CAT 1 DB

The nurse evaluates laboratory values for a client experiencing diaphoresis and weight loss. Which value will the nurse immediately report to the health care professional? 1.Calcium 9.0 mg/dL (2.25 mmol/L). 2.Hemoglobin A1C 8% (0.08). 3.Magnesium 2.2 mg/dL (1.10 mmol/L). 4.Blood glucose 118 mg/dL (6.55 mmol/L).

1) A calcium level of 9.0 mg/dL (2.25 mmol/L) is within normal limits. This value would not cause diaphoresis and weight loss. 2) CORRECT — A hemoglobin A1C value of 8% (0.08) indicates hyperglycemia. This blood level evaluates the levels of blood glucose over the previous months. Diaphoresis and weight loss are manifestations of an elevated blood glucose level. 3) A magnesium level of 2.2 mg/dL (1.10 mmol/L) is within normal limits. This value would not cause diaphoresis and weight loss. 4) A blood glucose level of 118 mg/dL (6.55 mmol/L) is considered high-normal, although within normal limits. This isolated value would not cause diaphoresis and weight loss.

The nurse provides care for a client experiencing a sickle cell crisis. Which nursing diagnosis is the priority for the nurse to include in the plan of care? 1.Risk for infection.2.Risk for ineffective cerebral tissue perfusion.3.Activity intolerance.4.Ineffective peripheral tissue perfusion.

1) A client is at risk for infection but it is not highest priority. 2) Risk for ineffective cerebral tissue perfusion is a concern but not the highest priority. 3) Activity intolerance related to fatigue is a problem but not as high of a priority as ineffective peripheral tissue perfusion. 4) CORRECT - Due to infarction, ineffective peripheral tissue perfusion is the highest priority for a client with a sickle cell crisis.

A client who is pregnant asks the nurse what an elevated serum alpha-fetoprotein (AFP) level indicates. Which information does the nurse provide to the mother? 1.Gestational diabetes.2.A neural tube defect.3.Trisomy 21 (Down syndrome).4.Lack of lung maturity.

1) A glucose tolerance test is used to diagnose gestational diabetes. 2) CORRECT— An elevated AFP level may indicate a neural tube defect, which is the most common birth defect in the United States. 3) A low AFP level may indicate Trisomy 21 (Down syndrome). 4) An amniocentesis is used to determine lung maturity.

The nurse notes that a 4-hour-old newborn has blue hands and feet. Which action does the nurse implement next? 1.Place the neonate in a warmer.2.Swaddle the neonate in double blankets.3.Notify the health care provider.4.Proceed with the assessment.

1) A warmer is not needed unless the newborn is exposed to a cold environment that could aggravate acrocyanosis. 2) Swaddling is not needed unless the newborn is exposed to a cold environment that could aggravate acrocyanosis. 3) The health care provider does not need to be contacted for an expected finding. 4) CORRECT — The newborn has acrocyanosis, which is a normal finding for 2 to 6 hours of age. This results from diminished peripheral circulation. The newborn should be monitored and the nurse can continue with the assessment.

The nurse provides care for a client in the final stage of chronic kidney disease. The client's serum calcium level is 7.5 mg/dL (1.8 mmol/L) and the phosphate level is 6.0 mg/dL (1.9 mmol/L). Which priority nursing diagnosis does the nurse use to plan care for this client? 1.Activity intolerance.2.Risk for injury.3.Imbalanced nutrition.4.Failure to thrive.

1) Activity intolerance is not priority nursing diagnosis for the client experiencing hypocalcemia and hyperphosphatemia during the final stage of chronic kidney disease. 2) CORRECT — This client is experiencing both hypocalcemia and hyperphosphatemia. Normal range for serum calcium is 9.0 to 10.5 mg/dL (2.25 to 2.75 mmol/L), while the normal range for phosphate is 3.0 to 4.5 mg/dL (0.97 to 1.45 mmol/L). The client in the final stage of chronic kidney disease is at risk for osteodystrophy due to bone mineral loss leading to an increased risk for fractures or osteoporosis. Due to this condition, the client is at risk for serious injuries during a fall. 3) While the client may need decreased phosphorus and increased calcium in the diet, this is not the priority diagnosis. 4) There is no data to support failure to thrive as a priority nursing diagnosis for this client.

The nurse instructs a client on advance directives. Which client statement indicates to the nurse a need for further education? 1."Advance directives should be completed long before a medical crisis develops." 2."I decide who will make health care decisions for me if I chose a Health Care Proxy." 3."A living will means my family will know what life-sustaining measures I want taken." 4."A power of attorney for health care prevents my children from selling my home."

1) Advance directives should be completed before a medical crisis to allow the client to take careful consideration regarding health care options. This statement does not require the nurse to provide additional education to the client. 2) In the event the client no longer has the capacity to make health care decisions, a proxy allows the client to assign a surrogate decision maker. This statement does not require the nurse to provide additional education to the client. 3) A living will identifies interventions a client wishes to receive, or not receive, in a near death situation. This statement does not require the nurse to provide additional education to the client. 4) CORRECT- A durable power of attorney for health care is different from the power of attorney for financial matters. This statement requires the nurse to provide the client with additional education.

The nurse provides care for a client with an enteral feeding tube. The nurse discovers that the client's continuous enteral tube feeding is 100 mL behind the prescribed infusion schedule. Which action should the nurse take first? 1.Flush the tube.2.Reposition the tube.3.Increase the flow rate.4.Measure residual volume.

1) After the residual volume is assessed and the tube feeding continues to be sluggish, then the nurse should flush the tube to determine patency. 2) Location of the feeding tube does need to be determined; however, depending on the type of feeding tube used, repositioning the tube may be beyond the nurse's scope of practice. 3) Increasing the flow rate could lead to adverse effects from receiving too much or too rapid of a feeding solution. This action is not recommended. 4) CORRECT — The reason the prescribed amount of tube feeding may not have infused could be due to a high gastric residual volume. Assessing the current residual volume is the first thing that the nurse should do.

The nurse notes that a client is prescribed alendronate. Which instruction will the nurse include when teaching about this medication? 1."Take the medication at bedtime with a snack."2."Take the medication in the morning after breakfast."3."Lie down for 30 minutes after taking the medication."4."Take the medication with a full glass of water." View Explanation

1) Alendronate is to be taken on an empty stomach. 2) Alendronate can be taken anytime during the day with an empty stomach. 3) The client must remain upright 30 minutes after taking alendronate to prevent esophagitis. 4) CORRECT - Alendronate must be taken with a full glass of water to prevent acid reflux.

The nursing instructor is explaining the difference between hand washing and surgical hand hygiene to a nursing student. Which statement by the student indicates the need for further teaching? 1."All hand jewelry should be removed for surgical hand antisepsis."2."Surgical hand antisepsis is performed for at least 15 seconds, depending on the antibacterial agent."3."Hands are held higher than the elbows during washing with surgical antisepsis."4."Faucets are regulated with elbow, knee, or foot controls."

1) All hand jewelry, including watches, should be removed for surgical hand antisepsis. 2) CORRECT — Hand washing, not surgical hand hygiene, should be performed for at least 15 seconds. Surgical hand hygiene is performed for 2 to 6 minutes, depending on the antibacterial agent used. 3) Hands are held higher than the elbows during washing, rinsing, and drying with surgical hand antisepsis. 4) Faucets are regulated with elbow, knee, or foot controls during surgical hand antisepsis.

The graduate nurse attends an orientation to the oncology unit. Which statement indicates that the graduate nurse understands the teaching? 1."Angiogenesis is only accomplished by malignant cells."2."Everyone diagnosed with cancer will die from it."3."Cancers metastasize through lymphatic spread to organs."4."Cell mutations cannot be managed by the body's immune system." View Explanation

1) Angiogenesis is the creation of a blood supply. The human body does this for many reasons; it is not unique to tumors. 2) Cancer is not always lethal. Most cancers, when detected early, are treatable for cure or remission. 3) CORRECT - Cancers metastasize primarily by spreading cancerous cells through the lymph system. 4) Normally, the body can manage and destroy cell mutations.

The nurse assesses the coping skills of a client receiving chemotherapy after a mastectomy for breast cancer. Which client statement indicates effective coping? 1."I am glad the nausea and vomiting are subsiding."2."I do not need as much pain medication as was prescribed."3."I made an appointment to get fitted for prosthesis."4."I will begin the next round of chemotherapy next week."

1) Being glad the nausea and vomiting are subsiding is not an example of a coping skill. 2) Needing less pain medication is not an example of a coping skill. 3) CORRECT— Making an appointment for a prosthesis is planning for the future. When a person is under stress and believes something can be done about the problem, the person is using problem-focused coping. People facing life-changing experiences need to maintain hope. Hope is the anticipation of a continued good or an improvement or the lessening of something unpleasant. Hope energizes and comforts people as they face personal challenges, and it enhances their coping skills. 4) Beginning the next round of chemotherapy next week is not an example of a coping skill.

Prior to the beginning of a site survey, the charge nurse advises the nurse to deny any knowledge of a recent sentinel event if asked by the surveyor. Which action will the nurse take? 1.Notify the unit manager.2.Notify the medical director.3.Tell the charge nurse about being uncomfortable lying to the surveyor.4.Tell the surveyor the nurse is not allowed to talk to them. View Explanation

1) CORRECT - Always follow the direct chain of command. If asked about the event by the surveyor prior to speaking with the unit manager, do not lie. Nurses have a professional and ethical responsibility to tell the truth in all situations. 2) The medical director is not the nurse's direct supervisor. 3) Confronting the charge nurse will not resolve the issue and will likely increase the tension of an already stressful situation. 4) If asked about the event by the surveyor prior to speaking with the unit manager, do not lie. Nurses have a professional and ethical responsibility to tell the truth in all situations.

The health care provider prescribes a unit of packed red blood cells for a client admitted with lower gastrointestinal bleeding. Which step will the nurse take when administering the blood product? (Select all that apply.) 1.Ensure adequate infusion access is present before obtaining the blood from the blood bank.2.Initiate the transfusion within 1 hour of removing the blood from the blood bank refrigerator.3.Use a two-person verification process to match the unit of blood to the prescription and the client to the unit of blood.4.Monitor the client closely during the first 15 to 30 minutes of administration.5.Ensure the administration time does not exceed 6 hours.

