitamin B1 (thiamine). Symptoms of Wernicke encephalopathy include confusion and loss of mental activity that can progress to coma and death.

When assessing a client with an ionized calcium level of 17 mg/dL (4.25 mol/L), which intervention is most important for the nurse to implement? Reference Range: Ionized Calcium [Reference Range: Adult 4.5 to 5.6 mg/dL (1.05 to 1.3 mol/L)] A Assess strength of deep tendon reflexes. B Compare muscle strength bilaterally. C Determine apical pulse rate and rhythm. D Observe color and amount of urine.

C Determine apical pulse rate and rhythm. Low levels of calcium can result in muscle cramping, abdominal cramping, tingling fingers, and muscle twitches. A prolonged QT segment are clinical manifestation the nurse would anticipate when providing care to a patient with hypocalcemia. Someone who is experiencing unusual thirst, high levels of urination, fatigue, weakness, and a loss of appetite may have high calcium levels that can be detected on this blood test. A shortened ST segment, ventricular dysrhythmia, and increased digitalis effects are anticipated when providing care to a patient with hypercalcemia. Elevated serum calcium levels can decrease cardiac output and cause cardiac dysrhythmias. Connecting the client to a cardiac monitor is a priority to assess for lethal cardiac changes.

Prior to surgery, written consent must be obtained. Which is the nurse's legal responsibility with regard to obtaining written consent. A Explain the surgical procedure to the client and ask the client to sign the consent form. B Ask the client or a family member to sign the surgical consent form. C Determine that the surgical consent form has been signed and is included in the client's record. D Validate the client's understanding of the surgical procedure to be conducted.

C Determine that the surgical consent form has been signed and is included in the client's record. Nurse's legal responsibility for surgical consent: Correct answer: C - Determine that the surgical consent form has been signed and is included in the client's record. Rationale: Correct (C): Nurse's responsibility is to verify consent is obtained and documented. Incorrect: A, B) Obtaining consent is the physician's responsibility. D) While important, it's not the nurse's legal responsibility.

When caring for a client with diabetes insipidus (DI), it is most important for the nurse to include frequent assessment for which conditions in the client's plan of care? A Elevated blood pressure, petechiae. B Nausea and vomiting, muscle weakness. C Dry mucous membranes, hypotension. D Decreased appetite, headache.

C Dry mucous membranes, hypotension. - Assessing for dry mucous membranes and hypotension allows the nurse to promptly identify dehydration and initiate appropriate interventions.

A male client tells the nurse that he is concerned that he may have a stomach ulcer, because he is experiencing heartburn and a dull gnawing pain that is relieved when he eats. Which is the best response by the nurse? A Advise the client that he needs to seek immediate medical evaluation and treatment of these symptoms. B Assure the client that his symptoms may only reflect reflux, since ulcer pain is not relieved with food. C Encourage the client to obtain a complete physical exam, since these symptoms are consistent with an ulcer. D Instruct the client that these mild symptoms can generally be controlled with changes in his diet.

C Encourage the client to obtain a complete physical exam, since these symptoms are consistent with an ulcer. - Heartburn and dull gnawing pain relieved by eating are consistent with the typical presentation of a peptic ulcer. While the symptoms could potentially be due to acid reflux/GERD as well, the pain from peptic ulcers can sometimes be relieved by eating, unlike reflux pain which is often exacerbated by food.

The nurse observes a practical nurse (PN) pouring warm water over the perineal area of a female client who has frequent urinary incontinence while the client is positioned on a bedpan. Which action should the nurse take? A Suggest contacting the healthcare provider for a prescription for catheter insertion. B Recommend a complete bath to cleanse the perineal area more fully. C Evaluate the effectiveness of this measure to stimulate client voiding. D Instruct the PN that this technique promotes infection in elderly females.

C Evaluate the effectiveness of this measure to stimulate client voiding. - Stimulation methods can include pulling on the pubic hairs, massaging the lower stomach, or the inner thighs. Provide the patient with routine voiding measures including privacy, normal voiding positions, or the sound of running water. Also lightly tapping over the bladder.

A client in the third trimester of pregnancy reports that she feels some "lumpy places" in her breasts and that her nipples sometimes leak a yellowish fluid. She has an appointment with her healthcare provider in two weeks. Which action should the nurse take? A Reschedule the client's prenatal appointment for the following day. B Recommend that the client start wearing a supportive brassiere. C Explain that this normal secretion can be assessed at the next visit. D Tell the client to begin nipple stimulation to prepare for breast feeding.

C Explain that this normal secretion can be assessed at the next visit. - The client's symptoms are normal physiological changes that occur as the breasts prepare for lactation. These changes are caused by hormonal fluctuations and do not require immediate medical attention if the client is not experiencing pain, fever, or other concerning symptoms.

The nurse identifies several nursing problems for client who is immobile and who has been experiencing fecal incontinence and diarrhea for several days. The client's spouse is the primary caregiver in planning care, which problem has highest priority? A Impaired bed mobility B Caregiver role strain C Fluid volume deficit D Bowel incontinence

C Fluid volume deficit Choice C Reason: This is correct because fluid volume deficit is a life-threatening condition that can result from diarrhea and fecal incontinence. The nurse should monitor the client's fluid intake and output, electrolytes, weight, urine specific gravity, and skin turgor.

A client with Addison's disease becomes weak, confused, and dehydrated following the onset of an acute viral infection. The client's laboratory values include: sodium 129 mEq/L (129 mmol/L), glucose 54 mg/dL (2.97 mml) and potassium 5.3 mEq/L (5.3 mmol/L). When reporting the findings to the healthcare provider, the nurse anticipates a prescription for which intravenous medication? Reference Range: Sodium [136 to 145 mEq/L (136 to 145 mmol/L)] Glucose [74 to 106 mg/dL (4.1 to 5.9 mmol/L)] Potassium [3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)] A Broad spectrum antibiotic. B Regular insulin. C Hydrocortisone. D Potassium chloride.

C Hydrocortisone. - Given the client's history of Addison's disease, current symptoms of weakness, confusion, and dehydration, as well as abnormal laboratory results, the nurse should anticipate prescribing intravenous hydrocortisone. Addison's disease is characterized by insufficient cortisol production, and acute stressors such as viral infections can induce adrenal crises, necessitating increased glucocorticoid replacement.

When is it most important for the nurse to assess a pregnant client's deep tendon reflexes (DTRS)? A When the client has ankle edema. B During admission to labor and delivery. C If the client has an elevated blood pressure. D Within the first trimester of pregnancy.

C If the client has an elevated blood pressure. Rationale: Correct (C): Elevated BP with hyperreflexia can indicate preeclampsia. Incorrect: (A, B, D) These situations don't specifically warrant DTR assessment. Correct answer: D - A disoriented client removed the mesh wrapped IV line for the second time.

A client is admitted to the surgical intensive care unit following the removal of a large portion of the intestines due to a gunshot wound to the abdomen. The client begins to display signs of septic shock and a sepsis protocol ls initiated. Which intervention is most important for the nurse to include in the plan of care? A Keep head of bed raised 45 degrees. B Assess warmth of extremities. C Maintain strict intake and output. D Monitor blood glucose level.

C Maintain strict intake and output. - Sepsis can often lead to fluid dysregulation and fluid shift, resulting in hypervolemia or fluid overload. Oliguria is a common manifestation of acute kidney injury which frequently occurs in sepsis.

Four hours after surgery, a client reports nausea and begins to vomit. The nurse notes that the client has a scopolamine transdermal patch applied behind the ear. Which action should the nurse take? A Remove the transdermal patch until the vomiting subsides. B Reposition the transdermal patch to the client's trunk. C Notify the client's healthcare provider of the vomiting. D Explain that this is a side effect of the medication in the patch.

C Notify the client's healthcare provider of the vomiting. Rationale: Scopolamine used transdermally is used to prevent and relieve nausea and vomiting caused by anesthesia and surgery. If the drug is ineffective for the patient who undergo the surgery, the nurse should inform the healthcare provider. Additionally, to lessen nausea and vomiting, the patch should be place behind the ear and remained in place. Vomiting and nausea are not a drug side effect.

A client with possible acute kidney injury (AKI) is admitted to the hospital and mannitol is prescribed as a fluid challenge. Prior to carrying out this prescription, what intervention should the nurse implement? A No specific nursing action is required. B Instruct the client to empty the bladder. C Obtain vital signs and breath sounds. D Collect a clean catch urine specimen.

C Obtain vital signs and breath sounds. - This will aid in establishing baseline vital signs and status, as well as monitoring for any effects that the mannitol may have after administration. Mannitol is a diuretic that increases the amount of water expelled in the urine, resulting in a considerable drop in blood pressure. As a result, it is critical to monitor the patient's vital signs to ensure a safe diuretic infusion.

An older resident of an extended care facility has recurrent urinary tract infections. The nursing care plan includes the goal, "Increase daily intake of fluids." Which nursing intervention is most useful in assisting the resident to meet this goal? A Maintain a full pitcher of water at the bedside. B Record the client's intake and output every shift. C Offer a glass of fluid every hour while awake. D Increase fluids provided with the client's meals.

C Offer a glass of fluid every hour while awake. While all the options provided can contribute to increasing the resident's fluid intake, option C is the most proactive and direct approach. Offering fluids frequently throughout the day when the resident is awake is an effective behavioral strategy to promote increased fluid intake and hydration. The regular prompting and availability of fluids can help overcome barriers to adequate hydration, such as forgetfulness or limited mobility, which are common in older adults residing in care facilities.

An older male client arrives at the clinic complaining that his bladder always feels full. He complains of a weak urine low, frequent dribbling after voiding, and increasing nocturia with difficulty initiating his urine stream. Which action should the nurse implement? A Obtain a urine specimen for culture and sensitivity. B Instruct in effective techniques to cleanse the glans penis. C Palpate the client's suprapubic area for distention. D Advise the client to maintain a voiding diary for one week.

C Palpate the client's suprapubic area for distention. - If the patient's bladder is distended, it could indicate urinary retention or an enlarged prostate that requires immediate attention and intervention.

After performing a quick visual assessment, the nurse should prioritize care for the client who is exhibiting which finding? A High pressure alarm sounds when client is coughing B Diminished breath sounds in the right posterior base. C Restrained and restless with a low volume alarm sounding D An audible voice when client is trying to communicate

C Restrained and restless with a low volume alarm sounding C) Correct- This finding suggests that the client may have a ventilator disconnect, a leak in the circuit, or a cuff leak, which can compromise the client's oxygenation and ventilation. The nurse should immediately check the ventilator connections and tubing, and assess the client's vital signs and oxygen saturation. A) Incorrect- an audible voice when client is trying to communicate, indicates that the client has some air passing through the vocal cords, which may be due to a partially deflated cuff or a speaking valve. This is not a life-threatening situation, but the nurse should ensure that the cuff pressure is adequate and that the client is not experiencing any discomfort or aspiration risk. B) Incorrect- This may indicate atelectasis, pneumonia, or pleural effusion in that lung area. The nurse should auscultate the client's lungs more thoroughly, monitor the client's oxygenation and ventilation parameters, and report the findings to the provider. D) Incorrect- high-pressure alarm sounds when the client is coughing, which is a common occurrence in mechanically ventilated clients who have increased airway resistance due to secretions, bronchospasm, or coughing. The nurse should suction the client as needed, administer bronchodilators if prescribed, and ensure that the ventilator settings are appropriate for the client's condition.

A client who recently received a prescription for ramelteon to treat sleep deprivation reports experiencing several side effects since taking the drug. Which side effect should the nurse report to the health care provider? A A change in the sleep-wake cycle. B Mild sedation. C Somnambulism. D Dizziness reported after initial dose.

C Somnambulism. - Somnambulism, also known as sleepwalking, is a potentially dangerous side effect that needs immediate attention from the healthcare provider. The client's safety is at risk due to the potential for injury during sleepwalking episodes.

After a spider bite on the lower extremity, a client is admitted for treatment of an infection that is spreading up the leg. Which admission assessment findings should the nurse report to the healthcare provider? Select all that apply. A Location of the initial IV site B Red blood cell count (RBC) C Swollen lymph nodes in the groin D White blood cell count (WBC) E Core body temperature

C Swollen lymph nodes in the groin - Swollen lymph nodes indicate that the infection is spreading through the lymphatic system, which is a significant finding that needs to be reported to the healthcare provider. D WBC - An elevated WBC count is a marker of infection and inflammation. It helps in assessing the severity of the infection and the body's response to it. E Core body temperature - Fever is a common symptom of infection and indicates that the body is fighting the infection. Monitoring temperature is crucial for assessing the severity of the infection and the effectiveness of treatment. Incorrect: A - While the location of the IV site is important for ensuring proper administration of medications and fluids, it is not directly related to the assessment of the infection's spread or severity. B - The RBC count is not typically used to assess infection. It is more relevant for evaluating conditions like anemia, not for monitoring the spread of an infection.

A client who is admitted to the intensive care unit with a right chest tube attached to a chest drainage unit becomes increasingly anxious and complains of difficulty breathing. The nurse determines the client is tachypneic with absent breath sounds in the client's right lung fields. Which additional finding indicates that the client has developed a tension pneumothorax? A Decreased bright red bloody drainage. B Tachypnea with difficulty breathing. C Tracheal deviation toward the left lung. D Continuous bubbling in the water-seal chamber.

C Tracheal deviation toward the left lung. - In a tension pneumothorax, air accumulates in the pleural space and increases pressure, compressing the lung on the affected side. The increased pressure can shift the mediastinum and trachea toward the unaffected side. Tracheal deviation away from the side of the pneumothorax is a classic sign of a tension pneumothorax, indicating severe compression of the lung and mediastinal structures.

An older adult client presents to the emergency department with abdominal pain due to constipation. The nurse is providing a list of high-fiber foods to the client that the healthcare provider has recommended. Which action should the nurse implement when reviewing the list of foods? A Provide handouts written at a 12th grade reading level. I B Stand behind the client to avoid intimidation. C Turn on overhead lights while giving instructions. D Use background music to promote relaxation.

C Turn on overhead lights while giving instructions. This is a good practice. Adequate lighting can help the client see the handouts clearly, especially if they have vision problems. This ensures that the client can clearly see the information being presented. A Provide handouts written at a 12th grade reading level. This might not be the best approach. The average reading level of adults in the U.S. is around the 8th grade level. For older adults, who may have vision problems or cognitive decline, simpler language might be more appropriate. B Use background music to promote relaxation. While music can promote relaxation, it can also be a distraction when trying to understand new information. It's better to ensure a quiet, calm environment for the discussion. D Stand behind the client to avoid intimidation. This is not recommended. It's better to sit at the same level as the client and maintain eye contact. This promotes effective communication and shows respect.

An older client with Alzheimer's disease is confused and asking the nurse to call their mother who is deceased. Which nonpharmacological intervention should the nurse implement? A Clarify reality with the client about delusional thoughts. B Reduce the client's interaction with others during day. C Use distraction and therapeutic communication skills. D Awaken the client for reality checks every 4 hours at night.

C Use distraction and therapeutic communication skills. C) Correct- Clients with Alzheimer's disease often experience cognitive impairments and may have delusional thoughts or confusion, such as believing deceased loved ones are still alive. Nonpharmacological interventions are crucial to provide comfort and manage challenging behaviors. Distraction techniques involve redirecting the client's attention away from the delusion and onto a different, engaging activity. This can help decrease distress and anxiety related to their delusional thoughts. Therapeutic communication skills, such as validating the client's feelings and emotions, can also be beneficial. Simply telling the client that their mother is deceased may cause distress and confusion. Instead, providing comfort, empathizing with their emotions, and redirecting their focus can be more effective in managing the situation. A) Incorrect- Clarify reality with the client about delusional thoughts: Attempting to correct the client's delusional thoughts might cause frustration and agitation. Clients with Alzheimer's disease may have difficulty comprehending and retaining reality-based information. B) Incorrect- Reduce the client's interaction with others during the day: Social interaction is important for clients with Alzheimer's disease to maintain engagement and prevent feelings of isolation. Reducing interaction could worsen their emotional well-being. D) Incorrect- Awaken the client for reality checks every 4 hours at night: Disrupting the client's sleep schedule could lead to increased confusion and restlessness. It's important to provide a calm and consistent sleep routine for individuals with Alzheimer's disease. The nurse is managing 4 clients in the intensive care unit who are mechanically ventilated.

The nurse is providing teaching to a client newly diagnosed with type 2 diabetes mellitus about disease management. Which response by the client indicates understanding? A Obtain an A1c blood test every year to monitor glucose control. B Restrict alcoholic beverages to no more than 1 to 2 per week. C Wear closed-toe shoes that are comfortable and fit well. D Check blood sugar levels every four to six hours every day.

C Wear closed-toe shoes that are comfortable and fit well. - Proper foot care is crucial for clients with diabetes to prevent complications like foot ulcers, infections, and potential amputations. Wearing well-fitting, closed-toe shoes helps protect the feet from injuries and reduces the risk of complications.

A client with hyperthyroidism is admitted to the postoperative unit after a subdural thyroidectomy. Which of the client's serum laboratory values requires an intervention by the nurse? A T3 uptake at 50% B glucose 150 mg/dL C total calcium 5.0 mg/dL D Thyroxine 12 mcg/dL

C total calcium 5.0 mg/dL Serum lab value requiring intervention post-thyroidectomy: Correct answer: C - Total calcium 5.0 mg/dL Rationale: Correct (C): Low calcium indicates potential hypoparathyroidism, a complication of thyroidectomy. Incorrect: A) T3 uptake is within normal range. B) Glucose is slightly elevated but not critical. D) Thyroxine level is not immediately concerning post-surgery.

The public nurse health receives funding to initiate primary prevention program in the community. Which program the best fits the nurse's proposal? A Case management and screening for clients with HIV. B Regional relocation center for earthquake victims. C Vitamin supplements for high-risk pregnant women. D Lead screening for children in low-income housing.

C. Vitamin supplements for high-risk pregnant women. Rationale Primary prevention activities focus on health promotion and disease prevention, so vitamin supplementation for high-risk pregnant women (C) provides adequate vitamins and minerals for fetal developmental. (A and D) are both secondary prevention activities, such as early detection and treatment. (B) is tertiary prevention, such as recovery efforts.

The nurse observes a client prepare a meal in the kitchen of a rehabilitation facility prior to discharge. Which behaviors) indicate the client understands how to maintain balance safely? Select all that apply. A Widens stance while working near the sink. B Leans forward to pull a pan from a high shelf. C Brings a heavy can close to body before lifting. D Locks knees while preparing food on the counter. E Bends from the waist to pick trash off the floor.

Correct A Widens stance while working near the sink: This is a correct behavior. Widening the stance can help maintain balance, especially when performing tasks that require stability. C Brings a heavy can close to body before lifting: This is a correct behavior. Bringing a heavy object close to the body before lifting it reduces the risk of losing balance and falling. Incorrect: B Leans forward to pull a pan from a high shelf: This is not a correct behavior. Leaning forward can cause the body to lose balance and fall. D Locks knees while preparing food on the counter: This is not a correct behavior. Locking the knees while standing can lead to loss of balance. E Bends from the waist to pick trash off the floor: This is not a correct behavior. Bending from the waist can strain the back and lead to loss of balance.

An older adult client asks the nurse about the best foods to help prevent osteoporosis. Which type of foods should the nurse recommend to the client? A Low fat dairy products. B Fresh fruits and vegetables. C Iron-rich meats. D Water and herbal teas.

Correct (A): Dairy products are high in calcium, crucial for bone health. Incorrect: B, C, D) While healthy, not as directly beneficial for bone health as dairy.

The nurse implements a secondary prevention program for sexually transmitted infections in a local health center. Which outcome indicates that the program was effective? A Average client scores improved on specific risk factor knowledge tests. B More than 50% of at-risk clients were diagnosed early in their disease process. C Condoms were provided in all health clinics in the community colleges. D Healthcare providers prescribed 40% more human papilloma virus (HPV) vaccines.

Correct (B): Early diagnosis is a key indicator of effective secondary prevention, as it allows for prompt treatment and reduces disease spread. *include explanation of preventions Incorrect: A) Improved knowledge scores: While important, this is more indicative of primary prevention effectiveness. C) Providing condoms: This is a primary prevention strategy, not secondary. D) Increased HPV vaccine prescriptions: This is a primary prevention strategy, not secondary.

The nurse is assigning care of a client with prostatitis to a practical nurse (PN). Which instruction should the nurse provide the PN regarding care of this client? A Restrict oral fluid intake. B Strain all urine. C Maintain contact isolation. D Avoid urinary catheterization.

Correct (D): Catheterization can introduce bacteria, worsening prostatitis. Incorrect: (A) Fluid restriction isn't typically recommended for prostatitis. (B) Straining urine isn't necessary for prostatitis. (C) Contact isolation isn't required for prostatitis.

Following an acute myocardial infarction that occurred two weeks ago, an adult male presents for his follow-up appointment, accompanied by his spouse. He tells the nurse that he has lost his appetite, cannot seem to make decisions, and cannot sleep at night. Which intervention is most important for the nurse to implement? A Encourage the client to further describe his feelings. B Tell the spouse to wait outside so the client can be assessed for depression. C Explain that depression often occurs after a life-threatening experience. D Ask the spouse if the client seems to be depressed.

Correct - A Encourage the client to further describe his feelings. A. This option promotes open communication and allows the nurse to gather more information about the patient's emotional state. It also validates the patient's feelings and shows empathy. Incorrect: B. Tell the spouse to wait outside so the client can be assessed for depression. While it's important to assess the patient for depression, excluding the spouse may not be necessary or beneficial. The spouse could provide valuable insight into the patient's behavior and emotional state. C. Explain to the client that depression often occurs after a life-threatening experience. While this statement is true, it does not address the patient's immediate concerns or feelings. It might also make the patient feel that his feelings are being dismissed or minimized. D. Ask the spouse if the client seems to be depressed. This option involves the spouse in the care process and could provide additional information about the patient's behavior. However, it does not directly address the patient's feelings or concerns.

The nurse is educating parents about behaviors and risks that mostly impact health among adolescents. Which statement made by a parent about parental interaction with the adolescent should the nurse recognize as needing additional discussion? A Identify the dangers of alcohol and drugs. B Emphasize the need to monitor weight. C Discuss sexual and physical abuse. D Give strong advice about seat belt use.

Correct - B) "Emphasize the need to monitor weight." While maintaining a healthy weight is important, emphasizing weight monitoring can potentially lead to body image issues and eating disorders in adolescents. This statement might need additional discussion to ensure that the parent approaches this topic in a healthy and supportive way. Incorrect: A) "Identify the dangers of alcohol and drugs." This is an important topic for parents to discuss with their adolescents. Substance abuse can lead to serious health problems and risky behaviors. C) "Discuss sexual and physical abuse." It's crucial for parents to talk about these topics to protect their children from potential harm and to let them know they have a safe space to talk about any concerns. D) "Give strong advice about seat belt use." Encouraging safety measures like using seat belts is also an important part of parental guidance.

When conducting diet teaching for a client who is on a postoperative full liquid diet, which foods should the nurse encourage the client to eat? Vegetable juice. Creamy peanut butter. Canned fruit cocktail. Vanilla frozen yogurt. Clear beef broth.

Correct - Vegetable juice can be included in a postoperative full liquid diet, as long as it is free of solid particles. Correct - Vanilla frozen yogurt is a suitable option for a postoperative full-liquid diet, as it is in a liquid state when consumed. Correct - Clear beef broth is appropriate for a postoperative full-liquid diet, as it is a clear liquid and meets the dietary restrictions. Incorrect - Canned fruit cocktails may contain solid pieces of fruit, which are not suitable for a full-liquid diet. Incorrect - Creamy peanut butter is not appropriate for a full-liquid diet, as it is a solid food and does not meet the diet's requirements.

A client with schizophrenia reports auditory hallucinations when admitted to the hospital. What question is most important for the nurse to include in the assessment of this client? A "What are the voices saying?" B "Which medication works best?" C "When do you hear voices?" D "How do you cope with the voices?"

Correct answer: A - "What are the voices saying?" Rationale: Correct (A): Understanding the content of auditory hallucinations helps assess the risk and plan care. Incorrect: (B, C, D) These questions are important but secondary to understanding the content of hallucinations.

While making rounds, the charge nurse notices that a young adult client with asthma who was admitted yesterday is sitting on the side of the bed and leaning over the bed-side table. The client is currently receiving oxygen at 2 liters/minute via nasal cannula. The client is wheezing and is using pursed-lip breathing. Which intervention should the nurse implement? A Administer a nebulizer treatment. B Call for an Ambu resuscitation bag. C Increase oxygen to 6 liters/minute. D Assist the client to lie back in bed.

Correct answer: A - Administer a nebulizer treatment. Rationale: Correct (A): A nebulizer treatment can help relieve wheezing and improve breathing in an asthma exacerbation. Incorrect: (B) Ambu bag is for severe respiratory distress or arrest. (C) Increasing oxygen without addressing the underlying issue may not be effective. (D) Lying back may worsen respiratory effort.

The nurse receives a shift report about a male client with obsessive-compulsive disorder. The nurse completes morning rounds and approaches the client while he is repeatedly washing the top of the same table. Which intervention should the nurse implement? A Allow time for the behavior and then redirect the client to other activities. B Teach the client thought stopping techniques and ways to refocus behaviors. C Assist the client to identify stimuli that precipitates the activity. D Encourage the client to be calm and relax for a little while.

Correct answer: A - Allow time for the behavior and then redirect the client to other activities. Rationale: Correct (A): This approach respects the client's compulsion while gently redirecting. Incorrect: (B, C, D) These interventions may be too abrupt or ineffective in the moment.

After receiving report, the nurse can most safely plan to assess which client last? A An adult client with no postoperative drainage in the Jackson-Prat drain with the bulb compressed. B An older client with a distended abdomen and no drainage from the nasogastric tube. C An older client with dark red drainage on a postoperative dressing, but no drainage in the Hemovac D An adult client with a rectal tube draining clear, pale red liquid drainage.

Correct answer: A - An adult client with no postoperative drainage in the Jackson-Prat drain with the bulb compressed. Rationale: Correct (A): This client is stable and can be assessed last. Incorrect: (B, C, D) These clients have more urgent needs.

The nurse is caring for an immobile client after spinal surgery. Which action is most important for the nurse to take to prevent postoperative complications? A Apply intermittent pneumatic compression devices. B Maintain intervascular infusion rate. C Obtain frequent pain level assessments. D Progress diet slowly from ice chips to clear liquids.

Correct answer: A - Apply intermittent pneumatic compression devices. Rationale: Correct (A): These devices prevent deep vein thrombosis (DVT), a common and serious complication in immobile clients. Incorrect: B) Maintaining infusion rate is important but not specific to preventing complications from immobility. C) Pain assessments are important but not directly related to preventing complications from immobility. D) Progressing diet is important but not related to preventing complications from immobility.

A client who is receiving zidovudine reports the appearance of pinpoint, red, red round spots on the skin. Which results should the nurse report to the health care provider? A Complete blood count B Skin biopsy C Electromyography D Allergy test

Correct answer: A - Complete blood count Rationale: Correct (A): Zidovudine can cause bone marrow suppression; CBC monitors this. Incorrect: B, C, D) Less relevant to zidovudine side effects.

Prolonged exposure to high concentrations of supplemental oxygen over several days can cause which pathophysiological effect? A Disrupted surfactant production. B Metabolic acidosis. C Aphasia and memory loss. D Deep sleep or coma.

Correct answer: A - Disrupted surfactant production Rationale: Correct (A): High oxygen can damage alveoli and disrupt surfactant. Incorrect: B, C, D) Not direct effects of oxygen toxicity.

The home health nurse visits a client who has cancer the client reports having a good appetite but experiencing nausea when smelling food cooking which action should the nurse implement? A encourage family member to cook meals outdoors and bring the cooked food inside B assess the client's mucous membranes and report the finding to healthcare provider C advise the client to replace cooked foods with a variety of different nutritional supplement D instruct the client to take and antiemetic before meal to prevent excessive vomiting

Correct answer: A - Encourage family member to cook meals outdoors and bring the cooked food inside. Rationale: Correct (A): This reduces exposure to cooking smells that trigger nausea. Incorrect: B) Assessing mucous membranes doesn't address the smell issue. C) Replacing all cooked foods is unnecessary. D) Antiemetics before meals may help but don't address the smell issue.

An older client admitted for observation following a fall while getting out of the bath tub becomes increasingly confused. The family arrives with the home medication list and the client's healthcare power of attorney. When providing a report to the healthcare provider using SBAR (Situation, Background, Assessment, Recommendation) communication, which information should the nurse provide first? A Increasing confusion of the client. B Client's healthcare power of attorney. C Fall at home as reason for admission. D Currently prescribed medications.