1) CORRECT - An adequate intravenous catheter should be inserted prior to obtaining the blood from the blood bank. 2) The infusion should be started within 30 minutes of removing the blood from the blood bank refrigerator. 3) CORRECT - Two-person verification in the presence of the client is done to make sure that the blood product matches the health care provider's prescription and the blood product is properly identified to the client to prevent a blood incompatibility error. 4) CORRECT - The client should be closely monitored for the first 15 to 30 minutes of the transfusion. Most transfusion reactions occur within this time. 5) The blood administration time should not exceed 3 to 4 hours to reduce the risk for bacterial growth.

The nurse provides care to a client who experienced prolonged cold exposure. For which complication does the nurse closely monitor this client? 1.Ventricular fibrillation.2.Hypertension.3.Metabolic alkalosis.4.Shivering.

1) CORRECT - Cold-induced myocardial irritability may cause cardiac arrhythmias, especially ventricular fibrillation. 2) Hypotension, and not hypertension, is an adverse effect of hypothermia. 3) Metabolic acidosis, and not metabolic alkalosis, occurs with hypothermia as blood flow to the extremities becomes compromised. 4) Shivering, the body's self-warming mechanism, may be suppressed with hypothermia.

The nurse provides care to a client with an epidural catheter for pain control with fentanyl after spinal fusion surgery. Which action will the nurse include when providing post-operative care to this client? (Select all that apply.) 1.Perform peripheral neurovascular checks every 2 hours.2.Ambulate the client around the hallway.3.Assess for bowel and bladder distention.4.Keep the client at nothing by mouth status.5.Monitor client for nausea and vomiting.

1) CORRECT - Frequent neurovascular assessment is essential for clients with an epidural catheter, as it allows for early detection of sensory-motor impairment. 2) Ambulation is inappropriate for a client with an epidural catheter because of a risk for catheter displacement. 3) CORRECT - Assessment of bowel and bladder function is part of best practice guidelines for clients with epidural catheters. 4) It is not necessary to keep the client at nothing by mouth status because of an epidural catheter. 5) CORRECT - Nausea and vomiting are common side effects of opioids such as fentanyl.

The nurse provides care to a client in hypovolemic shock. Which intravenous solution will the nurse recognize as being an isotonic crystalloid solution? (Select all that apply.) 1.Normal saline.2.Lactated ringer.3.0.5% normal saline.4.10% dextrose.5.0.45% dextrose in normal saline. View Explanation

1) CORRECT - Normal saline is an isotonic crystalloid solution commonly used for resuscitation in hypovolemic shock. This solution has the same concentration of electrolytes as the extracellular fluid so it does not alter the concentrations of electrolytes in the vascular system. 2) CORRECT - Lactated ringer is an isotonic crystalloid solution commonly used for resuscitation in hypovolemic shock. This solution has the same concentration of electrolytes as the extracellular fluid so it does not alter the concentrations of electrolytes in the vascular system. 3) 0.5% normal saline is a hypotonic solution. 4) 10% dextrose is a hypertonic solution. 5) 0.45% dextrose in normal saline is a hypertonic solution.

A middle-aged client, newly diagnosed with type 2 diabetes, expresses disbelief at this diagnosis. The nurse explains that the development of diabetes in middle-age is most likely related to which factor? 1.Obesity.2.Increased sugar intake.3.Viral infections.4.Decreased cortisol level.

1) CORRECT - Obesity is a major risk factor for type 2 diabetes in middle-aged clients. 2) Increased sugar intake is not directly related to the development of diabetes. 3) Viral infections are not directly related to the development of diabetes. However, clients with diabetes are more prone to develop infections. 4) A decreased cortisol level is not related to the development of diabetes.

The nurse teaches a class on suicide prevention to high school students. Which risk factor is accurate with regard to suicide in adolescent clients? (Select all that apply.) 1.Possessions that are given to friends.2.A low grade point average.3.Statements like, "I may not be around anymore."4.Access to a gun at home.5.Frequent thoughts of suicide.

1) CORRECT - There is a correlation between this action and a high risk of suicidal tendencies or thoughts. 2) There is no specific correlation between a low grade point average and an increased risk for suicide. 3) CORRECT - There is a correlation between these types of statements and a high risk of suicidal tendencies or thoughts. 4) CORRECT - There is a correlation between easy access to a gun and an increased risk for suicide. 5) CORRECT - There is a correlation between frequent thoughts of suicide and an increased risk for suicide.

The nurse assigns a client diagnosed with cancer who is receiving chemotherapy to a nursing assistive personnel (NAP). Which instruction is most important for the nurse to include? 1.Perform hand hygiene frequently. 2.Wear a mask when entering the room. 3.Monitor the roommate for signs of infection. 4.Monitor the amount of protein the client eats.

1) CORRECT — Hand hygiene remains the most important intervention for preventing infection among chemotherapy clients who may be immunocompromised. 2) A mask is not necessary, unless the client is on neutropenic precautions. 3) Assessment is the responsibility of the nurse, not the NAP. 4) A high-protein diet is essential for general health and to prevent muscle wasting. The nurse would monitor the protein intake, but infection prevention is the priority for the NAP.

After receiving a unit of red blood cells, a child reports tingling in the ears, nose, fingers, and toes. Which electrolyte imbalance does the nurse suspect the client is experiencing? 1.Hypocalcemia.2.Hypercalcemia.3.Hyponatremia.4.Hypernatremia.

1) CORRECT — Hypocalcemia results from blood transfusions containing citrate. Citrate causes increased cell membrane permeability, leading to increased neuromuscular excitability, which may result in numbness or tingling of the ears, nose, fingers, and toes. If severe, laryngospasm, seizures, and cardiac arrest may occur. 2) Hypercalcemia causes decreased neuromuscular excitability. Signs of this imbalance include fatigue, hypoactive deep tendon reflexes, decreased muscle tone and strength, bone pain, and decreased gastrointestinal motility. 3) Hyponatremia results in fluid shifts into the cerebral space causing cerebral edema. Seizures, coma, and respiratory arrest may occur. 4) With hypernatremia, water shifts out of the intracellular fluid resulting in cellular dehydration. Cerebral vessels shrink and tear, resulting in cerebral hemorrhage. Manifestations of this imbalance include lethargy, irritability on stimulation, and a high-pitched cry.

The nurse provides care for a client diagnosed with head trauma. The client experiences a seizure. Which actions will the nurse implement? (Select all that apply.) 1.Keep the client in a side-lying position.2.Monitor the client's ability to maintain a patent airway.3.Arouse the client frequently to assess neurological status.4.Provide environmental stimuli to help the client awaken.5.Place suction equipment and an oral airway at the client's bedside. View Explanation

1) CORRECT — Placing the client in a side-lying position allows drainage of oral secretions while the client regains the ability to swallow, cough, and gag. 2) CORRECT — The client has lost the ability to protect the airway and is at risk of aspiration. 3) The client needs to be allowed to rest in the postictal state of seizure activity. Continuous arousal will agitate the client and may cause complications. 4) Noise, lights, and disruptions are harmful to the client who has head trauma and to the client with seizures. This client requires a reduction of stimuli for healing. 5) CORRECT — The client is currently at risk for aspiration and loss of airway, as well as being at risk for additional seizure activity.

The nurse provides care for a client diagnosed with a seizure disorder. Which client care activity does the nurse delegate to a nursing assistive personnel (NAP)? (Select all that apply.) 1.Place respiratory equipment at the bedside.2.Remove harmful objects from the client's reach.3.Apply foam padding around the bed rails.4.Time the duration of seizure activity.5.Teach the client about antiseizure medications.

1) CORRECT — Settting up essential supplies and equipment at the bedside is within the scope of practice for NAPs. 2) CORRECT — Assisting the nurse in maintaining a safe care environment is within the scope of practice for NAPs. 3) CORRECT — Applying padding around the bedside is within the scope of practice for NAPs. 4) Only the nurse can do assessments such as timing the duration of a seizure activity. 5) Teaching about medication is the nurse's responsibility.

A client with a history of intravenous drug abuse experiences a low-grade fever, cough, night sweats, fatigue, weight loss, and a productive cough with mucopurulent sputum. Which transmission-based precaution will the nurse use for this client? 1.Airborne.2.Contact.3.Droplet.4.Standard.

1) CORRECT — The client's history and signs suggest pulmonary tuberculosis, which is spread by airborne pathogens (M. tuberculosis). Airborne transmission-based precautions should be initiated immediately. 2) Contact transmission-based precautions are instituted for clients with infections spread through direct contact with skin or bodily secretions or with items in the client's environment. 3) Droplet transmission-based precautions are initiated for a client with a known or suspected infection spread by droplets. 4) Standard precautions should be followed when providing care for any client.

The nurse provides care to a client who had right femoral-popliteal bypass surgery 5 hours ago. Which finding will the nurse report immediately to the health care provider? 1.Develops pallor of the right extremity.2.Voids 180 mL of urine since surgery.3.Has an oral temperature of 99.8°F (37.6°C).4.Has a small amount of bright red bloody drainage on the dressing.

1) CORRECT— After femoral-popliteal bypass surgery, the nurse should monitor the patency of the graft by checking the extremity every 15 minutes for the first hour and then hourly for changes in color, temperature, and pulse intensity. The right leg is compared with the left one. If the right leg feels cold or is pale, ashen, or cyanotic, or if it has a decreased or absent pulse, the health care provider is contacted immediately. Pallor of the right extremity is related to shock from blood loss. 2) The nurse should report a urine output of less than 30 mL per hour (240 mL per 8-hour nursing shift) to the health care provider. Decreased urine output may indicate hypovolemia or renal complications. This output is within normal limits. 3) A slightly elevated temperature is expected following surgery. 4) The nurse should assess the dressing each time vital signs are measured. During dressing inspection, the nurse checks for drainage and records its amount, color, consistency, and odor. If drainage is present on a dressing or cast, its progression is monitored by outlining it with a pen and indicating the date and time.