Correct answer: A - Increasing confusion of the client. Rationale: Correct (A): Confusion is the immediate concern and priority. Incorrect: (B, C, D) These are important but secondary to the acute change in mental status.

What action should the school nurse implement to provide secondary prevention for school-aged children? A Initiate a hearing and vision screening program for first graders. B Prepare a presentation on how to prevent the spread of lice. C Observe a person with type 1 diabetes self-administer a dose of insulin. D Collaborate with a science teacher to prepare a health lesson.

Correct answer: A - Initiate a hearing and vision screening program for first graders. Rationale: Correct (A): Screening programs are secondary prevention, identifying issues early. Incorrect: (B, C, D) These are primary or tertiary prevention.

A client who is hypotensive is receiving dopamine, an adrenergic agonist, IV at the rate of 8 mcg/kg/min. Which intervention should the nurse implements while administering this medication? A Measure urinary output every hour. B Initiate seizure precautions. C Monitor serum potassium frequently. D Assess pupillary response to light hourly.

Correct answer: A - Measure urinary output every hour. Rationale: Correct (A): Dopamine affects renal blood flow; monitoring urine output is crucial. Incorrect: (B) Seizures aren't a primary concern with dopamine. (C) While important, potassium monitoring isn't the priority. (D) Pupillary response isn't directly affected by dopamine.

The nurse is caring for a 24-month-old toddler who has sensory sensitivity, difficulty engaging in social interaction, and has not yet spoken two word phrases which assessment should the nurse administer? A Modified checklist for autism in toddlers (M-Chat) B Psychological systems questionnaire (PHQ-2) C Behavioral style questionnaires (BSQ) D The ages and stages questionnaire (ASQ)

Correct answer: A - Modified checklist for autism in toddlers (M-Chat) Rationale: Correct (A): M-Chat is designed to screen for autism in toddlers. Incorrect: B) PHQ-2 is for depression screening. C) BSQ is not specific for autism screening. D) ASQ is general developmental screening.

2. A client with myasthenia gravis (MG) is receiving immunosuppressive therapy. Review of recent laboratory test results show that the client's serum magnesium level has decreased below the normal range. In addition to contacting the healthcare provider, what nursing action is most important? A. Observe rhythm on telemetry monitor. B. Check for visual difficulties. C. Assess for hip and hand joint pain. D. Note most recent hemoglobin level.

Correct answer: A - Observe rhythm on telemetry monitor. Rationale: Low magnesium can cause cardiac arrhythmias. Incorrect: B, C, D) Less directly related to low magnesium levels.

Three hours after birth, a newborn becomes jittery and tachypneic. What should the nurse do first? A Obtain a capillary glucose level. B Feed 30 mL of 10% dextrose in water. C Wrap tightly In a warm blanket. D Encourage the mother to breastfeed.

Correct answer: A - Obtain a capillary glucose level. Rationale: Correct (A): Jitteriness and tachypnea can indicate hypoglycemia, requiring immediate assessment. Incorrect: (B, C, D) These actions should follow glucose assessment.

A client is admitted for medical management of a bowel obstruction. The drainage volume from the nasogastric tube over the last 12 hours is 300 milliliters. Which assessment finding provides the earliest indication that the client is experiencing gastrointestinal motility? A Passing of flatus. B Normalized electrolytes. C Decreased nausea. D Return of appetite.

Correct answer: A - Passing of flatus Rationale: Correct (A): Flatus indicates return of bowel function. Incorrect: B, C, D) These occur later or are less specific indicators.

A male client admitted with chronic pulmonary obstruction disease (COPD) exacerbation is receiving assisted ventilation with continuous positive airway pressure (CPAP). His vital signs are: temperature 98.8 °F (37.1 °C), heart rate 118 beats/minute, respirations 46 breaths/minute, blood pressure 176/92 mmHg. While completing the pulmonary assessment, his oxygen saturation reading is 78% and he is difficult to arouse. Which action should the nurse implement? A Prepare for rapid sequence intubation. B Increase the oxygen delivery by 10%. C Administer PRN nebulizer treatment. D Complete neurological assessment.

Correct answer: A - Prepare for rapid sequence intubation. Rationale: Correct (A): Low oxygen saturation and decreased responsiveness indicate respiratory failure, requiring immediate intubation. Incorrect: (B) Increasing oxygen alone is insufficient. (C) Nebulizer treatment won't address severe hypoxemia. (D) Neurological assessment delays critical intervention.

A toddler presenting with a history of intermittent skin rashes, hives, abdominal pain, and vomiting that occurs after ingestion of milk products arrives to the clinic accompanied by the parents. Which type of testing should the nurse provide education to the toddler's family about? A Serum-immunoglobulin E (IgE) B intradermal tests C atopy patch test D placebo-controlled food challenge

Correct answer: A - Serum-immunoglobulin E (IgE) Rationale: Correct (A): Serum IgE testing can identify specific allergies, including milk. Incorrect: B) Intradermal tests: Less commonly used for food allergies. C) Atopy patch test: Typically used for contact dermatitis. D) Placebo-controlled food challenge: More invasive and usually a follow-up test. 10)

While caring for a toddler receiving oxygen via face mask, the nurse observes that the child's lips and nares are dry and cracked. Which intervention should the nurse implement? A Use a water soluble lubricant on affected oral and nasal mucosa. B Use a topical lidocaine analgesic for cracked lips. C Ask the mother what she usually uses on the child's lips and nose. D Apply a petroleum jelly to the child's nose and lips.

Correct answer: A - Use a water soluble lubricant on affected oral and nasal mucosa. Rationale: Water-soluble lubricant is safe with oxygen therapy. Incorrect: (B) Lidocaine isn't appropriate for this situation. (C) Mother's usual product may not be safe with oxygen. (D) Petroleum jelly is flammable and unsafe with oxygen.

In caring for a client who is receiving linezolid IV for nosocomial pneumonia, which assessment finding is most important for the nurse to report to the healthcare provider? A Watery diarrhea. B Increased fatigue. C Yellow-tinged sputum. D Nausea and headache.

Correct answer: A - Watery diarrhea. Rationale: Watery diarrhea can indicate C. difficile infection, a serious side effect of linezolid. Incorrect: (B, C, D) These are less urgent compared to potential C. difficile infection.

A mother calls the nurse to report that at 0900 she administered an oral dose of digoxin to her 4-month-old infant, but at 0920 the baby vomited the medicine. Which instruction should the nurse provide to this mother? A Withhold this dose. B Mix the next dose with food. C Give another dose. D Administer a half dose now.

Correct answer: A - Withhold this dose. Rationale: Correct (A): Withholding prevents potential overdose if some medication was absorbed. Incorrect: (B, C, D) These actions could lead to incorrect dosing.

An adult client experiences a gasoline tank fire when riding a motorcycle and is admitted to the emergency department (ED) with full thickness burns to all surfaces of both lower extremities. Which percentage of body surface area should the nurse document in the electronic medical record (EMR)? A 9%. B 36%. C 18%. D 45%.

Correct answer: B - 36%. Rationale: Correct (B): Each leg represents 18% of body surface area, so both legs equal 36%.

The nurse is planning care for a client who admits having suicidal thoughts. Which client behavior indicates the highest risk for client acting on suicidal thoughts? A Lacks interest in the activities of the family and friends B Begin to show signs of improvement in affect C Express feelings of sadness and loneliness D Neglects personal hygiene and has no appetite

Correct answer: B - Begin to show signs of improvement in affect Rationale: Correct (B): Sudden improvement can indicate a decision to act on suicidal thoughts. Incorrect: A, C, D) While concerning, these don't indicate imminent risk like B.

Which self-care measure is most important for the nurse to include in the plan of care of a client recently diagnosed with type 2 diabetes mellitus? A Self injection techniques B blood glucose monitoring C diabetic diet meal planning D a realistic exercise plan

Correct answer: B - Blood glucose monitoring Rationale: Correct (B): Essential for managing diabetes and adjusting treatment. Incorrect: A) Self-injection: Not all type 2 diabetics require insulin injections. C) Meal planning: Important but not as crucial as glucose monitoring. D) Exercise plan: Important but not as crucial as glucose monitoring.

An adult client is admitted to the critical care unit with systemic inflammatory response syndrome (SIRS) as a result of a postbur infection. The client has a long line peripherally inserted IV catheter for fluid and medication administration and current vital signs include temperature 102.8° F (39.3° C), heart rate 108 beats/minute, respirations 32 breaths/minute. Which action should the nurse implement first? A Provide bedside equipment for transmission and protective precautions. B Culture sputum, urine, burn wound, and all intravenous access sites. C Implement central line-associated bloodstream infection (CLABSI) protocols. D Evaluate daily serum electrolytes and hydration status.

Correct answer: B - Culture sputum, urine, burn wound, and all intravenous access sites. Rationale: Correct (B): Culturing identifies the infection source, crucial in SIRS. Incorrect: (A, C, D) These are important but secondary to identifying the infection source.

The charge nurse observes a new nurse preparing to irrigate an intravenous catheter. The new nurse is attaching an 18-gauge needle. Which action should the charge nurse take? A Suggest starting a secondary infusion at the IV tubing port. B Direct the nurse to remove the needle before the procedure. C Send an unlicensed assistive personnel to gather equipment. D Propose that the nurse use the antecubital site for IV access.

Correct answer: B - Direct the nurse to remove the needle before the procedure. Rationale: Correct (B): Needles should not be used to irrigate IV catheters due to risk of damage. Incorrect: A, C, D) Don't address the immediate safety concern.

The nurse is caring for a client on the first day postoperative for a descending aortic aneurysm repair. Which assessment finding should the nurse prioritize reporting to the healthcare provider? (Reference Range: 3.5 to 5 mEq/L (3.5 to 5 mmol/L)] A Serum potassium 4.8 mEg/L (4.8 mmol/L). B Electrocardiogram ST segment elevation. C Urine output 30 ml/ hour. D Blood pressure 130/80.

Correct answer: B - Electrocardiogram ST segment elevation. Rationale: ST elevation may indicate myocardial ischemia, a serious complication. Incorrect: (A, C, D): These are within normal limits or not critically abnormal.

The nurse is planning to teach infant care and preventive measures for sudden infant death syndrome (SIDS) to a group of new parents. Which information is most important for the nurse to include? A Prop the infant with a pillow when in a side-lying position. B Ensure that the infant's crib mattress is firm. C Place the infant in a prone position whenever possible. D Swaddle the infant in a blanket for sleeping.

Correct answer: B - Ensure that the infant's crib mattress is firm. Rationale: Correct (B): A firm mattress reduces SIDS risk. Incorrect: (A, C) Side-lying and prone positions increase SIDS risk. (D) Swaddling for sleep isn't recommended for SIDS prevention.

Before leaving the room of a client who is confused, the nurse observes that a half bow knot was used to attach the client's wrist restraints to the movable portion of the client's bed frame. Which action should the nurse take before leaving the room? A Move the ties so the restraints are secured to the side rails. B Ensure that the knot can be quickly released. C Ensure that the restraints are snug against the client's wrists. D Tie the knot with a double turn or square knot.

Correct answer: B - Ensure that the knot can be quickly released Rationale: Correct (B): Quick release is crucial for safety in restraints. Incorrect: A) Securing to side rails may not be appropriate. C) Snugness isn't the primary concern. D) Double turn or square knot may be too difficult to release quickly.

An adult female client tells the nurse that though she is afraid her abusive boyfriend might one day kill her, she keeps hoping that he will change. Which action should the nurse take first? A Report the finding to the police department. B Explore client's readiness to discuss the situation. C Determine the frequency and type of client's abuse. D Discuss treatment options for abusive partners.

Correct answer: B - Explore client's readiness to discuss the situation. Rationale: Correct (B): Assessing readiness to discuss abuse is crucial for effective intervention. Incorrect: (A) Reporting without consent may not be appropriate. (C) Frequency/type of abuse is secondary to readiness. (D) Treatment options are secondary to readiness.

A client with type 2 diabetes mellitus arrives to the clinic reporting episodes of weakness and palpitations. Which finding should the nurse identify may indicate an emerging situation? A potassium 3.5 mEq/L. B fingertips feel numb C sodium 135 mEq/L. D cervical spine stiffness.

Correct answer: B - Fingertips feel numb Rationale: Numbness can indicate neuropathy or hypoglycemia, both urgent in diabetes. Incorrect: A) Potassium 3.5 mEq/L: Normal range. C) Sodium 135 mEq/L: Normal range. D) Cervical spine stiffness: Not directly related to diabetes.

The nurse initiates the procedure to remove a client's peripherally inserted central catheter (PICC) when a code blue is called tor another client in the unit who collapsed in the hallway while ambulating with the unlicensed assistive personnel (UAP). Which action should the nurse take? A Call for an assistant. B Finish the procedure C Respond to the code. D Close the room door.

Correct answer: B - Finish the procedure. Rationale: Correct (B): It is crucial to complete the removal of the PICC line to prevent complications such as bleeding or infection. Incorrect: A) Calling for an assistant may delay the completion of the procedure. C) Responding to the code without finishing the procedure may leave the client at risk. D) Closing the room door doesn't address the immediate need to complete the procedure safely.

Which nursing intervention is most important for the nurse to include in the plan of care for a client with alcohol withdrawal delirium? A Confront the client's denial of substance abuse. B Maintain a quiet, non-stimulating environment. C Force oral fluids and provide frequent small meals. D Encourage attendance and group participation.

Correct answer: B - Maintain a quiet, non-stimulating environment. Rationale: Correct (B): A calm environment helps manage symptoms of alcohol withdrawal delirium. Incorrect: (A) Confrontation isn't appropriate during acute withdrawal. (C) Forcing fluids can be dangerous. (D) Group participation isn't appropriate during acute withdrawal.

Which intervention should the nurse include in the plan of care for the child with tetanus? A Encourage coughing and deep breathing. B Minimize the amount of stimuli in the room. C Reposition form side to side every hour. D Open window shades to provide natural light.

Correct answer: B - Minimize the amount of stimuli in the room. Rationale: Correct (B): Reducing stimuli helps prevent muscle spasms in tetanus. Incorrect: A) Encourage coughing: May trigger spasms. C) Reposition every hour: Frequent movement may trigger spasms. D) Open window shades: Increased light may trigger spasms.

The nurse is reviewing the diagnostic test prescribed for a client with a positive skin test. Which subjective findings reported by the client supports the diagnosis of tuberculosis? A barking cough and vomiting. B Mucopurulent cough and night sweats. C Dry cough and chest tightness. D Chronic cough and fatty stools.

Correct answer: B - Mucopurulent cough and night sweats. Rationale: Classic symptoms of TB. Incorrect: A) More indicative of croup. C) More indicative of asthma. D) Fatty stools not typical of TB.

Which assessment should the home health nurse include during a routine home visit for a client who was discharged home with a suprapubic catheter? A Assess perinea! area. B Observe insertion site. C Palpate flank area. D Measure abdominal girth

Correct answer: B - Observe insertion site. Rationale: Observing the insertion site helps detect infection or complications. Incorrect: (A) Perineal area isn't directly related to the catheter. (C) Flank area assessment isn't specific to catheter care. (D) Abdominal girth isn't relevant to suprapubic catheter.

A client is admitted to the hospital after experiencing a stroke or cerebrovascular accident (CVA). The nurse should request a referral for speech therapy if the client exhibits which finding? A Inappropriate or exaggerated mood swings. B Persistent coughing while drinking. C Abnormal responses for cranial nerves I and II. D Unilateral facial drooping.

Correct answer: B - Persistent coughing while drinking. Rationale: Correct (B): This indicates dysphagia, a common post-stroke complication requiring speech therapy. Incorrect: (A) Mood swings are more related to psychological support. (C) Abnormal cranial nerve responses I and II don't typically require speech therapy. (D) Facial drooping alone doesn't necessitate speech therapy.

A client with pancreatitis complains of severe epigastric pain, so the nurse administers a prescribed narcotic analgesic. Ten minutes later, the client insists on sitting up and leaning forward. Which intervention should the nurse implement? A Raise head of bed until to a 90 degree angle. B Position bedside table so the client can lean across it. C Place bed in a reverse trendelenburg position. D Encourage rest until the analgesic becomes effective.

Correct answer: B - Position bedside table so the client can lean across it. Rationale: Correct (B): Leaning forward often relieves pancreatitis pain. Incorrect: (A) 90-degree angle may increase pain. (C) Reverse Trendelenburg doesn't allow forward leaning. (D) Encouraging rest ignores the client's preferred position.

The nurse is performing a routine assessment of an IV site for a client receiving both IV fluids and medications through the line. The client reports tenderness when the nurse touches the arm above the site. Which finding should the nurse expect which will require immediate intervention? A Circumferential skin irritation. B Red streak tracking the vein. C Cool sensation above the site. D A sluggish blood return.

Correct answer: B - Red streak tracking the vein. Rationale: Correct (B): Red streaking indicates phlebitis, requiring immediate intervention. Incorrect: (A, C, D) These are less urgent compared to phlebitis. (C) Respiratory status monitoring is important but secondary.

A client with a history of dementia has become increasingly confused at night and is picking at an abdominal surgical dressing and the tape securing the intravenous (IV) line. The abdominal dressing is no longer occlusive, and the IV insertion site is pink. Which intervention should the nurse implement? A Leave the lights on in the room at night. B Redress the abdominal incision C Apply soft bilateral wrist restraints. D Replace the IV site with a smaller gauge.

Correct answer: B - Redress the abdominal incision. Rationale: Ensuring the dressing is occlusive prevents infection. Incorrect: (A, C, D) These don't address the immediate issue of the dressing.

An older client with a long history of coronary artery disease (CAD), hypertension (HTN), and heart failure (HF) arrives are the Emergency Department (ED) in respiratory distress. The healthcare provider prescribes furosemide IV. Which therapeutic responses to furosemide should the nurse expected in the client with acute HF? A Increased cardiac contractility B Reduced preload C Relaxed vascular tone D Decreased afterload

Correct answer: B - Reduced preload Rationale: Correct (B): Furosemide reduces preload by increasing diuresis. Incorrect: A) Increased cardiac contractility: Not a direct effect of furosemide. C) Relaxed vascular tone: Not a primary effect of furosemide. D) Decreased afterload: While it may occur, it's not the primary effect.

When providing client care the nurse identifies a problem and develops a related clinical question. Next, the nurse intends to gather evidence so that the decision-making process in response to the problem and clinical question is evidence-based. When gathering evidence, which consideration is most important? A Past experience with similar problems B Relevance to the situation C Related personal issues D Frequency that the problem occurs

Correct answer: B - Relevance to the situation Rationale: Correct (B): Evidence must be relevant to be applicable to the specific clinical situation. Incorrect: A, C, D) Less important than relevance in evidence-based practice.

Assessment findings for a client following a colectomy for familial polyposis include an ileostomy bag that contains a large amount of fecal liquid and an IV infusion of dextrose 5% in lactated Ringer's infusing at a rate of 100 mL/hour. Which assessment is most important for the nurse to monitor? A Peristomal skin integrity. B Serum electrolytes. C Urinary output. D Skin turgor.

Correct answer: B - Serum electrolytes Rationale: Correct (B): Large fluid losses from an ileostomy can cause significant electrolyte imbalances, which can be life-threatening if not monitored and managed promptly. Incorrect: A) Peristomal skin integrity: Important but less urgent than electrolyte balance. C) Urinary output: Important but secondary to electrolyte monitoring. D) Skin turgor: Important but less specific than serum electrolytes for assessing fluid balance.

Assessment findings for a client following a colectomy for a familiar polyposis includes an ileostomy bag that contains a large amount of fecal liquid and an IV infusion of dextrose 5 percent in lactated ringers infusing at their rate of 100 mL/hour. Which assessment is most important for the nurse to monitor? A Peristomal skin integrity B serum electrolytes C Urinary output D Skin turgor

Correct answer: B - Serum electrolytes Rationale: Correct (B): Large fluid losses from ileostomy can cause electrolyte imbalances. Incorrect: A, C, D) Important but less critical than electrolyte balance

Which laboratory results should the nurse closely monitor in a client who has end-stage renal disease (ESRD)? A Erythrocytes, hemoglobin, and hematocrit. B Serum potassium, calcium, and phosphorus. C Blood pressure, heart rate, and temperature. D Leukocytes, neutrophils, and thyroxine.

Correct answer: B - Serum potassium, calcium, and phosphorus. Rationale: ): These electrolytes are crucial to monitor in ESRD. Incorrect: (A, C, D) These aren't as directly impacted by ESRD.

The nurse is completing the admission assessment of a three-year old who is admitted with bacterial meningitis and hydrocephalus. Which assessment findings evident that the child is experiencing increase intercranial pressure (ICP)? A Tachycardia and tachypnea B sluggish and unequal pupillary responses C increase head circumference and bulging fontanels D blood pressure fluctuation and syncope

Correct answer: B - Sluggish and unequal pupillary responses Rationale: Correct (B): Indicates increased ICP. Incorrect: A) Tachycardia and tachypnea: Not specific to ICP. C) Increased head circumference and bulging fontanels: More relevant to infants. D) BP fluctuation and syncope: Less specific to ICP.

A mother brings her 4-month-old son to the clinic with a quarter taped over his umbilicus, and tells the nurse the quarter is supposed to fix her child's hernia. Which explanation should the nurse provide? A Restrictive clothing will be adequate to help the hernia go away. B This hernia is a normal variation that resolves without treatment. C The quarter should be secured with an elastic bandage wrap. D An abdominal binder can be worn daily to reduce the protrusion.

Correct answer: B - This hernia is a normal variation that resolves without treatment. Rationale: Correct (B): Umbilical hernias in infants often resolve naturally. Incorrect: (A, C, D) These interventions are unnecessary and potentially harmful.

A client with an acute myocardial infarction (MI) is given a thrombolytic medication, aspirin, and IV heparin in the emergency department. Which finding indicates the client is having a satisfactory response? A Guaiac test of the stools is positive. B S3 heart sounds are present with auscultation. C Activated partial thromboplastin time (aPTT) is 2 times the control value. D Cardiac tracing shows 1.2 mm wide Q waves half the height of the complex.

Correct answer: C - Activated partial thromboplastin time (aPTT) is 2 times the control value Rationale: Correct (C): This indicates therapeutic anticoagulation with heparin. Incorrect: A) Positive guaiac test suggests bleeding, a complication. B) S3 heart sounds indicate heart failure, not improvement. D) Wide Q waves suggest myocardial damage, not improvement.

A client tells the nurse about working out with a personal trainer and swimming three times a week in effort to lose weight and sleep better period the client states that it is still taking hours to fall asleep at night. Which action should the nurse implement? A Advise the client that lifestyle changes often takes several weeks to be effective. B Encourage the client to exercise every day to eliminate bedtime wakefulness. C Ask the client for a description of the exercise schedule that is being followed. D Determine the amount of weight that client has lost since increasing activity.

Correct answer: C - Ask the client for a description of the exercise schedule that is being followed Rationale: Correct (C): Understanding the exercise schedule can help identify potential issues. Incorrect: A, B, D) Don't address the specific concern or gather necessary information.

A client with leukemia who is receiving a myelosuppressive chemotherapy has a platelet count of 25,000/mm^3 (25×10^9/L). Which intervention is most important for the nurse to include in this client's plan of care? Reference Range: Platelet Count [150,000 to 400,000/mm^3 (150 to 400 × 10^9/L)] A Obtain client's temperature every 4 hours. B Require visitors to wear respiratory masks. C Assess urine and stool for occult blood. D Monitor for signs of activity intolerance.

Correct answer: C - Assess urine and stool for occult blood. Rationale: Low platelets increase bleeding risk; occult bleeding is a concern. Incorrect: A) While important, not the most critical for low platelets. B) Not directly related to low platelets. D) Less critical than bleeding risk.

In assessing a client with type 1 diabetes mellitus, the nurse notes that the client's respirations have changed from 16 breath/minute with a normal depth to 32 breath/minute and deep and the client has become lethargic. Which assessment data should the nurse obtain next? A temperature B breath sounds C blood glucose D white blood cell count

Correct answer: C - Blood glucose Rationale: Respiratory changes may indicate diabetic ketoacidosis; glucose level is crucial. Incorrect: A, B, D) Less immediately relevant to the respiratory changes in a diabetic patient. The father of a four-year-old has been battling metastatic lung cancer for the past two years period after discussing the remaining options with his healthcare provider the client requests that all treatments stop and that no heroic measures can be taken to save his life.

The nurse is providing care for a client with schizophrenia who receives haloperidol decanoate 75 mg intramuscularly every 4 weeks. The client begins developing puckering and smacking of the lips and facial grimacing. Which intervention should the nurse implement? A Monitor lying, sitting, and standing blood pressures. B Provide coaching in relaxation technique C Complete Abnormal Involuntary Movement Scale (AIMS) D Discontinue all medications immediately.

Correct answer: C - Complete Abnormal Involuntary Movement Scale (AIMS) Rationale: Correct (C): AIMS assesses for tardive dyskinesia, a side effect of antipsychotics. Incorrect: A) Not directly related to the symptoms. B) Won't address medication side effects. D) Abrupt discontinuation can be dangerous.

A client is being discharged with a prescription for warfarin. Which instruction should the nurse provide this client regarding diet? A Avoid eating all foods that contain any vitamin K because it is an antagonist of warfarin. B Increase the intake of dark green leafy vegetables while taking warfarin. C Eat approximately the same amount of leafy green vegetables daily so the amount of vitamin K consumed is consistent. D Eat two servings of raw dark green leafy vegetables daily and continue for 30 days after warfarin therapy is completed.

Correct answer: C - Eat approximately the same amount of leafy green vegetables daily so the amount of vitamin K consumed is consistent. Rationale: Consistent vitamin K intake helps maintain stable warfarin levels. Incorrect: (A) Avoiding all vitamin K is unnecessary and impractical. (B) Increasing vitamin K can counteract warfarin. (D) Continuing vitamin K after therapy isn't necessary.

The nurse is providing teaching to a client admitted with a blood glucose level of 580 mg/dL about preventing complications related to diabetes mellitus. Which statement by the client indicates understanding? (Reference range: glucose 74 to 106 mg/dL) A Do not take diabetes medication when feeling sick B Obtain an A1C blood test every year to monitor glucose control C Have some form of rapid acting glucose easily available D Using salt, herbs, and spices will improve the flavor of foods

Correct answer: C - Have some form of rapid acting glucose easily available Rationale: Correct (C): This shows understanding of hypoglycemia management. Incorrect: A) Medications should typically be continued when sick. B) A1C is typically done more frequently. D) Not directly related to glucose management.

A 6-week-old infant with pyloric stenosis is scheduled for a pyloromyotomy. Which pre-operative nursing action has the highest priority? A Instruct parents regarding care of the incisional area. B Mark an outline of the "olive-Shaped" mass in the right epigastric area. C Initiate a continuous infusion of IV fluids per prescription. D Monitor amount of intake and infant's response to feedings.

Correct answer: C - Initiate a continuous infusion of IV fluids per prescription. Rationale: Correct (C): Fluid balance is crucial pre-operatively for pyloric stenosis. Incorrect: (A, B, D): These are important but less urgent than fluid management.

A client is being urgently transported to radiology for a Computerized Tomography (CT scan) after a sudden decrease in level of consciousness. The client is orally intubated and has a left lateral chest tube to 20 cm suction. Which action is most important for the nurse to take? A Secure chest tube to the stretcher for transport. B Administer PRN pain medication prior to transport. C Keep chest tube container below the site of insertion. D Mark the amount of chest drainage on the container.

Correct answer: C - Keep chest tube container below the site of insertion. Rationale: Correct (C): This prevents backflow of drainage into the chest. Incorrect: (A, B, D) While important, these are less critical than maintaining proper drainage.

A client with cancer develops tumor lysis syndrome (TLS) following chemotherapy. Which nursing action has the highest priority in responding to the symptoms of this syndrome? A Instruct the client to take analgesics on a regular schedule. B Encourage the client to verbalize anxiety and grief. C Maintain intravenous therapy. D Identify potential sources of infection.

Correct answer: C - Maintain intravenous therapy. Rationale: IV therapy is crucial to manage electrolyte imbalances in TLS. Incorrect: (A, B, D) These are important but secondary to maintaining IV therapy.

An older client recently transferred to a rehabilitation facility after aortic valve replacement surgery is experiencing anxiety and difficulty adjusting to the transition. The healthcare provider prescribes an antidepressant and a mild sedative for sleep. Which intervention is most important for the nurse to include in client's plan of care? A Measure and record the client's urinary output every day. B Provide the client with teaching regarding a cardiac diet. C Obtain a blood pressure reading before client gets out of bed. D Obtain client's vital signs every 4 hours when awake.