The outpatient nurse assesses the client's use of crutches 1 week after knee surgery. Which outcome is most important? 1.The client is able to perform activities of daily living independently.2.The client has no tingling or numbness in the upper extremities.3.The client reports removing all the loose rugs from the kitchen and bath.4.The client is free of deep vein thrombosis signs and has a normal bowel pattern.

1) CORRECT— The client's ability to perform daily needs with no to minimal assistance is the primary desired outcome of this ambulatory assistance equipment. If this outcome is achieved, the client also likely will be free of adverse events such as nerve damage from crutch use, injury, and immobility complications. 2) The absence of an adverse effect, nerve damage, is not the most important outcome. 3) Removing trip hazards minimizes the potential for injury and is a positive action by the client, but the absence of an adverse effect, falling, is not the most important outcome. 4) The absence of immobility complications is positive, but the absence of complications is not the primarily desired outcome.

The client is 4 hours postoperative. The nurse increases the supplemental oxygen dose based on the pulse oximetry reading. After 15 minutes, the nurse assesses the client's response to the intervention. Which finding does the nurse report to the health care provider? 1.The client requires an increased dose of supplemental oxygen.2.The client is drowsy with a respiratory rate of 16 breaths per minute.3.The client has a loose, productive cough with deep inspiration.4.The client raises the head of the bed for breathing exercises

1) CORRECT— This client is demonstrating a steady, rapid decline in oxygenation status. Four hours after surgery the client should have stable oxygenation. Requiring increased oxygen therapy and pulse oximetry monitoring is an unexpected outcome variance indicating a complication. 2) A drowsy client is typical after surgery, and this client has an adequate respiratory rate. This finding is not concerning. 3) Postoperatively, clients typically have a loose cough and often this is productive. A cough after deep inspiration, typically when incentive spirometry is performed, is a positive outcome. 4) Raising the head of the bed, when tolerable and allowed, allows fuller lung expansion and better deep breathing and coughing, and it is a positive action.

The nurse prepares discharge instructions for a client who speaks very little English and is recovering from an emergency appendectomy. Which nursing action best helps this client understand wound care instructions? 1.Asking if the client understands the instruction.2.Demonstrating the procedure and having the client return the demonstration.3.Asking an interpreter to replay the instructions to the client.4.Writing out the instructions and having a family member read them to the client.

1) Clients may claim to understand discharge instructions when they do not actually understand. 2) CORRECT — When the client can repeat the action that was taught by the nurse, that best ensures that the client can perform wound care correctly at home. 3) An interpreter or family member may communicate verbal or written instructions inaccurately. 4) Family members are not considered appropriate and objective interpreters for clients.

The nurse palpates a client's neck to assess the lymph nodes. Which technique is most appropriate for the nurse to use? 1.Compress the lymph nodes between two fingers.2.Use the pads of two fingers in a rotating motion.3.Use the flat aspects of all four fingers in a vertical and then side-to-side motion.4.Use the back of one hand and observe temperature variation between the left and right nodes.

1) Compressing the lymph nodes does not allow proper assessment of the nodes. 2) CORRECT— The appropriate technique is to use the pads of two fingers, moving in a gentle circular motion over the nodes. 3) Using four fingers in a vertical and then side-to-side motion is not the correct technique to use. 4) Using the back of the hand to assess for temperature variation is not the proper technique to use.

The nurse admits a child with fever, malaise, headache, and a vesicular rash on the scalp, face, and trunk. Which transmission-based precaution does the nurse implement for this child? 1.Contact precautions.2.Airborne and contact precautions.3.Airborne and droplet precautions.4.Droplet precautions.

1) Contact precautions are not sufficient. 2) CORRECT — The client demonstrates signs of a varicella infection. Airborne and contact precautions are needed and should be maintained for at least 5 days after the onset of the rash and until the vesicular lesions are gone. 3) Airborne precautions are not sufficient and droplet precautions are not indicated. 4) Droplet precautions not are indicated.

The nurse provides care for a child who ingested an unknown substance. The client is unconscious with a respiratory rate of 10 breaths/min, pulse oximeter reading is 88%, and the heart rate is 160 beats/min. The nurse determines which nursing diagnosis is the highest priority for this client? 1.Decreased cardiac output.2.Ineffective breathing pattern.3.Ineffective tissue perfusion.4.Impaired cerebral tissue perfusion. View Explanation

1) Decreased cardiac output is not the highest priority in the scenario. Airway and breathing are higher priorities. 2) CORRECT—Ineffective breathing pattern is the highest priority and needs to be addressed first. 3) Ineffective tissue perfusion is not the highest priority in the scenario. The client must breathe effectively to have tissue perfusion. 4) Impaired cerebral tissue perfusion is not the highest priority in the scenario. Breathing is a higher priority than circulation.

The nurse provides care for a client who has undergone detoxification of long-term opioid use. The nurse plans discharge teaching for the client. Which medication does the nurse include in the discharge teaching? 1.Diazepam.2.Vareninclin.3.Naltrexone.4.Disulfiram.

1) Diazepam, a benzodiazepine, is used during acute alcohol withdrawal to prevent seizures. 2) A client who is attempting to quit smoking can take varenincline, which acts as a deterrent for using nicotine. Concurrent use with nicotine results in nausea, headache, vomiting, dizziness, and fatigue. 3) CORRECT — The client can take naltrexone, an opioid antagonist, during detoxification and continue to take this medication as maintenance therapy to eliminate craving. 4) A client who has undergone alcohol withdrawal can use disulfiram as an alcohol deterrent. Concurrent use with alcohol can result in facial flushing, nausea, vomiting, confusion, blurred vision, and possible severe hypotension.

A client with injuries from a motor vehicle accident is unconscious from a severe head injury. The client's identity is unknown, but the client needs emergency surgery to stabilize fractures. Which action is the best for the nurse to take when obtaining informed consent for the operative procedure? 1.Ask the emergency services team to sign the informed consent.2.Obtain an emergency court order for the surgical procedure.3.Transport the client to the operating room for surgery.4.Ask the police to identify the client and locate the family.

1) Emergency services personnel do not have the authority to provide consent for the client. 2) An emergency court order for surgery occurs when a client waives the right to give informed consent. 3) CORRECT - Informed consent of an adult is generally not needed when an emergency is present, and delaying treatment for the purpose of obtaining consent could result in injury or death of the client. 4) Asking the policy to identify the client and locate the family is not the best option because it may take time and would delay the surgical procedures that the client urgently needs.

A client reports having difficulty falling asleep at night. With which statement will the nurse respond to this client? (Select all that apply.) 1."Exercising immediately before bed will reduce stress."2."Reading or watching television in bed will help you relax."3."Eating a heavy meal before bedtime can interfere with sleep."4."Maintaining a regular sleep/wake schedule promotes sleep."5."Napping during the day can interfere with sleep at night." View Explanation

1) Exercise should be avoided for at least 2 hours before going to bed. 2) Reading or watching television in bed can interfere with sleep. The bedroom should be used for sleep and intimacy. 3) CORRECT — Eating a heavy meal before bedtime can cause insomnia. 4) CORRECT — The client should maintain a regular sleep/wake schedule. Getting up at the same time each day is an important factor. A sleep diary may help modify poor sleep habits. 5) CORRECT — Daytime napping can interfere with nighttime sleep. If napping is necessary to avoid an accident or injury, limit it to a maximum of 20 to 30 minutes and set a timer.

A client receiving a blood transfusion experiences a febrile reaction. Once the transfusion is discontinued, which action will the nurse take next? 1.Flush the blood tubing with normal saline. 2.Place tubing and bag in a red biohazard bag and discard.3.Keep the blood bag and tubing hung in case the health care provider wants to restart the transfusion.4.Place the bag and tubing in a biohazard container to send back to the blood bank.

1) Flushing the tubing will cause the blood that is in the tubing to be infused into the client, making the reaction worse. 2) The tubing and blood is not to be discarded. It is sent back to the blood bank. 3) It is unlikely that this transfusion will be restarted. 4) CORRECT - The tubing and blood bag should be sent to the blood bank for analysis.

The nurse provides education to parents regarding home safety. Which information does the nurse include to help keep a preschool child safe? 1.Use guard gates on stairs.2.Instruct child to never swim alone.3.Cover electrical outlets with safety plugs.4.Teach child to avoid strangers. View Explanation

1) Guard gates on stairs is a safety measure used for infants and toddlers, not preschool children. 2) A preschool child should never swim without adult supervision. It is parents of a school-aged child who would need to instruct the child to never swim alone. 3) Covering electrical outlets with safety plugs is a safety measure taken for infants and toddlers, not preschool children. 4) CORRECT— The nurse needs to instruct the parents that they must teach their preschool child to avoid talking to strangers. Safety education is essential for this age group. Preschoolers need to learn how to avoid safety hazards, and this includes talking to strangers.

The nurse attends a staff development conference on transfusion reactions. Which statement by the nurse indicates the need for further teaching? 1."I will keep the intravenous line open with normal saline after I stop the transfusion."2."I will obtain a urine specimen to determine the presence of hemoglobin."3."I will discard the blood bag and transfusion set in a waterproof bag."4."I will notify the blood bank if a client has a transfusion reaction."

1) If a transfusion reaction is suspected, STOP the transfusion immediately. The next steps include disconnecting the blood tubing and connecting the normal saline infusion to maintain an open intravenous line. This statement indicates understanding of the teaching. 2) If a transfusion reaction occurs, obtain a urine specimen and send it to the laboratory to determine the presence of hemoglobin as a result of red blood cell hemolysis. This statement indicates understanding of the teaching. 3) CORRECT - The blood bag and tubing need to be sent to the blood bank following a transfusion reaction. This statement indicates a need for further teaching. 4) If a transfusion reaction occurs, the blood bank should be notified. This statement indicates an understanding of the teaching.

The nurse provides care for a client who had a percutaneous coronary intervention (PCI) with an angiogram 1 hour ago. Which nursing action is priority? 1.Encourage the client to increase fluid intake.2.Monitor potassium and magnesium levels.3.Assist the client with toileting needs.4.Monitor the access site for signs of bleeding.

1) Increasing PO (per os) intake is important, but is not the priority 1 hour after a PCI. 2) Monitoring electrolytes is important, but is not a priority 1 hour after a PCI. 3) The client is on bed rest for 2 to 6 hours after a PCI and will need assistance toileting, but this is not the immediate priority. 4) CORRECT— Assessment for bleeding and hematoma is the priority concern soon after a PCI.

The parent of a school-age child diagnosed with type 1 diabetes mellitus reports that the child has been sick and has ketones in the urine. Which instruction will the nurse provide to the parent? 1.Hold the next dose of insulin.2.Administer an additional dose of regular insulin.3.Encourage the child to drink calorie-free liquids.4.Seek medical attention for additional assessment and treatment. View Explanation

1) Insulin doses should not be adjusted or changed. This is a medical decision. 2) Insulin doses should not be adjusted or changed. This is a medical decision. 3) CORRECT— If ketones are present, liquids are needed to aid in clearing them from the kidneys. No-calorie liquids should be encouraged to resolve the problem. 4) Additional medical attention is not necessary at this time.

The nurse provides care for a client experiencing status epilepticus. Which action is most appropriate for the nurse to take? 1.Place a tongue blade in the client's mouth.2.Prevent the client from flailing the arms.3.Remove all pillows and raise the bed rails.4.Maintain the client's head in a midline position.

1) It is not recommended that anything be placed in the client's mouth. Inserting objects into the client's mouth used to be done to prevent "swallowing the tongue," which is not possible. 2) Holding the client or preventing movement is not recommended as it may cause injury to the client. 3) CORRECT — Removing pillows and raising bed rails will help prevent the client from falling out of the bed, smothering, or sustaining additional injuries. Padding should be in place at the head of the bed and on the side rails to prevent further injury. 4) The client's head should be positioned so that the tongue and secretions can fall forward during seizure activity.

The nurse attends a conference on neonatal health problems. Which statement by the nurse indicates a correct understanding of neonatal jaundice? 1."Jaundice initially appears in the extremities and gradually progresses to the head."2."The conjunctival sacs and buccal mucosa appear yellow for the first month of life."3."Feeding, especially breastfeeding, is important in reducing serum bilirubin."4."Visual assessment of jaundice gives an accurate assessment of the serum bilirubin level."

1) Jaundice advances from head to toe and regresses in the opposite direction. It is especially evident in the sclera and mucous membranes. 2) Yellow conjunctival sacs and buccal mucosa require follow-up. 3) CORRECT - Feeding stimulates peristalsis, producing more rapid passage of meconium so reabsorption of unconjugated bilirubin is diminished. Bacteria introduced by feeding also aids in the reduction of bilirubin to urobilinogen. Colostrum, a natural laxative, facilitates meconium evacuation. 4) Visual assessment of jaundice does not provide an accurate assessment of the serum bilirubin level.

The nurse prepares to interview a client who is a suspected victim of domestic violence. The client's spouse is present. Which statement made by the nurse is appropriate? 1."Things discussed in this room are confidential." 2."This part of the exam must be done in private." 3."There are many shelters and groups available to you." 4."The results of the examination can be shared as desired."

1) Many states require mandatory reporting of domestic abuse, so this could be false information. 2) CORRECT - The nurse must provide for client privacy during the interview. The client may be less forthcoming with answers if the perpetrator is present. 3) The nurse must conduct the interview in private and provide client with resources at that time. 4) Stating that the client can share exam results places the client in an unsupported position and encourages the suspected perpetrator to ask the client questions.

The nurse uses research findings to improve client care. Which technique of care is the nurse using? 1.Nurse-sensitive indicators.2.Care management.3.Performance improvement.4.Utilization review.

1) Nurse-sensitive indicators are client outcomes and nursing workforce characteristics that are directly related to nursing care, such as changes in clients' symptom experiences, functional status, safety, total nursing hours per client day, and costs. 2) Case management encompasses the oversight and education activities conducted by health care professionals to help clients with chronic diseases and health conditions learn to understand their condition and live successfully with it. 3) CORRECT — Performance improvement typically involves clinical projects conceived in response to identified clinical problems and designed to use research findings to improve clinical practice. 4) A utilization review identifies and eliminates the overuse of diagnostic and treatment services prescribed by health care providers caring for clients on Medicare.

The nurse provides care for clients in a headache clinic. Which client should the nurse assess first? 1.The client reporting pain and neck stiffness.2.The client reporting abdominal pain and vomiting.3.The client with difficulty speaking to the receptionist.4.The client with a headache of 3 weeks' duration.

1) Pain and stiffness are common symptoms of tension headaches. 2) Abdominal pain, nausea, and vomiting are common symptoms for those clients who experience migraine headaches. 3) CORRECT — Difficulty speaking could be a sign of a cerebral vascular accident (CVA), a migraine complication. 4) Although 3 weeks is a long time to have a headache, this is not unusual for a tension headache.

The nurse provides care for a client that sleeps only 5 hours a night because of work and stress. The nurse explains to the client changes that occur in the body with inadequate rest. Which body response should the nurse include in the teaching? 1. Pain tolerance increases. 2. Immune response increases. 3. Accidents decrease. 4. Healing decreases.

1) Pain tolerance decreases with sleep deprivation. 2) Immune response decreases with sleep deprivation, leaving an individual more susceptible to illness. 3) Accidents have been shown to increase with sleep deprivation. 4) CORRECT - Healing is slower and sometimes is not complete when an individual is sleep deprived.

The nurse develops a teaching plan for a client diagnosed with hypertension and type 1 diabetes. The client's health care provider prescribes propranolol. Which information does the nurse include in the teaching plan? 1.Stop the drug immediately if experiencing adverse effects.2.Limit alcohol use to two drinks per day, as alcohol increases the drug's effect.3.Monitor blood glucose frequently. Propranolol may mask symptoms of hypoglycemia.4.Do not use glucagon, as it may increase the effects of propranolol.

1) Propranolol should not be stopped suddenly. Abrupt withdrawal of the medication may cause rebound hypertension or myocardial infarction. 2) Alcohol use during propranolol therapy should be discouraged because it can increase or decrease propranolol levels. The client should not drink 2 alcoholic beverages per day. 3) CORRECT — Propranolol may mask the typical signs of hypoglycemia. Therefore the client should be instructed to frequently test blood glucose. 4) Glucagon may antagonize propranolol; however, it may still be used in hypoglycemic emergencies.

The supervisor observes the nurse delegate a dressing change on a client with a fever, positive blood cultures, and a blood pressure of 86/42 mm Hg to the LPN/LVN. Which action will the supervisor take next? 1.Encourage the LPN/LVN to complete the dressing change as assigned.2.Assign another LPN/LVN who is more comfortable with dressings to complete the dressing change.3.Discuss with the nurse that the dressing change should not be delegated to the LPN/LVN.4.Ensure that the nurse follows up with the LPN/LVN after the dressing change is complete.

1) The LPN/LVN should not complete the dressing change since the client's condition is unstable. 2) Assigning another LPN/LVN to complete the dressing change is not appropriate since the client's condition is unstable. 3) CORRECT - The client is not stable and the nurse should complete the dressing change. 4) The LPN/LVN should not complete the dressing change. Following up with the LPN/LVN would not be appropriate.

A student nurse asks what the S represents when using SBAR communication. Which response does the nurse provide to the student? 1.System.2.Situation.3.Status.4.Service.

1) The S in SBAR communication does not represent system. 2) CORRECT— SBAR is an acronym that stands for situation-background-assessment-recommendation. 3) The S in SBAR communication does not represent status. 4) The S in SBAR communication does not represent service.

The nurse prepares teaching for a school-age child diagnosed with type 1 diabetes mellitus who has gymnastics practice three times per week. Which information is most important to provide to the child and parents to prevent hypoglycemia during practice? 1.Take the prescribed insulin at noon instead of in the morning.2.Eat twice the amount normally eaten at lunchtime.3.Take one-half the amount of prescribed insulin on practice days.4.Eat six graham crackers or drink a cup of juice before gymnastics practice. View Explanation

1) The child and parents should not be instructed to adjust the time of insulin administration. This is a medical decision. 2) Meal amounts should not be doubled. 3) The child and parents should not be instructed to adjust the dose of the insulin. This is a medical decision. 4) CORRECT— An extra snack of 15 to 30 grams of carbohydrates before sports activities will prevent hypoglycemia.

The nurse conducts a staff development workshop about organ donations. Which statement by a staff member indicates a correct understanding of the Uniform Anatomical Gift Act? 1."A client needs to complete an advance directive and identify a health care proxy to become an organ donor."2."The health care provider is the person who requests organ donation from a client's family members."3."The health care provider who signs the client's death certificate must supervise the removal of the client's donated organs."4."Family members can consent to organ donation after the client's death, even if the client had not expressed a desire to have organs donated." View Explanation

1) The client does not need to complete an advance directive and identify a health care proxy to become an organ donor. 2) The health care provider is not usually the person who requests organ donation from a client's family members. 3) The health care provider who signs the client's death certificate is not the person who removes the client's donated organs 4) CORRECT — Family members can consent to organ donation after the client's death, even if the clients had not expressed a desire to have organs donated.

The nurse provides care to clients in a skilled care facility. Which client will the nurse be most concerned about for the risk of a fall? 1.Client who received the flu vaccine. 2.Client started on a benzodiazepine. 3.Client prescribed psyllium. 4.Client receiving ibuprofen for leg pain.

1) The flu vaccine is not known to increase the risk for falls. 2) CORRECT — Older adult clients have increased sensitivity to and slower metabolism of benzodiazepines, which increases the risk for delirium and falls. 3) Psyllium is a bulk-forming laxative and is not associated with an increased risk for falls. 4) Ibuprofen is not associated with an increased risk for falls.