Correct answer: C - Obtain a blood pressure reading before client gets out of bed. Rationale: Correct (C): Preventing falls and ensuring safety is crucial with new medications. Incorrect: (A, B, D) These are important but secondary to fall prevention.

When the client is transferred to a palliative care unit which action is most important for the nurse working in the palliative care unit to take and facilitating continuity of care? A Reassure the client that his child will be allowed to visit. B provide the client written information about end-of-life care. C obtain a detailed report from the nurse transferring the client. D mark the chart with a client request for no heroic measures.

Correct answer: C - Obtain a detailed report from the nurse transferring the client. Rationale: Ensures continuity of care and understanding of the client's wishes. Incorrect: A, B, D) Important but less crucial for immediate continuity of care.

A client is receiving enoxaparin 30mg subcutaneously twice a day. In assessing for adverse effects of this medication, which serum laboratory value is the most important for the nurse to monitor? A glucose B calcium C platelet count D white blood cell count

Correct answer: C - Platelet count Rationale: Correct (C): Enoxaparin can cause heparin-induced thrombocytopenia. Incorrect: A, B, D) Not directly affected by enoxaparin.

An older client with a history of cataracts is recovering from intraocular lens implant (OL) surgery to the left eye. During the post-procedure period, which intervention should the nurse implement? A Encourage deep breathing and coughing exercises. B Obtain vital signs every 2 hours during hospitalization. C Provide an eye shield to be worn while sleeping. D Teach a family member to administer eye drops.

Correct answer: C - Provide an eye shield to be worn while sleeping. Rationale: Correct (C): An eye shield protects the eye post-surgery. Incorrect: (A, B, D) These are important but secondary to eye protection.

A male client reports to the on-call clinic nurse that he took tadalafil 10 mg by mouth two hours ago and his skin now feels flushed. He reports a history of stable angina, but denies experiencing any current or recent chest pain. Which action should the nurse take? A Tell the client to have someone bring him to an emergency department immediately. B Instruct the client to increase his intake of oral fluids until the skin flushing is relieved. C Reassure the client that skin flushing is a common side effect of the medication. D Advise the client to place one nitroglycerin tablet under his tongue as a precaution.

Correct answer: C - Reassure the client that skin flushing is a common side effect of the medication. Rationale: Correct (C): Flushing is a common, benign side effect of tadalafil. Incorrect: (A) Emergency department visit isn't necessary for this side effect. (B) Increasing fluids won't significantly affect flushing. (D) Nitroglycerin is contraindicated with tadalafil.

After receiving a change of shift report for clients on a medical surgical unit, which activity should the nurse delegate to the practical nurse (NP)? A Complete comprehensive assessments. B Evaluate and update plans of care for clients. C Remove discontinued peripheral intravenous catheters. D Begin initial sterile wound care for surgical clients.

Correct answer: C - Remove discontinued peripheral intravenous catheters. Rationale: Within the scope of practice for a practical nurse. Incorrect: A, B) Require RN level assessment and decision-making. D) Initial sterile wound care typically requires RN level skills.

The healthcare provider prescribes a low-fiber diet for a client with ulcerative colitis. Which food selection indicate to the nurse that the client understand the prescribed diet? A Roast pork, fresh strawberries. B Baked potato with skin, raw carrots. C Roasted turkey, canned vegetables. D Pancakes, whole-grain cereals.

Correct answer: C - Roasted turkey, canned vegetables. Rationale: Correct (C): These are low-fiber options suitable for ulcerative colitis. Incorrect: (A, B, D): These contain high-fiber foods.

A client with prescription for do not resuscitate (DNR) begins to manifest signs of impending death. Not notifying the family of the client's status what priority actions should the nurse implement? A The impending signs of death should be documented. B The client's status should be conveyed to the chaplain. C The client's need for pain medication should be determined. D The nurse manager should be updated on the client's status.

Correct answer: C - The client's need for pain medication should be determined. Rationale: Correct (C): Ensuring comfort is a priority in end-of-life care. Incorrect: A) Documenting signs: Important but not the highest priority. B) Notifying chaplain: Important but not the highest priority. D) Updating nurse manager: Important but not the highest priority.

A client is admitted to a medical unit and diagnosed with gastritis and chronic heavy alcohol abuse. What should the nurse administer to prevent the development of Wernicke's syndrome? A Lorazepam (Ativan) B Famotidine (Pepcid) C Thiamine (Vitamin B1) D Atenolol (Tenormin)

Correct answer: C - Thiamine (Vitamin B1) Rationale: Correct (C): Thiamine deficiency is the primary cause of Wernicke's syndrome, and supplementation can prevent its development. Incorrect: A) Lorazepam is used for alcohol withdrawal symptoms, not for preventing Wernicke's syndrome. B) Famotidine is used for gastritis, not for preventing Wernicke's syndrome. D) Atenolol is a beta-blocker and not relevant to Wernicke's syndrome prevention.

The nurses teaching a group of women about osteoporosis and exercise. The nurse should emphasize the need for which type of regular activity? A Core strengthening. B Aerobic exercise. C Weight bearing exercise. D Muscle stretching and toning.

Correct answer: C - Weight bearing exercise Rationale: Weight-bearing exercises strengthen bones. Incorrect: A) Core strengthening: Beneficial but not primary. B) Aerobic exercise: Beneficial but not primary. D) Muscle stretching and toning: Beneficial but not primary.

When preparing to administer a prescribed medication to a homeless male at a community psychiatric clinic, the client tells the nurse that he usually takes a different dosage. Which action should the nurse take? A Explain to the client that the dosage has been changed. B Tell him to take the medication then verify the dosage at the next healthcare team meeting. C Withhold the medication until the dosage can be confirmed D Inform him that he may refuse the medication and document whether or not he takes it.

Correct answer: C - Withhold the medication until the dosage can be confirmed. Rationale: Correct (C): Ensuring the correct dosage is crucial for safety. Incorrect: (A, B, D) These actions don't ensure the correct dosage.

The psychiatric nurse is caring for clients in an adolescent unit. Which client requires the nurse's immediate attention? A An 18-year-old client with antisocial behavior who is being yelled at by other clients. B A 17-year-old client diagnosed with bipolar disorder who is pacing around the lobby. C A 16-year-old client diagnosed with major depression who refuses to participate in a group. D A 14-year-old client with anorexia nervosa who is refusing to eat the evening snack.

Correct answer: D - A 14-year-old client with anorexia nervosa who is refusing to eat the evening snack. Rationale: ): Refusal to eat in anorexia nervosa requires immediate attention due to health risks. This is the only patient whose health is actively in danger. Incorrect: (A, B, C): While important, these situations are less urgent.

The nurse is working on an infectious disease unit. Which client should be assigned to a room with negative airflow, while requiring personnel to use a particulate respirator mask, and requiring staff to observe airborne, as well as standard precautions? A Twin siblings admitted with scarlet fever that is complicated with pneumonia. B An older client with scabies who is admitted from an extended care facility. C A female adolescent admitted with multiple genital Herpes simplex I lesions. D A client with a positive Mantoux and sputum cultures results positive for AFB.

Correct answer: D - A client with a positive Mantoux and sputum cultures results positive for AFB. Rationale: Correct (D): This indicates active tuberculosis, requiring airborne precautions. Incorrect: (A, B, C) These conditions don't require airborne precautions.

Which environmental factor is most significant when planning care for a client with osteomalacia? A Cool, moist air. B Stimulating sounds and activity. C Quiet, calm surroundings. D Adequate sunlight.

Correct answer: D - Adequate sunlight. Rationale: Correct (D): Sunlight helps synthesize vitamin D, crucial for bone health. Incorrect: (A, B, C) These don't directly address osteomalacia.

A client is unable to void following a procedure, so the nurse obtains a prescription to perform a straight catheterization. After inserting the catheter, the nurse observes that the client has an immediate output of 500 mL of clear yellow urine. Which action should the nurse implement next? A Remove the catheter and palpate the client's bladder for residual distention. B Clamp the catheter for thirty minutes and then resume draining. C Remove the catheter and replace it with an indwelling catheter. D Allow the bladder to empty completely or up to 1,000 mL of urine.

Correct answer: D - Allow the bladder to empty completely or up to 1,000 mL of urine. Rationale: Correct (D): Gradual bladder emptying prevents complications like hypotension. Incorrect: (A, B, C) These actions could cause discomfort or complications.

At the end of a preoperative teaching session on pain management techniques, a client starts to cry and states, "I just know I can't handle all the pain." Which is the priority nursing problem for this client? A Knowledge deficit. B Pain (acute). C Anticipatory grieving. D Anxiety.

Correct answer: D - Anxiety. Rationale: Correct (D): The client's emotional response indicates anxiety about pain management. Incorrect: (A) Knowledge deficit isn't the primary issue here. (B) Pain isn't currently present. (C) Anticipatory grieving doesn't fit the scenario.

What nursing intervention is particularly indicated for the second stage of labor? A Assessing the fetal heart rate and pattern for signs of fetal distress. B Monitoring effects gf oxytocin administration to help achieve cervical dilation. C Providing pain medication to increase the client's tolerance of labor pains. D Assisting the client to push effectively so that expulsion of the fetus can be achieved.

Correct answer: D - Assisting the client to push effectively so that expulsion of the fetus can be achieved. Rationale: Correct (D): Effective pushing is crucial in the second stage of labor. Incorrect: (A, B, C) These are important but secondary to assisting with pushing.

The nurse assesses a client who had bilateral total knee replacements (TKR) four hours ago. The nurse notes that the dressing on the client's right knee is saturated with serosanguineous drainage. Which action should the nurse implement? A Withhold next scheduled dose of low molecular weight heparin. B Confirm that the continuous passive motion device is intact. C Monitor the client's current white blood cell count (WBC). D Determine if the wound drainage device is functioning correctly.

Correct answer: D - Determine if the wound drainage device is functioning correctly Rationale: Correct (D): Excessive drainage could indicate malfunction of the drainage system. Incorrect: A) Withholding anticoagulation could increase thrombosis risk. B) CPM device isn't directly related to wound drainage. C) WBC count isn't immediately relevant to wound drainage.

The parents of a 6-year-old child recently diagnosed with Duchenne muscular dystrophy (DMD) tell the nurse that their child wants to continue attending swimming classes. How should the nurse respond? A Suggest that the child be encouraged to participate in a team sport to encourage socialization. B Explain that their child is too young to understand the risks associated with swimming. C Provide a list of alternative activities that are less likely to cause the child to experience fatigue. D Encourage the parents to allow the child to continue attending swimming lessons with supervision.

Correct answer: D - Encourage the parents to allow the child to continue attending swimming lessons with supervision. Rationale: Correct (D): Swimming is a low-impact exercise that can be beneficial for children with DMD, promoting muscle strength and cardiovascular health when supervised. Incorrect: (A) Team sports may be too strenuous. (B) The child's wishes should be respected. (C) Swimming is actually a good activity for DMD patients.

The nurse is preparing an adult with Addison's disease for self-management. Which information should the nurse include in the client's instructions? A Adherence to a high fiber, low fat diet. B Need to check temperature daily. C Importance of recording daily weights. D Events requiring steroid dose adjustments.

Correct answer: D - Events requiring steroid dose adjustments Rationale: Correct (D): Knowing when to adjust steroid doses is crucial for Addison's disease management. Incorrect: A) Diet isn't a primary concern in Addison's disease. B) Daily temperature checks aren't typically necessary. C) Daily weights aren't a primary concern in Addison's disease.

A male client with a brain tumor is scheduled for a biopsy in the morning. During the admission procedure, the client has a tonic-clonic seizure that lasts 50 seconds. Following the seizure, the client is lethargic and confused and his wife tells the nurse that her husband has never had a seizure before and has always been alert and communicative. Which action should the nurse take? A Ask the wife to wait outside the room until the nurse can talk with her. B Keep orienting the client to time and space until he is less confused. C Notify the emergency response team of the client's seizure. D Explain the postictal state that usually follows seizures.

Correct answer: D - Explain the postictal state that usually follows seizures. Rationale: Educating about the postictal state helps alleviate concerns. Incorrect: (A) Separating the wife isn't helpful. (B) Constant orientation isn't necessary. (C) Emergency response team isn't needed for a resolved seizure. Correct answers: B, C, F

An older male client, who is a retired chef, is hospitalized with a diabetic ulcer on his foot. His daughter tells the nurse that her father has become increasingly obsessed with the way his food is prepared in the hospital. The nurse's response should be based on what information? A The client probably has an organic brain disease and will likely have Alzheimer's disease within a few years B The family needs a social worker to talk to them about how to handle their father when he becomes annoying C The daughter is under stress and should be encouraged to think about happier times D If the client was compulsive about food when he was younger, the aging process can magnify this

Correct answer: D - If the client was compulsive about food when he was younger, the aging process can magnify this. Rationale: Correct (D): Recognizes that existing personality traits can become more pronounced with age. Incorrect: A) Assumes a diagnosis without evidence. B) Inappropriate to label client as annoying. C) Dismisses the current concern.

A 46-year-old male client who had a myocardial infarction (MI) 24-hours ago comes to the nurse's station fully dressed and wanting to go home. He tells the nurse that he is feeling much better at this time. Based on this behavior, which client problem should the nurse included in the plan of care? A Anxiety related to treatment plan. B Decisional conflict due to stress. C Deficient knowledge of lifestyle changes. D. Ineffective coping related to denial.

Correct answer: D - Ineffective coping related to denial. Rationale: Correct (D): The client's behavior suggests denial, a common coping mechanism post-MI. Incorrect: (A, B, C) These don't address the immediate issue of denial.

A client is receiving lactulose for signs of hepatic encephalopathy. To evaluate the client's therapeutic response to this medication, which assessment should the nurse obtain? A Blood glucose level. B Percussion of abdomen. C Serum electrolytes. D Level of consciousness.

Correct answer: D - Level of consciousness. Rationale: Correct (D): Lactulose reduces ammonia, improving mental status in hepatic encephalopathy. Incorrect: (A, B, C) These aren't primary indicators of lactulose effectiveness.

The nurse is teaching an older client about the prevention of osteoporosis. Which foods should the nurse recommend to the client to increase in the diet? A Fresh fruits and vegetables. B Iron-rich meats. C Water and herbal teas. D Low fat dairy products.

Correct answer: D - Low fat dairy products. Rationale: Correct (D): Dairy products are rich in calcium, essential for bone health. Incorrect: (A, B, C) These don't specifically address calcium needs for osteoporosis prevention.