The nurse provides care for four clients. Which client will benefit the most from a multidisciplinary conference? 1.A 3-month-old client with intussusception who is vomiting, has colicky abdominal pain, and is having jelly-like stools.2.A 2-month-old client with respiratory syncytial virus (RSV), who is wheezing and has moderate subcostal retractions and copious nasal discharge.3.A 3-day-old client with developmental dysplasia of the hip, who has unequal leg length, limited abduction of the left hip, and asymmetry of the gluteal folds.4.A 2-day-old client with body tremors and hyperirritability, who has intermittent episodes of sneezing and whose mother abused substances while pregnant.

1) The infant has signs that are characteristic of intussusception. There is no need for a multidisciplinary conference. 2) This infant has signs that are characteristic of RSV. There is no need for a multidisciplinary conference. 3) This infant has signs that are characteristic of developmental dysplasia of the hip. There is no need for a multidisciplinary conference. 4) CORRECT - This newborn is experiencing neonatal withdrawal from prenatal exposure to drugs while in utero. Since these drugs crossed the placenta, the infant suffers from withdrawal symptoms after birth and may experience long-term developmental and neurological deficits. Also, this newborn is at risk for abuse from the mother, as these infants are very difficult to console. A multidisciplinary conference including a social worker, a home health nurse, a nutritionist, and a mental health counselor could greatly benefit both the mother and newborn.

A client of Asian descent receives information about a recommended surgery from the health care provider, yet refuses to sign the consent form. Which response by the nurse is best? 1."Did you understand what the health care provider said to you about the surgery?"2."Why won't you sign the form after the health care provider recommended the surgery?"3."I will have to call the surgeon and have your surgery cancelled until you can make a decision."4."Are there other people that you want to talk with before making this decision?"

1) The major issue here is not about whether the client understands what the provider said; it is about the cultural issues that may be causing the client to apply a group perspective to the decision-making. 2) Asking why the client will not sign the form after it was recommended by the health care provider does not address the culturally-based concerns the client may have. 3) Canceling the surgery does not address the client's concerns. The Asian client may believe that another family member or member of the cultural group should make the decision about surgery. 4) CORRECT - It is apparent that the client has concerns that need to be addressed. Many Asians will not make important decisions without checking with an astrologer or an almanac to find a lucky day to have a procedure done.

The nurse documents assessment findings in a child's electronic medical record. Which measure does the nurse take to protect the child's confidentiality? 1.Share computer log-on information with coworkers who also care for the child.2.Log off the computer at the end of the shift.3.Leave client information visible to staff when leaving a computer unattended.4.Share documented findings only with those directly involved in the child's care. View Explanation

1) The nurse maintains the security of personal log-in information by not sharing the information with anyone. 2) To maintain client confidentiality, the nurse logs off whenever leaving the computer, not just at the end of the day. 3) To maintain client confidentiality, the nurse does not leave client information visible when the computer monitor screen is unattended. 4) CORRECT— To maintain client confidentiality, the nurse shares the findings only with those who are directly involved in the client's care.

The nurse is unable to locate an older client's left popliteal pulse. Which action will the nurse take next? 1.Check for the femoral pulse. 2.Check for the pedal pulse. 3.Ask another nurse to check for the popliteal pulse. 4.Measure the blood pressure on the left thigh.

1) The presence of the femoral pulse would not provide confirmation that arterial flow exists below that point. 2) CORRECT— The pedal pulse is more distal than the popliteal pulse. Its presence is an indication of adequate arterial circulation to the leg even though the popliteal artery has not been located. 3) The purpose of finding the popliteal pulse is to provide information about the arterial circulation to the leg, so it is appropriate to check the distal pulse before requesting assistance from another nurse. 4) Taking a thigh blood pressure requires locating the popliteal pulse first.

The nurse provides care for a client undergoing an exercise stress test. The cardiologist is suddenly called away for an emergency. Which action should the nurse take next? 1.Continue the test, as the client was almost finished.2.Stop the test and reschedule for another day.3.Ask the client to stay until the doctor returns.4.Inform the client that the test is finished.

1) The stress test cannot continue without a cardiologist present in case the client experiences an emergency from the exertion of the test. 2) CORRECT - The test would need to be rescheduled because a cardiologist must supervise cardiac stress testing. 3) The results will be altered by having the client restart the testing. 4) The stress test must be fully performed from start to finish to give accurate results.

The nurse is teaching the client about the warning signs and symptoms of lung cancer. Which statement is appropriate for the nurse to include in the teaching? 1."There are hardly any signs and symptoms with lung cancer."2."Early symptoms of lung cancer include constant cough and bloody sputum."3."Symptoms of lung cancer are vague and often present late in the disease."4."Wheezing on exhalation is usually considered a positive sign of lung cancer."

1) There are symptoms associated with lung cancer that are often vague and nonspecific. 2) Constant coughing and bloody sputum are late, not warning, symptoms of lung cancer. 3) CORRECT — Lung cancer is often diagnosed in late stages because the symptoms are vague and often attributed to other causes. 4) Wheezing can be due to a number of conditions and is not a positive sign for lung cancer.

The nurse notes that a client's peripheral intravenous catheter site is pale, swollen, and cool to the touch. Which action will the nurse take first? 1.Remove the catheter.2.Apply an ice pack to the site.3.Insert a new catheter.4.Stop the infusion

1) This is not the first step, although the catheter eventually will be removed. 2) This is not the first, although treatment of the site will be done. 3) Inserting a new catheter is not the first step. 4) CORRECT — The infusion of fluids should be stopped first to prevent any further tissue damage.

The nurse at an outpatient health center receives a call from a client who recently began taking birth control pills. The client reports severe leg pain that turned the skin red. Which is the most appropriate response by the nurse? 1."Could you have injured your leg playing sports?" 2."This is a side effect of the pill and will resolve in a week." 3."Have you ever had this problem occur before?" 4."Come to the clinic immediately to be evaluated."

1) This question regarding injury is irrelevant for a client taking birth control pills. 2) Severe leg pain and red skin are not expected side effects of birth control pills. 3) This question may be relevant, but it does not alter the need for the client to be evaluated for deep vein thrombosis (DVT). 4) CORRECT — DVT is a serious complication of birth control pills. The client is reporting symptoms of DVT.

The nurse receives a prescription to provide aspirin to a client with an emergent acute myocardial infarction. What is the best method to administer aspirin to this client? 1.Administer as a rectal suppository.2.Administer with a glass of milk or antacid.3.Give sublingually, times three doses.4.Have the client chew non-enteric coated ASA. View Explanation

1) To maximize immediate antiplatelet action of aspirin across the buccal mucosa, it is best to be chewed. 2) Antacid will reduce absorption of aspirin. 3) In acute myocardial infarction aspirin is given once, not in three doses. 4) CORRECT - To maximize immediate antiplatelet action of aspirin across the buccal mucosa, it is best to be chewed.

The nurse provides care for a client diagnosed with an exacerbation of chronic obstructive pulmonary disease (COPD) who is wheezing. This finding supports which priority nursing diagnosis when planning this client's care? 1.Decreased cardiac output. 2.Risk for anxiety. 3.Ineffective airway clearance. 4.Risk for aspiration.

1) While a client experiencing a COPD exacerbation may have cardiac implications, this is not a priority nursing diagnosis. 2) While a client experiencing a COPD exacerbation may experience anxiety, this is not a priority nursing diagnosis. 3) CORRECT — Wheezing indicates ineffective airway clearance. This is caused by an inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway. This finding requires immediate action. 4) Risk for aspiration is not a priority when the client with COPD is experiencing wheezing.

A client recovering from total hip replacement surgery reports increased pain with movement. Which nursing diagnosis is the most appropriate for this client? 1. Acute pain.2. Ineffective coping.3. Risk for injury.4. Activity intolerance.

The correct answer is 1 . You answered 1. 1) CORRECT — Pain is a priority problem for a client recovering from total hip replacement surgery. 2) There is no indication that the client is not coping well. 3) Risk for injury is related to inappropriate exercise/activity, frailty, and falls. While this nursing diagnosis could apply, it is not as appropriate as acute pain. 4) The client is expressing concerns about pain. There is no indication the client has insufficient physiological or psychosocial energy to complete daily activities.

The home care nurse provides wound care for a client in a home that does not have running water. Which does the nurse do before performing wound care for this client? 1. Perform hand hygiene using an alcohol-based hand rub.2. Inform the client that care cannot be given without running water in the home.3. Notify the nursing supervisor that wound care cannot be performed.4. Call the water company to have water turned on.

The correct answer is 1 . You answered 1. 1) CORRECT — The nurse needs to perform hand hygiene before and after caring for the client, even if the client's home does not have running water. Hand hygiene can be performed using an alcohol-based hand rub instead of using soap and water. 2) The resources that are available in an acute care setting are not always accessible in the home care setting. Home care nurses are often required to improvise when providing care. The nurse performs hand hygiene using an alcohol-based hand rub and then proceeds with performing wound care. 3) Wound care can be performed without running water in the home after the nurse performs hand hygiene using an alcohol-based hand rub. 4) The nurse notifies the client's case manager about the lack of running water in the home. The case manager has resources available to address the situation.

An older adult client is admitted to the hospital. Which nursing intervention helps prevent complications related to the "hazards of hospitalization"? 1. Avoid bedrest as much as possible.2. Use physical restraints when needed.3. Speak with family members often.4. Provide adequate sedation for sleep.

The correct answer is 1 . You answered 3. 1) CORRECT - Prolonged bed rest can lead to adverse outcomes, such as pressure injury, compromised respiratory and cardiovascular functioning, and atrophy of muscles. It can also cause depression, promote dependence, and diminish self-care. It should be avoided as much as possible. 2) Restraints are used as a last resort. They can lead to adverse outcomes, such as delirium and physical injury. 3) Speaking with family is part of comprehensive care, but it does not directly impact the "hazards of hospitalization". 4) Sedation is best avoided as a sleep aid for older adults due to higher risk for delirium. It also interferes with normal sleep cycles and can foster a dependency on sleep aids.

The nurse develops a brochure noting abbreviations that are no longer acceptable. Which abbreviation does The Joint Commission recommend avoiding? (Select all that apply.) 1. U.2. c.c.3. qid.4. mL.5. O.S.

The correct answer is 1, 2, 5 . You answered 1, 3, 5. 1) CORRECT— The abbreviation U (unit) can be mistaken for 0 (zero), the number 4 (four), or c.c. It needs to be written out. 2) CORRECT— The abbreviation c.c. (cubic centimeter) is not recommended. The preferred abbreviation is mL (milliliter). 3) Qid or qid (four times a day) is an acceptable abbreviation. 4) The abbreviation mL (milliliter) is acceptable. 5) CORRECT— The abbreviations O.D. (right eye), O.S. (left eye), and O.U. (both eyes) can be mistaken for each other. These abbreviations need to be written out.

The nurse provides care for a school-age child who has a peanut allergy. Which early manifestation of the allergy should the nurse expect the child to exhibit? (Select all that apply.) 1. Urticaria.2. Vomiting.3. Wheezing.4. Headache.5. Dyspnea.

The correct answer is 1, 3, 5 . You answered 1, 3, 5. 1) CORRECT - Urticaria is an early symptom of peanut allergy. 2) Vomiting is not a typical early symptom of peanut allergy. 3) CORRECT - Wheezing is an early symptom of peanut allergy. 4) Headache is not a typical early symptom of peanut allergy. 5) CORRECT - Dyspnea is an early symptom of peanut allergy.

The nurse provides care for a hospitalized client receiving ethambutol, isoniazid, pyrazinamide, and rifampin for active tuberculosis (TB). The client states, "I want to go home! I refuse to stay here another day!" Which statement by the nurse is most appropriate? 1. "You must remain in the hospital until you have finished the antibiotics."2. "I will notify the health care provider of your request."3. "You will have to wear a mask around sick people."4. "Let's test your sputum again for the presence of tuberculosis."

The correct answer is 2 . You answered 1. 1) The client can be discharged after antibiotics are initiated. The client remains on antibiotics for 6 to 9 months. 2) CORRECT — The client is a candidate for discharge since antibiotic therapy has been initiated. 3) The client with active tuberculosis must wear a mask around everyone, not just around sick people. 4) Hospital discharge is not contingent on negative sputum cultures. However, the hospitalized client remains in isolation for 2 to 4 weeks, or until the client has had three negative sputum cultures.

The nurse notes the presence of purulent drainage at the insertion site of a client's intravenous catheter. Which action will the nurse take after discontinuing the catheter? 1. Apply heat to the affected site.2. Save the catheter to send to the laboratory.3. Apply a pressure dressing.4. Insert a new intravenous catheter on the opposite extremity.

The correct answer is 2 . You answered 2. 1) Although treatment eventually will occur, this is not the next step for the nurse to take. 2) CORRECT — A culture of the catheter tip will identify the organism causing the infection at the insertion site. 3) A pressure dressing is not required. 4) Inserting a new catheter eventually will occur but is not the next step for the nurse to take.

The nurse teaches a group of nursing students about informed consent for medical treatment. The nurse includes teaching about informed consent involving minors. Which statement is correct for the nurse to include in the teaching? 1. Minors with cognitive impairment may consent with a parent.2. Minors in active military service may consent without a parent.3. Minors who need emergency surgery may sign the consent.4. Minors who are orphans cannot sign their informed consent.

The correct answer is 2 . You answered 2. 1) Cognitively impaired persons of any age cannot sign their own consent forms. 2) CORRECT— Minors who are in active military service are considered to be emancipated minors. This legal status allows them to consent to medical treatment on their own accord. 3) In an emergency, consent is not necessary and may not be obtainable quickly enough. 4) Being an orphan does not prevent an emancipated minor from consenting to medical treatment.

A client diagnosed with schizophrenia hears voices and tells the nurse that the building is going to explode. Which action will the nurse take first? 1. Escort the client to a quiet room.2. Engage the client to focus on the nurse.3. Provide an emergency dose of medication.4. Call for help since the client is going to run.

The correct answer is 2 . You answered 2. 1) Escorting the client to a quiet room may be necessary if the nurse is unable to orient the client to reality, but this is not the first action to take. 2) CORRECT — The nurse needs to use a one-to-one approach and guide the client to focus on the nurse instead of the hallucination. 3) An emergency dose of medication may be required, but this is not the first action to take. 4) Calling for help may be required if the situation escalates; however, this is not the first action to take.

The nurse provides care for a client with type 2 diabetes mellitus who experienced a large brain concussion. Which medication does the nurse expect to be prescribed for this client? 1. Metoprolol.2. Mannitol.3. Morphine.4. Metformin.

The correct answer is 2 . You answered 2. 1) Increased intracranial pressure and bradycardia is likely to occur with a large brain concussion. Metoprolol is a beta blocker used to manage hypertension. 2) CORRECT - Mannitol is an osmotic diuretic that is used to treat intracranial pressure from a large brain concussion. 3) Morphine may cause oversedation, masking early signs of increased intracranial pressure. It is used with extreme caution in a head injury. 4) Metformin helps manage the client's diabetes. Controlling the increased intracranial pressure is a priority.

The nurse prepares discharge instructions for a client with active tuberculosis who has been on a medication regimen for 14 days. Which statement by the client does the nurse recognize as the need for additional education? 1. "My family members will have to take one of the medicines for a long time too."2. "I am so glad that I only have to take that one combination pill now."3. "I will not return to work until after I see my health care provider in 10 to 14 days."4. "I will continue to cough into a tissue, throw it away immediately, and wash my hands."

The correct answer is 2 . You answered 2. 1) This response is accurate. Family members living with the client with active TB will be treated prophylactically with isoniazid (INH). 2) CORRECT- The client will be on four medications: INH, rifampin, ethambutol, and pyrazinamide. There are some combination drugs that include two of the four medications. However, they cost more and are used most often only when medication adherence is a concern. 3) This response is accurate. The client is considered infectious for 2 to 3 weeks after treatment is initiated. The risk of exposing others is greatest if the client is contagious. 4) This response is accurate. Sputum containment and handwashing should continue.

The nurse teaches the client's spouse about home care. The client is immobile and incontinent. Which instruction does the nurse include? 1. Place a pillow at the client's abdomen for side-lying position.2. Position the drawsheet from the shoulders to below the hips.3. Use three incontinence pads on the bed with changes.4. Avoid laying the client completely flat during positioning.

The correct answer is 2 . You answered 4. 1) Place a pillow at the client's back, under the head, and under the uppermost leg or between the knees for the side-lying position. 2) CORRECT— Positioning is easier on both the client and the caregiver if the sheet is positioned from the shoulders to below the hips so that the bulk of the client's weight can be evenly distributed for the person performing the positioning. 3) Using multiple incontinence pads is considered detrimental to the client's skin health as it creates additional areas of pressure at each pad edge and multiple pads tend to become wrinkled more easily. 4) If tolerable, the client should be flat while bathed or turned. This makes the turn easier for the client and caregiver and is more efficient, decreasing shear and friction.

A nurse provides care for a client who sustained a fracture of the proximal tibia. The nurse assesses the client following application of a cast. Which finding indicates to the nurse that the client is developing compartment syndrome? (Select all that apply.) 1. 3+ pedal pulse.2. Pain unrelieved with opioids.3. Feeling of pressure under the cast.4. Numbness and tingling in the toes.5. Foot warm to touch.

The correct answer is 2, 3, 4 . You answered 2, 3, 4. 1) Compartment syndrome can occur following a fracture as a result of pressure within a small space from a cast, edema, or bleeding. Therefore, the nurse expects a diminished or absent pedal pulse as pressure impedes circulation. 2) CORRECT - The pain that occurs with compartment syndrome does not respond to opioids because the pain is a result of edema and increasing pressure. 3) CORRECT - Compartment syndrome can occur following a fracture as a result of pressure within a small space from a cast, edema, or bleeding. Therefore, the client is likely to report a feeling of pressure. 4) CORRECT - As compartment syndrome continues to progress, obstructed blood flow leads to nerve cell damage. This damage results in numbness and tingling. 5) As compartment syndrome continues to progress, obstructed blood flow leads to pallor and coolness of the extremity.

A client with end stage liver disease and hepatic encephalopathy has ascites and esophageal varices. Which data does the nurse gather first during the physical assessment? 1. Glasgow coma scale. 2. Cardiac rhythm. 3. Respiratory effort. 4. Abdominal appearance.

The correct answer is 3 . You answered 1. 1) Hepatic encephalopathy leads to altered mental status. It is important to determine the client's Glasgow coma scale score, but this assessment is not a priority at this time. 2) Assessing cardiac rhythm is not the priority assessment for this client. 3) CORRECT - The presence of ascites can impede respiratory function and cause shortness of breath. Assessing respiratory effort is the priority assessment. 4) Because this client has ascites, the client's abdomen will be distended and firm. This is not a priority assessment.

The nurse provides care for a client diagnosed with lymphoma. The client has a large tumor. Which intervention by the nurse is most important in preventing tumor lysis syndrome? 1. Record vital signs every 2 to 4 hours.2. Send a urinalysis test every 6 hours.3. Administer a high rate of intravenous fluid.4. Ask the client to report decreased urine output.

The correct answer is 3 . You answered 1. 1) Recording vital signs will not prevent tumor lysis syndrome, but might alert the nurse to symptoms resulting from it. 2) A urinalysis helps detect tumor lysis syndrome early in its course, but will not prevent it. 3) CORRECT - In the client with a large tumor burden, the nurse should anticipate, or advocate, for the client to have sodium bicarbonate, a xanthine oxidase inhibitor, and a high rate of fluid. The fluid administration will help prevent effects of tumor lysis syndrome, such as hyperkalemia, hyperuricemia, cardiac failure, and renal failure. 4) The nurse is responsible for keeping a strict record of intake and output. Asking the client to keep up with the urine output is not a safe practice.