The nurse is caring for a client with a fractured femur. Following removal of traction and the application of a full-leg cast, which action should the nurse prioritize? A Leg elevation B Pain management. C Ambulation teaching. D Neurovascular checks.

Correct answer: D - Neurovascular checks. Rationale: Correct (D): Ensuring circulation and nerve function is crucial after cast application. Incorrect: (A, B, C) These are important but secondary to neurovascular checks.

The nurse is caring for a client who reports a sudden, severe headache, and facial numbness. The nurse asks the client to smile and observes an uneven smile with facial droop to the right side and a hand grasp strength that is weaker on the right than the left. The client denies a recent history of headaches or trauma. After obtaining vital signs, the nurse should implement which intervention? A Initiate bilateral intermittent sequential pneumatic compression devices. B Administer aspirin to prevent further clot formation and platelet clumping. C Place an indwelling urinary catheter and measure strict intake and output. D Obtain a focused history to determine recent bleeding and use of anticoagulants.

Correct answer: D - Obtain a focused history to determine recent bleeding and use of anticoagulants. Rationale: Correct (D): Determining bleeding history and anticoagulant use is crucial before considering thrombolytic therapy. Incorrect: A) Pneumatic compression devices are not a priority in acute stroke management. B) Aspirin administration is contraindicated until hemorrhagic stroke is ruled out. C) Urinary catheterization is not a priority in the initial management of stroke symptoms.

The nurse is providing education to a client who experiences recurrent levels of moderate anxiety to situations and perceived stress. In addition to information about prescribed medication and administration, which instruction should the nurse include in the teaching? A Find outlets for more social interaction. B Think about reasons the episodes occur. C Center attention on positive upbeat music. D Practice using muscle relaxation techniques.

Correct answer: D - Practice using muscle relaxation techniques. Rationale: Correct (D): Muscle relaxation is an effective non-pharmacological anxiety management technique. Incorrect: A) Social interaction may not always help anxiety. B) Overthinking reasons may increase anxiety. C) While positive, this alone isn't a comprehensive strategy.

The nurse on a pediatric unit observes a distraught mother in the hallway scolding her 3-year-old son for wetting his pants. What initial action should the nurse take? A Inform the mother that toilet training is slower for boys. B Refer the mother to a community parent education program. C Suggest that the mother consult a pediatric nephrologist. D Provide disposable training pants while calming the mother.

Correct answer: D - Provide disposable training pants while calming the mother. Rationale: Correct (D): This addresses the immediate issue and provides emotional support. Incorrect: (A, B, C) These responses don't address the immediate situation.

Five days after surgical fixation of a fractured femur, a client suddenly reports chest pain and difficulty in breathing. The nurse suspects that the client may have had a pulmonary embolus. Which action should the nurse take first? A Bring the emergency crash cart to the bedside. B Prepare a continuous heparin infusion per protocol. C Notify the healthcare provider. D Provide supplemental oxygen.

Correct answer: D - Provide supplemental oxygen. Rationale: Oxygen is the immediate intervention for suspected pulmonary embolism. Incorrect: (A, B, C) These are important but secondary to oxygen administration.

A client who underwent cardiac stent placement four days ago arrives to the emergency department reporting a sudden onset of chest pressure and shortness of breath. Which action should the nurse take next? A Count and record the number of premature ventricular contractions per minute. B Verify troponin level assessments are scheduled every 3 to 6 hours for a series of three. C Place an indwelling urinary catheter and institute strict intake and output measurements. D Record pain score and administer sublingual nitroglycerine every 5 minutes up to 3 doses.

Correct answer: D - Record pain score and administer sublingual nitroglycerine every 5 minutes up to 3 doses Rationale: Correct (D): This is the immediate intervention for suspected angina or MI. Incorrect: A, B, C) These are important but less urgent than treating potential cardiac ischemia.

54) The nurse is caring for a client with the sexually transmitted infection (STI) syphilis. The client reports having sex with someone who had many partners. Which response should the nurse provide? A Inform that follow-up may end after the treatment is finished. B Emphasize that using safe sex practices removes the risk of STls. C Clarity that all STls are transmitted through sexual intercourse. D Remain non-judgmental and assure the client of confidentiality.

Correct answer: D - Remain non-judgmental and assure the client of confidentiality. Rationale: Correct (D): Non-judgmental approach encourages open communication and trust. Incorrect: A) Follow-up may be necessary even after treatment. B) Safe sex practices reduce but don't eliminate risk. C) Not all STIs are transmitted through sexual intercourse.

The nurse observes an unlicensed assistive personnel (UP) applying an alcohol-based hand rub while leaving a client's room after taking vital signs. Which action should the nurse take? A Instruct the UP to return to the client's room to perform handwashing. B Advise the UP to wear gloves when obtaining vital signs for all clients. C Supervise the UP in the next client's room to evaluate hand hygiene. D Remind the UAP to continue rubbing the hands together until they are dry.

Correct answer: D - Remind the UAP to continue rubbing the hands together until they are dry - Alcohol-based hand rubs are effective when used properly. Incorrect: (A) Unnecessary if the alcohol-based hand rub is used correctly. (B) Not practical and does not replace the need for proper hand hygiene. (C) Not immediately necessary if the current issue can be corrected with a reminder.

The nurse is preparing a 4-day-old infant with a serum bilirubin level of 19 mg/d| (325 Mcmol/L) for discharge from the hospital. When teaching the parents about home phototherapy, which instruction should the nurse include in the discharge teaching plan? Reference Range Total Bilirubin [Reference Range: Newborn:0.1 to 10.5 mg/dL (1.7 to 180 Mcmol/L)] A Cover with a receiving blanket. B Perform diaper changes under the light. C Feed the infant every 4 hours. D Reposition the infant every 2 hours.

Correct answer: D - Reposition the infant every 2 hours. Rationale: Correct (D): Repositioning prevents pressure sores and ensures even exposure to phototherapy. Incorrect: (A) Blanket covers light exposure. (B) Diaper changes under light aren't necessary. (C) Feeding every 4 hours isn't specific to phototherapy.

A teenager presents to the emergency department with palpitation after vaping at a party. The client is anxious, fearful, and hyperventilating. The nurse anticipates the client developing which acid base imbalance? A Respiratory acidosis B metabolic alkalosis C metabolic acidosis D respiratory alkalosis

Correct answer: D - Respiratory alkalosis Rationale: Correct (D): Hyperventilation causes excessive CO2 loss, leading to respiratory alkalosis. Incorrect: A) Respiratory acidosis: Caused by CO2 retention. B) Metabolic alkalosis: Caused by loss of acids or gain of bicarbonate. C) Metabolic acidosis: Caused by gain of acids or loss of bicarbonate.

A client with influenza needs help in transferring to the bedside commode. The nurse observes the unlicensed assistive personnel (UAP) donning gloves and a gown to assist the cent. Which action should the nurse take? A Remind the UP to apply a fitted respirator mask before entering the client's room. B Assign the UP to provide care for another client and assume full care of the client. C Instruct the UP to notify the nurse of any changes in the client's respiratory status. D Review the need for the UP to wear a face mask while in close contact with the client.

Correct answer: D - Review the need for the UAP to wear a face mask while in close contact with the client. Rationale: Correct (D): Influenza requires droplet precautions, including a face mask. Incorrect: (A) Respirator mask isn't necessary for influenza. (B) Reassigning the UAP isn't necessary.

A client is scheduled for spinal computed tomography (CT) scan with contrast to evaluate for pulmonary embolism. Which information in the client's history requires follow up by the nurse? A CT scan has performed 6 months earlier. B Metal hip prosthesis was placed twenty years ago. C Report of client sobriety for the last five years. D Takes metformin for type 2 diabetes mellitus.

Correct answer: D - Takes metformin for type 2 diabetes mellitus. Rationale: Metformin and contrast dye can cause lactic acidosis; needs follow-up. Incorrect: A) Previous CT scan: Not a contraindication. B) Metal hip prosthesis: Not a contraindication for CT. C) Sobriety: Not relevant to CT scan.

The charge nurse is making assignments for one practical nurse (P) and three registered nurses (R) who are caring for neurologically compromised clients. Which client with which change in status is best to assign to the PN? A Myxedema coma whose blood pressure changed from 80/50 mm Hg to 70/40 mm Hg. B Diabetic ketoacidosis whose Glasgow Coma Scale score changed from 10 to 7. C Subdural hematoma whose blood pressure changed from 150/80 mm Hg to 170/60 mm Hg. D Viral meningitis whose temperature changed from 101° F (38.3° C) to 102° F (38.9° C).

Correct answer: D - Viral meningitis whose temperature changed from 101° F (38.3° C) to 102° F (38.9° C) Rationale: Correct (D): This change is least critical and within PN scope. Incorrect: A, B, C) These changes require more advanced assessment skills.

An adult male client reports that he recently experienced an episode of chest pressure and breathlessness when he was jogging. The client expresses concern because both of his deceased parents had heart disease and his father had diabetes. He lives with his male partner, is a vegetarian, and takes atenolol which maintains his blood pressure at 130/74 mm hg. Which risk factors should the nurse explore further with the client? SATA A History of hypertension. B Homosexual lifestyle. C Vegetarian diet. D Excessive aerobic exercise. E Family health history.

Correct answers: A - History of hypertension, E - Family health history. Rationale: Correct (A, E): These are established risk factors for heart disease. Incorrect: (B) Sexual orientation isn't a direct risk factor. (C) Vegetarian diet is generally heart-healthy. (D) Moderate exercise is beneficial, not a risk factor.

A client who is newly diagnosed with type 2 diabetes mellitus (DM) receives a prescription for metformin 500 mg PO twice daily. Which information should the nurse include in this client's teaching plan? (Select all that apply.) A Report persistent polyuria to the healthcare provider. B Use sliding scale insulin for fingerstick glucose elevations. C Take metformin with the morning and evening meal. D Recognize signs and symptoms of hypoglycemia. E Take an additional dose for signs of hyperglycemia.

Correct answers: A, C, D Rationale: Correct: (A) Polyuria can indicate poor glucose control. (C) Taking with meals helps reduce GI side effects. (D) Recognizing hypoglycemia signs is crucial. Incorrect: (B) Sliding scale insulin isn't typically used with metformin. (E) Additional doses aren't recommended for hyperglycemia.

A client with cirrhosis of the liver is admitted with complications related to end stage liver disease. Which intervention (s) should the nurse implement? (Select all that apply.) A Report serum albumin and globulin levels. B Provide diet low in phosphorus. C Increase oral fluid intake to 1,500 mL daily. D Note signs of swelling and edema. E Monitor abdominal girth.

Correct answers: A, D, E Rationale: (A) Albumin and globulin levels indicate liver function. (D) Swelling and edema are signs of fluid retention. (E) Abdominal girth monitors ascites. Incorrect: (B) Phosphorus isn't directly related to liver disease. (C) Fluid intake may need restriction.

The nurse is managing the care of a client with Cushing's syndrome. What intervention (s) should the nurse delegate to the unlicensed assistive personnel. Select all that apply. A Assess the client for weakness and fatigue. B Report any client mention of pain or discomfort. C Weigh the client and report any weight gain. D Note and report the client's food and liquid intake during meals and snacks. E Evaluate the client for sleep disturbances.

Correct answers: B, C, D Rationale: These are within UAP scope and don't require nursing judgment. Incorrect: A, E) Require nursing assessment skills.

The nurse is providing lifestyle change education for a client to slow the progression of coronary artery disease. Which statement(s)made by the client should the nurse recognize as needing additional education? (Select all that apply.) A Keep a food diary. B Eat more canned vegetables. C Consume foods with saturated fats. D Walk 30 minutes per day. E Include oatmeal for breakfast. F Use a salt substitute.

Correct answers: B, C, F Rationale: Correct (B, C, *F): These indicate misunderstandings about heart-healthy diet. *Salt substitutes, especially those containing potassium chloride, can be dangerous for some people with heart disease. They can raise potassium levels to dangerous levels in people with heart disease, and others like kidney disease, liver disease, and diabetes. It can also be dangerous for people with diminished kidney function, common in older people, or those on certain hypertension medications, i.e. ACE inhibitors and potassium-sparing diuretics. Incorrect: (A, D, E): These are appropriate lifestyle changes.

A nurse is preparing for a client who had below the knee amputation (BKA) for discharge to home. Which recommendations should the nurse provide to the client? (SATA). A avoid range of motion exercises. B use a residual limb shrinker. C apply alcohol to the stump after bathing. D inspect skin for redness. E washed the stump with soap and water.

Correct answers: B, D, E Rationale: B) Use residual limb shrinker: Helps shape the stump. D) Inspect skin for redness: Important for detecting complications. E) Wash stump with soap and water: Promotes hygiene. Incorrect: A) Avoid range of motion exercises: These are actually beneficial. C) Apply alcohol: Can dry and irritate the skin.

The nurse is stabilizing the client and preparing her for surgery. What goals should the nurse prioritize in the care plan for the client while in the emergency department? Select all that apply. A Infection prevention related to illness B Fluid volume management C Promotion of bowel routine D Client education about diagnosis and plan of care E Effective coping with illness related anxiety F Relief of acute pain G Prevention of deep vein thrombosis (DVT) related to immobility H A review of diet progression postoperatively

Correct answers: B, F, G Rationale: B) Fluid volume management is crucial in emergencies. F) Pain relief is a priority in emergency care. G) DVT prevention is important for immobile patients. Incorrect: A, C, D, E, H) These are important but less urgent in an emergency setting.

During discharge teaching, an overweight client with heart failure (HF) is asked to make a grocery list for the nurse to review. What food choices) included on the client's list should the nurse encourage? Select all that apply. A Canned fruit in heavy syrup. B Cheddar cheese cubes. C Plain, air-popped popcorn. D Natural whole almonds. E Lightly salted potato chips.

Correct answers: C - Plain, air-popped popcorn, D - Natural whole almonds Rationale: C) Low sodium, low fat option. D) Heart-healthy nuts, good source of protein and healthy fats. Incorrect: A) High in sugar, not recommended for HF. B) High in saturated fat and sodium. E) High in sodium, not recommended for HF.

The nurse is providing discharge teaching for an older client who had phacoemulsification of the left eye. Which in should the nurse provide? A Avoid straining at stool, stooping, or lifting heavy objects. B Have someone stay with you at all times for six weeks following surgery. C Keep eye drops close at hand for use when vision is cloudy. D Do not try to read for at least six weeks.

Correct option. A "Avoid straining at stool, stooping, or lifting heavy objects" - After phacoemulsification, it is important to avoid activities that can increase intraocular pressure, such as straining, stooping, or lifting heavy objects. This is to prevent complications and aid in the healing process. B. "Have someone stay with you at all times for six weeks following surgery" - While it's important to have support after surgery, it is not necessary for someone to stay with the patient at all times for six weeks. Incorrect option. C. "Keep eye drops close at hand for use when vision is cloudy" - It is important to use prescribed eye drops after phacoemulsification, but they are typically used for specific purposes such as preventing infection or reducing inflammation, not just when vision is cloudy. Incorrect option. D. "Do not try to read for at least six weeks" - There is no medical reason why a person should not read after having this type of eye surgery. Incorrect option.

An unlicensed assistive personnel (UP) leaves the unit without notifying the staff. In which order should the unit manager implement these interventions to address the UP's behavior? (Place the actions in order from first on top to last on bottom.) Plan for scheduled break times. Discuss the issue privately with the UAP. Note date and time of the behavior. Evaluate the UP for signs of improvement.

Correct order: =Note date and time of the behavior. =Discuss the issue privately with the UAP. =Plan for scheduled break times. =Evaluate the UAP for signs of improvement. Rationale: Correct order ensures documentation, private discussion, planning, and follow-up.

A client who is admitted for primary hypothyroidism is has early signs of myxedema coma. In assessing the client, in which sequence would the nurse complete these actions? Rank the first action at the top and the remainder in descending order. A observe breathing patterns. B assess blood pressure. C measure body temperature. D palpate for pedal edema.

Correct order: C, A, B, D Rationale: C) Measure body temperature: Hypothermia is a key sign of myxedema coma. A) Observe breathing patterns: Respiratory depression is common in myxedema coma. B) Assess blood pressure: Hypotension often occurs in myxedema coma. D) Palpate for pedal edema: Important but less urgent than the above.

A pre-school age child with a congenital heart defect is brought to the clinic by the parent because of a fever and an earache. During the assessment, the parent asks the nurse why the child is at the 5th percentile for weight and height for age. Which response Is best for the nurse to provide? A "You should not worry about the growth tables. They are only averages for children." B "Haven't you been feeding according to recommended daily allowances for children?" C "Does your child seem mentally slower than his peers also?" D "The smaller size is probably due to the heart disease."

D "The smaller size is probably due to the heart disease." - This can be due to several factors related to their heart condition, such as decreased oxygen and nutrient delivery to tissues, increased energy expenditure, and possibly reduced food intake due to increased work of breathing or fatigue. Providing the parent with this information helps to address their concern with a valid medical explanation, reassuring them that the child's smaller size can be a common issue related to their heart condition and not necessarily indicative of inadequate care or other unrelated health issues. This response is informative and compassionate, aiming to alleviate the parent's worries by explaining a possible cause for the child's growth pattern.

In planning care for a client with early stage Alzheimer's disease, the nurse establishes the nursing diagnosis of "Risk for injury related to impaired judgment." Which intervention is most important for the nurse to include in this client's plan of care? A Offer the client frequent reassurance of their safety. B Assign an unlicensed assistive personnel (UAP) to provide the client with total personal care. C Engage the client in regularly scheduled activities during the day. D Arrange the client's environment so the client can move about freely.

D - A patient with Alzheimer's needs to have a good support system for better prognosis of their disease. Part of this is to arrange the patient's environment so the patient can move about freely. This improves the patient's quality of life.

While changing a client's postoperative dressing, the nurse observes a red and swollen wound with a moderate amount of yellow and green drainage and a foul odor. Before reporting this finding to the healthcare provider, the nurse should evaluate which of the client's laboratory values? A Serum albumin. B C-reactive protein level. C Creatinine level. D Neutrophil count

D - Neutrophils are a type of white blood cell that plays a key role in the body's immune response, particularly against bacterial infections. Elevated neutrophil counts can indicate an ongoing infection, so monitoring this value is important when assessing purulent wound drainage.

An older adult client with a history of heart failure is admitted to the medical unit after falling at home and has become increasingly confused. The client's spouse is designated as the client's power of attorney. When reporting to the healthcare provider using SBAR (Situation, Background, Assessment, Recommendation) communication, which information should the nurse provide first? A Client's healthcare power of attorney. B Currently prescribed medications. C Fall at home as a reason for admission. D Increasing confusion of the client.

D - The current situation is that the patient confusion is increasing. This is crucial information because it indicates a change in the clients condition which may require immediate attention.

The nurse is working on an infectious disease unit. Which client should be assigned to a room with negative airflow and requiring staff to observe airborne, as well as standard precautions? A A female adolescent admitted with multiple genital Herpes simplex Il lesions. B An older client with scabies who is admitted from an extended care facility. C Twin siblings admitted with scarlet fever that is complicated with pneumonia. D A client with a positive Mantoux and sputum cultures results positive for AFB.

D A client with a positive Mantoux and sputum cultures results positive for AFB. - Positive Mantoux (TB skin test) and positive AFB (acid-fast bacilli) indicate the client has TB. Negative airflow rooms (AIIRs)are designed to prevent the spread of airborne infectious diseases by maintaining negative pressure relative to surrounding areas. This ensures that air flows from clean areas into the isolation room, preventing contaminated air from escaping. Patients with active pulmonary or laryngeal TB require airborne precautions, including placement in an AIIR with negative pressure ventilation.

Which situation indicates a need for the nurse to discuss the use of mitten restraints with the healthcare provider? A A client is walking the halls at night rubbing his hands together. B A family member expresses concern about their relative "picking" at the NG tube. C A16-year-old boy swung his fist at the nurse. D A disoriented client removed the mesh wrapped IV line for the second time.

D A disoriented client removed the mesh wrapped IV line for the second time Rationale: Correct (D): Repeated removal of essential medical devices may require restraints for safety. Incorrect: (A, B, C) These situations don't necessarily warrant restraints as a first response.

The nurse is providing education about disease transmission to a client with HIV who is pregnant. Which action should the nurse recognize as the client demonstrating an understanding of the disease transmission? A Sanitizes the bathroom between each use. B Avoids sharing food, dishes, and utensils with other people. C Understands that the child will be born with HIV. D Acknowledges the risk of HIV transmission through breast milk.

D Acknowledges the risk of HIV transmission through breast milk. - HIV can be transmitted from an HIV-positive mother to her child during pregnancy, childbirth, or breastfeeding. This is known as mother-to-child transmission (MTCT) or vertical transmission.

One hour after arriving on the postoperative unit, a woman who received spinal anesthesia 5 hours ago is complaining of severe abdominal incisional pain. Her vital signs include oral temperature 99° F (3.72° C), heart rate 110 beats/minute, respiratory rate 30 breaths/minute, and blood pressure 160/90 mm Hg. The client's skin is pale, and the surgical dressing is dry and intact. Which intervention is most important for the nurse to implement? A Place in a high-Fowler's position. B Provide pillow for splinting. C Assess the IV site for patency. D Administer an IV analgesic.

D Administer an IV analgesic. - The woman is experiencing severe abdominal incisional pain 5 hours after receiving spinal anesthesia, indicating that the spinal anesthesia has likely worn off and she requires additional pain management. Her vital signs suggest she is experiencing significant pain and stress response

The healthcare provider prescribes a 5% dextrose injection with 20 units of regular insulin for a client with a serum potassium level of 6.0 mEq/L (6.0 mmol/L) and glucose level of 180 mg/dL (10.0 mmol/L). Which evaluation is most important for the nurse to include in this client's plan of care? Reference Range: Potassium [3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)) Glucose [74 to 106 mg/dL (4.1 to 5.9 mmol/L.) A Evaluate glucose levels before and after meals. B Obtain a 12-lead electrocardiogram daily. C Monitor and document strict intake and output. D Assess the serum potassium level every 4 hours.

D Assess the serum potassium level every 4 hours. - Hyperkalemia can have significant cardiac implications, including the potential for life-threatening dysrhythmias. Therefore, close monitoring of the serum potassium level is crucial to assess the effectiveness of interventions and ensure that potassium levels are within a safe range.

After diagnosis and initial treatment of a pre-school age child with cystic fibrosis the nurse provides home care instructions to the parents. Which statement by the child's parents indicates that understanding of the home care treatment to promote pulmonary function? A Energy should be conserved by scheduling minimally strenuous activities. B Administer a cough suppressant every 8 hours. C Maintain supplemental oxygen at 4 to 6 L/minute. D Chest physiotherapy should be performed twice a day before a meal.

D Chest physiotherapy should be performed twice a day before a meal.Chest physiotherapy, also known as airway clearance therapy (ACT), is a crucial part of the daily treatment regimen for children with cystic fibrosis. It helps loosen and clear the thick, sticky mucus from the airways, allowing better breathing and reducing the risk of lung infections. The recommended frequency for chest physiotherapy is twice daily, typically before meals, as the treatment is more effective when the stomach is empty and it helps stimulate the child's appetite

A client has a prescription for the insertion of a nasogastric tube to low intermittent suction. When inserting the nasogastric tube, the nurse observes an immediate return of "coffee-ground" drainage. Which action should the nurse implement? A Immediately remove and then reinsert the nasogastric tube. B Connect the nasogastric tube to high continuous suction. C Connect the nasogastric tube to suction as prescribed. D Clamp the nasogastric tube and contact the healthcare provider.

D Clamp the nasogastric tube and contact the healthcare provider. - This it temporarily halts any further aspiration of stomach contents, which could be critical for the patient's condition, while ensuring that the healthcare provider is informed for further evaluation and management. "Coffee-ground" drainage upon insertion of a nasogastric (NG) tube suggests the presence of old blood in the stomach, which could indicate gastrointestinal bleeding or another serious condition. Other options could potentially worsen the patient's condition or lead to further complications.

The nurse-manager is involved in agency restructuring. During this re-engineering process, it is most important for the nurse to address which employee concern? A Changes in job descriptions. B New management's expectations. C Potential changes in employee benefits. D Employees job security.

D Employees job security. - Addressing job security can help to alleviate some of the stress and uncertainty that employees may feel during the restructuring process. By ensuring that employees feel secure in their jobs, the nurse-manager can maintain morale and productivity, which are crucial for a successful transition

The school nurse is screening students for scoliosis and notes that one student has lordosis. Which finding should the nurse document in the student's screening record? A Rounded spine from head to hips without concave curves. B Posterior curvature that is convex in the thoracic area. C Lateral curvature that creates asymmetry of the shoulders. D Excessive concave curvature of the lumbar spine.

D Excessive concave curvature of the lumbar spine. Lordosis is an excessive inward curvature of the lumbar spine, often called "swayback." Incorrect: A. This describes a normal spine alignment. B. This describes kyphosis, not lordosis. C. This describes scoliosis, not lordosis.

The nurse is caring for a client with pulmonary edema who is short of breath and coughing pink tinged sputum. Which position should the nurse place the client to ease respiratory distress? A Left lateral position. B Reverse Trendelenburg. C Supine. D High-Fowler's position.

D High-Fowler's position. - The High-Fowler's position, where the client is sitting upright at a 90-degree angle or as upright as tolerated, helps to improve lung expansion, reduce pressure on the diaphragm, and promote optimal oxygenation. This position is commonly used for clients with respiratory distress.

The nurse walks into a client's room and notices bright red blood on the sheets and on the floor by the IV pole. Which action should the nurse take first. A Apply direct pressure to the client's IV site. B Clean up the spilled blood to reduce infection transmission. C Notify the healthcare provider that the client appears to be bleeding D Identify the source and amount of bleeding.

D Identify the source and amount of bleeding. - Assessing the amount of bleeding helps determine the severity and urgency of the situation. Heavy, uncontrolled bleeding requires more rapid intervention compared to a small amount. Once the source and severity are identified, the nurse can then take targeted actions like applying pressure to the bleeding site, notifying the provider, or preparing for potential fluid resuscitation as needed

The nurse is assisting the healthcare provider with a wound debridement at the bedside of a client who is mildly confused. The client is draped and a sterile field is created. Which nursing intervention should the nurse implement for client safety? A Assess for discomfort when procedure is completed. B Verify that the client has given informed consent. C Pour cleansing solution onto the sterile cloth field. D Instruct the client to keep hands under the sterile field.

D Instruct the client to keep hands under the sterile field. When performing any sterile procedure like wound debridement, it is crucial to maintain the sterility of the field. Instructing the client, even if mildly confused, to keep their hands under the sterile drapes helps prevent contamination of the sterile field and ensures client safety. This nursing intervention helps maintain aseptic technique during the procedure. Wrong answers A. Assessing for discomfort when the procedure is completed is important, but it does not address the immediate need to maintain sterility and client safety. B. Verifying informed consent is a crucial step, but it is not a nursing intervention. C. Pouring cleansing solution onto the sterile field would contaminate the sterile field.

The nurse is caring for a client after thoracentesis that drained 50 mL of clear fluid from the left lung. Which assessment finding should the nurse report to the healthcare provider immediately? A Serosanguinous drainage from the chest tube. B Dullness bilaterally on percussion. C Diminished breath sounds in the left lower lobe. D Mediastinal shift to the right.

D Mediastinal shift to the right. - A mediastinal shift to the right after a thoracentesis on the left lung could indicate a potential complication of tension pneumothorax (collapsed lung), which requires immediate medical attention.

The nurse is planning care for a client with chronic kidney disease who is a resident at a long-term nursing facility. The client is anuric and has hemodialysis 3 times a week. Which intervention should the nurse include in the client's plan of care? A Initiate toileting schedule. B Provide perineal skin barrier cream. C Encourage intake of high potassium foods. D Monitor for signs of anemia.

D Monitor for signs of anemia. Correct (D): Anemia is a common complication in chronic kidney disease due to decreased erythropoietin production. Regular monitoring is crucial. Incorrect: A) Toileting schedule: Not necessary for an anuric client. B) Perineal skin barrier cream: Not a priority for an anuric client. C) High potassium foods: Contraindicated in kidney disease as the kidneys can't effectively remove excess potassium.

After receiving shift report, the nurse working on a postpartum unit should assess which client first? A Cesarean birth of twins today who is now complaining of pain. B Post-cesarean birth today with fundus at the umbilicus. C Vaginal birth today whose infant is refusing to breastfeed. D Multipara vaginal birth yesterday who is saturating two pads/hour.

D Multipara vaginal birth yesterday who is saturating two pads/hour - This could indicate postpartum hemorrhage - a potentially life-threatening complication that requires immediate assessment and intervention.