The staff nurse attends a presentation on legal and ethical issues in nursing. Which statement by the staff nurse indicates a need for additional teaching? 1. "Putting a client in a geriatric chair with the lap tray in front of the client in the day room to watch television is an example of false imprisonment."2. "Telling a client that you will insert a feeding tube if the client does not eat is an example of assault."3. "Telling the hospital chaplain that a client is terminally ill is an example of a breach of confidentiality."4. "Placing hands on a client who says 'do not touch me' is an example of battery."

The correct answer is 3 . You answered 1. 1) Unauthorized restraint or detention of a person is false imprisonment. 2) Assault is a threat of bodily harm or violence caused by a demonstration of force by the perpetrator. A feeling of imminent harm or feeling of immediate danger must exist for assault to be claimed. 3) CORRECT— The chaplain is considered a member of the interdisciplinary team and may be given information about clients. Confidentiality has a wide range of meanings. The nurse can convey information to health team colleagues at client-care conferences verbally or by reading nurse's notes. This statement requires additional teaching. 4) Actual or threatened physical harm caused to another person is battery. Battery may involve angry, forceful touching of people, their clothes, or anything attached to them or touching people against their will.

The nurse assesses a newborn's penis 2 days after a circumcision. The nurse notes a yellow exudate around the head of the penis. Which is the appropriate nursing intervention? 1. Wash the penis with soap and a warm washcloth.2. Take the newborn's temperature to determine if an infection is present.3. Leave the area alone, as this is a normal finding.4. Report the finding to the health care provider.

The correct answer is 3 . You answered 2. 1) Do not wash the penis with soap until the circumcision is healed (5 to 6 days). 2) There is no need to take the temperature, as this finding does not indicate an infection 3) CORRECT - The glans penis is dark red after circumcision and then becomes covered with yellow exudate within 24 hours. This occurrence is normal and persists for 2 to 3 days. It is not removed. 4) The yellow crust over the area is normal. It does not need to be reported to the health care provider.

The nurse teaches the client diagnosed with anal-rectal cancer about the side effects of external radiation therapy. Which side effect is most important for the nurse to include in this teaching plan? 1. Alopecia occurrence is reduced by the use of a cooling cap during therapy.2. Stomatitis is prevented by using salt and soda mouth rinses after meals.3. Fatigue is managed by incorporating frequent rest periods during activity.4. Thrombocytopenia can be treated with platelet infusions for bleeding.

The correct answer is 3 . You answered 3. 1) Alopecia is a concern with chemotherapy and with brain irradiation. A cooling cap may be used during some types of chemotherapy. 2) Oral stomatitis is not a concern for this client; the radiation is not directed at the head and neck. 3) CORRECT - Fatigue is the primary side effect for the person receiving radiation to the anal-rectal area; it is best relieved by periods of activity alternating with rest. 4) Thrombocytopenia is not an expected occurrence with anal-rectal radiation treatment. It would occur from chemotherapy administration or with radiation that covers an extended body surface.

The nurse auscultates crackles throughout all lung fields and measures a heart rate of 132 bpm, a respiratory rate of 30, and blood pressure of 102/54 mm Hg in a client recovering from an esophagectomy. Which action will the nurse take first? 1. Place the client on continuous pulse oximetry.2. Monitor the client for changes in blood pressure.3. Notify the health care provider.4. Assist the client to use the incentive spirometer.

The correct answer is 3 . You answered 3. 1) It is important to monitor pulse oximetry before hypoxia occurs; however, the client has urgent signs that warrant priority action. 2) It is important to monitor blood pressure changes before hypotension occurs; however, the client has urgent signs that warrant priority action. 3) CORRECT — The client is demonstrating signs of early shock and the health care provider should be notified. 4) Using an incentive spirometer may be helpful later; however, the client has urgent signs that warrant priority action.

The nurse provides care for a newly admitted client with chest pain. Which task will the nurse complete instead of delegating to nursing assistive personnel (NAP)? 1. Set up the client's meal tray.2. Obtain a urine specimen and send it to the laboratory.3. Remove the client's oxygen if chest pain is rated as zero.4. Place the client on the cardiac monitor.

The correct answer is 3 . You answered 3. 1) Setting up a meal tray is appropriate for NAP to complete. 2) Obtaining a urine specimen and sending it to the laboratory is appropriate for NAP to complete. 3) CORRECT - The nurse is telling NAP to assess chest pain and perform an intervention based on that assessment. This is not an appropriate task for NAP. 4) Placing cardiac leads and attaching to a monitor is appropriate for NAP to complete.

The nurse prepares a school-age client diagnosed with a fractured humerus to be discharged home with the parents. Which observation requires the nurse to make a referral to home health? 1. The child does not play with toys during the hospital stay.2. One parent is working the night shift.3. The mother has bruises around the wrists.4. The father is anxious to leave the hospital.

The correct answer is 3 . You answered 3. 1) The child may not play with toys because of pain or not feeling well related to the fracture. 2) This is not concerning if one parent works a second or third shift as long as the other parent is home or the child has proper supervision if the other parent is gone. 3) CORRECT — If the mother has bruises around her wrists, she could be getting abused at home. Violence in the family is a risk factor for child abuse and this child should be followed up with in the home. 4) Anxiety is not uncommon with parents, especially if one parent needs to get to work or is not comfortable in a hospital setting.

The nurse observes the umbilical cord protruding from the vagina of a client in labor. Which action does the nurse take next? 1. Place client in high Fowler's position.2. Attempt to reinsert cord into cervix.3. Contact the health care provider.4. Administer oxygen via nasal cannula.

The correct answer is 3 . You answered 3. 1) The client should be placed in extreme Trendelenburg, modified Sims' position, or a knee-chest position. The goal is to shift the fetal presenting part toward the mother's diaphragm. 2) The nurse should not attempt to replace the cord into the cervix. Doing so could traumatize and further reduce blood flow through the cord. The nurse should wrap the cord loosely in a sterile towel saturated with warm sterile normal saline solution to prevent drying of the cord. 3) CORRECT - This situation is a medical emergency. The nurse needs to contact the health care provider and prepare for immediate vaginal birth if the cervix is fully dilated or cesarean birth if it is not. 4) The nurse should administer oxygen via nonrebreather mask at 8 to 10 L/min to increase oxygen availability to the fetus. Priority is to prepare for immediate delivery of the fetus.

The nurse provides care for a client diagnosed with intractable pain. The client is prescribed magnesium sulfate 2 mg intravenous push (IVP) now and every 4 to 6 hours, PRN for pain. Which action should the nurse take first? 1. Administer the medication.2. Insert an intravenous access device. 3. Question the prescribed medication.4. Assess pain level using a numeric rating scale.

The correct answer is 3 . You answered 4. 1) Magnesium sulfate is not a pain medication. Administering this medication would cause a medication error. 2) An intravenous access device will need to be inserted to administer intravenous medications; however, that is not the priority action. 3) CORRECT- Magnesium sulfate is used as an electrolyte replacement or anticonvulsant. It is not used for pain management. The nurse will question this prescription. 4) Assessing current pain level is appropriate before administering pain medication; however, this medication is not an analgesic.

The nurse provides care for a client diagnosed with trigeminal neuralgia. The client reports severe burning and shooting pain. Which understanding does the nurse have about managing this type of pain? 1. It is usually well controlled with salicylates or nonsteroidal anti-inflammatory drugs (NSAIDs).2. It is acute and will require short-term treatment.3. Treatment will include low or moderate regular doses of oral opioids.4. Treatment will include the use of adjuvant analgesics.

The correct answer is 4 . You answered 1. 1) Salicylates or NSAIDs are not effective for the intensity of neuropathic pain. 2) Neuropathic pain is chronic and debilitating. 3) Oral opioids alone do not provide adequate pain relief. 4) CORRECT - Neuropathic pain is not well controlled by opioid analgesics alone and often requires the addition of tricyclic antidepressants or anti-seizure drugs to help prevent pain transmission.

A client reports having chest irradiation as a child for non-Hodgkin lymphoma (NHL). On which potential adulthood complication will the nurse focus when assessing this client? 1. Chronic infertility.2. Asthmatic bronchitis.3. Hodgkin lymphoma.4. Lung cancer.

The correct answer is 4 . You answered 2. 1) Radiation to the pituitary gland, ovaries, and testes, and alkylating agents may cause infertility. 2) Asthmatic bronchitis is not associated with radiation. Pneumonitis and pulmonary fibrosis can occur from radiation and alkylating agents. 3) Hodgkin disease may morph into NHL; however, does not occur in reverse. 4) CORRECT— The development of secondary cancers in adults is a long-term complication of childhood cancer treatment. These cancers can be site specific, such as lung cancer or leukemia.

The nurse prepares to teach a client about measures to prevent falls at home. Which point will the nurse include in the teaching plan? 1. Place a small area rug on the bathroom floor in front of the bathtub.2. Avoid using step stools.3. Allow damp areas on the floor to air dry.4. Do not attempt to do anything beyond reach.

The correct answer is 4 . You answered 2. 1) Small area rugs should be avoided because they pose a trip hazard. 2) The nurse should instruct the client to avoid unstable step stools and ladders. 3) The nurse should instruct the client to clean damp areas promptly to reduce the risk for slipping and falling. 4) CORRECT — The nurse should instruct the client to avoid attempting to do anything beyond reach to reduce the risk for falling.

The nurse receives reports on several clients. Which client will the nurse assess first? 1. 9-month-old client with a barking cough, not eating or drinking, with an oxygen saturation of 92% on room air.2. 14-month-old client with an oral temperature of 1020 F, green nasal drainage, and is pulling at the ears.3. 6-month-old client with a harsh cough, mild audible wheezes, and retractions noted in the ribs.4. 2-year-old client with a sore throat, sitting upright, refusing to swallow, and drooling.

The correct answer is 4 . You answered 3. 1) The client's oxygen saturation level is within normal range. This client would not need to be seen first. 2) The client with a possible ear infection is stable and would not need to be seen first. 3) The client's wheezing and retractions are mild. The client would not need to be seen first. 4) CORRECT - The client with a sore throat, sitting upright, refusing to swallow, and drooling could indicate epiglottitis, which causes severe edema in the epiglottis. Epiglottitis can cause loss of airway if the child is stressed, coughs, or cries. This client should be seen first.