Following a cardiac catheterization and placement of a stent in the right coronary artery, the nurse administers prasugrel, a platelet inhibitor, to the client. To monitor for adverse effects from the medication, which assessment is most important to the nurse to include in this client's plan of care? A Assess skin turgor. B Measure body temperature. C Check for pedal edema. D Observe color of urine.

D Observe color of urine. - Prasugrel, being a potent antiplatelet medication, increases the risk of bleeding. One of the most serious adverse effects to monitor for is bleeding, which can manifest as bloody or discolored urine.

The nurse is planning to assess a client's oxygen saturation to determine if additional oxygen is needed via nasal cannula. The client has a bilateral below-the-knee amputation and pedal pulses that are weak and thready. What action should the nurse take? A Document that an accurate oxygen saturation reading cannot be obtained B Elevate to client's hands for five minutes prior to obtaining a reading from the finger C Increase the oxygen based on the client's breathing patterns and lung sounds D Place the oximeter clip on the ear lobe to obtain the oxygen saturation reading

D Place the oximeter clip on the ear lobe to obtain the oxygen saturation reading Rationale: Correct (D): With bilateral below-knee amputations and weak pedal pulses, obtaining an accurate reading from extremities may be challenging. The earlobe provides an alternative site for pulse oximetry that isn't affected by the client's circulatory issues in the lower extremities. Incorrect: (A) Document inability to obtain reading: Premature without trying alternative sites. (B) Elevate hands: Unnecessary and doesn't address the circulatory issues in lower extremities. (C) Increase oxygen based on breathing and lung sounds: Inappropriate without accurate oxygen saturation measurement.

A client who underwent an uncomplicated gastric bypass surgery is having difficulty with diet management. Which dietary instruction is most important for the nurse to explain to the client? A Chew food slowly and thoroughly before attempting to swallow. B Sip fluids slowly with each meal and between meals. C Eliminate or reduce intake of fatty and gas forming foods. D Plan volume-controlled, evenly spaced meals throughout the day.

D Plan volume-controlled, evenly spaced meals throughout the day. The most crucial dietary instruction for the nurse to explain to the patient who underwent uncomplicated gastric bypass surgery and is having difficulty managing diet is to plan volume-controlled evenly-spaced meals throughout the day.

Which nursing responsibility is related to health promotion and teaching for the client with rheumatoid arthritis? A Immobilization of affected joints. B Avoidance of foods containing purine. C Application of heat and cold therapy. D Prevention through nutrition and exercise.

D Prevention through nutrition and exercise is the most comprehensive approach that aligns with health promotion and teaching for clients with rheumatoid arthritis. It includes educating clients on a balanced diet and physical activity to manage symptoms and improve overall health. Incorrect: A Application of heat and cold therapy can help manage symptoms but does not encompass the broader aspects of health promotion and teaching. B Avoidance of foods containing purine is more specific to conditions like gout rather than rheumatoid arthritis, and while diet is important, it does not fully represent health promotion and teaching. C Immobilization of affected joints is not a health promotion strategy and can actually worsen symptoms over time. Active and passive range-of-motion exercises are recommended instead.

An older adult client is being admitted to a short-term rehabilitation facility after a long hospitalization. The nurse is performing a functional assessment with the client. Which action should the nurse implement? A Assist the client with values clarification about end-of-life care options. B Ask the client how often episodes of sundowning are experienced. C Encourage the client to lie as still as possible during the assessment. D Question the client about the frequency of falls in recent months.

D Question the client about the frequency of falls in recent months- A functional assessment is an evaluation of an individual's ability to perform activities of daily living (ADLs), which includes tasks such as bathing, dressing, toileting, eating, and mobility. Falls are a common and significant issue among older adults and are a leading cause of injury and hospitalization. Therefore, it is important to assess the client's risk of falling and inquire about any recent falls to develop an appropriate plan of care to prevent falls.

Which snack selection indicates to the nurse that a school-age child with gastroesophageal reflux understands the dietary restrictions? A Pizza. B Tacos. C Chocolate milkshake. D Sugar cookies.

D Sugar cookies. - Sugar cookies, being low in fat, acid, and spice content, align with the dietary recommendations for children with gastroesophageal reflux disease (GERD). Selecting this snack option demonstrates an understanding of the appropriate dietary restrictions.

A nurse is providing care for a client with severe peripheral arterial disease (PAD). The client reports a history of rest ischemia, with leg pain that occurs during the night. Which action should the nurse take in response to this finding? A Elevate the legs to assess for color changes. B Provide a heating pad for PRN use. C Offer cold packs when the pain occurs. D Suggest dangling the legs when pain begins.

D Suggest dangling the legs when pain begins - Dangling improves blood flow to the feet and can decrease discomfort. Incorrect: A Elevation reduces blood flow. B Heat can burn if the patient has decreased sensation. C Cold causes vasoconstriction which reduces blood flow.

A client who delivered vaginally 2 days ago states that she wants to resume using her diaphragm for birth control. What information should the nurse share with her? A The most effective form of contraception is a diaphragm. B The diaphragm should be inserted 2 to 4 hours before intercourse. C Vaseline lubricant can be used when inserting the diaphragm. D The diaphragm must be refitted after childbirth.

D The diaphragm must be refitted after childbirth. - Its effectiveness can be compromised by changes in the anatomy of the vaginal canal, cervix, and pelvic structures, such as those that occur after childbirth. After vaginal childbirth, the pelvic structures may undergo changes, including stretching and possible loss of tone. These changes can affect the fit and position of the diaphragm, leading to decreased contraceptive efficacy. Therefore, it's important for women who have given birth to have their diaphragm refitted by a healthcare provider before resuming its use.

The charge nurse is making assignments for one practical nurse (PN) and three registered nurses (RN) who are caring for neurologically compromised clients. Which client with which change in status is best to assign to the PN? A Myxedema coma whose blood pressure changed from 80/50mmHg to 70/40mmHg . B Subdural hematoma whose blood pressure changed from 150/80mmHg to 170/60mmHg. C Diabetic ketoacidosis whose Glasgow Coma Scale score changed from 10 to 7. D Viral meningitis whose temperature changed from 101°F(38.3°C) to 102°F(38.9°C) .

D Viral meningitis whose temperature changed from 101°F(38.3°C) to 102°F(38.9°C) . Prioritize the assignment based on the change in status of the clients. The practical nurse (PN) should be assigned a client whose change in status is less critical compared to the others, as the registered nurses (RNs) can handle more complex situations. Looking at the given scenarios, the change in status of the clients can be evaluated based on their blood pressure, Glasgow Coma Scale score, and temperature. Among the listed situations, the client with viral meningitis whose temperature changed from 101° F (38.3° C) to 102° F (38.9° C) has the least critical change in status. This change does not indicate an immediate life-threatening situation and can be managed by the practical nurse (PN).

A client is being discharged home after being treated for heart failure (HF). Which instruction should the nurse include in this client's discharge teaching plan? A Perform range of motion exercises. B Eat a high protein diet. C Limit fluid intake to 1,500 mL dally. D Weigh every morning.

D Weigh every morning. - This is an essential self-monitoring technique for heart failure patients as it helps assess fluid balance and detect early signs of fluid retention or weight gain, which can indicate worsening heart failure.

While changing a client's postoperative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values? A Hematocrit. B Platelet count. C Creatinine level. D White blood cell (WBC) count.

D White blood cell (WBC) count. The presence of purulent drainage at the wound indicates a potential infection, and monitoring the client's WBC count is an important laboratory value to assess for signs of infection. An elevated WBC count, specifically an increase in the neutrophil count (neutrophilia), can indicate an active infection and provide important information for the While hematocrit, platelet count, and creatinine level are essential laboratory values to assess the client's overall condition, they may not provide specific information regarding the presence of infection or purulent drainage at the wound site.

Which client will benefit most from the application of pneumatic compression devices to the lower extremities? The client who: A has pressure ulcers on several toes. B has diminished pedal pulse volume. C is confused and tries to climb out of bed. D is immobile on prescribed bedrest.

D is immobile on prescribed bedrest. - Being immobile on prescribed bedrest significantly increases the risk of DVT due to lack of movement and impaired blood flow in the legs. Applying pneumatic compression devices helps promote circulation and prevent blood clot formation in such immobilized patients.

When the nurse enters the room of a male client who was admitted for a fractured femur, his cardiac monitor displays a normal sinus rhythm (NSR), but he has no spontaneous respirations and his carotid pulse is not palpable. Which intervention should the nurse implement? A Observe for swelling at the fracture site. B Analyze the cardiac rhythm in another lead. C Obtain a 12-lead electrocardiogram. D Begin chest compressions at 100/minute.

D) Correct- The absence of spontaneous respirations and palpable carotid pulse indicates cardiac arrest. In this situation, immediate initiation of cardiopulmonary resuscitation (CPR) is critical to provide circulation and oxygenation to the vital organs. Chest compressions are the initial step to address cardiac arrest and ensure blood flow to the body. A) Incorrect- Observing for swelling at the fracture site is important for assessing the client's musculoskeletal condition, but it is not the priority intervention in this situation. The absence of spontaneous respirations and palpable carotid pulse indicates cardiac arrest, and immediate intervention is needed. B) Incorrect- Analyzing the cardiac rhythm in another lead is not the first priority when the client is in cardiac arrest. Cardiopulmonary resuscitation (CPR) should be initiated immediately to restore circulation. C) Incorrect- Obtaining a 12-lead electrocardiogram is not the initial intervention in a client in cardiac arrest. CPR and defibrillation (if indicated) are the immediate actions to provide circulation and oxygenation to the vital organs.

The nurse of a medical-surgical unit receives a report from a post-anesthesia care unit (PACU) nurse for a client who is being transferred following a right hemicolectomy. The PACU nurse reports, "The client has an intravenous (IV) infusion of 1000 mL lactated Ringer's infusing at 125 mL/hr into the left wrist with 300 mL remaining. Prescriptions include morphine sulfate 2 mg IV every 2 to 4 hours for pain, last administered 30 minutes ago; ondansetron 4 mg IV every 8 hours for nausea, last administered 15 minutes ago." Which additional information is most important for the nurse to obtain in the report? A History of vomiting at home for 3 days prior to surgery. B Declining to take ice chips for complaints of dry mouth. C Soft abdomen, absent bowel sounds, no bleeding on dressing. D Peripheral pulses present with full range of motion of both legs.

D) Correct- While all options are important to consider, the most critical information in this scenario is assessing peripheral pulses and the range of motion of both legs. A right hemicolectomy involves abdominal surgery and decreased or absent peripheral pulses along with a limited range of motion could indicate impaired circulation, thrombosis, or other post-operative complications. These findings might necessitate prompt intervention to prevent potential complications. A) Incorrect- While the history of vomiting is important to assess, it may not be the most crucial information to gather at this point, as the client is postoperative and the focus is on immediate postoperative care. B) Incorrect- While assessing for fluid intake is important, the client's refusal of ice chips is not an urgent concern compared to other potential complications, such as pain management, oxygenation, and fluid balance. C) Incorrect- These assessments are important, but the client's history of right hemicolectomy and the current infusion and medication administration require closer attention to fluid balance, pain control, and oxygenation.

The nurse is performing the preoperative care of a client for an open reduction and internal fixation (ORIF) of a fractured right tibia. Before the procedure, which action should the nurse prioritize? A Discuss NPO dietary restrictions. B Administer prescribed antibiotic. C Prepare pneumatic compression devices. D Verify client's signed consent.

D. "Verify client's signed consent" is crucial as it ensures that the client has been informed about the procedure, its risks, benefits, and alternatives, and has agreed to proceed. It's a legal requirement before any surgical procedure. Incorrect: A. "Discuss NPO dietary restrictions" refers to educating the patient about the need to fast (nothing by mouth) before surgery, which is important to prevent aspiration during anesthesia. B. "Administer prescribed antibiotic" is usually done to prevent infection, but it's not the first priority before surgery. C. "Prepare pneumatic compression devices" is done to prevent deep vein thrombosis (DVT), but it's not the immediate priority.

A client with unilateral hearing loss is admitted for a scheduled surgery. Which technique should the nurse use to provide education about pain relief options? A Repeat information to the client. B Talk loudly into the affected ear. C Write information on a whiteboard. D Speak directly facing the client.

Education technique for client with unilateral hearing loss: Correct answer: D - Speak directly facing the client. Rationale: Correct (D): Allows the client to use visual cues and hear better with the unaffected ear. Incorrect: A) Repetition alone may not be sufficient. B) Talking loudly into the affected ear isn't helpful. C) Writing isn't necessary for verbal communication with a hearing-impaired client.

A client is transferred from the operating room to the post-anesthesia care unit with the following vital signs: temperature 99.8° F (37.7° C), heart rate 62 beats/minute, respirations 8 breaths/minute, blood pressure 95/54 mmHg, and oxygen saturation 94%. Which medication should the nurse administer? A Naloxone. B Milrinone. C Acetaminophen. D Atropine.

Naloxone: This medication is an opioid antagonist, which means it can reverse the effects of opioid medication, including respiratory depression. This makes it the most suitable choice given the client's symptoms. Milrinone: This is a medication used to treat heart failure. It's not relevant to the client's current symptoms. Acetaminophen: This is a common pain reliever and fever reducer. While the client does have a slightly elevated temperature, it's not high enough to warrant administration of this medication. Atropine: This medication is used to treat certain types of heart rhythm problems, but the client's heart rate is within normal range.

The nurse is caring for a client with the sexually transmitted infection (STI) syphilis. The client reports having had prior sexually transmitted infections. Which response should the nurse provide? A Answer questions directly and correct any misinformation. B Discuss that partners without similar symptoms may not be infected. C Provide counseling that most contraceptives protect against infection. D Notify that persons with STIs are reported to local health departments.

Nurse's response to client with syphilis: Correct answer: A - Answer questions directly and correct any misinformation. Rationale: Correct (A): Providing accurate information is crucial for STI education and prevention. Incorrect: B) Partners without symptoms may still be infected. C) Not all contraceptives protect against STIs. D) While true, this isn't the most appropriate initial response.

The nurse identifies an electrolyte imbalance, a weight gain of 4.4 lbs in 24 hours and an elevated central venous pressure for a client with full thickness burns. Which intervention should the nurse implement? A Auscultate for irregular heart rate. B review arterial blood gases results. C measure ankle circumference. D document abdominal girth.

Rationale: Electrolyte imbalances can cause cardiac arrhythmias. Incorrect: B) ABG results: Less immediate concern. C) Measure ankle circumference: Less relevant. D) Document abdominal girth: Less immediate concern.