The nurse provides care for a client who reports severe right shoulder pain. Which abdominal organ should the nurse suspect is causing this client's discomfort? 1. Spleen.2. Pancreas.3. Stomach.4. Gall bladder.

The correct answer is 4 . You answered 4. 1) Left shoulder pain is referred from the spleen. 2) Left shoulder pain is referred from the pancreas. 3) Substernal pain is referred from the stomach. 4) CORRECT — Right shoulder pain is referred from the gall bladder.

The nurse documents care on a client who is 3 hours postoperative after a right leg amputation. Which charting entry indicates a problem with the documentation? 1. Client A/O x 4, gag reflex intact, reports nausea.2. Client post above the knee amputation, sequential compression device to left leg, scant amount bleeding on dressing.3. Client A/O x 4, dressing dry and intact, reports incisional pain at 5 on a 10 point scale.4. Client post above the knee amputation, voids without difficulty, 2+ dorsalis pedis pulses bilaterally.

The correct answer is 4 . You answered 4. 1) Nurse should document the orientation, gag reflex and any adverse symptoms due to the postoperative status of the client. There is no problem identified with documentation 2) Documentation would include any devices the client has, such as the SCD, and status of the dressing. 3) Documentation should include the client's orientation, dressing status, and any adverse symptoms such as pain with location and pain scale. 4) CORRECT - Since the client had right above knee amputation (AKA), the client no longer has a right doralis pedis pulse. This is incorrect documentation and should only reflect the doralis pedis pulse in the left leg.

The nurse provides care for a client diagnosed with sickle cell crisis. Which sign or symptom should the nurse immediately report to the healthcare provider? 1.Cyanosis of the tongue.2.Jaundiced skin.3.Slurred speech.4.Slow capillary refill.

1) Cyanosis of the tongue is a common finding with sickle cell crisis due to poor profusion. 2) Jaundiced skin is a common finding with sickle cell crisis due to the rapid breakdown of red blood cells. 3) CORRECT - Slurred speech indicates a possible stroke and should be reported immediately. 4) Slow capillary refill is common finding with sickle cell crisis due to poor capillary profusion.

A client recovering from surgery becomes confused and anxious and is hyperventilating. When using SBAR communication, which statement does the nurse make when notifying the health care provider? 1."The client's mental status has deteriorated."2."I am concerned about this client who has become confused and is hyperventilating."3."The problem seems to be the respiratory status of this client."4."Please come and see this client as the condition has changed."

1) "The client's mental status has deteriorated" does not adequately describe the situation. 2) CORRECT— "I am concerned about this client who has become confused and is hyperventilating" describes the situation, which is the S in SBAR (situation, background, assessment, recommendation). SBAR is a technique used to facilitate prompt, appropriate, and effective communication among health care providers. 3) "The problem seems to be the respiratory status of this client" does not adequately describe the situation. 4) "Please come and see this client as the condition has changed" is a recommendation rather than a description of the situation.

The nurse follows up with a client diagnosed with insomnia. The nurse seeks to determine if treatment was successful. Which response by the client best indicates treatment was successful? 1. "I am sleeping 4 hours a night."2. "I fall asleep within 1 to 2 hours at night now."3. "I am not napping in the day anymore."4. "I am waking up twice a night."

1) 4 hours may be an improvement, but is not an adequate amount of sleep. 2) 1 to 2 hours to fall asleep may be an improvement, but is not the most successful response to treatment. 3) CORRECT - Insomniacs typically nap in the daytime. Not napping indicates the client is getting through the day now. This is a positive response to treatment. 4) Continual interruption of sleep during the client's sleep time is not the most successful response.

The nurse provides care for a client diagnosed with colon cancer. The client is scheduled to have an endoscopy, a PET scan, and an MRI. The client questions the nurse as to why all these tests are necessary. Which response by the nurse is best? 1. "The tests serve to obtain a 3-dimensional view of the tumor." 2. "The tests help the provider gather detailed tumor information." 3. "The provider can use the tests to determine the grade of the tumor cells. 4. "The provider will use the tests to decide if chemotherapy will be helpful." The correct answer is 2 .

1) A 3-dimensional view is not possible with these scans. 2) CORRECT - These tests will provide details about the tumor's characteristics. 3) Tumor grade is determined when malignant cells are viewed under a microscope. 4) The results of multiple tests are not the sole factor in deciding a treatment plan, but many factors are used to determine if chemotherapy will be helpful.

The nurse provides care for a client diagnosed with type 2 diabetes. The health care provider has ordered exenatide for the client. When will the nurse administer this medication? 1. Twice a day within 1 hour before morning and evening meals.2. Once a day before bedtime.3. Twice a day within 2 hours before morning and evening meals.4. Twice a day within 1 hour after morning and evening meals.

The correct answer is 1 . You answered 2. 1) CORRECT - Exenatide stimulates the pancreas to secrete insulin when blood sugar levels are high. It should be administered twice a day within 1 hour before the morning and evening meals. 2) Exenatide should be administered twice a day within 1 hour before the morning and evening meals, not once a day before bedtime. 3) Exenatide should be administered twice a day within 1 hour before the morning and evening meals, not twice a day within 2 hours before morning and evening meals. 4) Exenatide should be administered twice a day within 1 hour before morning and evening meals, not after the morning and evening meals.

The health care provider prescribes fresh frozen plasma for a client with an arterial bleed. Which rationale will the nurse use when explaining the reason for this type of blood product to be transfused in the client? 1. Promote rapid volume expansion.2. Increase the hemoglobin level.3. Treat platelet loss.4. Increase hematocrit level.

The correct answer is 1 . You answered 2. 1) CORRECT — Fresh frozen plasma is often used for volume expansion caused by fluid and blood loss. 2) Fresh frozen plasma does not specifically increase hemoglobin. 3) Fresh frozen plasma does not contain platelets. 4) Fresh frozen plasma does not specifically increase hematocrit.

A client admitted with acute stroke suddenly becomes lethargic. Which action does the nurse take next? 1. Notify the health care provider.2. Keep the client NPO.3. Assess for signs of infection.4. Prepare the client for a CT scan.

The correct answer is 1 . You answered 1. 1) CORRECT - Sudden lethargy in a client with an evolving stroke can indicate an emergency or possible extension of the stroke. The health care provider should be immediately notified. 2) Although the client with acute stroke should take nothing by mouth because of the risk of aspiration, this is not a priority action. 3) There is no reason to assess this client for signs of an infection. 4) It is unknown if a CT scan was already done as part of the diagnostic work-up for the stroke. This is not a priority action.

The nurse provides care to a client with pneumonia, anorexia, and chronic pain. Which laboratory result does the nurse report to the health care provider immediately? 1. PaCO2 of 50 mm Hg.2. pH of 7.33.3. PaO2 of 86 mm Hg.4. HCO3 of 23 mEq/L. .

The correct answer is 1 . You answered 1. 1) CORRECT - The PaC02 is significantly higher than the normal range of 35 to 45 mm Hg. This finding suggests compromised alveolar exchange with a potential for respiratory acidosis. 2) This pH is slightly below the normal range of 7.35 to 7.45. 3) The PaO2 is within the normal range of 85 to 95 mm Hg. 4) The HCO3 is within the normal range of 22 to 26 mEq/L

The nurse observes that a client's peripheral intravenous (IV) dressing has loosened. Which action does the nurse take next? 1. Immediately change the IV dressing.2. Tape the IV dressing to secure it in place.3. Replace the IV catheter at another site.4. Apply a skin adhesive where the IV dressing loosened.

The correct answer is 1 . You answered 1. 1) CORRECT - The nurse should immediately change the dressing if it becomes loosened, dampened, or soiled to reduce the risk for an intravascular catheter-associated bloodstream infection. 2) Taping the dressing in place increases the risk for intravascular catheter-associated bloodstream infection. Instead, the nurse should immediately change the dressing. 3) It is not necessary to replace the catheter; instead, the nurse should change the dressing. 4) Applying a skin adhesive without first replacing the dressing increases the risk for intravascular-associated infection.

The nurse plans to fax health information to a facility in which a client is being transferred. Which action is appropriate for the nurse to take? (Select all that apply.) 1. Remove all identifiers on all the documents to be faxed.2. Fax documents during the least busy time in the other facility.3. Confirm that fax numbers are correct before sending.4. Use a cover sheet with the name of the recipient printed.5. Fax the information that is required for immediate needs.

The correct answer is 3, 4, 5 . You answered 3, 4, 5. 1) Removing identifiers will prevent the recipient from knowing which client's information is being faxed. 2) There is no restriction on the time when a fax can be sent. 3) CORRECT - Confirming that the fax number is correct ensures that the information is sent to the correct location. 4) CORRECT - Using a cover sheet eliminates the need for the recipient to read the information to determine who is to receive the fax. 5) CORRECT - Faxing information that is required for immediate needs eliminates sharing unwanted and unnecessary client information.

The nurse provides care for a client that has difficulty getting comfortable at night. The client remains awake until the client requests acetaminophen. The client is able to fall asleep about an hour after taking the acetaminophen. Which nursing intervention should the nurse add to the client's plan of care? 1. Talk with the health care provider about prescribing a sleep medication for the client.2. Talk with the health care provider about prescribing a stronger pain medication for the client.3. Instruct the client to avoid using acetaminophen routinely because of the adverse effects.4. Administer the acetaminophen about an hour before the client goes to sleep.

The correct answer is 4 . You answered 4. 1) Sleep medication is not needed if the client is able to get comfortable with acetaminophen. If the inability to sleep is from pain, the sleep medication will not address this issue. 2) Acetaminophen is effective for this client. A stronger pain medication is not indicated. 3) Acetaminophen is safe and effective if taken as prescribed. The scenario does not give details that would indicate the client should avoid acetaminophen. 4) CORRECT - The nurse should try to treat the discomfort so the client can become comfortable enough to sleep rather than losing sleep from discomfort.